1. Which of the following is the primary purpose of the nursing process?
a) To assess the patient's physical status
b) To develop a treatment plan for the patient
c) To promote patient-centered care and improve outcomes
d) To determine the patient’s medical diagnosis
Answer: c) To promote patient-centered care and improve outcomes
Rationale: The nursing process is a systematic, patient-centered method used to assess,
diagnose, plan, implement, and evaluate care to improve patient outcomes.
2. When performing a head-to-toe assessment, what is the first step a nurse
should take?
a) Assessing the respiratory system
b) Inspecting the skin for any lesions
c) Reviewing the patient’s medical history
d) Asking the patient about any pain or discomfort
Answer: c) Reviewing the patient’s medical history
Rationale: A thorough review of the patient’s medical history is essential before starting the
physical assessment to understand underlying conditions and past health issues.
3. What is the normal range for an adult’s resting heart rate?
a) 40-60 beats per minute
b) 60-100 beats per minute
c) 100-120 beats per minute
d) 120-140 beats per minute
Answer: b) 60-100 beats per minute
Rationale: The normal resting heart rate for an adult is between 60 and 100 beats per minute.
4. A nurse is caring for a patient with a stage II pressure ulcer. Which of the
following interventions should the nurse prioritize?
a) Administering antibiotics
b) Performing frequent repositioning
,c) Providing high-protein supplements
d) Using a wound vacuum device
Answer: b) Performing frequent repositioning
Rationale: Pressure ulcers are caused by prolonged pressure on the skin. Repositioning the
patient regularly helps reduce this pressure and prevents further damage to the skin.
5. Which of the following is a sign of dehydration in an older adult?
a) Increased urinary output
b) Increased blood pressure
c) Dry mucous membranes
d) Decreased respiratory rate
Answer: c) Dry mucous membranes
Rationale: Dehydration commonly leads to dry mucous membranes, which is a key sign in older
adults.
6. Which of the following positions should a nurse place a patient in for a lumbar
puncture?
a) Supine
b) Lateral recumbent
c) Prone
d) Fowler’s
Answer: b) Lateral recumbent
Rationale: For a lumbar puncture, the patient is typically placed in a lateral recumbent position
to allow proper access to the spinal column.
7. A nurse is caring for a patient receiving morphine for pain management.
Which of the following should the nurse monitor for as a potential side effect?
a) Hypertension
b) Respiratory depression
c) Diarrhea
d) Tachycardia
, Answer: b) Respiratory depression
Rationale: Opioids like morphine can cause respiratory depression, which is a serious side effect
that requires close monitoring.
8. Which of the following is the most appropriate nursing action when
administering a blood transfusion?
a) Administer the blood over 4 hours
b) Use a small gauge IV catheter
c) Start the transfusion slowly and monitor for reactions
d) Mix the blood with normal saline to prevent clotting
Answer: c) Start the transfusion slowly and monitor for reactions
Rationale: Transfusions should be started slowly to monitor for adverse reactions, such as fever,
chills, or an allergic response.
9. Which of the following is the best action to prevent the spread of infection
when caring for a patient with a respiratory illness?
a) Wearing a gown and gloves
b) Implementing airborne precautions
c) Applying an N95 respirator mask
d) Using a surgical mask for the patient
Answer: c) Applying an N95 respirator mask
Rationale: Airborne precautions, including wearing an N95 respirator, are necessary when
dealing with respiratory illnesses like tuberculosis or COVID-19 to prevent inhalation of
infectious particles.
10. A nurse is assessing a patient’s pupils. Which of the following responses
should the nurse expect to find in a normal, healthy adult?
a) Unequal pupils
b) Pupil constriction to light
c) Bilateral pupil dilation in response to light
d) Nonreactive pupils
a) To assess the patient's physical status
b) To develop a treatment plan for the patient
c) To promote patient-centered care and improve outcomes
d) To determine the patient’s medical diagnosis
Answer: c) To promote patient-centered care and improve outcomes
Rationale: The nursing process is a systematic, patient-centered method used to assess,
diagnose, plan, implement, and evaluate care to improve patient outcomes.
2. When performing a head-to-toe assessment, what is the first step a nurse
should take?
a) Assessing the respiratory system
b) Inspecting the skin for any lesions
c) Reviewing the patient’s medical history
d) Asking the patient about any pain or discomfort
Answer: c) Reviewing the patient’s medical history
Rationale: A thorough review of the patient’s medical history is essential before starting the
physical assessment to understand underlying conditions and past health issues.
3. What is the normal range for an adult’s resting heart rate?
a) 40-60 beats per minute
b) 60-100 beats per minute
c) 100-120 beats per minute
d) 120-140 beats per minute
Answer: b) 60-100 beats per minute
Rationale: The normal resting heart rate for an adult is between 60 and 100 beats per minute.
4. A nurse is caring for a patient with a stage II pressure ulcer. Which of the
following interventions should the nurse prioritize?
a) Administering antibiotics
b) Performing frequent repositioning
,c) Providing high-protein supplements
d) Using a wound vacuum device
Answer: b) Performing frequent repositioning
Rationale: Pressure ulcers are caused by prolonged pressure on the skin. Repositioning the
patient regularly helps reduce this pressure and prevents further damage to the skin.
5. Which of the following is a sign of dehydration in an older adult?
a) Increased urinary output
b) Increased blood pressure
c) Dry mucous membranes
d) Decreased respiratory rate
Answer: c) Dry mucous membranes
Rationale: Dehydration commonly leads to dry mucous membranes, which is a key sign in older
adults.
6. Which of the following positions should a nurse place a patient in for a lumbar
puncture?
a) Supine
b) Lateral recumbent
c) Prone
d) Fowler’s
Answer: b) Lateral recumbent
Rationale: For a lumbar puncture, the patient is typically placed in a lateral recumbent position
to allow proper access to the spinal column.
7. A nurse is caring for a patient receiving morphine for pain management.
Which of the following should the nurse monitor for as a potential side effect?
a) Hypertension
b) Respiratory depression
c) Diarrhea
d) Tachycardia
, Answer: b) Respiratory depression
Rationale: Opioids like morphine can cause respiratory depression, which is a serious side effect
that requires close monitoring.
8. Which of the following is the most appropriate nursing action when
administering a blood transfusion?
a) Administer the blood over 4 hours
b) Use a small gauge IV catheter
c) Start the transfusion slowly and monitor for reactions
d) Mix the blood with normal saline to prevent clotting
Answer: c) Start the transfusion slowly and monitor for reactions
Rationale: Transfusions should be started slowly to monitor for adverse reactions, such as fever,
chills, or an allergic response.
9. Which of the following is the best action to prevent the spread of infection
when caring for a patient with a respiratory illness?
a) Wearing a gown and gloves
b) Implementing airborne precautions
c) Applying an N95 respirator mask
d) Using a surgical mask for the patient
Answer: c) Applying an N95 respirator mask
Rationale: Airborne precautions, including wearing an N95 respirator, are necessary when
dealing with respiratory illnesses like tuberculosis or COVID-19 to prevent inhalation of
infectious particles.
10. A nurse is assessing a patient’s pupils. Which of the following responses
should the nurse expect to find in a normal, healthy adult?
a) Unequal pupils
b) Pupil constriction to light
c) Bilateral pupil dilation in response to light
d) Nonreactive pupils
