1. The nurse is caring for a patient with a central venous catheter.
Which of the following actions should the nurse take to reduce the risk
of infection?
A. Change the dressing around the catheter site weekly
B. Administer antibiotics regularly
C. Maintain strict aseptic technique during catheter care
D. Flush the catheter with saline only when needed
Answer: c) Maintain strict aseptic technique during catheter care
Rationale: Strict aseptic technique during catheter care reduces the risk
of infection and ensures that the catheter remains free from pathogens.
2. When administering an intramuscular injection, which of the
following is the most appropriate site for the nurse to use?
A. Abdomen
B. Forearm
C. Dorsogluteal
D. Ventrogluteal
Answer: d) Ventrogluteal
Rationale: The ventrogluteal site is preferred for intramuscular
injections as it is free of major blood vessels and nerves.
,3. A nurse is assessing a patient’s pain level. Which of the following is
the most accurate way to assess the patient’s pain?
A. Rely on the nurse’s judgment of the patient’s condition
B. Ask the patient to rate their pain using a numerical scale
C. Observe the patient’s behavior and make an assumption
D. Check the patient’s vital signs for indications of pain
Answer: b) Ask the patient to rate their pain using a numerical scale
Rationale: Pain is subjective, and the most accurate way to assess it is
by asking the patient to describe it, typically using a pain scale.
4. Which of the following is the most appropriate action for the nurse
to take when a patient requests information about their medical
diagnosis?
A. Provide the patient with detailed information about the diagnosis
B. Refer the patient to their healthcare provider for more information
C. Tell the patient not to worry and focus on recovery
D. Avoid discussing the diagnosis to prevent anxiety
Answer: b) Refer the patient to their healthcare provider for more
information
Rationale: The healthcare provider is responsible for discussing medical
diagnoses in detail with the patient.
, 5. Which of the following is the primary purpose of a care plan in
nursing practice?
A. To provide a document for legal purposes
B. To outline the patient’s nursing interventions
C. To record the healthcare provider’s orders
D. To track the patient’s insurance details
Answer: b) To outline the patient’s nursing interventions
Rationale: A care plan is a dynamic document that outlines
individualized nursing interventions to address the patient’s health
needs.
6. A nurse is assessing a patient's vital signs. Which of the following
findings would be considered abnormal in a healthy adult?
A. Heart rate of 90 beats per minute
B. Blood pressure of 110/70 mmHg
C. Respiratory rate of 24 breaths per minute
D. Temperature of 101.2°F (38.4°C)
Answer: d) Temperature of 101.2°F (38.4°C)
Rationale: A temperature of 101.2°F (38.4°C) is considered a fever and
suggests an infection or other illness.
Which of the following actions should the nurse take to reduce the risk
of infection?
A. Change the dressing around the catheter site weekly
B. Administer antibiotics regularly
C. Maintain strict aseptic technique during catheter care
D. Flush the catheter with saline only when needed
Answer: c) Maintain strict aseptic technique during catheter care
Rationale: Strict aseptic technique during catheter care reduces the risk
of infection and ensures that the catheter remains free from pathogens.
2. When administering an intramuscular injection, which of the
following is the most appropriate site for the nurse to use?
A. Abdomen
B. Forearm
C. Dorsogluteal
D. Ventrogluteal
Answer: d) Ventrogluteal
Rationale: The ventrogluteal site is preferred for intramuscular
injections as it is free of major blood vessels and nerves.
,3. A nurse is assessing a patient’s pain level. Which of the following is
the most accurate way to assess the patient’s pain?
A. Rely on the nurse’s judgment of the patient’s condition
B. Ask the patient to rate their pain using a numerical scale
C. Observe the patient’s behavior and make an assumption
D. Check the patient’s vital signs for indications of pain
Answer: b) Ask the patient to rate their pain using a numerical scale
Rationale: Pain is subjective, and the most accurate way to assess it is
by asking the patient to describe it, typically using a pain scale.
4. Which of the following is the most appropriate action for the nurse
to take when a patient requests information about their medical
diagnosis?
A. Provide the patient with detailed information about the diagnosis
B. Refer the patient to their healthcare provider for more information
C. Tell the patient not to worry and focus on recovery
D. Avoid discussing the diagnosis to prevent anxiety
Answer: b) Refer the patient to their healthcare provider for more
information
Rationale: The healthcare provider is responsible for discussing medical
diagnoses in detail with the patient.
, 5. Which of the following is the primary purpose of a care plan in
nursing practice?
A. To provide a document for legal purposes
B. To outline the patient’s nursing interventions
C. To record the healthcare provider’s orders
D. To track the patient’s insurance details
Answer: b) To outline the patient’s nursing interventions
Rationale: A care plan is a dynamic document that outlines
individualized nursing interventions to address the patient’s health
needs.
6. A nurse is assessing a patient's vital signs. Which of the following
findings would be considered abnormal in a healthy adult?
A. Heart rate of 90 beats per minute
B. Blood pressure of 110/70 mmHg
C. Respiratory rate of 24 breaths per minute
D. Temperature of 101.2°F (38.4°C)
Answer: d) Temperature of 101.2°F (38.4°C)
Rationale: A temperature of 101.2°F (38.4°C) is considered a fever and
suggests an infection or other illness.
