Questions
Nursing Process
1. A nurse is assessing a client admitted with dehydration. Which finding should the
nurse prioritize in the assessment phase?
A. Client’s favorite food preferences.
B. Dry mucous membranes and skin turgor.
C. Client’s preferred time for bathing.
D. Family history of chronic illnesses.
Correct Answer: B. Dry mucous membranes and poor skin turgor are key indicators
of dehydration, requiring immediate attention.
2. During the planning phase, a nurse sets a goal for a client with impaired mobility.
Which goal is most appropriate?
A. Client will walk 50 feet without assistance by discharge.
B. Client will avoid all physical activity to prevent falls.
C. Client will learn about mobility aids in 6 months.
D. Client will remain in bed indefinitely.
Correct Answer: A. A specific, measurable, and time-bound goal promotes mobility
and independence.
3. A nurse evaluates a client’s response to pain medication. Which finding indicates
the intervention was effective?
A. Client reports a pain level of 8/10.
B. Client is grimacing and guarding the abdomen.
C. Client reports a pain level of 2/10 and is resting comfortably.
D. Client refuses to ambulate due to discomfort.
Correct Answer: C. A reduced pain level and relaxed demeanor indicate effective
pain management.
4. A nurse is developing a care plan for a client with a new colostomy. Which nursing
diagnosis is most relevant?
A. Risk for impaired skin integrity related to stoma care.
B. Risk for acute pain related to chronic illness.
C. Risk for infection related to immobility.
D. Risk for falls related to medication side effects.
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, Correct Answer: A. A new colostomy increases the risk of skin breakdown around
the stoma site.
5. During the implementation phase, a nurse assists a client with deep breathing
exercises post-surgery. Which action is most appropriate?
A. Instruct the client to exhale quickly and shallowly.
B. Demonstrate slow inhalation through the nose and exhalation through the
mouth.
C. Encourage the client to hold their breath for 10 seconds.
D. Perform the exercises for the client while they rest.
Correct Answer: B. Slow, deep breathing promotes lung expansion and prevents
atelectasis.
6. A nurse is collecting data for a client with diabetes. Which question best supports
the assessment phase?
A. “What is your favorite dessert?”
B. “How often do you check your blood glucose?”
C. “Do you prefer morning or evening walks?”
D. “What TV shows do you watch?”
Correct Answer: B. Monitoring blood glucose frequency provides critical health
data.
7. A nurse is evaluating a client’s understanding of a low-sodium diet. Which state-
ment indicates the outcome was met?
A. “I can eat canned soup daily.”
B. “I’ll choose fresh vegetables over processed foods.”
C. “I’ll add table salt to enhance flavor.”
D. “I prefer salty snacks like chips.”
Correct Answer: B. Choosing fresh vegetables reflects adherence to a low-sodium
diet.
8. A nurse identifies a client’s risk for impaired gas exchange post-operatively. Which
intervention should be included in the care plan?
A. Restrict fluid intake to reduce lung congestion.
B. Encourage incentive spirometry every 2 hours.
C. Keep the client in a supine position.
D. Limit oxygen administration to conserve resources.
Correct Answer: B. Incentive spirometry promotes lung expansion and prevents
respiratory complications.
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, 9. A nurse is assessing a client with a pressure injury. Which finding should be docu-
mented in the assessment phase?
A. Client’s room temperature preference.
B. Size, depth, and exudate of the wound.
C. Client’s preferred meal schedule.
D. Family’s visiting hours.
Correct Answer: B. Objective wound characteristics are essential for assessment
and planning.
10. During the evaluation phase, a nurse reviews a client’s fluid intake goal. Which
finding indicates the goal was not met?
A. Client consumed 2000 mL of fluid in 24 hours.
B. Client consumed 800 mL of fluid in 24 hours.
C. Client reports no thirst.
D. Client’s urine output is 1500 mL daily.
Correct Answer: B. Low fluid intake suggests the goal was not achieved, risking
dehydration.
Safety
1. A nurse is preparing to transfer a client with hemiparesis from bed to wheelchair.
Which action ensures safety?
A. Position the wheelchair on the client’s weaker side.
B. Lock the wheelchair brakes before transfer.
C. Transfer the client without using a gait belt.
D. Place the wheelchair at a 90-degree angle to the bed.
Correct Answer: B. Locking the brakes prevents the wheelchair from moving during
transfer.
2. A client with a history of falls is admitted. Which intervention is most effective in
preventing falls?
A. Keep the bed in the highest position.
B. Ensure the call light is within reach.
C. Place all furniture against the walls.
D. Encourage the client to ambulate alone.
Correct Answer: B. A reachable call light allows the client to request assistance,
reducing fall risk.
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