,Question 1
A nurse is caring for a client who has just returned from surgery. The client's oxygen saturation
is 85%. Which action should the nurse take first?
A. Administer the prescribed analgesic
B. Raise the head of the bed
C. Encourage the client to ambulate
D. Offer oral fluids
Correct Answer: B. Raise the head of the bed
Rationale: Raising the head of the bed promotes lung expansion and can improve ventilation by
reducing pressure on the diaphragm. This is an appropriate initial, relatively noninvasive
intervention for postoperative oxygen desaturation. The client should then be reassessed and
additional oxygen or other interventions provided according to the clinical situation and orders.
A similar question appears in publicly available practice material, but the question here is
independently written. Docsity
Question 2
Which action is most important when a nurse enters the room of a client who is on contact
precautions?
A. Put on sterile gloves immediately
B. Perform appropriate hand hygiene and don required PPE
C. Wear an N95 respirator regardless of the infection
D. Keep the client's door permanently closed
Correct Answer: B. Perform appropriate hand hygiene and don required PPE
Rationale: Contact precautions require appropriate hand hygiene and PPE based on the
anticipated exposure. Gloves and gowns are commonly required when contact with the client or
contaminated surfaces is anticipated.
Question 3
Which finding should the nurse recognize as a normal adult resting respiratory rate?
A. 6/min
B. 12/min
,C. 28/min
D. 36/min
Correct Answer: B. 12/min
Rationale: A normal resting adult respiratory rate is generally about 12–20 breaths/minute. A
rate of 28 or 36/min indicates tachypnea and requires assessment in context.
Question 4
A nurse is obtaining a client's blood pressure. Which action promotes the most accurate
measurement?
A. Place the cuff over thick clothing
B. Position the arm below heart level
C. Use an appropriately sized cuff
D. Ask the client to talk during measurement
Correct Answer: C. Use an appropriately sized cuff
Rationale: Cuff size significantly affects blood-pressure accuracy. The bladder should
appropriately encircle the arm, and the arm should be supported at heart level.
Question 5
Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client reporting new-onset difficulty breathing
C. Client requesting a snack
D. Client awaiting discharge instructions
Correct Answer: B. Client reporting new-onset difficulty breathing
Rationale: Airway and breathing problems take priority. New respiratory difficulty can indicate a
potentially life-threatening condition and requires immediate assessment.
Question 6
Which statement correctly describes the first step of the nursing process?
, A. Planning
B. Assessment
C. Implementation
D. Evaluation
Correct Answer: B. Assessment
Rationale: Assessment involves collecting subjective and objective data. The nurse uses this
information to identify client problems, establish priorities, plan interventions, and evaluate
outcomes.
Question 7
Which finding is objective data?
A. "My stomach hurts."
B. "I feel dizzy."
C. Blood pressure of 148/92 mmHg
D. "I am anxious."
Correct Answer: C. Blood pressure of 148/92 mmHg
Rationale: Objective data are observable or measurable findings obtained through examination,
monitoring, or diagnostic testing. Statements made by the client are subjective data.
Question 8
Which statement is an example of subjective data?
A. Temperature 38.2°C
B. Respiratory rate 24/min
C. Oxygen saturation 91%
D. "I feel short of breath."
Correct Answer: D. "I feel short of breath."
Rationale: Subjective data are symptoms or experiences reported by the client. Shortness of
breath is a subjective sensation.
Question 9
A nurse is caring for a client who has just returned from surgery. The client's oxygen saturation
is 85%. Which action should the nurse take first?
A. Administer the prescribed analgesic
B. Raise the head of the bed
C. Encourage the client to ambulate
D. Offer oral fluids
Correct Answer: B. Raise the head of the bed
Rationale: Raising the head of the bed promotes lung expansion and can improve ventilation by
reducing pressure on the diaphragm. This is an appropriate initial, relatively noninvasive
intervention for postoperative oxygen desaturation. The client should then be reassessed and
additional oxygen or other interventions provided according to the clinical situation and orders.
A similar question appears in publicly available practice material, but the question here is
independently written. Docsity
Question 2
Which action is most important when a nurse enters the room of a client who is on contact
precautions?
A. Put on sterile gloves immediately
B. Perform appropriate hand hygiene and don required PPE
C. Wear an N95 respirator regardless of the infection
D. Keep the client's door permanently closed
Correct Answer: B. Perform appropriate hand hygiene and don required PPE
Rationale: Contact precautions require appropriate hand hygiene and PPE based on the
anticipated exposure. Gloves and gowns are commonly required when contact with the client or
contaminated surfaces is anticipated.
Question 3
Which finding should the nurse recognize as a normal adult resting respiratory rate?
A. 6/min
B. 12/min
,C. 28/min
D. 36/min
Correct Answer: B. 12/min
Rationale: A normal resting adult respiratory rate is generally about 12–20 breaths/minute. A
rate of 28 or 36/min indicates tachypnea and requires assessment in context.
Question 4
A nurse is obtaining a client's blood pressure. Which action promotes the most accurate
measurement?
A. Place the cuff over thick clothing
B. Position the arm below heart level
C. Use an appropriately sized cuff
D. Ask the client to talk during measurement
Correct Answer: C. Use an appropriately sized cuff
Rationale: Cuff size significantly affects blood-pressure accuracy. The bladder should
appropriately encircle the arm, and the arm should be supported at heart level.
Question 5
Which client should the nurse assess first?
A. Client requesting assistance with bathing
B. Client reporting new-onset difficulty breathing
C. Client requesting a snack
D. Client awaiting discharge instructions
Correct Answer: B. Client reporting new-onset difficulty breathing
Rationale: Airway and breathing problems take priority. New respiratory difficulty can indicate a
potentially life-threatening condition and requires immediate assessment.
Question 6
Which statement correctly describes the first step of the nursing process?
, A. Planning
B. Assessment
C. Implementation
D. Evaluation
Correct Answer: B. Assessment
Rationale: Assessment involves collecting subjective and objective data. The nurse uses this
information to identify client problems, establish priorities, plan interventions, and evaluate
outcomes.
Question 7
Which finding is objective data?
A. "My stomach hurts."
B. "I feel dizzy."
C. Blood pressure of 148/92 mmHg
D. "I am anxious."
Correct Answer: C. Blood pressure of 148/92 mmHg
Rationale: Objective data are observable or measurable findings obtained through examination,
monitoring, or diagnostic testing. Statements made by the client are subjective data.
Question 8
Which statement is an example of subjective data?
A. Temperature 38.2°C
B. Respiratory rate 24/min
C. Oxygen saturation 91%
D. "I feel short of breath."
Correct Answer: D. "I feel short of breath."
Rationale: Subjective data are symptoms or experiences reported by the client. Shortness of
breath is a subjective sensation.
Question 9
