1. The nurse is using the SBAR communication tool. What does
"B" stand for?
A. Background
B. Behavior
C. Baseline
D. Best practice
Answer: A
Rationale: "B" in SBAR stands for Background, which provides
context for the situation.
2. A patient is prescribed oxygen therapy via nasal cannula.
What is the maximum flow rate that can be delivered through
this device?
A. 2 L/min
B. 4 L/min
C. 6 L/min
D. 8 L/min
Answer: C
Rationale: The nasal cannula delivers oxygen at a flow rate of up to
6 L/min, providing 24-44% oxygen concentration.
3. A nurse observes an older adult patient with a high risk for
falls. Which intervention is most effective?
A. Restraining the patient in bed
B. Placing a call light within reach
C. Keeping the bed in the highest position
D. Turning off the room lights
Answer: B
Rationale: Ensuring the call light is within reach promotes safety
and independence without increasing fall risk.
4. The nurse auscultates wheezes in a patient’s lungs. What is
the likely cause?
A. Fluid overload
B. Airway obstruction
C. Atelectasis
D. Pleural friction rub
, Answer: B
Rationale: Wheezes result from narrowed airways, often caused by
obstruction or asthma.
5. When performing a physical assessment, the nurse uses the
dorsal surface of the hand. This technique is best for assessing
which of the following?
A. Skin texture
B. Temperature
C. Pulse
D. Vibration
Answer: B
Rationale: The dorsal surface of the hand is more sensitive to
temperature changes.
6. Which of the following is the most reliable indicator of pain?
A. Vital signs
B. Facial expressions
C. Self-report by the patient
D. Body movements
Answer: C
Rationale: The patient's self-report is the gold standard for
assessing pain.
7. Which nursing action demonstrates maintaining patient
confidentiality?
A. Discussing the patient's condition in a private room
B. Sharing the patient's information with family members
C. Posting about the patient’s care on social media
D. Reviewing the patient’s chart for personal curiosity
Answer: A
Rationale: Confidentiality is maintained by discussing sensitive
information privately and only with authorized individuals.
8. The nurse is caring for a patient with hypernatremia. Which
intervention is most appropriate?
A. Restrict fluid intake
B. Administer a diuretic as prescribed
C. Encourage oral water intake
"B" stand for?
A. Background
B. Behavior
C. Baseline
D. Best practice
Answer: A
Rationale: "B" in SBAR stands for Background, which provides
context for the situation.
2. A patient is prescribed oxygen therapy via nasal cannula.
What is the maximum flow rate that can be delivered through
this device?
A. 2 L/min
B. 4 L/min
C. 6 L/min
D. 8 L/min
Answer: C
Rationale: The nasal cannula delivers oxygen at a flow rate of up to
6 L/min, providing 24-44% oxygen concentration.
3. A nurse observes an older adult patient with a high risk for
falls. Which intervention is most effective?
A. Restraining the patient in bed
B. Placing a call light within reach
C. Keeping the bed in the highest position
D. Turning off the room lights
Answer: B
Rationale: Ensuring the call light is within reach promotes safety
and independence without increasing fall risk.
4. The nurse auscultates wheezes in a patient’s lungs. What is
the likely cause?
A. Fluid overload
B. Airway obstruction
C. Atelectasis
D. Pleural friction rub
, Answer: B
Rationale: Wheezes result from narrowed airways, often caused by
obstruction or asthma.
5. When performing a physical assessment, the nurse uses the
dorsal surface of the hand. This technique is best for assessing
which of the following?
A. Skin texture
B. Temperature
C. Pulse
D. Vibration
Answer: B
Rationale: The dorsal surface of the hand is more sensitive to
temperature changes.
6. Which of the following is the most reliable indicator of pain?
A. Vital signs
B. Facial expressions
C. Self-report by the patient
D. Body movements
Answer: C
Rationale: The patient's self-report is the gold standard for
assessing pain.
7. Which nursing action demonstrates maintaining patient
confidentiality?
A. Discussing the patient's condition in a private room
B. Sharing the patient's information with family members
C. Posting about the patient’s care on social media
D. Reviewing the patient’s chart for personal curiosity
Answer: A
Rationale: Confidentiality is maintained by discussing sensitive
information privately and only with authorized individuals.
8. The nurse is caring for a patient with hypernatremia. Which
intervention is most appropriate?
A. Restrict fluid intake
B. Administer a diuretic as prescribed
C. Encourage oral water intake
