ASSESSMENT QUESTION WITH WELL VERIFIED ANSWERS
180 Original Practice Questions with Answers & Rationales
SECTION I — FUNDAMENTALS & BASIC CARE
1. A nurse is caring for a client who is at risk for pressure injury. Which intervention is most
appropriate?
A. Massage reddened areas
B. Reposition the client regularly
C. Keep the skin moist
D. Place a donut-shaped device under the sacrum
**Answer: .B**
**Rationale:** Regular repositioning relieves pressure and helps prevent tissue injury.
Reddened areas should not be massaged.
2. Which finding indicates that a client may be experiencing dehydration?
A. Bounding pulse
B. Moist mucous membranes
,C. Dark, concentrated urine
D. Increased urine output
**Answer: .C**
**Rationale:** Concentrated, dark urine is a common sign of fluid deficit.
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3. A client has difficulty swallowing. Which intervention should the nurse implement?
A. Give thin liquids
B. Position the client upright during meals
C. Encourage the client to eat rapidly
D. Place food at the back of the mouth
**Answer: .B**
**Rationale:** Upright positioning reduces aspiration risk.
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### 4. Which action is appropriate when administering oral medications to a client?
A. Leave medications at the bedside
,B. Verify the client's identity using two identifiers
C. Ask another client to identify the medication
D. Crush all medications
**Answer: .B**
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### 5. A client reports severe pain. Which action should the nurse take first?
A. Ignore the report until vital signs change
B. Assess the pain using an appropriate pain scale
C. Tell the client that pain is expected
D. Administer every available analgesic
**Answer: .B**
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### 6. Which finding requires immediate intervention?
A. Respiratory rate of 8/min
B. Temperature of 37°C
C. Pulse of 78/min
D. Blood pressure of 118/72 mmHg
, **Answer: .A**
**Rationale:** Bradypnea can indicate respiratory depression and requires prompt assessment.
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### 7. Which position is generally appropriate for a client experiencing dyspnea?
A. Supine
B. High-Fowler's
C. Trendelenburg
D. Prone
**Answer: .B**
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### 8. Which action reduces the risk of infection when caring for a client?
A. Performing hand hygiene
B. Reusing gloves
C. Recapping contaminated needles
D. Wearing gloves instead of performing hand hygiene