RNSG 1430 RN CONCEPT BASED ASSESSMENT LEVEL 1
NEWEST 2026 ACTUAL EXAM 100 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
ALREADY GRADED A+
A nurse is providing discharge teaching about nutrition management to a client who has
COPD. Which of the following instructions should the nurse include in the teaching? -
...ANSWER...Have a high-calorie protein drink between meals.
RATIONALE: The nurse should encourage a client who has COPD to drink a high-calorie
protein drink between meals.
Anorexia is a manifestation of COPD and this added nutritional intake promotes weight gain.)
A nurse is caring for a client who has dysphagia following a stroke. Which of the following
actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration?
- ...ANSWER...Delay the clients meal-time if he is fatigued.
RATIONALE: To facilitate safe swallowing and decrease the risk of aspiration, the nurse
should encourage the client to test prior to meal-time. If the client is fatigued, the nurse
should delay the meal-time and give the client time to rest.)
A nurse is teaching the parent of a toddler about home injury prevention. When discussing
snacks, which of the following
statements by the parent indicates an understanding of the teaching? - ...ANSWER..."I can
give her watermelon pieces after I remove the seeds."
RATIONALE: The nurse should inform the parent that toddlers can easily choke on seeds
from fruits, such as watermelon seeds or cherry pits, because of their round shape and size.
Removing the seeds and cutting the watermelon into pieces provides the toddler with a
nutritious snack that does not increase the toddler's risk of foreign body obstruction.)
A nurse is asked by a provider to perform an invasive procedure for which he has not
received training. Which of the following actions should the nurse take to ensure that it is
within his legal scope of practice to perform this procedure? -
...ANSWER...Check the states nurse practice act before performing the procedure.
RATIONALE: The nurse should check the state's nurse practice act to verify that
performance is within his scope of practice. This will ensure that the nurse follows legal
guidelines for his scope of practice. If the nurse works in more than one state, he should check
the nurse practice act for each state, because guidelines for this procedure might differ from
state to state. If the procedure is within the nurse's scope of practice, he should take necessary
steps to gain competence in the procedure before performing it on a client.)
A nurse is caring for a older adult client who has a leg wound following a fall on the stairs.
The nurse would identify which of the following factors as an expected, age-related change
in older adults that can impair wound healing? -
...ANSWER...Elastin fibers separate and thicken. RATIONALE: The nurse should identify
that elastin fibers in an older adult client thicken and separate, which can cause
,delayed wound healing and lead to a "saggy" appearance due to decreased skin elasticity.)
A nurse in a long-term care facility discovers a small fire in a client's trash can. After
moving the client to safety, which of the following actions should the nurse take next? -
...ANSWER...Pull the alarm to notify emergency services. RATIONALE: Evidence-based
practice indicates the nurse should first rescue and remove clients in immediate danger and
then activate the alarm to notify authorities of the situation.)
A nurse is preparing to leave the room who is on isolation precautions. Which of the
following actions should the nurse take when removing a tied surgical mask? -
...ANSWER...Remove the mask by securely holding the ties and moving it away from the
face.
RATIONALE: The nurse should untie the bottom strings and then the top strings. Finally,
while still holding the strings, the nurse should remove the mask from her face. This action
prevents the nurse from touching the front of the mask, which is contaminated.)
A nurse is searching electronic databases for clinical research about behavioral indicators.
Which of the following online sources should the nurse select to research this infant care
issue? - ...ANSWER...Cumulative Index to Nursing and Allied Health Literature (CINAHL)
RATIONALE: The nurse should select the Cumulative Index to Nursing and Allied Health
Literature (CINAHL) to locate clinical research about health-related client care issues.
CINAHL is a cumulative index that the nurse can search electronically to locate reliable data
related to the specific topic being researched.)
A nurse is preparing to administer three medications to a client who has an NG tube: a
levothyroxine tablet, an ibuprofen gel cap, and a delayed-release omeprazole capsule.
