Complete Practice Questions with Verified
Answers & Detailed Rationales | Latest
Update 2026/2027
Question 1
A nurse is teaching a client and his family how to care for the client's tracheostomy at
home. Which of the following instructions should the nurse include in the teaching?
A. Remove the outer cannula cautiously for routine cleaning
B. Use tracheostomy covers when outdoors
C. Use sterile techniques when performing tracheostomy care at home
D. Cleanse irritated skin with full-strength hydrogen peroxide
Answer: B
Rationale: Tracheostomy covers should be used when outdoors to filter and warm the
air. The outer cannula should not be removed, sterile technique is not required at home,
and hydrogen peroxide is too harsh for irritated skin.
Question 2
A home health nurse is performing a follow up visit for a client who has a gastrostomy
tube through which they receive intermittent feedings and medications. The client has
recently developed diarrhea. Which of the following findings should the nurse identify
as a possible cause of the diarrhea?
A. The client is receiving formula at room temperature
B. The feedings infuse at a slow, continuous drip over 8 hours each night
C. The client's caregiver washes out the feedings bag with warm water once every 24
hours
D. The client's caregiver flushes the tubing with water before and after administering
medications
Answer: C
Rationale: Washing the feeding bag only once every 24 hours can allow bacterial
growth, leading to diarrhea. The feeding bag should be rinsed thoroughly after each use.
pg. 1
,Question 3
A nurse is talking with an older adult client who is contemplating retirement. The client
states, "I keep thinking about how much I enjoy my job. I am not sure I want to retire."
Which of the following responses should the nurse make?
A. "You would have so much more time to spend with your family"
B. "You should consider getting a part time job or doing volunteer work"
C. "Let's talk about how the change in your job status will affect you"
D. "Why wouldn't you want to retire and relax?"
Answer: B
Rationale: Suggesting part-time work or volunteering acknowledges the client's
enjoyment of work and provides alternatives. Option C is therapeutic but does not
address the client's specific concern about missing work.
Question 4
A nurse is assessing a client who reports increased pain following physical therapy.
Which of the following questions should the nurse ask when assessing the quality of the
client's pain?
A. "Is your pain constant or intermittent?"
B. "What would you rate your pain on a scale of 0 to 10?"
C. "Does the pain radiate?"
D. "Is your pain sharp or dull?"
Answer: D
Rationale: Quality refers to the descriptive nature of pain (e.g., sharp, dull, burning,
aching). "Is your pain sharp or dull?" assesses quality.
Question 5
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal
cancer. Which of the following actions should the nurse take?
A. Discuss the risk factors for colon cancer
B. Focus teaching on what the client will need to do in the future to manage his illness
C. Provide the client with written information about the phases of loss and grief
D. Reassure the client that this is an expected response to grief
Answer: D
Rationale: Anger is a normal stage of grief. Reassuring the client that this is an
expected response validates his feelings and provides support.
pg. 2
,Question 6
A nurse is caring for a client who reports pain. When documenting the quality of the
client's pain on an initial pain assessment, the nurse should record which of the
following client statements?
A. "I am having mild pain"
B. "The pain is like a dull ache in my stomach"
C. "I notice that the pain gets worse after I eat"
D. "The pain makes me feel nauseous"
Answer: B
Rationale: Quality describes the nature of the pain. "The pain is like a dull ache"
describes quality.
Question 7
A client in non-ambulatory notifies the nurse that his trash can is on fire. After the nurse
confirms the presence of the fire, which of the following actions should the nurse take
next?
A. Activate the emergency fire alarm
B. Extinguish the fire
C. Evacuate the client
D. Confine the fire
Answer: C
Rationale: RACE: Rescue (evacuate the client first), Alarm, Contain, Extinguish. The
priority is to remove the client from immediate danger.
Question 8
A nurse is completing an admission assessment for a client who reports vomiting and
diarrhea for the past 3 days. Which of the following findings should the nurse expect?
A. Neck vein distention
B. Urine specific gravity 1.010
C. Rapid heart rate
D. Blood pressure 144/82 mmHg
Answer: C
Rationale: Vomiting and diarrhea cause fluid loss, leading to dehydration. Tachycardia
(rapid heart rate) is an expected compensatory response to decreased fluid volume.
pg. 3
, Question 9
A nurse has accepted a verbal prescription for "three tenths of a milligram of
levothyroxine IV stat" for a client who has myxedema coma. How should the nurse
transcribe the dosage of this medication in the client's medical record?
A. .3 mg
B. 0.3 mg
C. 0.30 mg
D. 3/10 mg
Answer: B
Rationale: The correct transcription is 0.3 mg. Leading zeros should be used (0.3 mg),
but trailing zeros should be avoided (not 0.30 mg). Fractions should not be used.
Question 10
A nurse is preparing a heparin infusion for a client who was admitted to the facility with
deep vein thrombosis. The prescription reads: 25,000 units of heparin in 0.9% sodium
chloride 250 mL to infuse at 800 units/hour. At what rate should the nurse set the
infusion pump?
Answer: 8 mL/hour
Rationale: 25,000 units / 250 mL = 100 units/mL. 800 units/hour ÷ 100 units/mL =
8 mL/hour.
Question 11
A nurse is caring for a client who has a prescription for wound irrigation. Which of the
following actions should the nurse take?
A. Wear sterile gloves when removing the old dressing
B. Warm the irrigation solution to 40.5°C (105°F)
C. Cleanse the wound from the center outward
D. Use a 20 mL syringe to irrigate the wound
Answer: C
Rationale: Cleaning from the center outward prevents spreading contaminants from
the skin into the wound. Clean gloves are sufficient for removing old dressing; solution
should be room temperature; a 30-60 mL syringe with an 18-19 gauge catheter is
typically used.
pg. 4