3 Verified NGN-Style Versions with Answers
Question 1
A post-operative client reports sudden shortness of breath and chest pain. Which
assessment finding should the nurse obtain FIRST?
Options: A. Oxygen saturation by pulse oximetry
B. Chest auscultation bilaterally
C. Pain rating on 0–10 scale
D. Capillary refill time
Correct Answer: A
Rationale: Oxygen saturation is the quickest way to determine if the client is
hypoxemic and guides immediate oxygen therapy. While chest auscultation is
important, it takes longer and does not quantify oxygenation. Pain rating and
capillary refill are valuable but not the priority when airway/breathing compromise
is suspected.
Question 2
The nurse is caring for a client with Clostridioides difficile. Which actions are
appropriate? Select all that apply.
Options: A. Place client in a private room with contact precautions
B. Use alcohol-based hand rub after glove removal
C. Don gown and gloves before entering room
D. Assign reusable blood-pressure cuff to this client only
E. Clean equipment with bleach-based disinfectant
Correct Answer: A, C, D, E
Rationale: Contact precautions plus private room are required. Alcohol does not
kill C. diff spores; soap-and-water hand hygiene is required. Dedicated equipment
prevents cross-transmission. Bleach is sporicidal. B is incorrect because alcohol
hand rub is ineffective.
Question 3
Order the steps for inserting an indwelling urinary catheter in a female client.
, 1. Secure catheter to thigh
2. Inflate balloon with 10 mL sterile water
3. Clean perineum with antiseptic solution
4. Insert catheter 5–7 cm (2–3 in) past urine return
5. Open sterile tray maintaining sterile field
Correct Answer: 5 → 3 → 4 → 2 → 1
Rationale: Sterile setup (5) precedes cleansing (3). Insertion (4) until urine
flows ensures proper placement, then balloon inflation (2) anchors catheter.
Securing (1) prevents traction.
Question 4
A client is prescribed metformin 1 g PO BID. The pharmacy supplies 500 mg
tablets. How many tablets will the nurse administer per dose?
Drop-down: ___ tablet(s)
Correct Answer: 2
Rationale: 1 g = 1000 mg; 1000 mg ÷ 500 mg/tablet = 2 tablets.
Question 5
During a physical assessment, the nurse notes a 2 cm firm, non-tender, mobile
lymph node in the anterior cervical region. What is the BEST nursing action?
Options: A. Document finding and continue assessment
B. Apply warm compress for 20 minutes
C. Notify provider immediately
D. Re-palpate with gloves
Correct Answer: A
Rationale: Small, mobile, non-tender nodes are often normal variants.
Documentation and completing the assessment are appropriate. Immediate
notification is unnecessary without systemic symptoms. Warm compress is not
indicated.
Question 6
Which breakfast selection by a Muslim client indicates understanding of halal
dietary requirements?
Options: A. Turkey sausage and eggs
, B. Pancakes with maple syrup
C. Yogurt parfait with gelatin
D. Cheese omelet with turkey bacon
Correct Answer: B
Rationale: Maple syrup pancakes contain no animal-derived ingredients violating
halal. Turkey products must be halal-certified; standard gelatin often contains pork.
Without certification, A, C, and D are questionable.
Question 7
A nurse witnesses a colleague documenting vital signs before assessment. What is
the LEGAL responsibility of the witnessing nurse?
Options: A. Ignore—no harm occurred
B. Report to nurse manager
C. Confront colleague privately
D. Rewrite documentation correctly
Correct Answer: B
Rationale: Falsified documentation is fraud and jeopardizes patient safety. The
witnessing nurse must report through chain of command. Confrontation alone does
not ensure patient protection; rewriting is outside scope.
Question 8
The nurse delegates bed-making for a stable client to assistive personnel (AP).
Which instruction is ESSENTIAL?
Options: A. “Keep soiled linen close to your uniform.”
B. “Shake linens to remove crumbs.”
C. “Perform hand hygiene before and after.”
D. “Place clean sheets on the bedside chair.”
Correct Answer: C
Rationale: Hand hygiene prevents cross-contamination. Shaking linens aerosolizes
microbes; soiled linen should be rolled away from body and placed directly in
laundry bag. Clean linens should not contact potentially contaminated surfaces.
Question 9
A client’s temperature is 38.9 °C (102 °F) orally. Which non-pharmacologic
intervention should the nurse implement FIRST?
Options: A. Administer acetaminophen 650 mg