Edition – Latest Real Exam Questions
with 150+ Verified Answers (Graded A+)
Questions and Answers
1. Question: What is the priority action for a nurse caring for a client with a new
tracheostomy?
Answer: Ensure airway patency
Rationale: Maintaining a patent airway prevents respiratory distress, a critical priority for
tracheostomy care.
2. Question: What should a nurse do before administering medication through a nasogastric
tube?
Answer: Verify tube placement
Rationale: Confirming placement with pH testing of aspirate prevents medication
administration into the lungs, ensuring safety.
3. Question: What intervention should a nurse prioritize for a client with dehydration and a
heart rate of 112 bpm?
Answer: Initiate IV fluid administration as prescribed
Rationale: IV fluids restore volume and stabilize vital signs in dehydration.
4. Question: What should a nurse do when applying restraints to a confused client?
Answer: Check restraints every 2 hours
Rationale: Regular checks ensure proper fit, circulation, and skin integrity, adhering to
safety standards.
5. Question: What task can a nurse delegate to an assistive personnel (AP) for a stable
client?
Answer: Measure vital signs
, Rationale: Measuring vital signs is within the AP’s scope, freeing the nurse for tasks
requiring judgment.
6. Question: What should a client state to indicate understanding of proper hand hygiene?
Answer: I should scrub my hands for at least 20 seconds
Rationale: Scrubbing for 20 seconds ensures effective pathogen removal, per CDC
guidelines.
7. Question: How often should a nurse reposition a client with a stage II pressure ulcer?
Answer: Every 2 hours
Rationale: Repositioning every 2 hours reduces pressure, promoting healing and
preventing worsening.
8. Question: What should a nurse teach a client about infection prevention at home?
Answer: Cover mouth when coughing
Rationale: Covering the mouth prevents droplet transmission of pathogens.
9. Question: What is the first step when transferring a client from bed to a wheelchair?
Answer: Lock the wheelchair wheels
Rationale: Locking the wheels ensures stability, preventing falls during transfer.
10. Question: What should a nurse assess first for a client with a urinary catheter reporting
discomfort?
Answer: Catheter patency
Rationale: Ensuring patency prevents complications like bladder distension or infection.
11. Question: What intervention should a nurse implement for a disoriented client with a
history of falls?
Answer: Use a bed alarm
Rationale: A bed alarm alerts staff to prevent falls in clients at risk for wandering.
, 12. Question: What food should a client on a low-sodium diet avoid?
Answer: Canned soup
Rationale: Canned soups are high in sodium, which can exacerbate conditions like
hypertension.
13. Question: What should a nurse monitor for in a client with a new leg cast?
Answer: Signs of compartment syndrome
Rationale: Compartment syndrome (pain, pallor, pulselessness) is a serious complication
requiring immediate intervention.
14. Question: In which position should a nurse place a client for an enema?
Answer: Left Sims’ position
Rationale: The left Sims’ position facilitates enema flow into the descending colon.
15. Question: What precaution should a nurse implement for a client receiving oxygen
therapy?
Answer: Post a “No Smoking” sign
Rationale: Smoking near oxygen increases fire risk, a critical safety concern.
16. Question: What should a nurse assess first for a client reporting pain at an IV site?
Answer: Signs of infiltration
Rationale: Infiltration (swelling, coolness) can cause pain and requires stopping the IV to
prevent tissue damage.
17. Question: What should a nurse teach a client about proper body mechanics for lifting?
Answer: Bend at the knees when lifting heavy objects
Rationale: Bending at the knees reduces back strain and injury risk.
18. Question: Which client should a nurse prioritize for immediate care?
Answer: Client with chest pain and shortness of breath
Rationale: These symptoms indicate a potential cardiac or respiratory emergency,
requiring urgent attention.