1. Which of the following is the priority nursing action when caring for a patient
who is experiencing chest pain?
A. Administering pain medication
B. Ensuring the patient is in a comfortable position
C. Assessing the patient's vital signs
D. Applying oxygen
Answer: D. Applying oxygen
Rationale: The priority is to increase oxygen supply to the heart, which can help relieve
ischemic pain. Administering pain medication and other interventions are important, but oxygen
is the immediate priority.
2. A nurse is teaching a client how to perform a wound dressing change at home.
What is the most appropriate instruction to provide the patient?
A. "Make sure to apply a sterile bandage directly over the wound."
B. "Clean the wound with soap and water, then cover it with a non-sterile bandage."
C. "Wash your hands thoroughly before and after changing the dressing."
D. "Leave the wound exposed to the air for faster healing."
Answer: C. "Wash your hands thoroughly before and after changing the dressing."
Rationale: Hand hygiene is the most important action to prevent infection during any wound
care procedure.
3. A patient is recovering from surgery and is receiving intravenous fluids. The
nurse notes that the patient is developing edema. Which of the following should
the nurse assess first?
A. Respiratory rate
B. Blood pressure
C. Urine output
D. Oxygen saturation
Answer: C. Urine output
Rationale: Edema could indicate fluid retention, so assessing urine output helps determine if the
kidneys are effectively excreting excess fluids.
, 4. A patient diagnosed with pneumonia is receiving antibiotic therapy. What is
the most important indicator that the patient’s condition is improving?
A. The patient's fever decreases.
B. The patient reports decreased pain.
C. The patient's white blood cell count decreases.
D. The patient’s appetite improves.
Answer: A. The patient's fever decreases.
Rationale: A decrease in fever is a key sign that the body is responding to the antibiotic therapy
and the infection is being controlled.
5. Which of the following is the most appropriate action for the nurse when
caring for a patient with a history of hypertension who presents with a headache,
blurred vision, and a blood pressure of 210/120 mmHg?
A. Administer an antihypertensive medication as ordered.
B. Encourage the patient to rest in a quiet, dark room.
C. Monitor the patient's blood pressure every 30 minutes.
D. Notify the healthcare provider immediately.
Answer: D. Notify the healthcare provider immediately.
Rationale: A blood pressure of 210/120 mmHg is a hypertensive crisis, requiring immediate
intervention to prevent complications like stroke or organ damage.
6. A nurse is caring for a client who is scheduled for a lumbar puncture. What is
the priority action before the procedure?
A. Assess the client’s level of consciousness.
B. Obtain informed consent.
C. Ensure the client has an empty bladder.
D. Apply a topical anesthetic.
Answer: B. Obtain informed consent.
Rationale: The nurse must ensure that the client understands the procedure, its risks, and
benefits, and consents to it before proceeding.
7. A client with diabetes mellitus asks the nurse how to prevent hypoglycemia.
Which of the following is the best response?
who is experiencing chest pain?
A. Administering pain medication
B. Ensuring the patient is in a comfortable position
C. Assessing the patient's vital signs
D. Applying oxygen
Answer: D. Applying oxygen
Rationale: The priority is to increase oxygen supply to the heart, which can help relieve
ischemic pain. Administering pain medication and other interventions are important, but oxygen
is the immediate priority.
2. A nurse is teaching a client how to perform a wound dressing change at home.
What is the most appropriate instruction to provide the patient?
A. "Make sure to apply a sterile bandage directly over the wound."
B. "Clean the wound with soap and water, then cover it with a non-sterile bandage."
C. "Wash your hands thoroughly before and after changing the dressing."
D. "Leave the wound exposed to the air for faster healing."
Answer: C. "Wash your hands thoroughly before and after changing the dressing."
Rationale: Hand hygiene is the most important action to prevent infection during any wound
care procedure.
3. A patient is recovering from surgery and is receiving intravenous fluids. The
nurse notes that the patient is developing edema. Which of the following should
the nurse assess first?
A. Respiratory rate
B. Blood pressure
C. Urine output
D. Oxygen saturation
Answer: C. Urine output
Rationale: Edema could indicate fluid retention, so assessing urine output helps determine if the
kidneys are effectively excreting excess fluids.
, 4. A patient diagnosed with pneumonia is receiving antibiotic therapy. What is
the most important indicator that the patient’s condition is improving?
A. The patient's fever decreases.
B. The patient reports decreased pain.
C. The patient's white blood cell count decreases.
D. The patient’s appetite improves.
Answer: A. The patient's fever decreases.
Rationale: A decrease in fever is a key sign that the body is responding to the antibiotic therapy
and the infection is being controlled.
5. Which of the following is the most appropriate action for the nurse when
caring for a patient with a history of hypertension who presents with a headache,
blurred vision, and a blood pressure of 210/120 mmHg?
A. Administer an antihypertensive medication as ordered.
B. Encourage the patient to rest in a quiet, dark room.
C. Monitor the patient's blood pressure every 30 minutes.
D. Notify the healthcare provider immediately.
Answer: D. Notify the healthcare provider immediately.
Rationale: A blood pressure of 210/120 mmHg is a hypertensive crisis, requiring immediate
intervention to prevent complications like stroke or organ damage.
6. A nurse is caring for a client who is scheduled for a lumbar puncture. What is
the priority action before the procedure?
A. Assess the client’s level of consciousness.
B. Obtain informed consent.
C. Ensure the client has an empty bladder.
D. Apply a topical anesthetic.
Answer: B. Obtain informed consent.
Rationale: The nurse must ensure that the client understands the procedure, its risks, and
benefits, and consents to it before proceeding.
7. A client with diabetes mellitus asks the nurse how to prevent hypoglycemia.
Which of the following is the best response?
