1. Which of the following is the primary purpose of performing hand hygiene?
a) To prevent the spread of infections
b) To remove dead skin cells
c) To prevent dry skin
d) To ensure proper circulation in the hands
Answer: a) To prevent the spread of infections
Rationale: Hand hygiene is essential to prevent the transmission of pathogens and reduce the
risk of infection in both healthcare settings and the community.
2. A nurse is caring for a patient post-surgery. What is the primary focus of the nurse's
care?
a) Promoting comfort
b) Preventing complications
c) Providing emotional support
d) Educating the family
Answer: b) Preventing complications
Rationale: After surgery, preventing complications such as infection, blood clots, and
respiratory issues is critical to ensuring a positive recovery outcome.
3. The nurse is assessing a patient’s blood pressure and notices a reading of 160/95 mmHg.
What does this indicate?
a) Normal blood pressure
b) Hypertension stage 1
c) Hypertension stage 2
d) Hypotension
Answer: b) Hypertension stage 1
Rationale: A systolic reading of 160 mmHg and a diastolic reading of 95 mmHg are classified
as stage 1 hypertension according to the American College of Cardiology.
4. The nurse is administering a medication to a patient. Which action is most important to
ensure the patient receives the correct medication?
a) Verify the patient’s ID using two identifiers
b) Document the time of administration
,c) Educate the patient on the medication side effects
d) Ensure the medication is at room temperature
Answer: a) Verify the patient’s ID using two identifiers
Rationale: To ensure patient safety, two identifiers (such as the patient's name and date of birth)
must be used to verify that the correct patient is receiving the correct medication.
5. A patient is exhibiting signs of respiratory distress. Which of the following would be the
priority intervention?
a) Administering pain medication
b) Providing oxygen therapy
c) Increasing fluid intake
d) Reassuring the patient
Answer: b) Providing oxygen therapy
Rationale: When a patient shows signs of respiratory distress, the first priority is to ensure
adequate oxygenation through oxygen therapy to prevent further complications.
6. When caring for a patient with a wound infection, which of the following should the
nurse wear to prevent the spread of microorganisms?
a) Gown and gloves
b) Mask and gloves
c) Gown, gloves, and mask
d) Mask only
Answer: a) Gown and gloves
Rationale: Contact precautions should be followed for wound infections. Gown and gloves
prevent the spread of microorganisms through contact with bodily fluids.
7. A nurse is caring for a patient who is at risk for falls. What is the most appropriate
intervention to prevent falls?
a) Keep the side rails up at all times
b) Encourage the patient to ambulate independently
c) Use a fall risk assessment tool and implement fall prevention protocols
d) Restrict fluid intake to reduce bathroom visits
, Answer: c) Use a fall risk assessment tool and implement fall prevention protocols
Rationale: A fall risk assessment tool helps identify patients at risk, and implementing
appropriate fall prevention protocols can significantly reduce fall incidents.
8. A nurse is preparing to perform a sterile dressing change. What is the most important
step in maintaining sterility during the procedure?
a) Keep the sterile field dry
b) Touch only sterile items with sterile gloves
c) Maintain eye contact with the patient throughout the procedure
d) Cleanse the wound before donning sterile gloves
Answer: b) Touch only sterile items with sterile gloves
Rationale: Sterile technique requires that only sterile items touch the sterile field and that gloves
remain sterile to avoid contamination.
9. The nurse is caring for a patient with an indwelling catheter. What is the most important
nursing intervention to prevent urinary tract infections?
a) Change the catheter every 24 hours
b) Ensure the catheter bag is below the level of the bladder
c) Use sterile technique for routine care
d) Administer antibiotics prophylactically
Answer: b) Ensure the catheter bag is below the level of the bladder
Rationale: The catheter bag should always be kept below the level of the bladder to prevent
urine from flowing back into the bladder, which can cause infections.
10. A nurse is caring for a patient with a fever. What is the primary reason for assessing
the patient’s temperature regularly?
a) To identify the cause of the fever
b) To monitor the effectiveness of antipyretic therapy
c) To educate the patient on fever management
d) To assess the need for antibiotics
Answer: b) To monitor the effectiveness of antipyretic therapy
Rationale: Regular temperature assessments are crucial to monitor the effectiveness of
interventions such as antipyretics, which are used to reduce fever.
a) To prevent the spread of infections
b) To remove dead skin cells
c) To prevent dry skin
d) To ensure proper circulation in the hands
Answer: a) To prevent the spread of infections
Rationale: Hand hygiene is essential to prevent the transmission of pathogens and reduce the
risk of infection in both healthcare settings and the community.
