CCR EXAM 2025 Update|Complete Exam
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Section 1: Patient Care and Safety (Questions 1-20)
1. A patient is admitted with a diagnosis of pneumonia. Which of the following
actions is the priority for the nurse?
A. Administer antibiotics as prescribed.
B. Assess respiratory status and oxygen saturation.
C. Encourage increased fluid intake.
D. Provide a quiet environment for rest.
B. Assess respiratory status and oxygen saturation.
Rationale: The priority for a patient with pneumonia is to assess airway,
breathing, and circulation (the ABCs). Assessing respiratory status and oxygen
saturation is the first step to ensure the patient is adequately oxygenating before
other interventions.
2. A patient with a history of falls is being admitted. Which of the following
interventions should the nurse implement? (Select All That Apply)
A. Place the bed in the lowest position.
B. Keep the call light within reach.
C. Apply a bed alarm.
D. Keep the side rails up on all four sides.
E. Ensure adequate lighting in the room.
Rationale: A bed alarm (C) and adequate lighting (E) are appropriate fall
precautions. Keeping the bed low (A) and the call light within reach (B) are also
correct, but in the context of a SATA question, C and E are specific safety
interventions. Keeping all four side rails up (D) is considered a restraint and is not
a standard fall precaution.
3. A nurse is preparing to administer a blood transfusion. Which of the
following is the most critical action to take before starting the transfusion?
A. Obtain the patient's vital signs.
,B. Verify the blood product with a second nurse.
C. Ensure the patient has a patent IV line.
D. Explain the procedure to the patient.
B. Verify the blood product with a second nurse.
Rationale: The most critical step is verifying the blood product with a second
licensed professional to prevent a fatal hemolytic transfusion reaction. This
involves checking the patient's identification, blood type, and unit number against
the blood bank form.
4. A patient is prescribed a clear liquid diet. Which of the following items
should the nurse remove from the patient's meal tray?
A. Apple juice
B. Jell-O
C. Milk
D. Clear broth
Rationale: A clear liquid diet consists of liquids that are transparent at room
temperature. Milk is not a clear liquid and should be removed. Apple juice, Jell-O,
and clear broth are all appropriate for a clear liquid diet.
5. The nurse is caring for a patient with a nasogastric (NG) tube. Which of the
following actions should the nurse take to verify tube placement before
feeding?
A. Auscultate for a "whoosh" sound by injecting air.
B. Check the pH of the gastric aspirate.
B. Check the pH of the gastric aspirate.
C. Measure the length of the tube from the nares.
D. Ask the patient to speak.
Rationale: Checking the pH of gastric aspirate is the most reliable bedside
method for verifying NG tube placement. A pH of 5.5 or lower indicates gastric
placement. The auscultation method is no longer considered reliable.
6. A patient is on strict intake and output (I&O) monitoring. The nurse
records the patient's intake as 8 oz of coffee, 4 oz of juice, and 12 oz of water.
What is the total intake in milliliters?
A. 600 mL
,B. 720 mL
C. 720 mL
D. 840 mL
Rationale: To convert ounces to milliliters, multiply by 30. 8 oz (coffee) + 4
oz (juice) + 12 oz (water) = 24 oz. 24 oz x 30 mL/oz = 720 mL.
7. A nurse is assisting a patient with ambulation. The patient becomes dizzy
and starts to fall. Which action should the nurse take first?
A. Attempt to catch the patient and hold them up.
B. Call for help.
C. Ease the patient gently to the floor.
D. Check the patient's blood pressure.
Rationale: The priority is to protect both the patient and the nurse from injury.
Easing the patient to the floor prevents a more serious fall and injury. Attempting
to catch the patient can cause injury to the nurse's back.
8. A patient has an order for restraints. Which of the following assessments
should the nurse perform at least every 15 minutes?
A. Skin integrity and range of motion.
B. Vital signs and oxygen saturation.
C. Circulation, sensation, and movement of the restrained extremity.
D. The patient's level of consciousness.
Rationale: When a patient is in restraints, the nurse must assess the
circulation, sensation, and movement (CSM) of the restrained extremity at least
every 15 minutes to prevent neurovascular compromise.
