Questions with Correct Answers (Verified Update)
50 questions
1. Using the ABCs, which patient should the nurse see first?
A. A patient with a blood pressure of 150/92
B. A patient with a pain score of 6/10
C. A patient with stridor and drooling after a bee sting
D. A patient requesting discharge paperwork
Correct Answer: C. A patient with stridor and drooling after a bee sting
Rationale: Stridor indicates airway compromise.
2. Which patient is the highest priority?
A. A patient with type 1 diabetes who is diaphoretic and confused
B. A patient with stable chronic back pain
C. A patient awaiting a routine X-ray
D. A patient asking about visiting hours
Correct Answer: A. A patient with type 1 diabetes who is diaphoretic and confused
Rationale: Diaphoresis and confusion suggest hypoglycemia, an acute emergency.
3. According to Maslow's hierarchy, which need should be addressed first?
A. Oxygenation
B. Self-esteem
C. Belonging
D. Self-actualization
Correct Answer: A. Oxygenation
Rationale: Physiological needs come first.
4. Which problem is an actual rather than a potential problem?
A. Risk for infection
B. Risk for falls
C. Active bleeding from a surgical wound
D. Risk for impaired skin integrity
Correct Answer: C. Active bleeding from a surgical wound
Rationale: Actual problems generally take priority.
5. A patient 2 days after hip replacement suddenly develops shortness of breath, chest pain and
anxiety. The nurse should suspect and prioritize:
A. Normal post-operative recovery
B. Constipation
C. Mild anxiety only
D. Pulmonary embolism
Correct Answer: D. Pulmonary embolism
Rationale: Sudden respiratory symptoms after orthopedic surgery require immediate action.
6. Which finding is expected and does NOT need immediate action?
A. Serosanguineous drainage on the first post-operative day
B. A new irregular heart rhythm with dizziness
C. Sudden slurred speech
D. Oxygen saturation of 84%
Correct Answer: A. Serosanguineous drainage on the first post-operative day
Rationale: Small amounts of serosanguineous drainage are common early after surgery.
, 7. A nurse receives report on four patients. Which should be seen first?
A. A patient with diabetes who needs a scheduled snack
B. A patient with heart failure whose SpO2 dropped from 95% to 87% with crackles
C. A patient going home who needs discharge teaching
D. A patient with osteoarthritis requesting a pillow
Correct Answer: B. A patient with heart failure whose SpO2 dropped from 95% to 87% with
crackles
Rationale: Acute respiratory deterioration is the most urgent.
8. A confused patient is repeatedly trying to climb out of bed. The priority is:
A. Completing documentation
B. Giving a routine medication on time
C. Patient safety (fall prevention)
D. Calling the family about visiting hours
Correct Answer: C. Patient safety (fall prevention)
Rationale: Safety needs rank high in prioritization.
9. Which of the five rights of delegation ensures the delegatee has the skills and knowledge for
the task?
A. Right person
B. Right task
C. Right circumstance
D. Right supervision
Correct Answer: A. Right person
Rationale: The delegatee must be competent and within scope.
10. Which task is appropriate to delegate to UAP?
A. Assessing a new admission
B. Ambulating a stable post-operative patient
C. Teaching insulin self-injection
D. Evaluating a patient's response to pain medication
Correct Answer: B. Ambulating a stable post-operative patient
Rationale: Routine tasks for stable patients can be delegated.
11. Which task should the RN NOT delegate to an LPN?
A. Giving oral medications to a stable patient
B. The initial assessment of a newly admitted patient
C. Reinforcing previously taught diet instructions
D. Measuring blood glucose in a stable patient
Correct Answer: B. The initial assessment of a newly admitted patient
Rationale: Initial assessment requires RN judgment.
12. The RN delegates vital signs to UAP. Which instruction best follows the right directions and
communication?
A. 'Check vitals sometime.'
B. 'Let me know if anything seems weird.'
C. 'Take vital signs at 10:00 and tell me right away if the systolic BP is below 100 or heart rate is
above 110.'
D. 'Do whatever you think is best.'
Correct Answer: C. 'Take vital signs at 10:00 and tell me right away if the systolic BP is below
100 or heart rate is above 110.'
Rationale: Clear, specific instructions with parameters prevent errors.