EXAMS (A+ GRADED 100% VERIFIED)
1.
A nurse prepares to administer an IM injection to an adult patient. Which
site is safest for a 2 mL injection?
A. Deltoid
B. Dorsogluteal
C. Ventrogluteal
D. Vastus lateralis
Answer: C
Rationale: The ventrogluteal site is the safest for large-volume IM
injections in adults due to minimal nerves and blood vessels.
2.
Which of the following nursing actions best demonstrates the use of critical
thinking in patient care?
A. Following physician orders exactly as written
B. Questioning an order that seems inappropriate for the patient
C. Documenting care after leaving the patient’s room
D. Delegating all assessments to assistive personnel
Answer: B
Rationale: Critical thinking involves questioning unclear or unsafe orders to
ensure patient safety and proper judgment.
3.
,A nurse is reinforcing teaching about a low-sodium diet. Which food
selection shows the patient understands the teaching?
A. Canned soup
B. Fresh fruits and vegetables
C. Processed meats
D. Pickles
Answer: B
Rationale: Fresh produce contains minimal sodium, while processed foods
are high in salt and preservatives.
4.
A patient receiving a blood transfusion develops chills, fever, and back pain.
What is the nurse’s priority action?
A. Slow the transfusion rate
B. Stop the transfusion immediately
C. Notify the healthcare provider first
D. Recheck the blood type
Answer: B
Rationale: Signs of a transfusion reaction require immediate discontinuation
of the transfusion and maintaining IV access with normal saline.
5.
A nurse assesses a postoperative patient who has shallow respirations and
drowsiness after receiving morphine. What is the likely cause?
A. Drug allergy
B. Opioid toxicity
C. Pain relief
D. Normal postoperative sedation
Answer: B
Rationale: Morphine can cause respiratory depression due to CNS
suppression; naloxone may be needed.
,6.
Which intervention has the highest priority for a patient receiving IV fluids?
A. Measuring urine output every shift
B. Checking IV site for infiltration or phlebitis
C. Weighing the patient weekly
D. Encouraging oral fluids
Answer: B
Rationale: Monitoring IV sites prevents complications such as infiltration,
infection, and phlebitis.
7.
The nurse observes a nursing assistant performing hand hygiene incorrectly.
What is the most appropriate action?
A. Report the assistant to the nurse manager
B. Ignore the behavior
C. Provide immediate, tactful correction
D. Document the observation
Answer: C
Rationale: Patient safety requires timely, constructive feedback to correct
infection control errors immediately.
8.
A nurse instructs a patient on how to use an incentive spirometer. Which
statement shows correct understanding?
A. “I’ll exhale quickly into the device.”
B. “I’ll inhale slowly and deeply to raise the marker.”
C. “I’ll blow into the tube as hard as possible.”
D. “I’ll use it only once per shift.”
Answer: B
, Rationale: Incentive spirometry encourages deep inspiration to expand
alveoli and prevent atelectasis.
9.
A nurse must administer 250 mg of a drug that comes in 125 mg per tablet.
How many tablets should be given?
A. 1 tablet
B. 1.5 tablets
C. 2 tablets
D. 2.5 tablets
Answer: C
Rationale: 250 ÷ 125 = 2 tablets. Accurate dose calculation ensures proper
medication administration.
10.
A patient with heart failure is prescribed furosemide. Which finding should
the nurse report immediately?
A. Weight loss of 1 lb in 2 days
B. Serum potassium of 2.9 mEq/L
C. Clear lung sounds
D. Blood pressure 118/72 mmHg
Answer: B
Rationale: Furosemide can cause hypokalemia, which may lead to
arrhythmias and muscle weakness.
11.
A nurse cares for a patient with COPD. Which oxygen delivery device is
most appropriate for long-term use?
A. Non-rebreather mask
B. Nasal cannula