9. The nurse is caring for a patient with a new colostomy. Which of the
following statements by the patient indicates a need for further teaching?
A. "I should empty the pouch when it is one-third to one-half full."
B. "I can use a gentle adhesive remover to change the wafer."
C. "I should change the entire pouching system every day."
D. "I will check the stoma for any changes in color or size."
Rationale: The pouching system typically needs to be changed every 3 to 7
days, not every day. Daily changes can damage the skin. The other statements are
correct.
, 10. A patient is receiving oxygen therapy via a nasal cannula at 4 L/min.
Which of the following is the most important nursing consideration?
A. Ensure the patient is in a high-Fowler's position.
B. Humidify the oxygen.
B. Humidify the oxygen.
C. Check the oxygen saturation every 8 hours.
D. Encourage the patient to breathe through their mouth.
Rationale: Oxygen flow rates greater than 4 L/min can dry and irritate the
mucous membranes. Therefore, humidification is required for flow rates of 4
L/min or more. The other options are not as critical.
11. A nurse is caring for a patient who is NPO (nothing by mouth). Which of
the following actions is essential?
A. Provide frequent mouth care.
B. Administer IV fluids.
A. Provide frequent mouth care.
C. Offer ice chips.
D. Weigh the patient daily.
Rationale: A patient who is NPO is at risk for dry mouth and mucous
membranes. Providing frequent mouth care is an essential nursing intervention for
comfort and hygiene. IV fluids may be ordered but are not an independent nursing
action. Ice chips are not allowed for a patient who is strictly NPO.
12. A patient with a chest tube has continuous bubbling in the water seal
chamber. What does this indicate?
A. The chest tube is functioning correctly.
B. There is an air leak in the system.
C. The lung has re-expanded.
D. The suction is set too high.
Rationale: Continuous bubbling in the water seal chamber indicates an air leak
in the system. The nurse should check the connections and the insertion site.
Intermittent bubbling is normal with coughing or exhalation.
13. A nurse is performing a focused assessment on a patient with heart failure.
Which of the following findings requires immediate intervention?
Set Questions And Verified Answers | Get It
100% Accurate!!| Already Passed A+
Section 1: Patient Care and Safety (Questions 1-20)
1. A patient is admitted with a diagnosis of pneumonia. Which of the following
actions is the priority for the nurse?
A. Administer antibiotics as prescribed.
B. Assess respiratory status and oxygen saturation.
C. Encourage increased fluid intake.
D. Provide a quiet environment for rest.
B. Assess respiratory status and oxygen saturation.
Rationale: The priority for a patient with pneumonia is to assess airway,
breathing, and circulation (the ABCs). Assessing respiratory status and oxygen
saturation is the first step to ensure the patient is adequately oxygenating before
other interventions.
2. A patient with a history of falls is being admitted. Which of the following
interventions should the nurse implement? (Select All That Apply)
A. Place the bed in the lowest position.
B. Keep the call light within reach.
C. Apply a bed alarm.
D. Keep the side rails up on all four sides.
E. Ensure adequate lighting in the room.
Rationale: A bed alarm (C) and adequate lighting (E) are appropriate fall
precautions. Keeping the bed low (A) and the call light within reach (B) are also
correct, but in the context of a SATA question, C and E are specific safety
interventions. Keeping all four side rails up (D) is considered a restraint and is not
a standard fall precaution.
3. A nurse is preparing to administer a blood transfusion. Which of the
following is the most critical action to take before starting the transfusion?
A. Obtain the patient's vital signs.
,B. Verify the blood product with a second nurse.
C. Ensure the patient has a patent IV line.
D. Explain the procedure to the patient.
B. Verify the blood product with a second nurse.
Rationale: The most critical step is verifying the blood product with a second
licensed professional to prevent a fatal hemolytic transfusion reaction. This
involves checking the patient's identification, blood type, and unit number against
the blood bank form.
4. A patient is prescribed a clear liquid diet. Which of the following items
should the nurse remove from the patient's meal tray?
A. Apple juice
B. Jell-O
C. Milk
D. Clear broth
Rationale: A clear liquid diet consists of liquids that are transparent at room
temperature. Milk is not a clear liquid and should be removed. Apple juice, Jell-O,
and clear broth are all appropriate for a clear liquid diet.
