Essential Nursing Questions and Answers with Full Explanations
1. What is the normal range for an adult’s respiratory rate?
Answer: 12–20 breaths per minute
Explanation:
The normal respiratory rate for a healthy adult at rest is between 12 and 20 breaths per minute. This
range indicates adequate ventilation, oxygen exchange, and overall respiratory function. A rate below 12
(bradypnea) may suggest neurological depression, drug overdose, or metabolic issues, while a rate
above 20 (tachypnea) can indicate fever, anxiety, respiratory distress, shock, or metabolic acidosis.
Monitoring respiratory rate is one of the most sensitive early indicators of patient deterioration, so any
deviation from this range requires further assessment and prompt intervention.
2. Which site is commonly used to check the pulse during CPR on an adult?
Answer: Carotid artery
Explanation:
During CPR, the carotid artery—located in the neck beside the trachea—is the preferred pulse-checking
site for adults because it remains palpable even when cardiac output is extremely low. Peripheral pulses
(like radial) often disappear during cardiac arrest or shock, making them unreliable. The carotid artery
allows quick and accurate assessment of circulation within the recommended 10 seconds. Identifying
the absence of a pulse here confirms the need for immediate chest compressions and resuscitation
efforts.
3. What is the primary purpose of the Glasgow Coma Scale (GCS)?
Answer: To assess a patient’s level of consciousness.
Explanation:
The Glasgow Coma Scale is a standardized tool used in nursing to objectively measure a patient’s
neurological status, specifically their level of consciousness. It evaluates three components: eye
opening, verbal response, and motor response. Scores range from 3 (deep coma) to 15 (fully alert). GCS
is especially important in trauma, stroke, or other neurological conditions where changes in
consciousness indicate worsening or improving brain function. Regular assessment helps detect subtle
changes early and informs urgent medical decisions.
4. A patient with dehydration is likely to present with which symptom?
Answer: Poor skin turgor
Explanation:
Poor skin turgor is a classic sign of dehydration because reduced body water decreases the skin’s
elasticity. When the skin is gently pinched and released, it returns to normal slowly instead of snapping
, back immediately. Other dehydration symptoms include dry mucous membranes, concentrated urine,
dizziness, and tachycardia. Assessing skin turgor—especially over the sternum or forearm—is an
important nursing tool, although it may be less accurate in older adults due to naturally decreased
elasticity.
5. What is the recommended angle for administering a subcutaneous injection?
Answer: 45° to 90°
Explanation:
Subcutaneous injections are given into the fatty tissue beneath the skin, and the angle of insertion
depends on the patient’s body habitus and needle length. A 45° angle is used for thinner patients to
avoid reaching muscle, while a 90° angle is used when there is more subcutaneous tissue. Proper angle
selection ensures the medication is delivered to the correct layer for slow, sustained absorption, which
is essential for drugs like insulin and certain anticoagulants. Incorrect technique can lead to poor
absorption or tissue damage.
6. Which electrolyte imbalance is associated with cardiac arrhythmias?
Answer: Hyperkalemia or hypokalemia
Explanation:
Potassium plays a critical role in maintaining normal cardiac electrical activity. Both hyperkalemia (high
potassium) and hypokalemia (low potassium) can cause dangerous arrhythmias. Hyperkalemia may lead
to peaked T waves, widened QRS complexes, and cardiac arrest, while hypokalemia can cause flattened
T waves, U waves, and ventricular tachycardia. Because potassium imbalances can be rapidly fatal,
nurses must closely monitor ECG changes, lab values, and patient symptoms, especially in patients on
diuretics, dialysis, or cardiac medications.
7. What is the first nursing action when a patient is found unresponsive?
Answer: Check for responsiveness and call for help
Explanation:
The initial action follows the Basic Life Support (BLS) algorithm: assess for responsiveness by tapping the
patient and calling out to them. This determines whether the patient is unconscious or simply sleeping.
If unresponsive, the nurse must immediately call for help or activate the emergency response system
before checking breathing and pulse. Early recognition and prompt activation of emergency support
significantly increase survival rates in cardiac or respiratory arrest. This step ensures that additional help
and resuscitation equipment arrive quickly.
