BANK QUESTIONS AND CORRECT VERIFIED ANSWERS.
1. The nurse working on a pediatric unit has received the hand-off report. Which
client should the nurse plan to see first?
A. A toddler with bronchiolitis on room air and mild wheezing
B. An infant with pertussis receiving oxygen via nasal cannula
C. A preschooler with otitis media awaiting discharge
D. A school-age child with a simple fracture in a cast
Answer: B. An infant with pertussis receiving oxygen via nasal cannula
Rationale: Infants with pertussis are at high risk for apnea and severe respiratory
compromise. Any child on supplemental oxygen with a respiratory diagnosis is a
higher priority than stable conditions. Early recognition and intervention are
essential in pediatric safety.
2. The nurse has received the hand-off report and is assigning tasks to
unlicensed assistive personnel (UAP). Which task should the nurse instruct the
UAP to perform first?
A. Assist a client post-hip replacement with first ambulation
B. Obtain a capillary blood glucose on a client who had a hypoglycemic episode 30
minutes ago and received dextrose IV
C. Change linens for a client who was incontinent of urine
D. Take vital signs on a client scheduled for afternoon surgery
Answer: B. Obtain a capillary blood glucose on a client who had a hypoglycemic
episode 30 minutes ago and received dextrose IV
Rationale: Rechecking blood glucose after treatment of hypoglycemia is time-
sensitive and determines if treatment was effective. Delegating this stable but
urgent reassessment to UAP is appropriate.
,3. A client with COPD has ABGs: pH 7.30, PaCO₂ 55 mmHg. The nurse interprets
this as:
A. Respiratory alkalosis
B. Metabolic acidosis
C. Respiratory acidosis
D. Metabolic alkalosis
Answer: C. Respiratory acidosis
Rationale: The pH is low (acidotic) and PaCO₂ is elevated, indicating respiratory
acidosis. In COPD, carbon dioxide retention is common due to impaired gas
exchange.
4. Which laboratory value indicates therapeutic anticoagulation with warfarin?
A. INR 0.8
B. INR 1.0
C. INR 2.5
D. INR 6.0
Answer: C. INR 2.5
Rationale: Most clients receiving warfarin have a therapeutic INR of
approximately 2-3 for standard indications. Values below 2 indicate
subtherapeutic levels, while values above 5 indicate increased bleeding risk.
5. The nurse is caring for a client who has a sealed radiation implant. Which
precaution should the nurse implement?
A. Assign a different nurse to care for the client each day
B. Limit visitors to 30 minutes per day and have them stay at least 6 feet away
C. Place the client in a semiprivate room with another stable client
D. Allow pregnant staff to provide care if they wear lead aprons
Answer: B. Limit visitors to 30 minutes per day and have them stay at least 6
feet away
,Rationale: Radiation safety includes time, distance, and shielding principles:
minimize time, maximize distance, and use shielding as appropriate. Pregnant
staff should avoid caring for these clients.
6. The nurse working in the emergency department is triaging clients following
an explosion. Which client should the nurse identify as the priority for
treatment?
A. A client with a simple arm laceration and controlled bleeding
B. A client with second-degree burns to the chest and arms with respiratory rate
greater than 30
C. A client with a closed tibia fracture and intact pulses
D. A client with minor abrasions and mild anxiety
Answer: B. A client with second-degree burns to the chest and arms with
respiratory rate greater than 30
Rationale: In mass-casualty triage, compromised airway or breathing (burns to
chest + tachypnea) gets immediate priority (red tag). Other injuries are important
but do not threaten life as acutely.
7. The nurse is caring for a client who has severe hypocalcemia. Which
intervention should the nurse include in the plan of care?
A. Place the client on seizure precautions
B. Limit the client's fluid intake
C. Encourage high-phosphorus foods
D. Place the client in high Fowler's position at all times
Answer: A. Place the client on seizure precautions
Rationale: Severe hypocalcemia increases neuromuscular excitability, leading to
tetany and seizures. Safety measures such as seizure precautions are a priority.
8. The nurse preceptor is observing a newly hired nurse. Which action by the
newly hired nurse indicates correct care?
, A. Using a family member as an interpreter for informed consent
B. Priming IV tubing with normal saline before a blood transfusion
C. Administering an influenza vaccine using the Z-track method
D. Prepping an IV site with alcohol in a back-and-forth pattern
Answer: B. Priming IV tubing with normal saline before a blood transfusion
Rationale: IV tubing should be primed with normal saline before blood transfusion.
The Z-track method is not used for vaccines, family members should not be used
as interpreters for informed consent, and alcohol should be applied in a circular
motion from center to periphery.
9. The nurse is assessing a client who has hyperkalemia. Which ECG finding is
expected?
A. Flat T waves
B. Peaked T waves
C. Prolonged PR interval only
D. U waves
Answer: B. Peaked T waves
Rationale: Hyperkalemia commonly causes peaked T waves and can progress to
lethal dysrhythmias. Flat T waves and U waves are associated with hypokalemia.
10. The nurse is caring for assigned clients. Which action demonstrates proper
delegation to an assistive personnel (AP)?
A. Initial assessment
B. Care plan development
C. Ambulating a stable client
D. Client teaching
Answer: C. Ambulating a stable client
Rationale: APs may perform routine, stable, non-assessment tasks such as
ambulation. Assessment, teaching, and care planning require licensed nursing
judgment.