5. The nurse is caring for a patient with a nasogastric (NG) tube. Which of the
following actions should the nurse take to verify tube placement before
feeding?
A. Auscultate for a "whoosh" sound by injecting air.
B. Check the pH of the gastric aspirate.
B. Check the pH of the gastric aspirate.
C. Measure the length of the tube from the nares.
D. Ask the patient to speak.
Rationale: Checking the pH of gastric aspirate is the most reliable bedside
method for verifying NG tube placement. A pH of 5.5 or lower indicates gastric
placement. The auscultation method is no longer considered reliable.
6. A patient is on strict intake and output (I&O) monitoring. The nurse
records the patient's intake as 8 oz of coffee, 4 oz of juice, and 12 oz of water.
What is the total intake in milliliters?
A. 600 mL
,B. 720 mL
C. 720 mL
D. 840 mL
Rationale: To convert ounces to milliliters, multiply by 30. 8 oz (coffee) + 4
oz (juice) + 12 oz (water) = 24 oz. 24 oz x 30 mL/oz = 720 mL.
7. A nurse is assisting a patient with ambulation. The patient becomes dizzy
and starts to fall. Which action should the nurse take first?
A. Attempt to catch the patient and hold them up.
B. Call for help.
C. Ease the patient gently to the floor.
D. Check the patient's blood pressure.
Rationale: The priority is to protect both the patient and the nurse from injury.
Easing the patient to the floor prevents a more serious fall and injury. Attempting
to catch the patient can cause injury to the nurse's back.
8. A patient has an order for restraints. Which of the following assessments
should the nurse perform at least every 15 minutes?
A. Skin integrity and range of motion.
B. Vital signs and oxygen saturation.
C. Circulation, sensation, and movement of the restrained extremity.
D. The patient's level of consciousness.
Rationale: When a patient is in restraints, the nurse must assess the
circulation, sensation, and movement (CSM) of the restrained extremity at least
every 15 minutes to prevent neurovascular compromise.
9. The nurse is caring for a patient with a new colostomy. Which of the
following statements by the patient indicates a need for further teaching?
A. "I should empty the pouch when it is one-third to one-half full."
B. "I can use a gentle adhesive remover to change the wafer."
C. "I should change the entire pouching system every day."
D. "I will check the stoma for any changes in color or size."
Rationale: The pouching system typically needs to be changed every 3 to 7
days, not every day. Daily changes can damage the skin. The other statements are
correct.
, 10. A patient is receiving oxygen therapy via a nasal cannula at 4 L/min.
Which of the following is the most important nursing consideration?
A. Ensure the patient is in a high-Fowler's position.
B. Humidify the oxygen.
B. Humidify the oxygen.
C. Check the oxygen saturation every 8 hours.
D. Encourage the patient to breathe through their mouth.
Rationale: Oxygen flow rates greater than 4 L/min can dry and irritate the
mucous membranes. Therefore, humidification is required for flow rates of 4
L/min or more. The other options are not as critical.
11. A nurse is caring for a patient who is NPO (nothing by mouth). Which of
the following actions is essential?
A. Provide frequent mouth care.
B. Administer IV fluids.
A. Provide frequent mouth care.
C. Offer ice chips.
D. Weigh the patient daily.
Rationale: A patient who is NPO is at risk for dry mouth and mucous
membranes. Providing frequent mouth care is an essential nursing intervention for
comfort and hygiene. IV fluids may be ordered but are not an independent nursing
action. Ice chips are not allowed for a patient who is strictly NPO.
12. A patient with a chest tube has continuous bubbling in the water seal
chamber. What does this indicate?
A. The chest tube is functioning correctly.
B. There is an air leak in the system.
C. The lung has re-expanded.
D. The suction is set too high.
Rationale: Continuous bubbling in the water seal chamber indicates an air leak
in the system. The nurse should check the connections and the insertion site.
Intermittent bubbling is normal with coughing or exhalation.
13. A nurse is performing a focused assessment on a patient with heart failure.
Which of the following findings requires immediate intervention?
