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Question 1: A nurse is assessing a client who has Parkinson's disease. Which of the following manifestations should
the nurse expect?
A) Pruritus
B) Hypertension
C) Tremors
D) Hyperactivity
Answer: C
Rationale: Parkinson's disease is characterized by tremors, rigidity, bradykinesia, and postural instability. Pruritus
and hyperactivity are not associated with Parkinson's disease.
Question 2: A nurse is assessing four clients for fluid balance. Which client is exhibiting manifestations of
dehydration?
A) Client with bounding pulses
B) Client with jugular venous distention
C) Client with dry mucous membranes and poor skin turgor
D) Client with peripheral edema
Answer: C
Rationale: Dry mucous membranes, poor skin turgor, and decreased urine output are classic signs of dehydration.
Bounding pulses, JVD, and edema are signs of fluid overload.
Question 3: A nurse is discussing restorative health care with a newly licensed nurse. Which of the following
examples should the nurse include? (Select all that apply)
A) Home health care
B) Rehabilitation facilities
C) Skilled nursing facilities
D) Emergency departments
E) Intensive care units
Answer: A, B, C
Rationale: Restorative health care includes services that help clients regain function after illness or injury, such as
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,home health care, rehabilitation facilities, and skilled nursing facilities. Emergency departments and ICUs provide
acute care, not restorative care.
Question 4: A nurse is preparing to administer a cleansing enema to a client. Which action should the nurse plan to
take?
A) Position the client on the right side
B) Insert the enema tube 10-15 cm (4-6 inches)
C) Administer the enema solution rapidly
D) Use cool solution to stimulate peristalsis
Answer: B
Rationale: The enema tube should be inserted 10-15 cm (4-6 inches) for a cleansing enema. The client should be
positioned on the left side (Sims' position). The solution should be administered slowly, and warm solution (not cool)
is typically used.
Question 5: A nurse is caring for a client who is postoperative and has paralytic ileus. Which of the following
abdominal assessments should the nurse expect?
A) Hyperactive bowel sounds with distention
B) Absent bowel sounds with distention
C) Normal bowel sounds with flat abdomen
D) High-pitched bowel sounds with cramping
Answer: B
Rationale: Paralytic ileus is characterized by absent bowel sounds and abdominal distention due to decreased or
absent peristalsis. Hyperactive bowel sounds are associated with early obstruction, not ileus.
Question 6: A nurse is preparing a sterile field. Which action should the nurse take?
A) Keep the sterile field at least 6 feet away from the client's bedside
B) Instruct the client to refrain from coughing and sneezing during the dressing change
C) Open the sterile pack with the top flap opening away from the body
D) Place sterile items within 1 inch of the edge of the sterile field
Answer: B
Rationale: The client should be instructed to refrain from coughing and sneezing during a sterile procedure to
prevent contamination. The sterile field should be at least 1 inch from the edge of the drape, and the top flap should
open away from the body.
Question 7: A nurse is following the six rights of medication administration. Which of the following is one of the
six rights?
A) Right assessment
B) Right documentation
C) Right time
D) Right room
Answer: C
Rationale: The six rights of medication administration are: right client, right medication, right dose, right route,
right time, and right documentation.
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, Question 8: A nurse is preparing for a presentation on professional identity in nursing. Which statement should the
nurse use to describe professional identity?
A) "Professional identity is defined by the healthcare facility's policies."
B) "Professional identity is the internalization of the values and beliefs of the nursing profession."
C) "Professional identity is determined by the number of years in practice."
D) "Professional identity is the same as clinical competence."
Answer: B
Rationale: Professional identity is the internalization of the values, beliefs, and ethical standards of the nursing
profession. It goes beyond clinical skills and encompasses the nurse's sense of self as a professional.
Question 9: A nurse is caring for a client who is admitted for observation and has full range of motion. Which is the
best manner to encourage the client to void?
A) Offer the bedpan
B) Provide privacy and run water
C) Insert a urinary catheter
D) Restrict fluids
Answer: B
Rationale: Providing privacy and running water are noninvasive techniques to encourage voiding. The bedpan may
be offered, but privacy and environmental stimuli (running water, warm water over the perineum) are effective first-
line interventions.
Question 10: Which of the following actions should the nurse take when removing a client's restraints?
A) Remove restraints every 4 hours for range of motion
B) Remove restraints every 2 hours for range of motion
C) Remove restraints only at the client's request
D) Remove restraints when the client is sleeping
Answer: B
Rationale: Restraints should be removed every 2 hours for range-of-motion exercises, toileting, and reassessment of
the client's condition. This helps prevent complications such as skin breakdown, contractures, and circulatory
impairment.
Question 11: A nurse is caring for a client who has a new tracheostomy. Which action should the nurse take
FIRST?
A) Suction the tracheostomy
B) Assess the client's respiratory status
C) Change the tracheostomy dressing
D) Secure the tracheostomy ties
Answer: B
Rationale: The nurse should first assess the client's respiratory status to ensure the airway is patent. Suctioning
should only be performed if indicated by assessment findings (e.g., adventitious breath sounds, decreased SpO₂).
Question 12: A nurse is caring for a client who has an indwelling urinary catheter. Which action should the nurse
take to prevent infection?
A) Empty the drainage bag when it is completely full
B) Secure the catheter tubing to the client's leg
C) Place the drainage bag on the client's bed
D) Irrigate the catheter daily
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