, Question 1
A community health nurse is planning a primary prevention program for a
population with a high incidence of type 2 diabetes. Which intervention best
exemplifies the core domain of Health Promotion and Maintenance?
A. Screening all adults over 45 for hemoglobin A1c levels.
B. Providing weekly foot care clinics for patients with existing diabetic
neuropathy.
C. Implementing a culturally tailored nutrition and exercise education
campaign in local schools and workplaces.
D. Referring newly diagnosed patients to a diabetes self-management
education program.
Correct Answer: C - Implementing a culturally tailored nutrition
and exercise education campaign in local schools and workplaces.
RATIONALE
Primary prevention aims to prevent disease before it occurs; a
nutrition and exercise campaign addresses modifiable risk factors in
the community. Screening (A) is secondary prevention, while foot
care (B) and self-management education (D) are tertiary prevention for
those already diagnosed.
Question 2
A patient with heart failure is prescribed furosemide and digoxin. Which
assessment finding most urgently requires the nurse to hold the digoxin and
notify the provider?
A. Heart rate 58 beats/min and regular.
B. Serum potassium 3.1 mEq/L and new-onset nausea.
C. Urine output 1,200 mL over the past 24 hours.
D. Blood pressure 106/68 mm Hg.
Correct Answer: B - Serum potassium 3.1 mEq/L and new-onset
nausea.
Page 2
, RATIONALE
Hypokalemia, often caused by loop diuretics like furosemide,
increases the risk of digoxin toxicity; nausea is an early sign of
toxicity, so digoxin should be held. The other findings are not
immediate contraindications, though bradycardia (A) may warrant
monitoring.
Question 3
A nurse is caring for a patient with a new colostomy. Which statement by the
patient indicates a need for further teaching about stoma care?
A. I will clean the stoma with mild soap and water and pat it dry.
B. I should change the pouch every 3 to 7 days and whenever it leaks.
C. I can use alcohol-based cleansers to remove adhesive residue around
the stoma.
D. I will measure the stoma and cut the skin barrier to fit precisely.
Correct Answer: C - I can use alcohol-based cleansers to remove
adhesive residue around the stoma.
RATIONALE
Alcohol-based products can irritate the stoma and peristomal skin;
only mild soap and water or approved adhesive removers should be
used. The other statements reflect correct colostomy care principles.
Question 4
A nurse is reviewing a prescription for a patient with a new diagnosis of
tuberculosis. Which combination of medications is considered first-line therapy
for active TB?
A. Isoniazid, rifampin, pyrazinamide, and ethambutol.
B. Streptomycin, amikacin, and ciprofloxacin.
C. Rifabutin, clarithromycin, and linezolid.
D. Dapsone, clofazimine, and ofloxacin.
Page 3
, Correct Answer: A - Isoniazid, rifampin, pyrazinamide, and
ethambutol.
RATIONALE
The standard initial regimen for active TB is four-drug therapy:
isoniazid, rifampin, pyrazinamide, and ethambutol (or streptomycin).
The other options are used for drug-resistant TB or other
mycobacterial infections.
Question 5
A nurse is preparing to administer packed red blood cells. Which action is most
critical to prevent a hemolytic transfusion reaction?
A. Verify the blood product with another nurse using two identifiers.
B. Prime the tubing with 0.9% sodium chloride.
C. Administer the transfusion over 4 hours.
D. Monitor vital signs every 15 minutes during the first hour.
Correct Answer: A - Verify the blood product with another nurse
using two identifiers.
RATIONALE
The most critical step to prevent hemolytic reaction is accurate
identification of the patient and blood product, requiring two-person
verification. While the other actions are important, they do not directly
prevent ABO incompatibility.
Question 6
A nurse is caring for a patient with a chest tube connected to water-seal
drainage. Which finding indicates a need for immediate intervention?
A. Continuous bubbling in the water-seal chamber.
B. Tidaling of the water level with respirations.
C. Drainage of 50 mL of serosanguineous fluid in the first hour.
D. The dressing is dry and intact.
Page 4
A community health nurse is planning a primary prevention program for a
population with a high incidence of type 2 diabetes. Which intervention best
exemplifies the core domain of Health Promotion and Maintenance?
