1. What is the first step in the nursing process?
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B
Rationale: Assessment is the initial step in the nursing process,
providing data for diagnosis and planning.
16. A nurse is administering an intramuscular injection to an
adult patient. Which site is most appropriate?
A. Deltoid
B. Vastus lateralis
C. Ventrogluteal
D. Dorsogluteal
Answer: C
Rationale: The ventrogluteal site is recommended for adults as it is
free from major nerves and blood vessels.
2. 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.
3. A nurse is preparing to administer a medication. Which of the
following actions demonstrates adherence to the five rights of
medication administration?
A. Checking the patient’s wristband for identification
B. Documenting the medication after administering it
C. Verifying the medication against the prescription
D. All of the above
Answer: D
Rationale: Ensuring the correct patient, medication, dose, route, and
time are essential to safe medication administration.
, 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 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.
6. 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
C. Wash from the cleanest to dirtiest areas
D. Avoid using soap on the patient
Answer: C
Rationale: Washing from the cleanest to the dirtiest areas prevents
the spread of bacteria.
7. A patient’s lab results indicate hyperkalemia. Which food
should the nurse instruct the patient to avoid?
A. Apples
B. Bananas
C. Rice
D. Chicken
Answer: B
Rationale: Bananas are high in potassium, which can worsen
hyperkalemia.
A. Planning
B. Assessment
C. Implementation
D. Evaluation
Answer: B
Rationale: Assessment is the initial step in the nursing process,
providing data for diagnosis and planning.
16. A nurse is administering an intramuscular injection to an
adult patient. Which site is most appropriate?
A. Deltoid
B. Vastus lateralis
C. Ventrogluteal
D. Dorsogluteal
Answer: C
Rationale: The ventrogluteal site is recommended for adults as it is
free from major nerves and blood vessels.
2. 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.
3. A nurse is preparing to administer a medication. Which of the
following actions demonstrates adherence to the five rights of
medication administration?
A. Checking the patient’s wristband for identification
B. Documenting the medication after administering it
C. Verifying the medication against the prescription
D. All of the above
Answer: D
Rationale: Ensuring the correct patient, medication, dose, route, and
time are essential to safe medication administration.
, 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 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.
6. 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
C. Wash from the cleanest to dirtiest areas
D. Avoid using soap on the patient
Answer: C
Rationale: Washing from the cleanest to the dirtiest areas prevents
the spread of bacteria.
7. A patient’s lab results indicate hyperkalemia. Which food
should the nurse instruct the patient to avoid?
A. Apples
B. Bananas
C. Rice
D. Chicken
Answer: B
Rationale: Bananas are high in potassium, which can worsen
hyperkalemia.
