1. What is the primary purpose of a nurse performing a comprehensive assessment?
a) To establish a nursing diagnosis
b) To develop an individualized plan of care
c) To establish a therapeutic nurse-patient relationship
d) To ensure the patient’s confidentiality
Answer: b) To develop an individualized plan of care
Rationale: The comprehensive assessment allows the nurse to gather data that forms the basis
for creating a personalized and effective care plan for the patient.
2. Which of the following actions is a priority for a nurse when caring for a patient who has
just been admitted with chest pain?
a) Take the patient’s vital signs.
b) Notify the healthcare provider immediately.
c) Administer prescribed pain medication.
d) Perform a focused cardiovascular assessment.
Answer: a) Take the patient’s vital signs.
Rationale: Taking vital signs helps to determine the severity of the chest pain and monitor for
any potential life-threatening changes in the patient’s condition.
3. A nurse is teaching a patient how to perform a breast self-exam. Which of the following
statements by the patient indicates an understanding of the teaching?
a) "I will perform the exam once a year."
b) "I will do the exam in the shower with soapy hands."
c) "I will perform the exam only if I feel a lump."
d) "I will perform the exam only on the left side."
Answer: b) "I will do the exam in the shower with soapy hands."
Rationale: Performing a breast self-exam in the shower with soapy hands is recommended
because it allows for easier palpation and better detection of abnormalities.
4. A nurse is caring for a postoperative patient and notices that the surgical wound is red,
swollen, and warm to the touch. What is the nurse's most appropriate action?
a) Continue to monitor the wound and document findings.
b) Apply an ice pack to the wound to reduce inflammation.
,c) Notify the healthcare provider about the potential signs of infection.
d) Administer pain medication as ordered.
Answer: c) Notify the healthcare provider about the potential signs of infection.
Rationale: Redness, swelling, and warmth are signs of inflammation, possibly indicating an
infection. The healthcare provider should be notified promptly to prevent complications.
5. Which of the following is the most important nursing action when caring for a patient
who is at risk for falls?
a) Provide the patient with a bedside table.
b) Ensure that the patient’s environment is free from hazards.
c) Instruct the patient to avoid getting out of bed.
d) Place the patient in restraints as a precaution.
Answer: b) Ensure that the patient’s environment is free from hazards.
Rationale: The most important action is ensuring the environment is safe and free from hazards,
such as clutter or slippery floors, which can help prevent falls.
6. When assessing a patient’s pulse, the nurse notes a weak, thready pulse. Which of the
following could be the cause of this finding?
a) Dehydration
b) Hypertension
c) Hyperthermia
d) Pain
Answer: a) Dehydration
Rationale: Dehydration leads to decreased circulating blood volume, which can result in a weak,
thready pulse.
7. A nurse is caring for a patient who has a prescription for furosemide (Lasix). What is the
nurse's priority assessment before administering this medication?
a) Blood pressure
b) Serum potassium level
c) Respiratory rate
d) Blood glucose level
, Answer: b) Serum potassium level
Rationale: Furosemide is a diuretic that can cause potassium depletion, so checking the serum
potassium level is essential to prevent hypokalemia.
8. Which of the following is a priority intervention for a patient experiencing anaphylaxis?
a) Administering an antihistamine
b) Administering epinephrine
c) Applying a cool compress
d) Elevating the patient’s legs
Answer: b) Administering epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis as it helps to reverse the life-
threatening symptoms of an allergic reaction, such as airway constriction.
9. A nurse is teaching a patient with diabetes mellitus about the importance of monitoring
blood glucose levels. Which of the following should the nurse include in the teaching?
a) "You should check your blood sugar only when you feel symptoms of hypoglycemia."
b) "It is important to check your blood sugar at the same time each day."
c) "Blood glucose should be monitored at least four times a day, regardless of symptoms."
d) "You should check your blood glucose level after meals only."
Answer: b) "It is important to check your blood sugar at the same time each day."
Rationale: Consistent timing helps with accurate tracking of blood glucose patterns and
improves the management of diabetes.
10. What is the best nursing intervention to promote effective communication with a
patient who is hearing impaired?
a) Speaking loudly and slowly
b) Facing the patient and speaking directly to them
c) Writing out all communication
d) Using a picture board for all communication
Answer: b) Facing the patient and speaking directly to them
Rationale: It’s important to face the patient and speak directly to them, as this allows the patient
to use lip reading and read facial expressions to aid in understanding.
a) To establish a nursing diagnosis
b) To develop an individualized plan of care
c) To establish a therapeutic nurse-patient relationship
d) To ensure the patient’s confidentiality
Answer: b) To develop an individualized plan of care
Rationale: The comprehensive assessment allows the nurse to gather data that forms the basis
for creating a personalized and effective care plan for the patient.
