1. When using a gait belt to assist a patient with ambulation,
where should the nurse stand?
A. In front of the patient
B. Behind the patient
C. On the patient’s weaker side
D. On the patient’s stronger side
Answer: C
Rationale: Standing on the weaker side provides support and
stability if the patient begins to fall.
2. 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.
3. 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.
4. When a nurse delegates a task to an unlicensed assistive
personnel (UAP), which responsibility remains with the nurse?
A. Performing the task
B. Supervising the UAP
C. Documenting the task
D. Assigning the task
Answer: B
Rationale: The nurse retains responsibility for supervision and
ensuring tasks are performed correctly.
, 5. Which is the correct technique for donning sterile gloves?
A. Touching the inside surface of the glove with a bare hand
B. Adjusting the gloves after touching the outside
C. Keeping hands below waist level during application
D. Using one glove to help apply the other
Answer: A
Rationale: Only the inside of the glove should be touched to
maintain sterility.
6. 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
D. Provide a high-sodium diet
Answer: C
Rationale: Encouraging water intake helps dilute the excess sodium
in the body, addressing hypernatremia.
7. 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.
8. What is the recommended depth for chest compressions in
adult CPR?
A. At least 1 inch
B. At least 2 inches
C. 3-4 inches
D. Less than 2 inches
Answer: B
Rationale: Chest compressions should be at least 2 inches deep to
where should the nurse stand?
A. In front of the patient
B. Behind the patient
C. On the patient’s weaker side
D. On the patient’s stronger side
Answer: C
Rationale: Standing on the weaker side provides support and
stability if the patient begins to fall.
2. 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.
3. 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.
4. When a nurse delegates a task to an unlicensed assistive
personnel (UAP), which responsibility remains with the nurse?
A. Performing the task
B. Supervising the UAP
C. Documenting the task
D. Assigning the task
Answer: B
Rationale: The nurse retains responsibility for supervision and
ensuring tasks are performed correctly.
, 5. Which is the correct technique for donning sterile gloves?
A. Touching the inside surface of the glove with a bare hand
B. Adjusting the gloves after touching the outside
C. Keeping hands below waist level during application
D. Using one glove to help apply the other
Answer: A
Rationale: Only the inside of the glove should be touched to
maintain sterility.
6. 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
D. Provide a high-sodium diet
Answer: C
Rationale: Encouraging water intake helps dilute the excess sodium
in the body, addressing hypernatremia.
7. 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.
8. What is the recommended depth for chest compressions in
adult CPR?
A. At least 1 inch
B. At least 2 inches
C. 3-4 inches
D. Less than 2 inches
Answer: B
Rationale: Chest compressions should be at least 2 inches deep to
