NUR 1020 Comprehensive Exam
BundleWITH 100 QUESTIONS AND VERIFIED
ANSWERS WITH RATIONALE GRADE a+
1. A nurse is preparing to administer medication to a client. Which of the following is the priority
action before administration?
A. Document the medication in the chart
B. Verify the client's identity using two identifiers
C. Check the medication expiration date
D. Explain the medication's purpose to the client
Answer: B
Rationale: Verifying client identity using two identifiers (name and DOB, or name and MRN) is the
priority safety measure to prevent medication errors. This must occur before any other step in the
medication administration process.
2. Which vital sign finding would the nurse report immediately to the healthcare provider?
A. Temperature 98.6°F (37°C)
B. Heart rate 120 beats/min
C. Respiratory rate 18 breaths/min
D. Blood pressure 118/76 mmHg
Answer: B
Rationale: A heart rate of 120 beats/min indicates tachycardia, which is outside normal range (60-
100 bpm) and requires immediate reporting as it may indicate underlying complications such as
pain, bleeding, infection, or cardiac issues.
3. A nurse is performing hand hygiene. How long should the hand washing process take with soap
and water?
A. 5 seconds
B. 10 seconds
C. At least 20 seconds
,D. 5 minutes
Answer: C
Rationale: The CDC recommends washing hands with soap and water for at least 20 seconds to
effectively remove pathogens and reduce transmission of infection.
4. Which of the following is a correct principle of surgical asepsis?
A. A sterile object becomes unsterile when touched by another sterile object
B. The edges of a sterile field are considered sterile
C. Only the top surface of a sterile field is considered sterile
D. Sterile objects can touch clean, non-sterile surfaces
Answer: C
Rationale: In surgical asepsis, only the top surface of a sterile field is considered sterile. The outer 1-
inch border is considered contaminated, and sterile touching sterile remains sterile, not unsterile.
5. A client is diagnosed with a stage 2 pressure injury. Which characteristic best describes this stage?
A. Intact skin with non-blanchable redness
B. Full-thickness tissue loss with visible bone
C. Partial-thickness skin loss with exposed dermis
D. Full-thickness skin loss with slough present
Answer: C
Rationale: Stage 2 pressure injuries present as partial-thickness loss of skin with exposed dermis,
appearing as a shallow open ulcer with a pink/red wound bed, without slough.
6. When using Maslow's Hierarchy of Needs to prioritize care, which need should be addressed first?
A. Self-esteem
B. Safety and security
C. Physiological needs
D. Love and belonging
,Answer: C
Rationale: Maslow's hierarchy prioritizes physiological needs (oxygen, fluids, nutrition, elimination)
as the foundation that must be met before addressing higher-level needs like safety, love, esteem,
and self-actualization.
7. A nurse is caring for a client with an IV infusion. Which finding indicates infiltration?
A. Redness and warmth at the site
B. Swelling and coolness at the site
C. Purulent drainage at the site
D. Red streaking along the vein
Answer: B
Rationale: Infiltration occurs when IV fluid leaks into surrounding tissue, causing swelling, coolness,
and pallor at the site due to fluid accumulation outside the vein. Redness/warmth suggests phlebitis;
purulent drainage suggests infection.
8. Which action should the nurse take first when a client experiences an anaphylactic reaction to a
medication?
A. Document the reaction
B. Notify the healthcare provider
C. Stop the medication administration
D. Check the client's vital signs
Answer: C
Rationale: The immediate priority is to stop the medication administration to prevent further
allergen exposure. This should be followed by assessing the client, calling for help, and notifying the
provider.
9. A nurse is teaching a client about the use of a walker. Which instruction is correct?
A. Move the walker forward, then step with the weaker leg first
B. Move the walker forward, then step with the stronger leg first
C. Step with the stronger leg, then move the walker forward
D. Move both legs simultaneously with the walker
, Answer: A
Rationale: The correct technique is to move the walker forward first, then step with the weaker leg
into the walker, followed by the stronger leg, providing support and stability throughout the gait
cycle.
10. Which of the following best describes the purpose of using therapeutic communication
techniques?
A. To give advice to clients
B. To share personal opinions with clients
C. To facilitate client expression and understanding
D. To complete documentation quickly
Answer: C
Rationale: Therapeutic communication techniques are used to facilitate effective information
exchange, help clients express feelings, and promote understanding between nurse and client,
fostering a therapeutic relationship.
11. A client's urine output is 25 mL/hr for 2 consecutive hours. What is the priority nursing action?
A. Continue to monitor
B. Increase IV fluid rate independently
C. Notify the healthcare provider
D. Document findings only
Answer: C
Rationale: Urine output less than 30 mL/hr indicates oliguria and possible renal impairment or
inadequate perfusion. This requires immediate notification of the healthcare provider for further
evaluation and intervention.
12. Which nursing diagnosis takes priority for a client with dysphagia?
A. Impaired verbal communication
B. Risk for aspiration
C. Imbalanced nutrition: less than body requirements
BundleWITH 100 QUESTIONS AND VERIFIED
ANSWERS WITH RATIONALE GRADE a+
1. A nurse is preparing to administer medication to a client. Which of the following is the priority
action before administration?
A. Document the medication in the chart
B. Verify the client's identity using two identifiers
C. Check the medication expiration date
D. Explain the medication's purpose to the client
Answer: B
Rationale: Verifying client identity using two identifiers (name and DOB, or name and MRN) is the
priority safety measure to prevent medication errors. This must occur before any other step in the
medication administration process.
2. Which vital sign finding would the nurse report immediately to the healthcare provider?
A. Temperature 98.6°F (37°C)
B. Heart rate 120 beats/min
C. Respiratory rate 18 breaths/min
D. Blood pressure 118/76 mmHg
Answer: B
Rationale: A heart rate of 120 beats/min indicates tachycardia, which is outside normal range (60-
100 bpm) and requires immediate reporting as it may indicate underlying complications such as
pain, bleeding, infection, or cardiac issues.
3. A nurse is performing hand hygiene. How long should the hand washing process take with soap
and water?
A. 5 seconds
B. 10 seconds
C. At least 20 seconds
,D. 5 minutes
Answer: C
Rationale: The CDC recommends washing hands with soap and water for at least 20 seconds to
effectively remove pathogens and reduce transmission of infection.
4. Which of the following is a correct principle of surgical asepsis?
A. A sterile object becomes unsterile when touched by another sterile object
B. The edges of a sterile field are considered sterile
C. Only the top surface of a sterile field is considered sterile
D. Sterile objects can touch clean, non-sterile surfaces
Answer: C
Rationale: In surgical asepsis, only the top surface of a sterile field is considered sterile. The outer 1-
inch border is considered contaminated, and sterile touching sterile remains sterile, not unsterile.
5. A client is diagnosed with a stage 2 pressure injury. Which characteristic best describes this stage?
A. Intact skin with non-blanchable redness
B. Full-thickness tissue loss with visible bone
C. Partial-thickness skin loss with exposed dermis
D. Full-thickness skin loss with slough present
Answer: C
Rationale: Stage 2 pressure injuries present as partial-thickness loss of skin with exposed dermis,
appearing as a shallow open ulcer with a pink/red wound bed, without slough.
6. When using Maslow's Hierarchy of Needs to prioritize care, which need should be addressed first?
A. Self-esteem
B. Safety and security
C. Physiological needs
D. Love and belonging
,Answer: C
Rationale: Maslow's hierarchy prioritizes physiological needs (oxygen, fluids, nutrition, elimination)
as the foundation that must be met before addressing higher-level needs like safety, love, esteem,
and self-actualization.
7. A nurse is caring for a client with an IV infusion. Which finding indicates infiltration?
A. Redness and warmth at the site
B. Swelling and coolness at the site
C. Purulent drainage at the site
D. Red streaking along the vein
Answer: B
Rationale: Infiltration occurs when IV fluid leaks into surrounding tissue, causing swelling, coolness,
and pallor at the site due to fluid accumulation outside the vein. Redness/warmth suggests phlebitis;
purulent drainage suggests infection.
8. Which action should the nurse take first when a client experiences an anaphylactic reaction to a
medication?
A. Document the reaction
B. Notify the healthcare provider
C. Stop the medication administration
D. Check the client's vital signs
Answer: C
Rationale: The immediate priority is to stop the medication administration to prevent further
allergen exposure. This should be followed by assessing the client, calling for help, and notifying the
provider.
9. A nurse is teaching a client about the use of a walker. Which instruction is correct?
A. Move the walker forward, then step with the weaker leg first
B. Move the walker forward, then step with the stronger leg first
C. Step with the stronger leg, then move the walker forward
D. Move both legs simultaneously with the walker
, Answer: A
Rationale: The correct technique is to move the walker forward first, then step with the weaker leg
into the walker, followed by the stronger leg, providing support and stability throughout the gait
cycle.
10. Which of the following best describes the purpose of using therapeutic communication
techniques?
A. To give advice to clients
B. To share personal opinions with clients
C. To facilitate client expression and understanding
D. To complete documentation quickly
Answer: C
Rationale: Therapeutic communication techniques are used to facilitate effective information
exchange, help clients express feelings, and promote understanding between nurse and client,
fostering a therapeutic relationship.
11. A client's urine output is 25 mL/hr for 2 consecutive hours. What is the priority nursing action?
A. Continue to monitor
B. Increase IV fluid rate independently
C. Notify the healthcare provider
D. Document findings only
Answer: C
Rationale: Urine output less than 30 mL/hr indicates oliguria and possible renal impairment or
inadequate perfusion. This requires immediate notification of the healthcare provider for further
evaluation and intervention.
12. Which nursing diagnosis takes priority for a client with dysphagia?
A. Impaired verbal communication
B. Risk for aspiration
C. Imbalanced nutrition: less than body requirements