2. Which of the following actions is a priority for a nurse when caring for a patient who has
just been admitted with chest pain?
a) Take the patient’s vital signs.
b) Notify the healthcare provider immediately.
c) Administer prescribed pain medication.
d) Perform a focused cardiovascular assessment.
Answer: a) Take the patient’s vital signs.
Rationale: Taking vital signs helps to determine the severity of the chest pain and monitor for
any potential life-threatening changes in the patient’s condition.
3. A nurse is teaching a patient how to perform a breast self-exam. Which of the following
statements by the patient indicates an understanding of the teaching?
a) "I will perform the exam once a year."
b) "I will do the exam in the shower with soapy hands."
c) "I will perform the exam only if I feel a lump."
d) "I will perform the exam only on the left side."
Answer: b) "I will do the exam in the shower with soapy hands."
Rationale: Performing a breast self-exam in the shower with soapy hands is recommended
because it allows for easier palpation and better detection of abnormalities.
4. A nurse is caring for a postoperative patient and notices that the surgical wound is red,
swollen, and warm to the touch. What is the nurse's most appropriate action?
a) Continue to monitor the wound and document findings.
b) Apply an ice pack to the wound to reduce inflammation.
,c) Notify the healthcare provider about the potential signs of infection.
d) Administer pain medication as ordered.
Answer: c) Notify the healthcare provider about the potential signs of infection.
Rationale: Redness, swelling, and warmth are signs of inflammation, possibly indicating an
infection. The healthcare provider should be notified promptly to prevent complications.
5. Which of the following is the most important nursing action when caring for a patient
who is at risk for falls?
a) Provide the patient with a bedside table.
b) Ensure that the patient’s environment is free from hazards.
c) Instruct the patient to avoid getting out of bed.
d) Place the patient in restraints as a precaution.
Answer: b) Ensure that the patient’s environment is free from hazards.
Rationale: The most important action is ensuring the environment is safe and free from hazards,
such as clutter or slippery floors, which can help prevent falls.
6. When assessing a patient’s pulse, the nurse notes a weak, thready pulse. Which of the
following could be the cause of this finding?
a) Dehydration
b) Hypertension
c) Hyperthermia
d) Pain
Answer: a) Dehydration
Rationale: Dehydration leads to decreased circulating blood volume, which can result in a weak,
thready pulse.
7. A nurse is caring for a patient who has a prescription for furosemide (Lasix). What is the
nurse's priority assessment before administering this medication?
a) Blood pressure
b) Serum potassium level
c) Respiratory rate
d) Blood glucose level
, Answer: b) Serum potassium level
Rationale: Furosemide is a diuretic that can cause potassium depletion, so checking the serum
potassium level is essential to prevent hypokalemia.
8. Which of the following is a priority intervention for a patient experiencing anaphylaxis?
a) Administering an antihistamine
b) Administering epinephrine
c) Applying a cool compress
d) Elevating the patient’s legs
Answer: b) Administering epinephrine
Rationale: Epinephrine is the first-line treatment for anaphylaxis as it helps to reverse the life-
threatening symptoms of an allergic reaction, such as airway constriction.
9. A nurse is teaching a patient with diabetes mellitus about the importance of monitoring
blood glucose levels. Which of the following should the nurse include in the teaching?
a) "You should check your blood sugar only when you feel symptoms of hypoglycemia."
b) "It is important to check your blood sugar at the same time each day."
c) "Blood glucose should be monitored at least four times a day, regardless of symptoms."
d) "You should check your blood glucose level after meals only."
Answer: b) "It is important to check your blood sugar at the same time each day."
Rationale: Consistent timing helps with accurate tracking of blood glucose patterns and
improves the management of diabetes.
10. What is the best nursing intervention to promote effective communication with a
patient who is hearing impaired?
a) Speaking loudly and slowly
b) Facing the patient and speaking directly to them
c) Writing out all communication
d) Using a picture board for all communication
Answer: b) Facing the patient and speaking directly to them
Rationale: It’s important to face the patient and speak directly to them, as this allows the patient
to use lip reading and read facial expressions to aid in understanding.
