1. A nurse is caring for a patient with dysphagia. Which
intervention is most appropriate to prevent aspiration during
meals?
A. Encourage the patient to lie flat after eating
B. Provide thin liquids for easier swallowing
C. Position the patient in a high-Fowler’s position
D. Allow the patient to eat quickly
Answer: C
Rationale: Positioning the patient in a high-Fowler’s position
reduces the risk of aspiration during swallowing.
2. A patient is prescribed 0.9% sodium chloride IV at 125
mL/hr. How often should the nurse assess the infusion site?
A. Every shift
B. Every 4 hours
C. Every hour
D. Every 2 hours
Answer: C
Rationale: IV sites should be checked at least hourly to monitor for
complications like infiltration or phlebitis.
3. When assessing a patient’s pulse, the nurse should document
which of the following?
A. Rate and rhythm
B. Intensity and depth
C. Temperature and texture
D. Quality and frequency
Answer: A
Rationale: Pulse assessment includes rate (beats per minute) and
rhythm (regular or irregular).
4. When collecting a urine specimen from an indwelling
catheter, the nurse should:
A. Disconnect the catheter tubing and collect from the bag
B. Collect from the drainage bag after emptying it
C. Use the port with a sterile syringe
D. Allow the urine to drip directly into the container
, Answer: C
Rationale: Collecting urine from the port with a sterile syringe
ensures the sample is not contaminated.
5. The nurse is assessing for cyanosis in a dark-skinned
patient. Where is the best place to assess?
A. Fingernails
B. Palms of the hands
C. Oral mucosa
D. Sclera
Answer: C
Rationale: Cyanosis in dark-skinned patients is best observed in
areas with less pigmentation, such as the oral mucosa or conjunctiva.
6. A patient with a history of chronic obstructive pulmonary
disease (COPD) is receiving oxygen at 4 L/min via nasal
cannula. The patient reports increased dyspnea. What is the
nurse’s priority action?
A. Increase oxygen flow rate to 6 L/min
B. Notify the healthcare provider immediately
C. Assess the patient’s respiratory status
D. Switch to a non-rebreather mask
Answer: C
Rationale: Assessing respiratory status allows the nurse to
determine the cause of the increased dyspnea before taking further
action.
7. Which of the following findings indicates a possible urinary
tract infection (UTI)?
A. Straw-colored urine
B. Urine pH of 6
C. Foul-smelling urine
D. Clear urine
Answer: C
Rationale: Foul-smelling urine may indicate the presence of a UTI.
8. When assisting a patient with a bed bath, the nurse should:
A. Use the same washcloth for the entire bath
B. Wash from the dirtiest to cleanest areas
intervention is most appropriate to prevent aspiration during
meals?
A. Encourage the patient to lie flat after eating
B. Provide thin liquids for easier swallowing
C. Position the patient in a high-Fowler’s position
D. Allow the patient to eat quickly
Answer: C
Rationale: Positioning the patient in a high-Fowler’s position
reduces the risk of aspiration during swallowing.
2. A patient is prescribed 0.9% sodium chloride IV at 125
mL/hr. How often should the nurse assess the infusion site?
A. Every shift
B. Every 4 hours
C. Every hour
D. Every 2 hours
Answer: C
Rationale: IV sites should be checked at least hourly to monitor for
complications like infiltration or phlebitis.
3. When assessing a patient’s pulse, the nurse should document
which of the following?
A. Rate and rhythm
B. Intensity and depth
C. Temperature and texture
D. Quality and frequency
Answer: A
Rationale: Pulse assessment includes rate (beats per minute) and
rhythm (regular or irregular).
4. When collecting a urine specimen from an indwelling
catheter, the nurse should:
A. Disconnect the catheter tubing and collect from the bag
B. Collect from the drainage bag after emptying it
C. Use the port with a sterile syringe
D. Allow the urine to drip directly into the container
, Answer: C
Rationale: Collecting urine from the port with a sterile syringe
ensures the sample is not contaminated.
5. The nurse is assessing for cyanosis in a dark-skinned
patient. Where is the best place to assess?
A. Fingernails
B. Palms of the hands
C. Oral mucosa
D. Sclera
Answer: C
Rationale: Cyanosis in dark-skinned patients is best observed in
areas with less pigmentation, such as the oral mucosa or conjunctiva.
6. A patient with a history of chronic obstructive pulmonary
disease (COPD) is receiving oxygen at 4 L/min via nasal
cannula. The patient reports increased dyspnea. What is the
nurse’s priority action?
A. Increase oxygen flow rate to 6 L/min
B. Notify the healthcare provider immediately
C. Assess the patient’s respiratory status
D. Switch to a non-rebreather mask
Answer: C
Rationale: Assessing respiratory status allows the nurse to
determine the cause of the increased dyspnea before taking further
action.
7. Which of the following findings indicates a possible urinary
tract infection (UTI)?
A. Straw-colored urine
B. Urine pH of 6
C. Foul-smelling urine
D. Clear urine
Answer: C
Rationale: Foul-smelling urine may indicate the presence of a UTI.
8. When assisting a patient with a bed bath, the nurse should:
A. Use the same washcloth for the entire bath
B. Wash from the dirtiest to cleanest areas
