1. Which of the following is the most important action for a nurse to take when
caring for a patient with a potential for falls?
A) Ensure the patient's call light is within reach.
B) Provide the patient with a written list of safety instructions.
C) Place a bed alarm on the patient.
D) Ensure the patient's bed is in the lowest position.
Answer: D) Ensure the patient's bed is in the lowest position.
Rationale: The primary goal for preventing falls is to reduce the risk of injury. Placing the bed
in the lowest position decreases the distance the patient would fall, should they attempt to get up
without assistance.
2. A nurse is caring for a patient receiving a blood transfusion. The nurse notices
that the patient is experiencing chills and a fever. What is the priority action?
A) Stop the transfusion and notify the healthcare provider.
B) Administer an antipyretic and continue the transfusion.
C) Obtain a blood culture and complete the transfusion.
D) Increase the flow rate of the transfusion.
Answer: A) Stop the transfusion and notify the healthcare provider.
Rationale: Chills and fever can indicate a transfusion reaction. The transfusion should be
stopped immediately, and the healthcare provider should be notified to assess the situation and
manage the reaction.
3. A nurse is educating a patient on the correct way to use a cane. Which of the
following statements by the patient indicates understanding of the teaching?
A) "I should hold the cane on the side of my stronger leg."
B) "I should keep the cane close to my body."
C) "I should use the cane on the opposite side of my weak leg."
D) "I should use the cane on the same side as my weak leg."
Answer: C) "I should use the cane on the opposite side of my weak leg."
Rationale: The cane should be used on the opposite side of the weak leg to provide better
support and balance during walking.
,4. Which of the following is the best method for a nurse to assess the orientation
of a patient?
A) Ask the patient to name the current year.
B) Ask the patient to describe a familiar person.
C) Ask the patient their name and location.
D) Ask the patient for the current time.
Answer: C) Ask the patient their name and location.
Rationale: Assessing a patient's orientation to time, place, and person is key to determining their
cognitive status. Asking about their name and location is a basic and effective approach.
5. A nurse is caring for a patient with a chest tube. Which of the following actions
is the nurse's priority when caring for a chest tube?
A) Ensure the tubing is free of kinks and obstruction.
B) Secure the chest tube to the patient's dressing.
C) Keep the collection system below the level of the chest.
D) Check the dressing for wetness or drainage.
Answer: C) Keep the collection system below the level of the chest.
Rationale: Keeping the collection system below the level of the chest helps ensure that gravity
assists in draining the fluid or air from the pleural space and prevents backflow into the chest.
6. A nurse is preparing to administer an intramuscular injection. Which of the
following sites is preferred for an adult patient?
A) Dorsogluteal site
B) Ventrogluteal site
C) Deltoid site
D) Vastus lateralis site
Answer: B) Ventrogluteal site
Rationale: The ventrogluteal site is the preferred location for intramuscular injections in adults
because it is a large muscle and is free from major nerves and blood vessels, minimizing the risk
of injury.
, 7. A nurse is assessing a patient who has just undergone a right-sided
mastectomy. Which of the following interventions is most important to promote
lymphatic drainage in the affected arm?
A) Elevate the patient's right arm on a pillow.
B) Apply compression to the right arm to reduce swelling.
C) Instruct the patient to avoid moving the right arm.
D) Apply a warm compress to the right arm to promote circulation.
Answer: A) Elevate the patient's right arm on a pillow.
Rationale: Elevating the affected arm helps reduce swelling and promote lymphatic drainage,
which is important following a mastectomy to prevent lymphedema.
8. A nurse is caring for a patient who is receiving opioids for pain. Which of the
following assessments should be the priority for the nurse?
A) Blood pressure
B) Respiratory rate
C) Oxygen saturation
D) Level of consciousness
Answer: B) Respiratory rate
Rationale: Opioids can depress the respiratory system. Therefore, assessing the patient's
respiratory rate is a priority to detect any respiratory depression early and intervene promptly.
9. A patient has been prescribed a diuretic for heart failure. Which of the
following should the nurse monitor regularly?
A) Potassium levels
B) Calcium levels
C) Blood glucose levels
D) Cholesterol levels
Answer: A) Potassium levels
Rationale: Diuretics, especially loop diuretics, can cause a loss of potassium. Monitoring
potassium levels helps prevent hypokalemia, which can lead to serious cardiac arrhythmias.
caring for a patient with a potential for falls?