Which of the following actions should the nurse take? -
...ANSWER...Crush the levothyroxine tablet into a powder and dissolve it into 30 mL of
warm sterile water.
RATIONALE: The nurse should prepare simple tablets for NG administration by crushing
them into a fine powder and dissolving them in at least 30 mL of warm sterile water. Cold
water can cause discomfort. Sterile water eliminates the possible problem of chemicals in
tap water interacting with the medication.)
A nurse is planning care who has an indwelling urinary catheter. Which of the following
interventions include in the plan to prevent the development of a catheter-associated urinary
tract infection (CAUTI)? - ...ANSWER...Secure the catheter tubing to the client's leg.
RATIONALE: The nurse should assess the client's need for urinary catheterization and
should follow evidence-based practice to prevent or reduce the risk of CAUTI development.
This includes securing the catheter tubing to the client's leg so that the catheter does not
move, reducing the risk of urethral trauma and introduction of bacteria into the urinary
system.)
A nurse is caring for a 2-year-old toddler who is immediately postoperative. Which of the
following pain scales should the nurse use to access the toddler's pain level? -
...ANSWER...FLACC scale
, RATIONALE: The nurse should use the FLACC scale to assess pain for a 2-year-old child.
The FLACC scale assesses facial expression, leg movement, activity, cry, and consolability
in children 2 months to 7 years of age. The nurse assigns a score of 0 to 2 for each area.)
A nurse is caring for a client who has cancer and is planning discharge to home with hospice
care. Which of the following statements by the client indicates that he is experiencing
spiritual distress? - ...ANSWER..."I wish God had not allowed this cancer to invade my
body."
RATIONALE: The nurse should identify that this statement indicates the client is
experiencing spiritual distress, which occurs when there is a disturbance in a client's belief
system. This client is expressing spiritual anger and not accepting his condition.)
A nurse is planning care for a client who has breast cancer and is scheduled for
chemotherapy. The client reports experiencing chemotherapy-induced nausea and vomiting
(CINV) during her previous round of treatment. Which of the following interventions should
the nurse include in the client's plan of care? - ...ANSWER...Administer ondansetron to the
client prior to chemotherapy administration.
RATIONALE: The nurse should incorporate evidence-based practice interventions into the
client's plan of care to prevent and treat CINV. Evidence-based research indicates that
prevention of CINV is best achieved when antiemetics, such as ondansetron, are given prior
to the administration of chemotherapy.)
A nurse in a long-term care facility is admitting a new client following a brief stay in acute
care. In adherence with the Joint Commission National Patient Safety Goals regarding
medication administration, which of the following actions should the nurse take? -
...ANSWER...Compare a list of the client's current medications with the ones he will take in
long-term care.
RATIONALE: The Joint Commission National Patient Safety Goals regarding medication
reconciliation includes maintaining and communicating accurate client medication
information. The nurse should complete a medication reconciliation to identify and resolve
any discrepancies by comparing the client's list of current medications with the medications
he will take in the long-term care facility and addressing any duplications, omissions, or
interactions.)
A nurse in a long-term care facility is performing a fall risk assessment on a newly admitted
client using the Timed Up and Go (TUG) test. The client reports using a tripod cane for
ambulation. Which of the following actions should the nurse take when using this test? -
...ANSWER...Observe the client ambulating a distance of 3 m (10 feet) during the TUG test.
(The nurse should mark a spot 3 m (10 feet) away from the client's sitting location. The nurse
should instruct the client to stand, ambulate to the marked spot, turn, ambulate back to the
chair, and sit down. The nurse should observe the client's ability to perform the test and use a
stopwatch to time the client. The nurse should identify that the client is at increased risk of
falls if it takes longer than 14 seconds to complete the test.)
