Questions and Answers | Latest
Version | 2025/2026 | Correct & Verified
A nurse enters a client’s room and finds the client attempting to get out of bed without assistance.
The safest initial action is to
A. Leave and get another nurse
✔✔B. Stay with the client and assist them back to bed
C. Tell the client to stay still until you return
D. Restrain the client immediately
A nurse is preparing to obtain a blood pressure reading. Which action will prevent an inaccurate
reading?
A. Using a cuff that is too small
B. Placing the cuff over clothing
✔✔C. Ensuring the arm is at heart level and the cuff fits properly
D. Deflating the cuff very rapidly
A nurse is teaching a client about proper use of a metered-dose inhaler. The client understands
when stating
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,A. “I should exhale into the inhaler before pressing it.”
✔✔B. “I should shake the inhaler, exhale fully, then inhale as I press the canister.”
C. “I should hold my breath before using it.”
D. “I should use it only after eating a large meal.”
A nurse is caring for a client with a nasogastric tube for suction. The priority nursing action is to
A. Place the client in a supine position
✔✔B. Maintain the head of bed at least 30 degrees
C. Clamp the tube every hour
D. Flush the tube with cold water
A nurse is caring for a client who needs assistance to ambulate. The safest technique is to
A. Hold the client’s arm tightly
B. Walk behind the client holding the gown
✔✔C. Use a gait belt and stand slightly behind on the weaker side
D. Have the client hold on to the wall
A nurse is preparing to administer an intramuscular injection in the deltoid. The correct site is
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,A. Two inches below the acromion process
✔✔B. Two to three finger widths below the acromion process in the middle of the muscle
C. Lateral aspect of the thigh
D. Outer quadrant of the buttock
A nurse is reinforcing discharge teaching about wound care. The client correctly states
A. “I will wash my wound with soap and rub it dry.”
✔✔B. “I will wash my hands before and after changing the dressing.”
C. “I will reuse the same dressing if it looks clean.”
D. “I will leave the wound uncovered to heal faster.”
A nurse observes a coworker document a medication as given, but the dose is still in the
medication cup. The appropriate response is to
A. Ignore the situation
✔✔B. Address the coworker and clarify the documentation
C. Give the medication for them
D. Write a note in the chart
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, A nurse is caring for a client who has orthostatic hypotension. The best intervention is to
A. Have the client change positions quickly
✔✔B. Encourage the client to rise slowly from lying to sitting
C. Restrict fluids
D. Avoid using assistive devices
A nurse is assisting a client with meal selection to reduce cholesterol. The best option is
A. Fried chicken with mashed potatoes
B. Bacon and eggs
✔✔C. Grilled salmon with steamed vegetables
D. Cheeseburger and fries
A nurse is preparing to take an axillary temperature. The correct technique is to
A. Place the thermometer in the client’s mouth
✔✔B. Place the thermometer in the center of the axilla and hold the arm against the body
C. Insert the thermometer rectally
D. Place the thermometer on top of the shoulder
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