A. Screening all adults over 45 for hemoglobin A1c levels.
B. Providing weekly foot care clinics for patients with existing diabetic
neuropathy.
C. Implementing a culturally tailored nutrition and exercise education
campaign in local schools and workplaces.
D. Referring newly diagnosed patients to a diabetes self-management
education program.
Correct Answer: C - Implementing a culturally tailored nutrition
and exercise education campaign in local schools and workplaces.
RATIONALE
Primary prevention aims to prevent disease before it occurs; a
nutrition and exercise campaign addresses modifiable risk factors in
the community. Screening (A) is secondary prevention, while foot
care (B) and self-management education (D) are tertiary prevention for
those already diagnosed.
Question 2
A patient with heart failure is prescribed furosemide and digoxin. Which
assessment finding most urgently requires the nurse to hold the digoxin and
notify the provider?
A. Heart rate 58 beats/min and regular.
B. Serum potassium 3.1 mEq/L and new-onset nausea.
C. Urine output 1,200 mL over the past 24 hours.
D. Blood pressure 106/68 mm Hg.
Correct Answer: B - Serum potassium 3.1 mEq/L and new-onset
nausea.
Page 2
, RATIONALE
Hypokalemia, often caused by loop diuretics like furosemide,
increases the risk of digoxin toxicity; nausea is an early sign of
toxicity, so digoxin should be held. The other findings are not
immediate contraindications, though bradycardia (A) may warrant
monitoring.
Question 3
A nurse is caring for a patient with a new colostomy. Which statement by the
patient indicates a need for further teaching about stoma care?
A. I will clean the stoma with mild soap and water and pat it dry.
B. I should change the pouch every 3 to 7 days and whenever it leaks.
C. I can use alcohol-based cleansers to remove adhesive residue around
the stoma.
D. I will measure the stoma and cut the skin barrier to fit precisely.
Correct Answer: C - I can use alcohol-based cleansers to remove
adhesive residue around the stoma.
RATIONALE
Alcohol-based products can irritate the stoma and peristomal skin;
only mild soap and water or approved adhesive removers should be
used. The other statements reflect correct colostomy care principles.
Question 4
A nurse is reviewing a prescription for a patient with a new diagnosis of
tuberculosis. Which combination of medications is considered first-line therapy
for active TB?
A. Isoniazid, rifampin, pyrazinamide, and ethambutol.
B. Streptomycin, amikacin, and ciprofloxacin.
C. Rifabutin, clarithromycin, and linezolid.
D. Dapsone, clofazimine, and ofloxacin.
Page 3
, Correct Answer: A - Isoniazid, rifampin, pyrazinamide, and
ethambutol.
RATIONALE
The standard initial regimen for active TB is four-drug therapy:
isoniazid, rifampin, pyrazinamide, and ethambutol (or streptomycin).
The other options are used for drug-resistant TB or other
mycobacterial infections.
Question 5
A nurse is preparing to administer packed red blood cells. Which action is most
critical to prevent a hemolytic transfusion reaction?
A. Verify the blood product with another nurse using two identifiers.
B. Prime the tubing with 0.9% sodium chloride.
C. Administer the transfusion over 4 hours.
D. Monitor vital signs every 15 minutes during the first hour.
Correct Answer: A - Verify the blood product with another nurse
using two identifiers.
RATIONALE
The most critical step to prevent hemolytic reaction is accurate
identification of the patient and blood product, requiring two-person
verification. While the other actions are important, they do not directly
prevent ABO incompatibility.
Question 6
A nurse is caring for a patient with a chest tube connected to water-seal
drainage. Which finding indicates a need for immediate intervention?
A. Continuous bubbling in the water-seal chamber.
B. Tidaling of the water level with respirations.
C. Drainage of 50 mL of serosanguineous fluid in the first hour.
D. The dressing is dry and intact.
Page 4