A nurse in an orthopedic clinic is documenting data about several clients. Which of the
following actions should the nurse take to comply with the regulations of the Health
Portability and Accountability Act (HIPAA)? -
NEWEST 2026 ACTUAL EXAM 100 QUESTIONS AND
CORRECT DETAILED ANSWERS WITH RATIONALES
ALREADY GRADED A+
A nurse is providing discharge teaching about nutrition management to a client who has
COPD. Which of the following instructions should the nurse include in the teaching? -
...ANSWER...Have a high-calorie protein drink between meals.
RATIONALE: The nurse should encourage a client who has COPD to drink a high-calorie
protein drink between meals.
Anorexia is a manifestation of COPD and this added nutritional intake promotes weight gain.)
A nurse is caring for a client who has dysphagia following a stroke. Which of the following
actions should the nurse take to facilitate safe swallowing and decrease the risk of aspiration?
- ...ANSWER...Delay the clients meal-time if he is fatigued.
RATIONALE: To facilitate safe swallowing and decrease the risk of aspiration, the nurse
should encourage the client to test prior to meal-time. If the client is fatigued, the nurse
should delay the meal-time and give the client time to rest.)
A nurse is teaching the parent of a toddler about home injury prevention. When discussing
snacks, which of the following
statements by the parent indicates an understanding of the teaching? - ...ANSWER..."I can
give her watermelon pieces after I remove the seeds."
RATIONALE: The nurse should inform the parent that toddlers can easily choke on seeds
from fruits, such as watermelon seeds or cherry pits, because of their round shape and size.
Removing the seeds and cutting the watermelon into pieces provides the toddler with a
nutritious snack that does not increase the toddler's risk of foreign body obstruction.)
A nurse is asked by a provider to perform an invasive procedure for which he has not
received training. Which of the following actions should the nurse take to ensure that it is
within his legal scope of practice to perform this procedure? -
...ANSWER...Check the states nurse practice act before performing the procedure.
RATIONALE: The nurse should check the state's nurse practice act to verify that
performance is within his scope of practice. This will ensure that the nurse follows legal
guidelines for his scope of practice. If the nurse works in more than one state, he should check
the nurse practice act for each state, because guidelines for this procedure might differ from
state to state. If the procedure is within the nurse's scope of practice, he should take necessary
steps to gain competence in the procedure before performing it on a client.)
A nurse is caring for a older adult client who has a leg wound following a fall on the stairs.
The nurse would identify which of the following factors as an expected, age-related change
in older adults that can impair wound healing? -
...ANSWER...Elastin fibers separate and thicken. RATIONALE: The nurse should identify
that elastin fibers in an older adult client thicken and separate, which can cause
,delayed wound healing and lead to a "saggy" appearance due to decreased skin elasticity.)
A nurse in a long-term care facility discovers a small fire in a client's trash can. After
moving the client to safety, which of the following actions should the nurse take next? -
...ANSWER...Pull the alarm to notify emergency services. RATIONALE: Evidence-based
practice indicates the nurse should first rescue and remove clients in immediate danger and
then activate the alarm to notify authorities of the situation.)
A nurse is preparing to leave the room who is on isolation precautions. Which of the
following actions should the nurse take when removing a tied surgical mask? -
...ANSWER...Remove the mask by securely holding the ties and moving it away from the
face.
RATIONALE: The nurse should untie the bottom strings and then the top strings. Finally,
while still holding the strings, the nurse should remove the mask from her face. This action
prevents the nurse from touching the front of the mask, which is contaminated.)
A nurse is searching electronic databases for clinical research about behavioral indicators.
Which of the following online sources should the nurse select to research this infant care
issue? - ...ANSWER...Cumulative Index to Nursing and Allied Health Literature (CINAHL)
RATIONALE: The nurse should select the Cumulative Index to Nursing and Allied Health
Literature (CINAHL) to locate clinical research about health-related client care issues.
CINAHL is a cumulative index that the nurse can search electronically to locate reliable data
related to the specific topic being researched.)
A nurse is preparing to administer three medications to a client who has an NG tube: a
levothyroxine tablet, an ibuprofen gel cap, and a delayed-release omeprazole capsule.
