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Rationales 2026 Q&A Instant Download PDF
Question 1
A nurse is preparing to assess a newly admitted patient. Which
action should the nurse perform first?
A. Review the patient's laboratory results
B. Perform an initial assessment of the patient
C. Administer the patient's scheduled medications
D. Develop the patient's discharge plan
The initial assessment provides baseline information about the
patient's physical, psychological, and functional status. This
information allows the nurse to identify actual or potential
problems, establish priorities, and determine appropriate
nursing interventions. Assessment should generally precede
interventions unless an immediate life-threatening problem
requires urgent action.
Question 2
,Which component of the nursing process involves determining
whether the patient's goals have been achieved?
A. Assessment
B. Diagnosis
C. Planning
D. Evaluation
Evaluation is the final step of the nursing process and involves
determining whether nursing interventions have produced the
desired outcomes. The nurse compares the patient's current
condition with established goals and outcomes. If goals have
not been met, the plan of care may need to be modified.
Question 3
A patient tells the nurse, "I feel extremely anxious about my
surgery tomorrow." Which response demonstrates therapeutic
communication?
A. "Don't worry; everything will be fine."
B. "You shouldn't be anxious because this is a routine
procedure."
C. "Tell me more about what concerns you about the surgery."
D. "My other patients have been through the same procedure."
This response encourages the patient to express feelings and
concerns without judgment. Open-ended questions are useful in
,therapeutic communication because they allow patients to
provide information in their own words. Reassurance that
minimizes feelings or comparisons with other patients can
discourage further communication.
Question 4
Which vital sign measurement is generally considered a normal
resting adult respiratory rate?
A. 4–8 breaths/minute
B. 12–20 breaths/minute
C. 24–32 breaths/minute
D. 35–45 breaths/minute
For a resting adult, a respiratory rate of approximately 12–20
breaths per minute is commonly considered normal. Respiratory
rate should be assessed for rate, rhythm, depth, and effort
because abnormalities may indicate respiratory or
cardiovascular problems.
Question 5
A nurse is assessing a patient's pulse. Which characteristic
should the nurse document?
, A. Skin color only
B. Body temperature only
C. Rate, rhythm, and strength
D. Blood glucose and oxygen saturation
Pulse assessment includes determining the rate, rhythm, and
strength or amplitude of the pulse. Changes in these
characteristics can provide important information about
cardiovascular status. Documentation should accurately
describe relevant findings and any abnormalities.
Question 6
Which action is most effective for preventing the transmission
of infection in a healthcare setting?
A. Wearing a mask for every patient encounter
B. Administering antibiotics routinely
C. Performing appropriate hand hygiene
D. Keeping all patients in isolation
Hand hygiene is one of the most important measures for
preventing transmission of microorganisms in healthcare
settings. Hands can become contaminated through contact with
patients, body fluids, equipment, and environmental surfaces.
Proper hand hygiene reduces the risk of transferring organisms
between patients and healthcare personnel.