Practice Test Bank (Questions 1-160)2026
1. A school-age client with diabetes is placed on intermediate-acting
insulin and regular insulin before breakfast and before dinner. She will
receive a snack of milk and cereal at bedtime. What does the nurse tell
the client the snack is intended to do?
A. Provide additional calories for growth
B. Prevent late night hypoglycemia
C. Enhance the effectiveness of the morning insulin
D. Satisfy hunger before sleep
Correct Answer: B. Prevent late night hypoglycemia.
Rationale: The combination of intermediate-acting insulin (NPH) peaking
during the night and the client's overnight fasting period creates a risk for
nocturnal hypoglycemia. The bedtime snack provides carbohydrates to
maintain blood glucose levels through the night. This is a standard part of
diabetes management for clients taking NPH insulin .
2. A well-known public official is admitted to the emergency
department following chest pain. Several nurses from the medical unit
access the official's electronic medical record. What is the best
response for the nurse manager to make?
A. "You should have asked for permission first."
B. "Assessing the official's medical record is a breach of confidentiality."
C. "Only the primary nurse should access the record."
D. "You can access it if you are providing care."
*Correct Answer: B. "Assessing the official's medical record is a breach
of confidentiality." *
,Rationale: Accessing a client's medical record without a need-to-know basis
violates HIPAA and confidentiality policies. Healthcare workers may only
access records for clients they are directly caring for. Public figures do not
have reduced privacy rights .
3. A 4-year-old child diagnosed with acute lymphocytic leukemia has a
low WBC count, especially neutrophils. What is the most important
intervention the nurse should teach the parents?
A. Monitor the child for signs of bleeding
B. Protect the child from infections because resistance is decreased
C. Ensure the child attends school regularly
D. Encourage all physical activity
Correct Answer: B. Protect the child from infections because resistance
is decreased.
Rationale: Leukemia and chemotherapy cause decreased white blood cell
counts (neutropenia), increasing infection risk. Parents should be taught to
protect the child from infections through hand hygiene, avoiding crowds, and
monitoring for fever. Neutropenia is the most significant risk .
4. The nurse is caring for a client with influenza. The most effective
way to decrease the spread of microorganisms is:
A. Placing the client in isolation
B. Washing the hands frequently
C. Wearing a mask at all times
D. Using gloves for all care
Correct Answer: B. Washing the hands frequently.
,Rationale: Hand hygiene is the single most effective measure to prevent the
spread of microorganisms in healthcare settings. While isolation and PPE are
important, handwashing remains the primary defense against transmission .
5. A client with a history of hypertension is prescribed a new
antihypertensive and reports dizziness. Which is the best way for the
nurse to assess blood pressure?
A. In the supine position only
B. In the sitting position only
C. In the supine, sitting, and standing positions
D. In the standing position only
Correct Answer: C. In the supine, sitting, and standing positions.
Rationale: Orthostatic hypotension is a common side effect of
antihypertensives. Assessing blood pressure in all three positions helps
identify drops in blood pressure with position changes that can cause
dizziness and falls .
6. A client has a soft wrist-safety device. Which assessment finding
should the nurse investigate further?
A. Warm, pink fingers
B. Capillary refill of 2 seconds
C. Cool, pale fingers
D. Radial pulse 2+
Correct Answer: C. Cool, pale fingers.
Rationale: Cool, pale fingers indicate impaired circulation from the restraint
and require immediate investigation. Normal findings include warm pink
, skin, capillary refill <3 seconds, and palpable pulses. The restraint should be
loosened to restore perfusion .
7. A client with anemia has been admitted. Which assessment findings
are characteristic of iron deficiency anemia?
A. Nausea, vomiting, and anorexia
B. Dyspnea, tachycardia, and pallor
C. Headache, blurred vision, and hypertension
D. Abdominal pain, diarrhea, and fever
Correct Answer: B. Dyspnea, tachycardia, and pallor.
Rationale: Iron deficiency anemia causes decreased oxygen-carrying capacity,
resulting in dyspnea, tachycardia, and pallor. These are classic signs of
anemia .
8. The nurse is discontinuing an IV catheter on a 10-year-old client
with hemophilia. What is the most important intervention for this
client?
A. Apply a pressure dressing and check in 30 minutes
B. Apply firm pressure on the site for 5 minutes after removal
C. Elevate the arm above heart level
D. Apply ice to the site
Correct Answer: B. Apply firm pressure on the site for 5 minutes after
removal.
Rationale: Clients with hemophilia lack clotting factors and are at high risk
for bleeding. Firm pressure for at least 5 minutes after IV removal helps
achieve hemostasis .