Which of the following actions should the nurse take? -
...ANSWER...Crush the levothyroxine tablet into a powder and dissolve it into 30 mL of
warm sterile water.
RATIONALE: The nurse should prepare simple tablets for NG administration by crushing
them into a fine powder and dissolving them in at least 30 mL of warm sterile water. Cold
water can cause discomfort. Sterile water eliminates the possible problem of chemicals in
tap water interacting with the medication.)
A nurse is planning care who has an indwelling urinary catheter. Which of the following
interventions include in the plan to prevent the development of a catheter-associated urinary
tract infection (CAUTI)? - ...ANSWER...Secure the catheter tubing to the client's leg.
RATIONALE: The nurse should assess the client's need for urinary catheterization and
should follow evidence-based practice to prevent or reduce the risk of CAUTI development.
This includes securing the catheter tubing to the client's leg so that the catheter does not
move, reducing the risk of urethral trauma and introduction of bacteria into the urinary
system.)
A nurse is caring for a 2-year-old toddler who is immediately postoperative. Which of the
following pain scales should the nurse use to access the toddler's pain level? -
...ANSWER...FLACC scale
, RATIONALE: The nurse should use the FLACC scale to assess pain for a 2-year-old child.
The FLACC scale assesses facial expression, leg movement, activity, cry, and consolability
in children 2 months to 7 years of age. The nurse assigns a score of 0 to 2 for each area.)
A nurse is caring for a client who has cancer and is planning discharge to home with hospice
care. Which of the following statements by the client indicates that he is experiencing
spiritual distress? - ...ANSWER..."I wish God had not allowed this cancer to invade my
body."
RATIONALE: The nurse should identify that this statement indicates the client is
experiencing spiritual distress, which occurs when there is a disturbance in a client's belief
system. This client is expressing spiritual anger and not accepting his condition.)
A nurse is planning care for a client who has breast cancer and is scheduled for
chemotherapy. The client reports experiencing chemotherapy-induced nausea and vomiting
(CINV) during her previous round of treatment. Which of the following interventions should
the nurse include in the client's plan of care? - ...ANSWER...Administer ondansetron to the
client prior to chemotherapy administration.
RATIONALE: The nurse should incorporate evidence-based practice interventions into the
client's plan of care to prevent and treat CINV. Evidence-based research indicates that
prevention of CINV is best achieved when antiemetics, such as ondansetron, are given prior
to the administration of chemotherapy.)
A nurse in a long-term care facility is admitting a new client following a brief stay in acute
care. In adherence with the Joint Commission National Patient Safety Goals regarding
medication administration, which of the following actions should the nurse take? -
...ANSWER...Compare a list of the client's current medications with the ones he will take in
long-term care.
RATIONALE: The Joint Commission National Patient Safety Goals regarding medication
reconciliation includes maintaining and communicating accurate client medication
information. The nurse should complete a medication reconciliation to identify and resolve
any discrepancies by comparing the client's list of current medications with the medications
he will take in the long-term care facility and addressing any duplications, omissions, or
interactions.)
A nurse in a long-term care facility is performing a fall risk assessment on a newly admitted
client using the Timed Up and Go (TUG) test. The client reports using a tripod cane for
ambulation. Which of the following actions should the nurse take when using this test? -
...ANSWER...Observe the client ambulating a distance of 3 m (10 feet) during the TUG test.
(The nurse should mark a spot 3 m (10 feet) away from the client's sitting location. The nurse
should instruct the client to stand, ambulate to the marked spot, turn, ambulate back to the
chair, and sit down. The nurse should observe the client's ability to perform the test and use a
stopwatch to time the client. The nurse should identify that the client is at increased risk of
falls if it takes longer than 14 seconds to complete the test.)
A nurse in an orthopedic clinic is documenting data about several clients. Which of the
following actions should the nurse take to comply with the regulations of the Health
Portability and Accountability Act (HIPAA)? -
