QUESTIONS AND CORRECT ANSWERS WITH
DETAILED RATIONALES
Part 1: Foundations of Nursing Practice (Questions 1-30)
1. A nurse is caring for a client who is post-operative. The nurse identifies a
nursing diagnosis of "Risk for Infection." What is the most appropriate initial
intervention?
A) Administer prescribed antibiotics.
B) Maintain strict hand hygiene.
C) Monitor the client's white blood cell count.
D) Ensure the client's wound dressing is dry.
Correct Answer: B
Rationale: The initial intervention for any risk for infection is to prevent the
introduction of pathogens. Hand hygiene is the single most effective way to
prevent infection. While monitoring and administering antibiotics are
important, they come after implementing prevention strategies.
2. A client is using defense mechanisms. Which of the following is an example
of sublimation?
A) A student who fails an exam blames the teacher.
B) A person who is angry goes for a run.
C) A woman who is jealous of her friend says she doesn't want a promotion
anyway.
D) A man who has aggressive impulses becomes a professional boxer.
,Correct Answer: D
Rationale: Sublimation is a mature defense mechanism where socially
unacceptable impulses are transformed into socially acceptable actions.
Turning aggressive impulses into a career as a boxer is a classic example.
Option A is projection, B is a healthy coping mechanism but not sublimation,
and C is sour-graping/rationalization.
3. A nurse is preparing to administer medication to a client. The nurse verifies
the client's identity using two identifiers. Which of the following is the most
acceptable way to do this?
A) Ask the client, "Are you Mr. Smith?"
B) Check the client's room number and bed number.
C) Check the client's wristband and ask the client to state their name and date
of birth.
D) Check the medication administration record (MAR) against the client's
chart.
Correct Answer: C
Rationale: The Joint Commission requires two patient identifiers, and neither
should be the room number or bed number. The most reliable method is to
use a unique identifier like a wristband and ask the patient to state their name
and date of birth.
4. A client with a new colostomy is reluctant to look at the stoma. What is the
nurse's best initial response?
A) "You'll get used to it in a few days."
B) "It's normal to feel this way. Would you like to just look at it for a moment?"
C) "Don't worry, your family will be able to help you care for it."
D) "You need to look at it so we can start your teaching."
Correct Answer: B
,Rationale: The nurse should acknowledge the client's feelings (validation) and
gently encourage them to begin the process of acceptance at their own pace.
Option B is the most therapeutic and allows the client some control.
5. A nurse is using therapeutic communication. Which statement is an
example of a broad opening?
A) "Tell me more about how you are feeling."
B) "What would you like to talk about today?"
C) "It seems like you are feeling anxious."
D) "Are you feeling sad?"
Correct Answer: B
Rationale: A broad opening is an open-ended question that gives the client the
freedom to choose the topic of conversation. "What would you like to talk
about today?" is a direct example.
6. A nurse is educating a client about their new prescription for an ACE
inhibitor. The nurse should instruct the client to report which adverse effect
immediately?
A) Dizziness.
B) Dry cough.
C) Angioedema.
D) Headache.
Correct Answer: C
Rationale: Angioedema (swelling of the lips, tongue, throat) is a rare but life-
threatening adverse effect of ACE inhibitors. It can cause airway obstruction
and requires immediate medical attention.
, 7. A nurse is planning care for a client with impaired mobility. Which of the
following actions best prevents pressure injuries?
A) Massage the client's bony prominences.
B) Reposition the client every 2 hours.
C) Keep the client's skin moist with lotion.
D) Use a donut-shaped cushion for the client to sit on.
Correct Answer: B
Rationale: Repositioning every 2 hours is the most effective way to relieve
pressure on bony prominences and prevent ischemia. Massaging bony
prominences is no longer recommended as it can damage capillaries. Donut
cushions can create a ring of pressure and are not recommended.
8. A client states, "I'm not sure I want to take this medicine. It makes me feel
strange." What is the nurse's best response?
A) "The doctor prescribed it for you, so you must take it."
B) "Tell me more about how it makes you feel."
C) "You'll get used to the side effects."
D) "Let me call the doctor to change the order."
Correct Answer: B
Rationale: This response uses therapeutic communication by asking for
clarification and exploring the client's feelings. It respects the client's
autonomy and allows for further assessment of the side effects.
9. A nurse is preparing a sterile field. Which action would cause a
contamination?
A) Placing the sterile drape on the table and only touching it with sterile
gloves.
B) Opening the sterile pack away from the body.