1. Which of the following is a priority action when a nurse is caring for a patient
with a wound infection?
a) Administer pain medications b) Check the patient’s vital signs c) Perform wound irrigation d)
Prepare for surgical debridement
Answer: b) Check the patient’s vital signs
Rationale: Vital signs are the most immediate indicator of infection or systemic response. Fever,
increased heart rate, and increased respiratory rate may indicate an infection. Once the vital signs
are assessed, further interventions like pain management and wound care can be done.
2. A patient asks about the purpose of an intravenous (IV) catheter. The nurse
should explain that an IV catheter is used for:
a) Delivering oxygen directly to the bloodstream b) Administering fluids and medications c)
Drawing blood for laboratory tests d) Monitoring vital signs
Answer: b) Administering fluids and medications
Rationale: An IV catheter is primarily used to administer fluids, medications, and electrolytes
directly into the bloodstream, which is essential for patients who need immediate or ongoing
treatment.
3. Which of the following should be included in a nurse’s initial assessment of a
patient with a head injury?
a) Assessing the Glasgow Coma Scale (GCS) b) Obtaining a 12-lead EKG c) Checking the
patient’s blood pressure d) Evaluating the patient's wound dressing
Answer: a) Assessing the Glasgow Coma Scale (GCS)
Rationale: The Glasgow Coma Scale is essential in assessing the neurological status of patients
with head injuries to monitor for changes in level of consciousness and brain function.
4. When preparing a sterile field, which action is correct?
a) Hold sterile items above waist level b) Touch sterile items with ungloved hands c) Keep the
sterile field open and unprotected d) Ensure sterile gloves are worn for all tasks
Answer: a) Hold sterile items above waist level
Rationale: Sterile items should be handled carefully and kept above the waist to prevent
contamination. The sterile field must be maintained and not touched with non-sterile hands.
, 5. A nurse is caring for a postoperative patient who is not responding to verbal
stimuli. The nurse should:
a) Call the doctor immediately b) Check the patient’s blood pressure c) Reassess the patient’s
airway and breathing d) Administer pain medication
Answer: c) Reassess the patient’s airway and breathing
Rationale: If a patient is not responding to stimuli, ensuring that the airway is clear and that
breathing is adequate is the priority action.
6. A nurse is providing care for a patient with a chest tube. Which of the
following is the most important action?
a) Encourage the patient to cough and deep breathe b) Keep the chest tube clamps at the bedside
c) Change the dressing daily d) Keep the drainage system above the level of the chest
Answer: a) Encourage the patient to cough and deep breathe
Rationale: Coughing and deep breathing promote lung expansion, reduce the risk of pneumonia,
and help with the drainage of fluid from the pleural space.
7. Which of the following should a nurse monitor when a patient is receiving
intravenous (IV) potassium chloride?
a) Respiratory rate b) Serum potassium level c) Blood pressure d) Liver function
Answer: b) Serum potassium level
Rationale: Potassium chloride administration can lead to hyperkalemia, so monitoring serum
potassium levels is essential to avoid complications such as arrhythmias.
8. A nurse is caring for a patient with a nasogastric tube. Which of the following
actions should the nurse take to confirm tube placement before administering
medications?
a) Attach the tube to suction b) Inject air into the tube and listen for a gurgling sound c) Check
the pH of the aspirate d) Ensure the tube is secured to the patient’s nose
Answer: c) Check the pH of the aspirate
Rationale: Checking the pH of the gastric aspirate is the most reliable method to confirm proper
nasogastric tube placement and avoid the risk of aspiration.
with a wound infection?
a) Administer pain medications b) Check the patient’s vital signs c) Perform wound irrigation d)
Prepare for surgical debridement
Answer: b) Check the patient’s vital signs
Rationale: Vital signs are the most immediate indicator of infection or systemic response. Fever,
increased heart rate, and increased respiratory rate may indicate an infection. Once the vital signs
are assessed, further interventions like pain management and wound care can be done.
2. A patient asks about the purpose of an intravenous (IV) catheter. The nurse
should explain that an IV catheter is used for:
a) Delivering oxygen directly to the bloodstream b) Administering fluids and medications c)
Drawing blood for laboratory tests d) Monitoring vital signs
Answer: b) Administering fluids and medications
Rationale: An IV catheter is primarily used to administer fluids, medications, and electrolytes
directly into the bloodstream, which is essential for patients who need immediate or ongoing
treatment.
3. Which of the following should be included in a nurse’s initial assessment of a
patient with a head injury?
a) Assessing the Glasgow Coma Scale (GCS) b) Obtaining a 12-lead EKG c) Checking the
patient’s blood pressure d) Evaluating the patient's wound dressing
Answer: a) Assessing the Glasgow Coma Scale (GCS)
Rationale: The Glasgow Coma Scale is essential in assessing the neurological status of patients
with head injuries to monitor for changes in level of consciousness and brain function.
4. When preparing a sterile field, which action is correct?
a) Hold sterile items above waist level b) Touch sterile items with ungloved hands c) Keep the
sterile field open and unprotected d) Ensure sterile gloves are worn for all tasks
Answer: a) Hold sterile items above waist level
Rationale: Sterile items should be handled carefully and kept above the waist to prevent
contamination. The sterile field must be maintained and not touched with non-sterile hands.
, 5. A nurse is caring for a postoperative patient who is not responding to verbal
stimuli. The nurse should:
a) Call the doctor immediately b) Check the patient’s blood pressure c) Reassess the patient’s
airway and breathing d) Administer pain medication
Answer: c) Reassess the patient’s airway and breathing
Rationale: If a patient is not responding to stimuli, ensuring that the airway is clear and that
breathing is adequate is the priority action.
6. A nurse is providing care for a patient with a chest tube. Which of the
following is the most important action?
a) Encourage the patient to cough and deep breathe b) Keep the chest tube clamps at the bedside
c) Change the dressing daily d) Keep the drainage system above the level of the chest
Answer: a) Encourage the patient to cough and deep breathe
Rationale: Coughing and deep breathing promote lung expansion, reduce the risk of pneumonia,
and help with the drainage of fluid from the pleural space.
7. Which of the following should a nurse monitor when a patient is receiving
intravenous (IV) potassium chloride?
a) Respiratory rate b) Serum potassium level c) Blood pressure d) Liver function
Answer: b) Serum potassium level
Rationale: Potassium chloride administration can lead to hyperkalemia, so monitoring serum
potassium levels is essential to avoid complications such as arrhythmias.
8. A nurse is caring for a patient with a nasogastric tube. Which of the following
actions should the nurse take to confirm tube placement before administering
medications?
a) Attach the tube to suction b) Inject air into the tube and listen for a gurgling sound c) Check
the pH of the aspirate d) Ensure the tube is secured to the patient’s nose
Answer: c) Check the pH of the aspirate
Rationale: Checking the pH of the gastric aspirate is the most reliable method to confirm proper
nasogastric tube placement and avoid the risk of aspiration.
