(2026) Q&A
1. The nurse is preparing to assess an adult patient's abdomen. Which sequence
should the nurse follow for this assessment?
A) Inspection, Palpation, Percussion, Auscultation
B) Auscultation, Inspection, Palpation, Percussion
C) Inspection, Auscultation, Percussion, Palpation
D) Palpation, Percussion, Inspection, Auscultation
Correct Answer: Inspection, Auscultation, Percussion, Palpation
Rationale: For abdominal assessment, the sequence is Inspection, Auscultation,
Percussion, then Palpation. Auscultation must precede palpation and percussion
because manipulating the abdomen can alter bowel sounds.
2. A nurse is using the ISBARR tool to communicate with a healthcare provider about
a patient's change in condition. What does the second "R" in ISBARR stand for?
A) Response
B) Readback
C) Recommendation
D) Reassessment
Correct Answer: Readback
Rationale: ISBARR stands for Introduction, Situation, Background, Assessment,
Recommendation, and Readback. Readback is the final step where the nurse confirms
that the provider has accurately received and understood the information.
,3. A patient asks the nurse, "Why do I need to have my vital signs checked so often?"
Which response by the nurse is most appropriate?
A) "It's hospital policy to check vital signs every four hours."
B) "Vital signs help us monitor your body's basic functions and detect changes in
your condition."
C) "I am just following the doctor's orders."
D) "Don't worry, it's a routine procedure."
Correct Answer: "Vital signs help us monitor your body's basic functions and detect
changes in your condition."
Rationale: This response provides a clear, patient-centered explanation of the
purpose of monitoring vital signs. It empowers the patient with knowledge and
promotes understanding of their care. The other options do not adequately address
the patient's question or provide meaningful information.
4. A nurse is preparing to administer oral medications to a patient. Which of the
following is the correct order for the "Three Checks" of medication administration?
A) Check before preparing, check after preparing, check before administering
B) Check before preparing, check before administering, check after administering
C) Check when removing from storage, check before preparing, check before
administering
D) Check when removing from storage, check before administering, check after
administering
Correct Answer: Check before preparing, check after preparing, check before
administering
, Rationale: The three checks of medication administration involve checking the
medication label: (1) when removing the medication from the storage area, (2) when
preparing the medication, and (3) before administering it to the patient. This process
ensures accuracy and patient safety.
5. The nurse is caring for a patient who is 24 hours post-operative. The patient rates
their pain as an 8 on a scale of 0 to 10. What is the nurse's priority action?
A) Document the pain score
B) Administer prescribed analgesic
C) Notify the healthcare provider
D) Reassess pain in 30 minutes
Correct Answer: Administer prescribed analgesic
Rationale: A pain score of 8 indicates severe pain requiring intervention. The nurse
should administer a prescribed analgesic to manage the patient's pain.
Documentation and reassessment are important but should follow intervention.
Notification of the provider is not necessary if there is a standing order for pain
medication.
6. Which of the following patients would require the nurse to implement contact
precautions?
A) A patient with tuberculosis
B) A patient with a wound infection caused by MRSA
C) A patient with influenza
D) A patient with pneumonia
Correct Answer: A patient with a wound infection caused by MRSA