A) Ensure the patient's call light is within reach.
B) Provide the patient with a written list of safety instructions.
C) Place a bed alarm on the patient.
D) Ensure the patient's bed is in the lowest position.
Answer: D) Ensure the patient's bed is in the lowest position.
Rationale: The primary goal for preventing falls is to reduce the risk of injury. Placing the bed
in the lowest position decreases the distance the patient would fall, should they attempt to get up
without assistance.
2. A nurse is caring for a patient receiving a blood transfusion. The nurse notices
that the patient is experiencing chills and a fever. What is the priority action?
A) Stop the transfusion and notify the healthcare provider.
B) Administer an antipyretic and continue the transfusion.
C) Obtain a blood culture and complete the transfusion.
D) Increase the flow rate of the transfusion.
Answer: A) Stop the transfusion and notify the healthcare provider.
Rationale: Chills and fever can indicate a transfusion reaction. The transfusion should be
stopped immediately, and the healthcare provider should be notified to assess the situation and
manage the reaction.
3. A nurse is educating a patient on the correct way to use a cane. Which of the
following statements by the patient indicates understanding of the teaching?
A) "I should hold the cane on the side of my stronger leg."
B) "I should keep the cane close to my body."
C) "I should use the cane on the opposite side of my weak leg."
D) "I should use the cane on the same side as my weak leg."
Answer: C) "I should use the cane on the opposite side of my weak leg."
Rationale: The cane should be used on the opposite side of the weak leg to provide better
support and balance during walking.
,4. Which of the following is the best method for a nurse to assess the orientation
of a patient?
A) Ask the patient to name the current year.
B) Ask the patient to describe a familiar person.
C) Ask the patient their name and location.
D) Ask the patient for the current time.
Answer: C) Ask the patient their name and location.
Rationale: Assessing a patient's orientation to time, place, and person is key to determining their
cognitive status. Asking about their name and location is a basic and effective approach.
5. A nurse is caring for a patient with a chest tube. Which of the following actions
is the nurse's priority when caring for a chest tube?
A) Ensure the tubing is free of kinks and obstruction.
B) Secure the chest tube to the patient's dressing.
C) Keep the collection system below the level of the chest.
D) Check the dressing for wetness or drainage.
Answer: C) Keep the collection system below the level of the chest.
Rationale: Keeping the collection system below the level of the chest helps ensure that gravity
assists in draining the fluid or air from the pleural space and prevents backflow into the chest.
6. A nurse is preparing to administer an intramuscular injection. Which of the
following sites is preferred for an adult patient?
A) Dorsogluteal site
B) Ventrogluteal site
C) Deltoid site
D) Vastus lateralis site
Answer: B) Ventrogluteal site
Rationale: The ventrogluteal site is the preferred location for intramuscular injections in adults
because it is a large muscle and is free from major nerves and blood vessels, minimizing the risk
of injury.
, 7. A nurse is assessing a patient who has just undergone a right-sided
mastectomy. Which of the following interventions is most important to promote
lymphatic drainage in the affected arm?
A) Elevate the patient's right arm on a pillow.
B) Apply compression to the right arm to reduce swelling.
C) Instruct the patient to avoid moving the right arm.
D) Apply a warm compress to the right arm to promote circulation.
Answer: A) Elevate the patient's right arm on a pillow.
Rationale: Elevating the affected arm helps reduce swelling and promote lymphatic drainage,
which is important following a mastectomy to prevent lymphedema.
8. A nurse is caring for a patient who is receiving opioids for pain. Which of the
following assessments should be the priority for the nurse?
A) Blood pressure
B) Respiratory rate
C) Oxygen saturation
D) Level of consciousness
Answer: B) Respiratory rate
Rationale: Opioids can depress the respiratory system. Therefore, assessing the patient's
respiratory rate is a priority to detect any respiratory depression early and intervene promptly.
9. A patient has been prescribed a diuretic for heart failure. Which of the
following should the nurse monitor regularly?
A) Potassium levels
B) Calcium levels
C) Blood glucose levels
D) Cholesterol levels
Answer: A) Potassium levels
Rationale: Diuretics, especially loop diuretics, can cause a loss of potassium. Monitoring
potassium levels helps prevent hypokalemia, which can lead to serious cardiac arrhythmias.
