150 Practice Questions with Rationales
SECTION 1: FUNDAMENTALS OF NURSING (Questions 1-30)
1. A nurse is preparing to perform a sterile dressing change. Which action by the
nurse 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 into a sterile container from 6 inches above
D. Keeping sterile items above waist level
Correct Answer: B
Rationale: The 1-inch (2.5 cm) 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 above 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, then goggles or face shield, and finally gloves. The gown is donned first to prevent
contamination of the uniform. Gloves are donned last to ensure they remain sterile and
are not contaminated during the process .
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 on a scale of 0 to 10?"
Correct Answer: C
Rationale: In the PQRST mnemonic: P = Provocation/Palliation, Q = Quality/Quantity, R =
Radiation (does the pain spread?), S = Severity Scale, T = Timing. Asking if pain spreads
assesses radiation .
4. A nurse is caring for a client with diabetes and a blood glucose of 48 mg/dL.
What is the priority action?
A. Administer insulin
B. Recheck blood glucose in 30 minutes
C. Administer 15g of fast-acting carbohydrate
D. Notify the provider
Correct Answer: C
Rationale: Hypoglycemia (blood glucose below 70 mg/dL) is life-threatening and requires
immediate intervention. The priority is to administer 15g of fast-acting carbohydrate (such
as glucose tablets or 4 oz of juice) and recheck in 15 minutes. This follows the "Rule of 15"
for hypoglycemia management .
,5. A nurse is administering 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 vein irritation; burning may indicate infiltration or too
rapid infusion and requires immediate action. IV potassium should never be given as a
bolus or push, and infusion rate should not exceed 10 mEq/hr via peripheral line .
6. A client experiencing opioid overdose should receive which medication?
A. Flumazenil
B. Naloxone
C. Atropine
D. Protamine sulfate
Correct Answer: B
Rationale: Naloxone (Narcan) is the opioid antagonist used to reverse opioid overdose.
Flumazenil reverses benzodiazepine overdose. Atropine is used for bradycardia. Protamine
sulfate reverses heparin .
7. Which client should the nurse assess FIRST after receiving change-of-shift
report?
A. A client reporting incisional pain 7/10 after surgery
B. A client with COPD reporting mild shortness of breath while eating
C. A client with diabetes and blood glucose of 48 mg/dL
D. A client scheduled for discharge teaching in 30 minutes
Correct Answer: C
, Rationale: Hypoglycemia is life-threatening and requires immediate intervention to
prevent seizure, coma, or death. Airway, breathing, and circulation priorities and unstable
glucose levels always take precedence .
8. Which action demonstrates the "right patient" principle during medication
administration?
A. Asking the client to state their 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. This follows the "right patient" principle of the Six Rights of
Medication Administration .
9. 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 before escalating or documenting. This respects the
client's autonomy and right to make informed decisions .
10. A nurse is providing discharge teaching after surgery. Which statement
indicates understanding?