,1. The nurse is caring for a group of patients on a medical-surgical unit. Which patient should the
licensed practical nurse/licensed vocational nurse (LPN/LVN) assess first?
1. A patient with a blood glucose of 42 mg/dL
2. A patient who reports a pain level of 2
3. A patient who has just received a diagnosis of cancer
4. A patient who has a respiratory rate of 22
ANS: 1 ✔
2. Which action reflects the application of evidence-based practice in nursing care?
1. Administering medications because "it's always been done that way"
2. Using the latest research to update clinical protocols
3. Delegating care tasks to unlicensed personnel without supervision
4. Relying solely on textbook knowledge for decision making
ANS: 2 ✔
3. A nurse observes another staff member speaking rudely to a confused patient. What is the
most appropriate initial action by the nurse?
1. Confront the staff member in front of the patient
2. Document the behavior in the chart
3. Report the incident to the nurse manager
4. Redirect the conversation and speak with the staff privately
ANS: 4 ✔
4. A culturally competent nurse is preparing to care for a patient who refuses blood transfusions
for religious reasons. What is the nurse's best response?
1. "You must accept the transfusion for your safety."
2. "Can we explore other treatment options together?"
3. "That belief is not supported by science."
4. "You may not refuse care in this hospital."
ANS: 2 ✔
5. A patient undergoing acupuncture for chronic pain asks the nurse how the treatment works.
Which is the most accurate response?
1. "It’s a placebo treatment with no proven effect."
2. "It involves surgical removal of nerve endings."
3. "It uses needles to stimulate specific body points."
4. "It replaces traditional medical treatments."
ANS: 3 ✔
, 6. A patient presents with muscle weakness and a potassium level of 2.6 mEq/L. What is the
nurse’s priority action?
1. Administer potassium as prescribed
2. Encourage fluid intake
3. Reassess potassium levels in 8 hours
4. Discontinue all medications
ANS: 1 ✔
7. A nurse finds a patient's IV site to be swollen, red, and tender. What should the nurse do first?
1. Increase the IV flow rate
2. Apply a cold compress
3. Discontinue the IV and restart elsewhere
4. Flush the IV line with saline
ANS: 3 ✔
8. Which infection control measure is most appropriate when caring for a patient with active
tuberculosis?
1. Droplet precautions
2. Contact precautions
3. Neutropenic precautions
4. Airborne precautions
ANS: 4 ✔
9. A nurse is assessing a patient in shock. Which early finding is most expected?
1. Bradycardia
2. Confusion and restlessness
3. Cyanosis of extremities
4. Absence of bowel sounds
ANS: 2 ✔
10. A patient receiving opioids for cancer pain reports increasing sedation and respiratory rate of
8 breaths/min. What should the nurse do first?
1. Call a code
2. Administer naloxone as ordered
3. Document the findings
4. Ask the patient to take deep breaths
ANS: 2 ✔
licensed practical nurse/licensed vocational nurse (LPN/LVN) assess first?
1. A patient with a blood glucose of 42 mg/dL
2. A patient who reports a pain level of 2
3. A patient who has just received a diagnosis of cancer
4. A patient who has a respiratory rate of 22
ANS: 1 ✔
2. Which action reflects the application of evidence-based practice in nursing care?
1. Administering medications because "it's always been done that way"
2. Using the latest research to update clinical protocols
3. Delegating care tasks to unlicensed personnel without supervision
4. Relying solely on textbook knowledge for decision making
ANS: 2 ✔
3. A nurse observes another staff member speaking rudely to a confused patient. What is the
most appropriate initial action by the nurse?
1. Confront the staff member in front of the patient
2. Document the behavior in the chart
3. Report the incident to the nurse manager
4. Redirect the conversation and speak with the staff privately
ANS: 4 ✔
4. A culturally competent nurse is preparing to care for a patient who refuses blood transfusions
for religious reasons. What is the nurse's best response?
1. "You must accept the transfusion for your safety."
2. "Can we explore other treatment options together?"
3. "That belief is not supported by science."
4. "You may not refuse care in this hospital."
ANS: 2 ✔
5. A patient undergoing acupuncture for chronic pain asks the nurse how the treatment works.
Which is the most accurate response?
1. "It’s a placebo treatment with no proven effect."
2. "It involves surgical removal of nerve endings."
3. "It uses needles to stimulate specific body points."
4. "It replaces traditional medical treatments."
ANS: 3 ✔
, 6. A patient presents with muscle weakness and a potassium level of 2.6 mEq/L. What is the
nurse’s priority action?
1. Administer potassium as prescribed
2. Encourage fluid intake
3. Reassess potassium levels in 8 hours
4. Discontinue all medications
ANS: 1 ✔
7. A nurse finds a patient's IV site to be swollen, red, and tender. What should the nurse do first?
1. Increase the IV flow rate
2. Apply a cold compress
3. Discontinue the IV and restart elsewhere
4. Flush the IV line with saline
ANS: 3 ✔
8. Which infection control measure is most appropriate when caring for a patient with active
tuberculosis?
1. Droplet precautions
2. Contact precautions
3. Neutropenic precautions
4. Airborne precautions
ANS: 4 ✔
9. A nurse is assessing a patient in shock. Which early finding is most expected?
1. Bradycardia
2. Confusion and restlessness
3. Cyanosis of extremities
4. Absence of bowel sounds
ANS: 2 ✔
10. A patient receiving opioids for cancer pain reports increasing sedation and respiratory rate of
8 breaths/min. What should the nurse do first?
1. Call a code
2. Administer naloxone as ordered
3. Document the findings
4. Ask the patient to take deep breaths
ANS: 2 ✔