2. A nurse is caring for a patient post-surgery. What is the primary focus of the nurse's
care?
a) Promoting comfort
b) Preventing complications
c) Providing emotional support
d) Educating the family
Answer: b) Preventing complications
Rationale: After surgery, preventing complications such as infection, blood clots, and
respiratory issues is critical to ensuring a positive recovery outcome.
3. The nurse is assessing a patient’s blood pressure and notices a reading of 160/95 mmHg.
What does this indicate?
a) Normal blood pressure
b) Hypertension stage 1
c) Hypertension stage 2
d) Hypotension
Answer: b) Hypertension stage 1
Rationale: A systolic reading of 160 mmHg and a diastolic reading of 95 mmHg are classified
as stage 1 hypertension according to the American College of Cardiology.
4. The nurse is administering a medication to a patient. Which action is most important to
ensure the patient receives the correct medication?
a) Verify the patient’s ID using two identifiers
b) Document the time of administration
,c) Educate the patient on the medication side effects
d) Ensure the medication is at room temperature
Answer: a) Verify the patient’s ID using two identifiers
Rationale: To ensure patient safety, two identifiers (such as the patient's name and date of birth)
must be used to verify that the correct patient is receiving the correct medication.
5. A patient is exhibiting signs of respiratory distress. Which of the following would be the
priority intervention?
a) Administering pain medication
b) Providing oxygen therapy
c) Increasing fluid intake
d) Reassuring the patient
Answer: b) Providing oxygen therapy
Rationale: When a patient shows signs of respiratory distress, the first priority is to ensure
adequate oxygenation through oxygen therapy to prevent further complications.
6. When caring for a patient with a wound infection, which of the following should the
nurse wear to prevent the spread of microorganisms?
a) Gown and gloves
b) Mask and gloves
c) Gown, gloves, and mask
d) Mask only
Answer: a) Gown and gloves
Rationale: Contact precautions should be followed for wound infections. Gown and gloves
prevent the spread of microorganisms through contact with bodily fluids.
7. A nurse is caring for a patient who is at risk for falls. What is the most appropriate
intervention to prevent falls?
a) Keep the side rails up at all times
b) Encourage the patient to ambulate independently
c) Use a fall risk assessment tool and implement fall prevention protocols
d) Restrict fluid intake to reduce bathroom visits
, Answer: c) Use a fall risk assessment tool and implement fall prevention protocols
Rationale: A fall risk assessment tool helps identify patients at risk, and implementing
appropriate fall prevention protocols can significantly reduce fall incidents.
8. A nurse is preparing to perform a sterile dressing change. What is the most important
step in maintaining sterility during the procedure?
a) Keep the sterile field dry
b) Touch only sterile items with sterile gloves
c) Maintain eye contact with the patient throughout the procedure
d) Cleanse the wound before donning sterile gloves
Answer: b) Touch only sterile items with sterile gloves
Rationale: Sterile technique requires that only sterile items touch the sterile field and that gloves
remain sterile to avoid contamination.
9. The nurse is caring for a patient with an indwelling catheter. What is the most important
nursing intervention to prevent urinary tract infections?
a) Change the catheter every 24 hours
b) Ensure the catheter bag is below the level of the bladder
c) Use sterile technique for routine care
d) Administer antibiotics prophylactically
Answer: b) Ensure the catheter bag is below the level of the bladder
Rationale: The catheter bag should always be kept below the level of the bladder to prevent
urine from flowing back into the bladder, which can cause infections.
10. A nurse is caring for a patient with a fever. What is the primary reason for assessing
the patient’s temperature regularly?
a) To identify the cause of the fever
b) To monitor the effectiveness of antipyretic therapy
c) To educate the patient on fever management
d) To assess the need for antibiotics
Answer: b) To monitor the effectiveness of antipyretic therapy
Rationale: Regular temperature assessments are crucial to monitor the effectiveness of
interventions such as antipyretics, which are used to reduce fever.
