1. A nurse is caring for a patient with a new diagnosis of diabetes mellitus. Which of the following
statements by the patient indicates a need for further teaching?
a) "I will monitor my blood sugar levels regularly."
b) "I will follow a healthy diet and exercise plan."
c) "I will take my medications as prescribed."
d) "I can continue eating whatever I want as long as I take my insulin."
Elaboration: This statement is incorrect. Patients with diabetes need to manage their diet carefully, even
with insulin therapy, to maintain stable blood glucose levels.
2. A nurse is caring for a patient who has just undergone a total hip replacement. Which of the
following nursing interventions is the priority in the immediate postoperative period?
a) Assessing the patient's pain level
b) Encouraging the patient to use the incentive spirometer
c) Monitoring the patient's neurovascular status in the affected leg
d) Assisting the patient with ambulation
Elaboration: Neurovascular assessment is crucial after orthopedic surgery to detect any complications
like compartment syndrome or nerve damage.
3. A nurse is caring for a patient with pneumonia. Which of the following assessment findings would
the nurse expect?
a) Fever and chills
b) Productive cough
c) Shortness of breath
d) All of the above
Elaboration: These are classic signs and symptoms of pneumonia caused by inflammation in the lungs.
4. A nurse is caring for a patient with congestive heart failure (CHF). Which of the following dietary
modifications would the nurse recommend?
a) Restrict sodium intake
b) Increase fluid intake
c) Eat a high-protein diet
, d) Limit potassium intake
Elaboration: Sodium restriction helps reduce fluid retention, a common problem in CHF.
5. A nurse is caring for a patient with a wound infection. Which of the following laboratory values
would the nurse expect to be elevated?
a) Hemoglobin
b) Platelet count
c) White blood cell count (WBC)
d) Red blood cell count
Elaboration: An elevated WBC count is a common sign of infection as the body increases its immune
response.
6. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which of the
following breathing techniques would the nurse teach the patient?
a) Deep breathing exercises
b) Pursed-lip breathing
c) Incentive spirometry
d) Diaphragmatic breathing
Elaboration: Pursed-lip breathing helps patients with COPD control their breathing and reduce air
trapping.
7. A nurse is caring for a patient with a urinary tract infection (UTI). Which of the following
medications would the nurse expect to be prescribed?
a) Antibiotics
b) Antivirals
c) Antifungals
d) Antihistamines
Elaboration: UTIs are typically caused by bacteria and require antibiotic treatment.
8. A nurse is caring for a patient with a stroke. Which of the following nursing diagnoses is the
priority?
a) Impaired physical mobility
, b) Risk for aspiration
c) Disturbed sensory perception
d) Self-care deficit
Elaboration: Maintaining a patent airway and preventing aspiration are critical for stroke patients,
especially those with dysphagia (difficulty swallowing).
9. A nurse is caring for a patient with a new diagnosis of cancer. Which of the following nursing
interventions is appropriate to address the patient's psychosocial needs?
a) Providing emotional support and active listening
b) Encouraging the patient to express their feelings and concerns
c) Referring the patient to support groups or counseling services
d) All of the above
Elaboration: Cancer diagnosis can have a significant emotional and psychological impact. Nurses need to
provide holistic care addressing those needs.
10. A nurse is caring for a patient with a history of falls. Which of the following interventions should
the nurse implement to prevent falls?
a) Keeping the bed in the lowest position
b) Ensuring the call light is within reach
c) Providing non-skid footwear
d) All of the above
Elaboration: These are standard fall prevention interventions to create a safe environment for the
patient.
11. A nurse is caring for a patient who is experiencing shortness of breath and has an oxygen
saturation of 88%. Which of the following actions should the nurse take first?
a) Notify the physician
b) Administer oxygen as prescribed
c) Reposition the patient to a high Fowler's position
d) Obtain a set of vital signs
, Elaboration: Airway and breathing are a priority. Administering oxygen will immediately address the
patient's low oxygen saturation.
12. A nurse is teaching a patient about the use of a metered-dose inhaler (MDI). Which of the
following instructions should the nurse include?
a) "Inhale deeply before pressing down on the canister."
b) "Hold your breath for 10 seconds after inhaling the medication."
c) "Rinse your mouth after using the inhaler."
d) All of the above
Elaboration: All of these steps are crucial for the proper use of an MDI, ensuring effective medication
delivery and preventing oral thrush.
13. A nurse is caring for a patient with a chest tube. Which of the following observations indicates a
potential air leak?
a) Continuous bubbling in the water seal chamber
b) Tidaling in the water seal chamber
c) Absence of drainage in the collection chamber
d) Fluctuation in the water seal chamber with respiration
Elaboration: Continuous bubbling in the water seal chamber suggests an air leak, which needs to be
addressed promptly to prevent complications.
14. A nurse is caring for a patient with a history of seizures. Which of the following precautions should
the nurse take?
a) Keep the bed in the lowest position.
b) Ensure that suction equipment is readily available.
c) Pad the side rails of the bed.
d) All of the above
Elaboration: These precautions are implemented to ensure the patient's safety during a seizure.
