Questions with Rationales | The #1 Nursing Review for
Prioritization, Delegation, and Critical Thinking
How to Use This Set
...,,,Answer,,,... each question bef ore reading the solution. Focus on saf ety, ABCs, acute
changes, delegation, medication saf ety, and the rationale f or the correct choice. The set is
organized by major PN content areas.
Fundamentals
1. A client has just returned from surgery and is difficult to arouse. Which
assessment is the priority?
...,,,Answer,,,...: Airway and breathing
Rationale: A decreased level of consciousness can compromise airway protection and
ventilation, so ABC assessment comes f irst.
2. Which action best prevents transmission of infection between clients?
...,,,Answer,,,...: Perf orm hand hygiene bef ore and af ter client contact
Rationale: Hand hygiene is the most important routine measure f or reducing transmission of
microorganisms.
3. A client reports sudden chest pressure. What should the PN do first?
...,,,Answer,,,...: Stop activity and assess the client
Rationale: Immediate assessment identif ies instability and guides urgent intervention.
4. Which finding requires immediate follow-up in a postoperative client?
...,,,Answer,,,...: Respiratory rate of 8/min
Rationale: Marked bradypnea can indicate opioid -related respiratory depression and requires
prompt intervention.
5. What is the best position for a client experiencing dyspnea?
...,,,Answer,,,...: High-Fowler's
Rationale: Upright positioning improves lung expansion and decreases the work of breathing.
,6. Which intervention is most effective for preventing pressure injuries?
...,,,Answer,,,...: Reposition the immobile client regularly
Rationale: Frequent repositioning relieves prolonged pressure and supports tissue perf usion.
7. A client is at risk for falls. Which action is appropriate?
...,,,Answer,,,...: Keep the call light within reach
Rationale: Easy access to assistance reduces unsaf e attempts to get out of bed.
8. Which assessment is most useful for evaluating pain?
...,,,Answer,,,...: The client's self -report
Rationale: Pain is subjective; the client's report is the primary assessment when the client can
communicate.
9. A sterile field becomes wet. What should the PN do?
...,,,Answer,,,...: Consider the f ield contaminated
Rationale: Moisture can allow microorganisms to pass through a barrier, so a wet sterile f ield is
contaminated.
10. Which action reduces aspiration risk during oral feeding?
...,,,Answer,,,...: Position the client upright
Rationale: An upright position promotes saf er swallowing and reduces aspiration risk.
11. What is the safest way to identify a client before medication
administration?
...,,,Answer,,,...: Use two approved identif iers
Rationale: Two identif iers reduce wrong-patient medication errors.
12. Which finding suggests dehydration?
...,,,Answer,,,...: Dry mucous membranes
Rationale: Dry mucous membranes commonly occur with reduced body f luid volume.
13. Which intervention helps prevent venous stasis in an immobile client?
...,,,Answer,,,...: Encourage leg exercises as prescribed
Rationale: Muscle contraction promotes venous return and reduces stasis.
14. A client becomes dizzy when standing. What should the PN do first?
...,,,Answer,,,...: Assist the client back to a saf e position
Rationale: Saf ety takes priority when orthostatic symptoms o ccur.
, 15. Which documentation is most appropriate?
...,,,Answer,,,...: Objective, timely, f actual observations
Rationale: Clinical documentation should be accurate, objective, and completed promptly.
Safety
16. A confused client repeatedly tries to climb out of bed. What is the best
initial intervention?
...,,,Answer,,,...: Use least-restrictive saf ety measures and increase observation
Rationale: Saf ety measures and close observation should be attempted bef ore restrictive
interventions when f easible.
17. A medication label is unreadable. What should the PN do?
...,,,Answer,,,...: Do not administer it; obtain a clearly labeled medication
Rationale: An unreadable label creates an unsaf e medication error risk.
18. Which client should be seen first?
...,,,Answer,,,...: A client with new stridor
Rationale: Stridor can signal upper-airway obstruction and requires immediate assessment.
19. A fire starts in a client's room. What is the first action?
...,,,Answer,,,...: Remove the client f rom immediate danger
Rationale: The f irst priority in a f ire is protecting people f rom immediate harm.
20. Which action is appropriate when using a wheelchair?
...,,,Answer,,,...: Lock the wheels bef ore transf erring the client
Rationale: Locked wheels stabilize the chair and reduce transf er-related f alls.
21. What should the PN do after discovering a medication error?
...,,,Answer,,,...: Assess the client and f ollow the f acility reporting process
Rationale: Client saf ety comes f irst, f ollowed by prompt reporting and documentation according
to policy.
22. Which environmental change best reduces fall risk?
...,,,Answer,,,...: Remove clutter f rom walking paths
Rationale: Clear pathways reduce tripping hazards.
23. A client has a seizure. Which action is appropriate?
...,,,Answer,,,...: Protect the head and clear nearby hazards