NURSING CARE SCENARIOS ACTUAL EXAM 2025, 162 QUESTIONS
WITH ACCURATE SOLUTIONS
1. If a newly licensed nurse demonstrates improper technique during a straight
catheterization, what should the nurse manager's immediate response be to
ensure client safety?
Ignore the mistake to avoid embarrassment
Correct the technique immediately and provide feedback
Document the error and report it later
Allow the nurse to continue without intervention
2. Why is it important for a nurse to check for gastric residual volume before
administering enteral feedings?
To ensure the tube is patent
To assess the client's ability to swallow
To prevent aspiration and ensure proper digestion
To determine the correct formula to use
3. A nurse is caring for a client who has been diagnosed with end-stage liver cancer.
Which of the following client responses is an indication the client is in the
denial phase of the grief process?
"The doctor has been so good to me. I know he has tried everything he
can. It is just my time."
"I can't believe that doctor graduated from medical school; he doesn't
know a thing about treating cancer."
"The doctor says I only have a few months to live, but I know he is
exaggerating to get me to take my medication."
"I can't believe this is happening. Even though I am not hurting right now, I
don't feel like I have the energy to get out of bed."
4. A nurse is caring for a client who is postoperative following a right-sided
mastectomy and has a drain connected to a portable drainage evacuator. Which
of the following actions should the nurse?
, Dangle the operative limb for 5 min every
hour. Place the head of the client's bed at a 15°
angle.
Keep the wound drain evacuator fully expanded at all times.
Take blood pressures on the client's non-affected arm.
5. A client is admitted with pneumonia and has a recent history of MRSA. The client is
placed in isolation. While caring for the client, which item should the nurse
place in a designated biohazard bag before it is removed from the room?
The nurse's stethoscope.
Paper mask and gown.
Bed linens.
A sputum culture.
6. Explain the significance of placing the tuning fork on the top of the client's head
during Weber's test. What does this action help to determine?
It helps to assess the client's overall hearing ability
It allows for comparison of sound perception between both ears
It measures the duration of sound perception
It evaluates the client's response to auditory stimuli
7. Explain why a coude catheter is preferred over a straight catheter for certain
patients during intermittent catheterization.
Because it is easier to insert and requires less training
Because its curved tip allows for easier navigation around obstructions
Because it is less likely to cause discomfort during insertion
Because it can be used for longer periods without complications
8. A nurse is admitting a client who states he takes ginkgo blob everyday to improve
his memory. The nurse should identify a potential interaction with which of the
following meds the client is taking?
Ranitidine
, Levothyroxine
Warfarin
Loratadine
9. A nurse is conducting Weber's test on a client who reports hearing loss in the right
ear. After placing the tuning fork on the top of the client's head, the nurse
notes
that the sound lateralizes to the right ear. What does this finding indicate about the
client's hearing condition?
The client has normal hearing in both ears
The client likely has sensorineural hearing loss in the right ear
The client likely has conduction deafness in the right ear
The client has a blockage in the left ear
10. The nurse is caring for a patient diagnosed with stage I colon cancer. When
assessing the need for psychological support, which question by the nurse will
provide the most information?
"How long ago were you diagnosed with this cancer?"
"Do you have any concerns about body image changes?"
"Can you tell me what has been helpful to you in the past when coping
with stressful events?"
"Are you familiar with the stages of emotional adjustment to a diagnosis
like cancer of the colon?"
11. If a nurse needs to administer diphenhydramine to another child weighing 30 kg,
and the prescribed dosage is 1 mg/kg, how many mL of the 12.5 mg/5 ml syrup
should the nurse prepare for administration?
6 ml
8 ml
10 ml
12 ml
, 12. Why is applying a bath blanket between the client and a cooling blanket
considered the best practice for managing a high fever?
A It prevents the client from feeling cold and uncomfortable.
B It allows for gradual cooling without causing shivering.
C It helps to increase the client's body temperature.
D It promotes excessive sweating to reduce fever.
13. The abbreviation BRP means:
bathroom privileges.
blood pressure.
bowel
movement.
14. Which of the following symptoms would most likely suggest that an NG tube has
been improperly placed in a client?
The client is experiencing a sore
throat The client is having difficulty
swallowing The client is coughing
The client is feeling nauseous
15. A nurse is caring for a patient with a potassium level of 1.8. What immediate
nursing intervention should the nurse implement while waiting for the provider's
orders?
A. Administer oral potassium supplements.
B. Monitor the patient's cardiac rhythm continuously.
C. Encourage the patient to increase dietary potassium.
D.Schedule a follow-up lab test for potassium levels.
16. A patient on warfarin therapy expresses interest in taking ginkgo biloba for
memory enhancement. As a nurse, what steps should you take to ensure patient
safety regarding this supplement?