8. Which isolation precaution is required for a patient with tuberculosis?
Answer: Airborne precautions
Explanation:
1. What is the normal range for an adult’s respiratory rate?
Answer: 12–20 breaths per minute
Explanation:
The normal respiratory rate for a healthy adult at rest is between 12 and 20 breaths per minute. This
range indicates adequate ventilation, oxygen exchange, and overall respiratory function. A rate below 12
(bradypnea) may suggest neurological depression, drug overdose, or metabolic issues, while a rate
above 20 (tachypnea) can indicate fever, anxiety, respiratory distress, shock, or metabolic acidosis.
Monitoring respiratory rate is one of the most sensitive early indicators of patient deterioration, so any
deviation from this range requires further assessment and prompt intervention.
2. Which site is commonly used to check the pulse during CPR on an adult?
Answer: Carotid artery
Explanation:
During CPR, the carotid artery—located in the neck beside the trachea—is the preferred pulse-checking
site for adults because it remains palpable even when cardiac output is extremely low. Peripheral pulses
(like radial) often disappear during cardiac arrest or shock, making them unreliable. The carotid artery
allows quick and accurate assessment of circulation within the recommended 10 seconds. Identifying
the absence of a pulse here confirms the need for immediate chest compressions and resuscitation
efforts.
3. What is the primary purpose of the Glasgow Coma Scale (GCS)?
Answer: To assess a patient’s level of consciousness.
Explanation:
The Glasgow Coma Scale is a standardized tool used in nursing to objectively measure a patient’s
neurological status, specifically their level of consciousness. It evaluates three components: eye
opening, verbal response, and motor response. Scores range from 3 (deep coma) to 15 (fully alert). GCS
is especially important in trauma, stroke, or other neurological conditions where changes in
consciousness indicate worsening or improving brain function. Regular assessment helps detect subtle
changes early and informs urgent medical decisions.
4. A patient with dehydration is likely to present with which symptom?
Answer: Poor skin turgor
Explanation:
Poor skin turgor is a classic sign of dehydration because reduced body water decreases the skin’s
elasticity. When the skin is gently pinched and released, it returns to normal slowly instead of snapping
, back immediately. Other dehydration symptoms include dry mucous membranes, concentrated urine,
dizziness, and tachycardia. Assessing skin turgor—especially over the sternum or forearm—is an
important nursing tool, although it may be less accurate in older adults due to naturally decreased
elasticity.
5. What is the recommended angle for administering a subcutaneous injection?
Answer: 45° to 90°
Explanation:
Subcutaneous injections are given into the fatty tissue beneath the skin, and the angle of insertion
depends on the patient’s body habitus and needle length. A 45° angle is used for thinner patients to
avoid reaching muscle, while a 90° angle is used when there is more subcutaneous tissue. Proper angle
selection ensures the medication is delivered to the correct layer for slow, sustained absorption, which
is essential for drugs like insulin and certain anticoagulants. Incorrect technique can lead to poor
absorption or tissue damage.
6. Which electrolyte imbalance is associated with cardiac arrhythmias?
Answer: Hyperkalemia or hypokalemia
Explanation:
Potassium plays a critical role in maintaining normal cardiac electrical activity. Both hyperkalemia (high
potassium) and hypokalemia (low potassium) can cause dangerous arrhythmias. Hyperkalemia may lead
to peaked T waves, widened QRS complexes, and cardiac arrest, while hypokalemia can cause flattened
T waves, U waves, and ventricular tachycardia. Because potassium imbalances can be rapidly fatal,
nurses must closely monitor ECG changes, lab values, and patient symptoms, especially in patients on
diuretics, dialysis, or cardiac medications.
7. What is the first nursing action when a patient is found unresponsive?
Answer: Check for responsiveness and call for help
Explanation:
The initial action follows the Basic Life Support (BLS) algorithm: assess for responsiveness by tapping the
patient and calling out to them. This determines whether the patient is unconscious or simply sleeping.
If unresponsive, the nurse must immediately call for help or activate the emergency response system
before checking breathing and pulse. Early recognition and prompt activation of emergency support
significantly increase survival rates in cardiac or respiratory arrest. This step ensures that additional help
and resuscitation equipment arrive quickly.
8. Which isolation precaution is required for a patient with tuberculosis?
Answer: Airborne precautions
Explanation:
