1.
A nurse is caring for a client who is at increased risk for falls. Which
intervention is the priority?
A. Keep all four side rails raised
B. Place the call light within reach
,C. Encourage the client to ambulate independently
D. Keep the room completely dark at night
Answer: B. Place the call light within reach
Rationale: Easy access to the call light allows the client to request
assistance before attempting to get out of bed.
2.
A nurse enters a client's room and finds the client on the floor. What
should the nurse do first?
A. Move the client back to bed
B. Complete an incident report
C. Assess the client for injury
D. Notify the provider
Answer: C. Assess the client for injury
Rationale: Assessment for injury and immediate stabilization take
priority after a fall.
3.
Which action is appropriate when performing hand hygiene?
A. Use hot water for at least 10 seconds
B. Rinse hands before applying soap
C. Rub all hand surfaces with soap and water
D. Dry hands on the client's towel
Answer: C. Rub all hand surfaces with soap and water
Rationale: Effective hand hygiene requires friction over all hand
surfaces.
,4.
A nurse is preparing to administer medication. Which identifier is
appropriate?
A. Room number
B. Diagnosis
C. Client's full name and date of birth
D. Client's bed number
Answer: C. Client's full name and date of birth
Rationale: Two approved client identifiers reduce medication and
treatment errors.
5.
A client reports dizziness when standing. Which action should the
nurse take first?
A. Encourage rapid ambulation
B. Assist the client back to a sitting position
C. Restrict oral fluids
D. Administer an antihypertensive medication
Answer: B. Assist the client back to a sitting position
Rationale: The immediate priority is preventing a fall and injury.
6.
Which finding requires immediate intervention?
A. Temperature 37.1°C (98.8°F)
B. Respiratory rate 8/min
C. Pulse 82/min
D. Blood pressure 118/72 mm Hg
, Answer: B. Respiratory rate 8/min
Rationale: Bradypnea can indicate respiratory depression and
impaired oxygenation.
7.
A nurse is positioning a client who is experiencing dyspnea. Which
position is most appropriate?
A. Supine
B. Trendelenburg
C. High-Fowler's
D. Prone
Answer: C. High-Fowler's
Rationale: Upright positioning promotes lung expansion and
decreases the work of breathing.
8.
Which finding indicates adequate oxygenation?
A. Cyanosis
B. Restlessness
C. Oxygen saturation 97%
D. Respiratory rate 6/min
Answer: C. Oxygen saturation 97%
Rationale: An oxygen saturation of 97% generally indicates adequate
oxygenation in a healthy adult.
9.