Advise the patient to stop taking warfarin before starting ginkgo biloba.
WITH ACCURATE SOLUTIONS
1. If a newly licensed nurse demonstrates improper technique during a straight
catheterization, what should the nurse manager's immediate response be to
ensure client safety?
Ignore the mistake to avoid embarrassment
Correct the technique immediately and provide feedback
Document the error and report it later
Allow the nurse to continue without intervention
2. Why is it important for a nurse to check for gastric residual volume before
administering enteral feedings?
To ensure the tube is patent
To assess the client's ability to swallow
To prevent aspiration and ensure proper digestion
To determine the correct formula to use
3. A nurse is caring for a client who has been diagnosed with end-stage liver cancer.
Which of the following client responses is an indication the client is in the
denial phase of the grief process?
"The doctor has been so good to me. I know he has tried everything he
can. It is just my time."
"I can't believe that doctor graduated from medical school; he doesn't
know a thing about treating cancer."
"The doctor says I only have a few months to live, but I know he is
exaggerating to get me to take my medication."
"I can't believe this is happening. Even though I am not hurting right now, I
don't feel like I have the energy to get out of bed."
4. A nurse is caring for a client who is postoperative following a right-sided
mastectomy and has a drain connected to a portable drainage evacuator. Which
of the following actions should the nurse?
, Dangle the operative limb for 5 min every
hour. Place the head of the client's bed at a 15°
angle.
Keep the wound drain evacuator fully expanded at all times.
Take blood pressures on the client's non-affected arm.
5. A client is admitted with pneumonia and has a recent history of MRSA. The client is
placed in isolation. While caring for the client, which item should the nurse
place in a designated biohazard bag before it is removed from the room?
The nurse's stethoscope.
Paper mask and gown.
Bed linens.
A sputum culture.
6. Explain the significance of placing the tuning fork on the top of the client's head
during Weber's test. What does this action help to determine?
It helps to assess the client's overall hearing ability
It allows for comparison of sound perception between both ears
It measures the duration of sound perception
It evaluates the client's response to auditory stimuli
7. Explain why a coude catheter is preferred over a straight catheter for certain
patients during intermittent catheterization.
Because it is easier to insert and requires less training
Because its curved tip allows for easier navigation around obstructions
Because it is less likely to cause discomfort during insertion
Because it can be used for longer periods without complications
8. A nurse is admitting a client who states he takes ginkgo blob everyday to improve
his memory. The nurse should identify a potential interaction with which of the
following meds the client is taking?
Ranitidine
, Levothyroxine
Warfarin
Loratadine
9. A nurse is conducting Weber's test on a client who reports hearing loss in the right
ear. After placing the tuning fork on the top of the client's head, the nurse
notes
that the sound lateralizes to the right ear. What does this finding indicate about the
client's hearing condition?
The client has normal hearing in both ears
The client likely has sensorineural hearing loss in the right ear
The client likely has conduction deafness in the right ear
The client has a blockage in the left ear
10. The nurse is caring for a patient diagnosed with stage I colon cancer. When
assessing the need for psychological support, which question by the nurse will
provide the most information?
"How long ago were you diagnosed with this cancer?"
"Do you have any concerns about body image changes?"
"Can you tell me what has been helpful to you in the past when coping
with stressful events?"
"Are you familiar with the stages of emotional adjustment to a diagnosis
like cancer of the colon?"
11. If a nurse needs to administer diphenhydramine to another child weighing 30 kg,
and the prescribed dosage is 1 mg/kg, how many mL of the 12.5 mg/5 ml syrup
should the nurse prepare for administration?
6 ml
8 ml
10 ml
12 ml
, 12. Why is applying a bath blanket between the client and a cooling blanket
considered the best practice for managing a high fever?
A It prevents the client from feeling cold and uncomfortable.
B It allows for gradual cooling without causing shivering.
C It helps to increase the client's body temperature.
D It promotes excessive sweating to reduce fever.
13. The abbreviation BRP means:
bathroom privileges.
blood pressure.
bowel
movement.
14. Which of the following symptoms would most likely suggest that an NG tube has
been improperly placed in a client?
The client is experiencing a sore
throat The client is having difficulty
swallowing The client is coughing
The client is feeling nauseous
15. A nurse is caring for a patient with a potassium level of 1.8. What immediate
nursing intervention should the nurse implement while waiting for the provider's
orders?
A. Administer oral potassium supplements.
B. Monitor the patient's cardiac rhythm continuously.
C. Encourage the patient to increase dietary potassium.
D.Schedule a follow-up lab test for potassium levels.
16. A patient on warfarin therapy expresses interest in taking ginkgo biloba for
memory enhancement. As a nurse, what steps should you take to ensure patient
safety regarding this supplement?
Advise the patient to stop taking warfarin before starting ginkgo biloba.
