Practice Questions
Form A - Fundamentals & Core Concepts
1. A nurse is preparing to perform a sterile dressing change. Which action
demonstrates a break in sterile technique?
A. Opening the sterile package away from the body
B. Placing sterile items on the edge of the sterile field
C. Pouring sterile solution from 6 inches above the container
D. Keeping sterile items above waist level
Correct Answer: B
Rationale: The 1-inch border of a sterile field is considered contaminated. Placing items on
the edge compromises sterility. Opening the package away from the body prevents
contamination, pouring from 6 inches prevents splashing, and keeping items above waist
level maintains sterility .
2. A nurse is caring for a client on contact precautions. Which PPE should the nurse
don first?
A. Gloves
B. Goggles
C. Gown
D. Mask
Correct Answer: C
Rationale: The correct order for donning PPE in contact precautions is gown first, then
mask, goggles or face shield, and gloves last. The gown is donned first to prevent
contamination of the uniform, while gloves are donned last to ensure they remain clean .
,3. A nurse is assessing a client's pain using the PQRST mnemonic. Which question
assesses "R" (Radiation)?
A. "Where is your pain located?"
B. "What makes your pain worse?"
C. "Does the pain spread anywhere?"
D. "How severe is your pain?"
Correct Answer: C
Rationale: "R" in PQRST stands for Radiation—asking if pain spreads identifies whether
pain radiates to other body areas. Location relates to "P" (Provocation/Palliation), "What
makes it worse" relates to Provocation, and severity relates to "S" (Severity) .
4. A nurse is prioritizing care for four clients. Which client should be seen first?
A. A client reporting incisional pain 7/10 after surgery
B. A client with COPD reporting mild shortness of breath
C. A client with diabetes and blood glucose of 48 mg/dL
D. A client scheduled for discharge teaching
Correct Answer: C
Rationale: Hypoglycemia (blood glucose 48 mg/dL) is life-threatening and requires
immediate intervention to prevent seizure, coma, or death. Airway, breathing, circulation
priorities and unstable glucose levels always take precedence over pain, stable respiratory
issues, or scheduled teaching .
5. A nurse is preparing to administer medications. Which action demonstrates the
"right patient" principle?
A. Asking the client to state full name and date of birth
B. Checking the room number before giving medication
C. Asking another nurse to verify the medication
D. Comparing the medication to the MAR
,Correct Answer: A
Rationale: Two patient identifiers such as name and date of birth are required to ensure
correct patient identification. Room numbers change and are not reliable identifiers.
Medication verification with another nurse addresses the "right medication" principle, not
patient identification .
6. A client refuses a prescribed treatment. What is the nurse's first action?
A. Document the refusal
B. Notify the provider immediately
C. Assess the client's understanding of the treatment
D. Ask family members to persuade the client
Correct Answer: C
Rationale: The nurse must first ensure informed refusal by assessing the client's
understanding of the treatment, risks, and benefits. Only after confirming understanding
should the nurse document the refusal and notify the provider. Coercion by family is
unethical .
7. A nurse is caring for a client with heart failure who reports sudden weight gain.
What is the priority action?
A. Increase fluid intake
B. Notify the provider
C. Encourage rest
D. Recheck weight in 1 week
Correct Answer: B
Rationale: Sudden weight gain (typically 2-3 lbs in 24 hours or 5 lbs in a week) indicates
fluid overload and worsening heart failure requiring prompt intervention. The provider
must be notified immediately to adjust diuretic therapy .
, 8. A nurse is caring for a client receiving IV potassium. Which finding is most
concerning?
A. Serum potassium 3.6 mEq/L
B. Burning at IV site
C. Heart rate 78 bpm
D. Urine output 40 mL/hr
Correct Answer: B
Rationale: IV potassium can cause severe vein irritation and tissue necrosis if infiltration
occurs. Burning at the site may indicate infiltration or too rapid infusion and requires
immediate action—stopping the infusion and assessing the site. A potassium of 3.6 is
slightly low but not immediately life-threatening .
9. A client is experiencing opioid overdose. Which medication should the nurse
prepare?
A. Flumazenil
B. Naloxone
C. Atropine
D. Protamine sulfate
Correct Answer: B
Rationale: Naloxone (Narcan) is the antidote for opioid overdose. It competes with opioids
at receptor sites and rapidly reverses respiratory depression. Flumazenil is for
benzodiazepine overdose, atropine for bradycardia, and protamine sulfate for heparin
overdose .
10. A nurse is providing discharge teaching after surgery. Which statement
indicates understanding?
A. "I will remove my dressing daily regardless of instructions"
B. "I will report redness, swelling, or drainage at the incision site"