– Complete Practice Questions & Rationales
Question 1
A client with a stage III pressure ulcer on the sacrum has a wound bed that is pale and
dry. Which dressing is most appropriate?
A. Dry gauze
B. Hydrogel dressing
C. Transparent dressing
D. Wet-to-dry dressing
*Correct Answer: B. *
Rationale: A pale, dry wound bed indicates poor perfusion and delayed healing. A hydrogel
dressing provides moisture to the wound bed, promoting autolytic debridement and
healing. Dry gauze would adhere to the wound and cause further damage.
Question 2
A client with herpes zoster (shingles) is prescribed acyclovir. Which teaching is most
important?
A. "Take the medication with food."
B. "Start the medication as soon as possible after the rash appears."
C. "Apply the medication directly to the rash."
D. "The medication will cure the infection."
*Correct Answer: B. *
,Rationale: Acyclovir is most effective when started within 72 hours of rash onset. It reduces
the severity and duration of the outbreak. It does not cure the infection but suppresses
viral replication. Oral acyclovir is taken with or without food.
Question 3
A client with a history of myocardial infarction is prescribed a beta-blocker. Which
finding indicates the medication is effective?
A. Heart rate of 110
B. Blood pressure of 130/80 mmHg
C. Respiratory rate of 24
D. Dizziness upon standing
*Correct Answer: B. *
Rationale: Beta-blockers are prescribed to lower blood pressure and heart rate. A blood
pressure of 130/80 mmHg indicates the medication is effective. Dizziness may indicate
orthostatic hypotension, and a heart rate of 110 is elevated.
Question 4
A client with a urinary tract infection (UTI) is prescribed ciprofloxacin. Which side effect
should the nurse monitor for?
A. Photosensitivity
B. Tendon rupture
C. Hepatotoxicity
D. Cardiotoxicity
*Correct Answer: B. *
Rationale: Ciprofloxacin is a fluoroquinolone antibiotic that can cause tendonitis and
tendon rupture, particularly in the Achilles tendon. Patients should be advised to report
,tendon pain and avoid strenuous activity. Photosensitivity is also a side effect but less
specific.
Question 5
A client with a history of asthma is prescribed montelukast (Singulair). Which teaching is
most important?
A. "This medication is used for acute asthma attacks."
B. "This medication is taken daily for long-term control."
C. "This medication should be taken with food."
D. "This medication will work immediately."
*Correct Answer: B. *
Rationale: Montelukast is a leukotriene receptor antagonist taken daily for asthma
prophylaxis. It is not used for acute attacks and may take several weeks to reach full effect.
It can be taken with or without food.
Question 6
A client with a history of heart failure is on a fluid restriction of 1500 mL per day. Which
statement indicates the client understands the restriction?
A. "I can drink as much as I want because diuretics remove excess fluid."
B. "I will measure all my fluids and keep a daily record."
C. "I only need to restrict water, not other beverages."
D. "I will drink extra fluids on hot days."
*Correct Answer: B. *
Rationale: Accurate measurement and recording of fluid intake is essential for clients on
fluid restriction. All fluids, including water, juice, and soups, should be counted. Diuretics
do not eliminate the need for fluid restriction.
, Question 7
A client with a history of COPD is receiving oxygen at 2 L/min. Which finding indicates
the oxygen is at an appropriate level?
A. Respiratory rate of 8
B. Oxygen saturation of 90-92%
C. Client reports confusion
D. Client reports headache
*Correct Answer: B. *
Rationale: For clients with COPD, the target oxygen saturation is typically 88-92% to avoid
suppressing the hypoxic drive. An oxygen saturation of 90-92% is appropriate. Lower
saturation may indicate inadequate oxygenation.
Question 8
A client with a wound infection is prescribed vancomycin. Which side effect should the
nurse monitor for?
A. Nephrotoxicity
B. Red man syndrome
C. Hepatotoxicity
D. Cardiotoxicity
*Correct Answer: B. *
Rationale: Vancomycin can cause red man syndrome, characterized by flushing, rash, and
hypotension, especially with rapid IV infusion. The infusion should be given over at least
60 minutes. Nephrotoxicity and ototoxicity are also concerns.