Real Exam Questions and Correct Verified Answers
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1. A nurse is preparing to administer a cleansing enema to an adult patient. Which
of the following is the correct amount of solution to administer?
A. 100-200 mL
B. 250-350 mL
C. 500-1,000 mL
D. 1,500-2,000 mL
Answer: C
Rationale: The standard volume for a cleansing enema in an adult is 500-1,000 mL.
Pediatric patients require smaller volumes (250-500 mL). Infants typically receive 100-200
mL. The solution should be warmed to body temperature to prevent cramping.
2. A patient with an indwelling urinary catheter has a urine output of 75 mL over 4
hours. Which of the following should the nurse do first?
A. Increase the patient's fluid intake
B. Irrigate the catheter with sterile saline
C. Assess the catheter tubing for kinks or obstruction
D. Notify the healthcare provider immediately
Answer: C
Rationale: The nurse should first assess the catheter tubing for kinks, obstruction, or proper
positioning that may be preventing urine drainage. Output of 75 mL over 4 hours (18.75
mL/hour) is below the minimum of 30 mL/hour. Increasing fluids, irrigation, or notifying
the provider should occur after assessing for mechanical obstruction.
,3. A nurse is providing perineal care to a female patient with an indwelling urinary
catheter. Which of the following is the correct technique?
A. Clean the perineal area from back to front
B. Clean the perineal area from front to back
C. Use a circular motion starting at the meatus
D. Use soap with antibacterial properties
Answer: B
Rationale: The perineal area should be cleaned from front to back to prevent introducing
bacteria from the rectal area to the urethra. A circular motion starting at the meatus is not
standard technique. Mild soap and water should be used; antibacterial soap is not
necessary and may cause irritation.
4. A nurse is applying a heating pad to a patient's lower back. Which of the
following actions is correct?
A. Place the heating pad directly on the skin
B. Apply the heating pad for 30 minutes at a time
C. Use the highest heat setting for effectiveness
D. Check the skin every 2 hours
Answer: B
Rationale: The heating pad should be applied for 20-30 minutes at a time to allow tissues
to warm without causing burns. A barrier (towel or cloth) should be placed between the
pad and the skin. The lowest effective heat setting should be used. Skin should be checked
more frequently, at least every 15-20 minutes.
5. A patient is receiving a blood transfusion and develops flushing, hives, and
itching. Which of the following is the nurse's priority action?
A. Slow the transfusion rate
B. Stop the transfusion immediately
C. Administer diphenhydramine as ordered
D. Continue the transfusion and monitor the patient
,Answer: B
Rationale: The first action for any suspected transfusion reaction is to stop the transfusion
immediately, keep the IV line open with normal saline, and notify the healthcare provider.
Slowing the rate or continuing the transfusion is unsafe. Antihistamines may be given
after the provider is notified.
6. A nurse is caring for a patient with a stage 3 pressure injury on the sacrum. The
wound bed is pink and moist with granulation tissue. Which of the following
dressings is most appropriate?
A. Transparent film dressing
B. Hydrocolloid dressing
C. Wet-to-dry dressing
D. Alginate dressing
Answer: B
Rationale: Hydrocolloid dressings are appropriate for wounds with granulation tissue and
light to moderate exudate. They provide a moist wound environment and promote
healing. Transparent film dressings are for dry wounds. Wet-to-dry dressings are for
debridement. Alginate dressings are for wounds with heavy exudate.
7. A nurse is preparing to administer an intramuscular injection in the
ventrogluteal site. Which of the following landmarks is used to locate this site?
A. The greater trochanter and the iliac crest
B. The acromion process and the axilla
C. The anterior superior iliac spine and the iliac crest
D. The xiphoid process and the umbilicus
Answer: A
Rationale: The ventrogluteal site is located using the greater trochanter of the femur and
the iliac crest. The patient should be positioned in a side-lying or supine position. The site
is located in the upper outer quadrant of the buttock. The acromion process is used for the
deltoid site.
, 8. A patient is receiving continuous enteral feeding via a nasogastric tube. Which
of the following positions should the patient be placed in during feeding?
A. Supine position
B. Left lateral position
C. Semi-Fowler's position (30-45 degrees)
D. Trendelenburg position
Answer: C
Rationale: The patient should be positioned in semi-Fowler's position (30-45 degrees)
during enteral feeding to prevent aspiration. Supine and Trendelenburg positions increase
aspiration risk. Left lateral position is not the preferred position for tube feeding.
9. A nurse is assessing a patient's pain using the PQRST method. What does the
"R" in PQRST stand for?
A. Response
B. Radiation
C. Rate
D. Relief
Answer: B
Rationale: PQRST stands for Provocation/Palliation, Quality, Region/Radiation, Severity,
and Timing. "R" stands for Radiation (where does the pain radiate to). This assessment
method helps the nurse gather comprehensive information about the patient's pain
experience.
10. A patient with a nasogastric tube has a gastric residual volume of 400 mL.
Which of the following actions should the nurse take?
A. Discard the residual and continue the feeding
B. Reinstall the residual and continue the feeding