2023 260 Multiple-Choice Questions with
Rationales Version 2 Table of Contents | Quiz
Format | Rationales | High-Yield Focus
TABLE OF CONTENTS
1.Management of Care (Questions 1–40)
2.Safety & Infection Control (Questions 41–70)
3.Health Promotion & Maintenance (Questions 71–100)
4.Psychosocial Integrity (Questions 101–130)
5.Basic Care & Comfort (Questions 131–160)
6.Pharmacological & Parenteral Therapies (Questions 161–200)
7.Reduction of Risk Potential (Questions 201–230)
8.Physiological Adaptation (Questions 231–260)
MANAGEMENT OF CARE (Questions 1–40)
Question 1
A nurse is caring for a client who has a prescription for physical
restraints. Which of the following actions should the nurse take?
A. Apply restraints for 4 hours before reassessing
B. Obtain a new restraint order every 24 hours
C. Tie restraints to the side rail of the bed
D. Remove restraints every 4 hours for range of motion
Correct Answer: B
Rationale: Restraint orders must be renewed every 24 hours (or per
facility policy, often every 4-8 hours for adults). Restraints should be
,removed every 2 hours (not 4 – D) for ROM. Never tie to side rails (C –
risk of injury).
Question 2 (Select all that apply)
A nurse is preparing to transfer a client to a long-term care facility. Which
information must be included in the transfer report? (Select all that apply)
A. Immunization history
B. Current functional status
C. Advanced directive status
D. Most recent laboratory results
E. Family contact phone numbers
Correct Answers: B, C, D
Rationale: Transfer reports include functional status (B), advance
directives (C), and recent labs (D). Immunization history (A) is not
urgent. Family contacts (E) are administrative.
Question 3
A nurse is caring for a client who is scheduled for surgery but has not
signed the consent form. The client says, "I don't understand what the
surgeon explained." What should the nurse do?
A. Explain the procedure in simple terms
B. Have the client sign and explain later
C. Notify the surgeon to clarify the information
D. Ask a family member to explain
Correct Answer: C
Rationale: Only the surgeon (or provider performing the procedure) can
clarify informed consent. The nurse should notify the surgeon. The nurse
does not explain the procedure (A).
,Question 4
A nurse is caring for a client who is being discharged home after a
myocardial infarction. The client lives alone and has difficulty
remembering medications. Which referral is most appropriate?
A. Physical therapy
B. Occupational therapy
C. Home health aide for medication setup
D. Speech therapy
Correct Answer: C
Rationale: A home health aide or nurse can set up medications in a pill
organizer. PT (A) and OT (B) are for mobility/ADLs. Speech (D) is for
swallowing/communication.
Question 5
A nurse is caring for a client who is crying and says, "The doctor said my
cancer is back. I can't do this again." Which response by the nurse is
therapeutic?
A. "Don't worry, you beat it once before."
B. "Tell me more about what you're feeling right now."
C. "You should focus on the positive."
D. "Let me call the chaplain for you."
Correct Answer: B
Rationale: Exploring the client’s feelings is therapeutic. False
reassurance (A) and platitudes (C) block communication. Calling the
chaplain (D) may be helpful but not first.
Question 6
A nurse is preparing to give change-of-shift report. Which client should
the nurse report on first?
, A. The client who has a new order for a blood transfusion
B. The client who has a pressure injury dressing change due in 2 hours
C. The client who has a family member requesting to speak with the
charge nurse
D. The client who has a potassium level of 3.2 mEq/L
Correct Answer: A
Rationale: The blood transfusion is time-sensitive and requires
immediate action. Potassium 3.2 (D) is low but not as urgent as a pending
transfusion. Dressing change (B) and family request (C) are lower
priority.
Question 7 (Select all that apply)
A nurse is reviewing HIPAA compliance. Which actions violate HIPAA?
(Select all that apply)
A. Discussing a client’s condition in a public elevator
B. Faxing records to another facility with a cover sheet
C. Leaving a client’s printed lab results on a shared desk
D. Sharing login information with a colleague
E. Providing handoff report at the client’s bedside
Correct Answers: A, C, D
Rationale: Elevator discussion (A), leaving results visible (C), and
sharing logins (D) violate HIPAA. Faxing with cover sheet (B) and
bedside handoff (E) are acceptable.
Question 8
A nurse is caring for a client who has a history of violence and is
becoming agitated. What should the nurse do first?
A. Apply wrist restraints
B. Call security
C. Use a calm voice and remove extra stimuli
D. Administer a sedative