1. Which of the following is the primary purpose of patient-centered care?
a) To increase healthcare costs
b) To promote autonomy and individualized care
c) To reduce the workload of healthcare providers
d) To standardize medical procedures
Answer: b) To promote autonomy and individualized care
Rationale: Patient-centered care focuses on the needs, preferences, and values of the patient. It
emphasizes treating the patient as a whole and respecting their autonomy in the decision-making
process.
2. A nurse is preparing to assess a patient's blood pressure. Which of the
following actions should the nurse take first?
a) Inflate the cuff to 20 mm Hg above the last palpated systolic pressure
b) Position the arm at the level of the heart
c) Apply the cuff over the patient’s clothing
d) Place the stethoscope over the brachial artery
Answer: b) Position the arm at the level of the heart
Rationale: Positioning the arm at the level of the heart ensures an accurate blood pressure
reading. The cuff should be applied directly to the skin, and the stethoscope should be placed
over the brachial artery.
3. A nurse is caring for a patient with a nasogastric tube. Which of the following
actions should the nurse take to prevent complications?
a) Check tube placement only when inserting the tube
b) Use normal saline to irrigate the tube at least every 4 hours
c) Position the patient in a semi-Fowler's position during tube feedings
d) Flush the tube with water before every feeding
Answer: c) Position the patient in a semi-Fowler's position during tube feedings
Rationale: Positioning the patient in a semi-Fowler’s position helps prevent aspiration during
tube feedings. Tube placement should be checked regularly, and irrigation should be done as
prescribed to maintain tube patency.
,4. Which of the following is an appropriate nursing intervention for a patient
who is experiencing pain following surgery?
a) Encourage the patient to avoid taking pain medications
b) Assess the patient’s pain level regularly
c) Limit the patient’s movement to reduce discomfort
d) Increase fluid intake to alleviate pain
Answer: b) Assess the patient’s pain level regularly
Rationale: Regular assessment of pain allows for timely intervention to manage and alleviate
discomfort. Pain management includes using medications and non-pharmacological methods as
appropriate.
5. When administering a medication via the intramuscular route, the nurse
should consider which of the following factors?
a) The needle length should be 3 inches for all adults
b) The injection site should be massaged immediately after administration
c) The needle should be inserted at a 90-degree angle to the skin
d) A smaller gauge needle should be used for thicker solutions
Answer: c) The needle should be inserted at a 90-degree angle to the skin
Rationale: Intramuscular injections are given at a 90-degree angle to ensure the medication is
deposited into the muscle. Needle length and gauge are selected based on the patient’s size and
the medication being administered.
6. A nurse is preparing to teach a patient how to perform a self-breast exam.
Which of the following should the nurse include in the teaching?
a) Perform the self-exam once a year
b) Examine the breast in the shower or while lying down
c) Only report lumps if they are painful
d) Perform the self-exam immediately before a menstrual cycle
Answer: b) Examine the breast in the shower or while lying down
Rationale: It is recommended to perform self-breast exams monthly in a consistent manner,
either in the shower or while lying down. Lumps should be reported regardless of pain, and the
timing of the exam can be done any time during the cycle, but not immediately before
menstruation.
, 7. Which of the following symptoms is most concerning for a patient with chronic
obstructive pulmonary disease (COPD)?
a) Increased shortness of breath with exertion
b) A slight change in sputum color
c) Fever and chills
d) A decrease in the frequency of coughing
Answer: c) Fever and chills
Rationale: Fever and chills may indicate an infection, such as pneumonia, which is a serious
complication in patients with COPD. Increased shortness of breath and changes in sputum color
can be typical, but fever is concerning for infection.
8. A nurse is caring for a patient who is at risk for developing a pressure ulcer.
Which of the following interventions should the nurse implement?
a) Reposition the patient at least every 4 hours
b) Use a doughnut-shaped cushion to relieve pressure
c) Encourage the patient to maintain good nutrition and hydration
d) Massage the skin over bony prominences to improve circulation
Answer: c) Encourage the patient to maintain good nutrition and hydration
Rationale: Good nutrition and hydration are critical for skin integrity and wound healing.
Repositioning should be done every 2 hours, and massaging over bony prominences can actually
cause skin damage.
9. A nurse is caring for a patient who is receiving a blood transfusion. Which of
the following is the most important action the nurse should take?
a) Monitor vital signs every 30 minutes
b) Administer the blood slowly to prevent an adverse reaction
c) Verify the patient’s identity and blood type before initiating the transfusion
d) Warm the blood prior to administration
Answer: c) Verify the patient’s identity and blood type before initiating the transfusion
a) To increase healthcare costs
b) To promote autonomy and individualized care
c) To reduce the workload of healthcare providers
d) To standardize medical procedures
Answer: b) To promote autonomy and individualized care
Rationale: Patient-centered care focuses on the needs, preferences, and values of the patient. It
emphasizes treating the patient as a whole and respecting their autonomy in the decision-making
process.
2. A nurse is preparing to assess a patient's blood pressure. Which of the
following actions should the nurse take first?
a) Inflate the cuff to 20 mm Hg above the last palpated systolic pressure
b) Position the arm at the level of the heart
c) Apply the cuff over the patient’s clothing
d) Place the stethoscope over the brachial artery
Answer: b) Position the arm at the level of the heart
Rationale: Positioning the arm at the level of the heart ensures an accurate blood pressure
reading. The cuff should be applied directly to the skin, and the stethoscope should be placed
over the brachial artery.
3. A nurse is caring for a patient with a nasogastric tube. Which of the following
actions should the nurse take to prevent complications?
a) Check tube placement only when inserting the tube
b) Use normal saline to irrigate the tube at least every 4 hours
c) Position the patient in a semi-Fowler's position during tube feedings
d) Flush the tube with water before every feeding
Answer: c) Position the patient in a semi-Fowler's position during tube feedings
Rationale: Positioning the patient in a semi-Fowler’s position helps prevent aspiration during
tube feedings. Tube placement should be checked regularly, and irrigation should be done as
prescribed to maintain tube patency.
,4. Which of the following is an appropriate nursing intervention for a patient
who is experiencing pain following surgery?
a) Encourage the patient to avoid taking pain medications
b) Assess the patient’s pain level regularly
c) Limit the patient’s movement to reduce discomfort
d) Increase fluid intake to alleviate pain
Answer: b) Assess the patient’s pain level regularly
Rationale: Regular assessment of pain allows for timely intervention to manage and alleviate
discomfort. Pain management includes using medications and non-pharmacological methods as
appropriate.
5. When administering a medication via the intramuscular route, the nurse
should consider which of the following factors?
a) The needle length should be 3 inches for all adults
b) The injection site should be massaged immediately after administration
c) The needle should be inserted at a 90-degree angle to the skin
d) A smaller gauge needle should be used for thicker solutions
Answer: c) The needle should be inserted at a 90-degree angle to the skin
Rationale: Intramuscular injections are given at a 90-degree angle to ensure the medication is
deposited into the muscle. Needle length and gauge are selected based on the patient’s size and
the medication being administered.
6. A nurse is preparing to teach a patient how to perform a self-breast exam.
Which of the following should the nurse include in the teaching?
a) Perform the self-exam once a year
b) Examine the breast in the shower or while lying down
c) Only report lumps if they are painful
d) Perform the self-exam immediately before a menstrual cycle
Answer: b) Examine the breast in the shower or while lying down
Rationale: It is recommended to perform self-breast exams monthly in a consistent manner,
either in the shower or while lying down. Lumps should be reported regardless of pain, and the
timing of the exam can be done any time during the cycle, but not immediately before
menstruation.
, 7. Which of the following symptoms is most concerning for a patient with chronic
obstructive pulmonary disease (COPD)?
a) Increased shortness of breath with exertion
b) A slight change in sputum color
c) Fever and chills
d) A decrease in the frequency of coughing
Answer: c) Fever and chills
Rationale: Fever and chills may indicate an infection, such as pneumonia, which is a serious
complication in patients with COPD. Increased shortness of breath and changes in sputum color
can be typical, but fever is concerning for infection.
8. A nurse is caring for a patient who is at risk for developing a pressure ulcer.
Which of the following interventions should the nurse implement?
a) Reposition the patient at least every 4 hours
b) Use a doughnut-shaped cushion to relieve pressure
c) Encourage the patient to maintain good nutrition and hydration
d) Massage the skin over bony prominences to improve circulation
Answer: c) Encourage the patient to maintain good nutrition and hydration
Rationale: Good nutrition and hydration are critical for skin integrity and wound healing.
Repositioning should be done every 2 hours, and massaging over bony prominences can actually
cause skin damage.
9. A nurse is caring for a patient who is receiving a blood transfusion. Which of
the following is the most important action the nurse should take?
a) Monitor vital signs every 30 minutes
b) Administer the blood slowly to prevent an adverse reaction
c) Verify the patient’s identity and blood type before initiating the transfusion
d) Warm the blood prior to administration
Answer: c) Verify the patient’s identity and blood type before initiating the transfusion
