Questions with Correct Answers & Detailed Rationales – Latest
Update 2026/2027 | Graded A+
Question 1
A nurse is caring for a client who is at risk for falls. Which intervention should
the nurse implement?
A. Place the client’s personal items within reach
B. Raise all four side rails on the bed
C. Keep the room dark to promote sleep
D. Encourage the client to ambulate without assistance
Correct Answer: A. Place the client’s personal items within reach
Rationale:
Keeping frequently used items within reach reduces the need for the client to
attempt unsafe movements. Raising all four side rails is considered a restraint
and may increase injury risk.
Question 2
A nurse is preparing to administer medication to a client. Which action
demonstrates correct use of medication safety principles?
A. Verify the medication using two client identifiers
B. Ask another client to confirm the medication
C. Administer medications without checking allergies
D. Document medication before administration
Correct Answer: A. Verify the medication using two client identifiers
Rationale:
Using two identifiers, such as name and date of birth, helps prevent
medication errors and ensures the medication is given to the correct client.
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,Question 3
A nurse enters a client’s room and finds the client lying on the floor. What is
the nurse’s priority action?
A. Assess the client for injury
B. Complete an incident report immediately
C. Help the client back into bed
D. Notify the family first
Correct Answer: A. Assess the client for injury
Rationale:
The nurse should first assess the client’s condition, including airway,
breathing, circulation, and possible injuries before moving the client.
Question 4
A nurse is caring for a client who has a prescription for oxygen therapy. Which
action is appropriate?
A. Assess the client’s respiratory status regularly
B. Apply petroleum-based products around the oxygen device
C. Allow smoking near oxygen equipment
D. Discontinue oxygen without an order
Correct Answer: A. Assess the client’s respiratory status regularly
Rationale:
Oxygen therapy requires ongoing assessment of respiratory status and oxygen
effectiveness. Oxygen increases fire risk, and petroleum products should be
avoided.
Question 5
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,A nurse is preparing to perform hand hygiene. When should the nurse
perform hand hygiene?
A. Before and after every client contact
B. Only after contact with bodily fluids
C. Once at the beginning of the shift
D. Only when hands appear dirty
Correct Answer: A. Before and after every client contact
Rationale:
Hand hygiene is the most effective method to prevent healthcare-associated
infections.
Question 6
A nurse is caring for a client who has a prescription for a sterile dressing
change. Which action maintains sterile technique?
A. Keep sterile supplies above waist level
B. Touch sterile gloves with bare hands
C. Place sterile items on the floor
D. Reach across the sterile field
Correct Answer: A. Keep sterile supplies above waist level
Rationale:
Items below waist level are considered contaminated. Maintaining the sterile
field prevents infection.
Question 7
A nurse is admitting a client to the unit. Which assessment finding requires
immediate attention?
A. Difficulty breathing
B. Mild anxiety
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, C. Request for food
D. Need for assistance with bathing
Correct Answer: A. Difficulty breathing
Rationale:
Airway and breathing problems are immediate priorities according to the ABC
approach.
Question 8
A nurse is educating a client about informed consent. Which statement
indicates understanding?
A. “The provider explains the procedure and risks before I sign.”
B. “The nurse explains all surgical risks.”
C. “I must sign even if I do not understand.”
D. “My family can sign without my permission.”
Correct Answer: A. “The provider explains the procedure and risks
before I sign.”
Rationale:
The healthcare provider performing the procedure is responsible for
explaining risks, benefits, and alternatives before consent.
Question 9
A nurse is caring for a client who reports pain. Which action should the nurse
take first?
A. Assess the pain characteristics
B. Administer medication immediately
C. Tell the client pain is expected
D. Ignore the complaint
Correct Answer: A. Assess the pain characteristics
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