1. A patient is at risk for pressure ulcers. Which intervention is
most appropriate?
A. Massage over bony prominences
B. Reposition the patient every 2 hours
C. Apply alcohol-based lotion to the skin
D. Use a donut-shaped cushion
Answer: B
Rationale: Regular repositioning helps to prevent pressure ulcers by
relieving pressure points.
2. 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.
3. The nurse is caring for a client with a nasogastric tube.
Which of the following is the best method to confirm
placement?
A. Injecting air and listening over the stomach
B. Observing for gastric content aspirate
C. Testing pH of aspirate
D. Asking the patient if they feel discomfort
Answer: C
Rationale: Testing the pH of aspirate is the most reliable bedside
method for confirming nasogastric tube placement.
4. 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.
5. 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.
6. 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.
7. A nurse observes a colleague not performing hand hygiene
before patient care. What is the most appropriate action?
A. Report the colleague to the manager immediately
B. Ignore the situation to avoid conflict
C. Privately remind the colleague to wash their hands
D. Document the observation in the patient’s chart
Answer: C
Rationale: Addressing the situation privately and professionally
promotes accountability without confrontation.
8. 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,
most appropriate?
A. Massage over bony prominences
B. Reposition the patient every 2 hours
C. Apply alcohol-based lotion to the skin
D. Use a donut-shaped cushion
Answer: B
Rationale: Regular repositioning helps to prevent pressure ulcers by
relieving pressure points.
2. 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.
3. The nurse is caring for a client with a nasogastric tube.
Which of the following is the best method to confirm
placement?
A. Injecting air and listening over the stomach
B. Observing for gastric content aspirate
C. Testing pH of aspirate
D. Asking the patient if they feel discomfort
Answer: C
Rationale: Testing the pH of aspirate is the most reliable bedside
method for confirming nasogastric tube placement.
4. 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.
5. 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.
6. 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.
7. A nurse observes a colleague not performing hand hygiene
before patient care. What is the most appropriate action?
A. Report the colleague to the manager immediately
B. Ignore the situation to avoid conflict
C. Privately remind the colleague to wash their hands
D. Document the observation in the patient’s chart
Answer: C
Rationale: Addressing the situation privately and professionally
promotes accountability without confrontation.
8. 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,