15. A nurse is caring for a patient who has undergone a total knee replacement. Which of the
following exercises would the nurse encourage the patient to perform to prevent complications?
a) Ankle pumps and quadriceps sets
statements by the patient indicates a need for further teaching?
a) "I will monitor my blood sugar levels regularly."
b) "I will follow a healthy diet and exercise plan."
c) "I will take my medications as prescribed."
d) "I can continue eating whatever I want as long as I take my insulin."
Elaboration: This statement is incorrect. Patients with diabetes need to manage their diet carefully, even
with insulin therapy, to maintain stable blood glucose levels.
2. A nurse is caring for a patient who has just undergone a total hip replacement. Which of the
following nursing interventions is the priority in the immediate postoperative period?
a) Assessing the patient's pain level
b) Encouraging the patient to use the incentive spirometer
c) Monitoring the patient's neurovascular status in the affected leg
d) Assisting the patient with ambulation
Elaboration: Neurovascular assessment is crucial after orthopedic surgery to detect any complications
like compartment syndrome or nerve damage.
3. A nurse is caring for a patient with pneumonia. Which of the following assessment findings would
the nurse expect?
a) Fever and chills
b) Productive cough
c) Shortness of breath
d) All of the above
Elaboration: These are classic signs and symptoms of pneumonia caused by inflammation in the lungs.
4. A nurse is caring for a patient with congestive heart failure (CHF). Which of the following dietary
modifications would the nurse recommend?
a) Restrict sodium intake
b) Increase fluid intake
c) Eat a high-protein diet
, d) Limit potassium intake
Elaboration: Sodium restriction helps reduce fluid retention, a common problem in CHF.
5. A nurse is caring for a patient with a wound infection. Which of the following laboratory values
would the nurse expect to be elevated?
a) Hemoglobin
b) Platelet count
c) White blood cell count (WBC)
d) Red blood cell count
Elaboration: An elevated WBC count is a common sign of infection as the body increases its immune
response.
6. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). Which of the
following breathing techniques would the nurse teach the patient?
a) Deep breathing exercises
b) Pursed-lip breathing
c) Incentive spirometry
d) Diaphragmatic breathing
Elaboration: Pursed-lip breathing helps patients with COPD control their breathing and reduce air
trapping.
7. A nurse is caring for a patient with a urinary tract infection (UTI). Which of the following
medications would the nurse expect to be prescribed?
a) Antibiotics
b) Antivirals
c) Antifungals
d) Antihistamines
Elaboration: UTIs are typically caused by bacteria and require antibiotic treatment.
8. A nurse is caring for a patient with a stroke. Which of the following nursing diagnoses is the
priority?
a) Impaired physical mobility
, b) Risk for aspiration
c) Disturbed sensory perception
d) Self-care deficit
Elaboration: Maintaining a patent airway and preventing aspiration are critical for stroke patients,
especially those with dysphagia (difficulty swallowing).
9. A nurse is caring for a patient with a new diagnosis of cancer. Which of the following nursing
interventions is appropriate to address the patient's psychosocial needs?
a) Providing emotional support and active listening
b) Encouraging the patient to express their feelings and concerns
c) Referring the patient to support groups or counseling services
d) All of the above
Elaboration: Cancer diagnosis can have a significant emotional and psychological impact. Nurses need to
provide holistic care addressing those needs.
10. A nurse is caring for a patient with a history of falls. Which of the following interventions should
the nurse implement to prevent falls?
a) Keeping the bed in the lowest position
b) Ensuring the call light is within reach
c) Providing non-skid footwear
d) All of the above
Elaboration: These are standard fall prevention interventions to create a safe environment for the
patient.
11. A nurse is caring for a patient who is experiencing shortness of breath and has an oxygen
saturation of 88%. Which of the following actions should the nurse take first?
a) Notify the physician
b) Administer oxygen as prescribed
c) Reposition the patient to a high Fowler's position
d) Obtain a set of vital signs
, Elaboration: Airway and breathing are a priority. Administering oxygen will immediately address the
patient's low oxygen saturation.
12. A nurse is teaching a patient about the use of a metered-dose inhaler (MDI). Which of the
following instructions should the nurse include?
a) "Inhale deeply before pressing down on the canister."
b) "Hold your breath for 10 seconds after inhaling the medication."
c) "Rinse your mouth after using the inhaler."
d) All of the above
Elaboration: All of these steps are crucial for the proper use of an MDI, ensuring effective medication
delivery and preventing oral thrush.
13. A nurse is caring for a patient with a chest tube. Which of the following observations indicates a
potential air leak?
a) Continuous bubbling in the water seal chamber
b) Tidaling in the water seal chamber
c) Absence of drainage in the collection chamber
d) Fluctuation in the water seal chamber with respiration
Elaboration: Continuous bubbling in the water seal chamber suggests an air leak, which needs to be
addressed promptly to prevent complications.
14. A nurse is caring for a patient with a history of seizures. Which of the following precautions should
the nurse take?
a) Keep the bed in the lowest position.
b) Ensure that suction equipment is readily available.
c) Pad the side rails of the bed.
d) All of the above
Elaboration: These precautions are implemented to ensure the patient's safety during a seizure.
15. A nurse is caring for a patient who has undergone a total knee replacement. Which of the
following exercises would the nurse encourage the patient to perform to prevent complications?
a) Ankle pumps and quadriceps sets
