| Multiple-Choice | Detailed Rationales
QUESTIONS 1-200
1. A nurse enters a client's room to obtain vital signs. What is the priority action?
- A. Put on gloves
- B. Perform hand hygiene
- C. Adjust the bed height
- D. Introduce herself
Answer: B. Perform hand hygiene
Rationale: Hand hygiene is the single most effective measure to prevent the transmission of infectious
microorganisms and should always be performed before direct patient contact, regardless of whether
gloves will be worn.
2. A nurse is planning care for a group of clients. Which of the following tasks should the nurse delegate
to an assistive personnel (AP)?
- A. Changing the dressing for a client who has a stage 3 pressure injury
- B. Determining a client's response to a diuretic
- C. Comparing radial pulses for a client who is postoperative
- D. Providing postmortem care to a client
Answer: D. Providing postmortem care to a client
Rationale: Providing postmortem care is a routine, noninvasive task within the scope of practice for AP.
Dressing changes, assessment of diuretic response, and pulse comparisons require licensed nursing
judgment and cannot be delegated.
,3. A client with active pulmonary tuberculosis is placed on which type of transmission precautions?
- A. Droplet
- B. Airborne
- C. Protective Environment
- D. Contact
Answer: B. Airborne
Rationale: Pulmonary tuberculosis is transmitted via small particle droplet nuclei that remain
suspended in the air, requiring airborne precautions including an N95 respirator and negative airflow
room.
4. Which client requires only standard precautions?
- A. Active tuberculosis
- B. Influenza
- C. MRSA wound infection
- D. Hypertension
Answer: D. Hypertension
Rationale: Hypertension is not infectious and requires only standard precautions. Standard precautions
apply to all clients regardless of diagnosis and include hand hygiene, gloves, gown, mask, and safe
injection practices. Active TB requires airborne, influenza requires droplet, and MRSA requires contact
precautions.
5. A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG tube.
Which of the following actions should the nurse take?
,- A. Attach the restraints securely to the side rails of the client's bed
- B. Apply the restraints to allow as little movement as possible
- C. Allow room for two fingers to fit between the client's skin and the restraints
- D. Remove the restraints every 4 hours
Answer: C. Allow room for two fingers to fit between the client's skin and the restraints
Rationale: Restraints must never be applied tightly. The nurse should ensure that two fingers can fit
between the restraint and the client's skin to prevent injury, impaired circulation, and skin breakdown.
Restraints should be removed every 2 hours for range of motion and circulation checks.
6. A nurse is using the I-SBAR communication tool to provide the client's provider with information. The
nurse should convey the client's pain status in which portion of the report?
- A. Introduction
- B. Assessment
- C. Background
- D. Recommendation
Answer: B. Assessment
Rationale: In the I-SBAR (Identify, Situation, Background, Assessment, Recommendation) tool, the nurse
provides assessment findings—including vital signs, pain assessment, and changes in assessment
findings—in the Assessment portion of the report.
7. A nurse is caring for a client who has influenza and is on isolation precautions. Which action should
the nurse take to prevent the spread of infection?
- A. Wear a mask when working within 3 feet of the client
- B. Administer metronidazole
- C. Don protective eyewear before entering the room
, - D. Place the client in a negative airflow room
Answer: A. Wear a mask when working within 3 feet of the client
Rationale: Influenza requires droplet precautions. A mask should be worn when working within 3 feet of
the client. Negative airflow rooms are for airborne precautions (TB, measles, chickenpox).
Metronidazole is an antibacterial, not antiviral.
8. A nurse is caring for a group of clients. Which of the following tasks should the nurse delegate to an
LPN?
- A. Administer IV push morphine
- B. Perform initial admission assessment
- C. Create the nursing care plan
- D. Insert a Foley catheter
Answer: D. Insert a Foley catheter
Rationale: LPNs can perform stable, predictable procedures such as Foley catheter insertion, PEG tube
feedings, and sterile dressing changes. IV push medications, initial assessments, and care plan creation
are RN responsibilities.
9. A nurse is preparing to insert an indwelling urinary catheter for a client. Which technique is essential
to reduce the risk of CAUTI (catheter-associated urinary tract infection)?
- A. Clean gloves and sterile scissors
- B. Sterile gloves, sterile drape, and antiseptic solution
- C. Non-sterile gloves and povidone-iodine swabs
- D. Clean technique with sterile catheter
Answer: B. Sterile gloves, sterile drape, and antiseptic solution