Practice Questions with Answers & Rationales
Q1: A nurse is assessing a client admitted with dehydration. Which assessment finding requires
immediate intervention?
A. Dry mucous membranes
B. Blood pressure 80/50 mmHg
C. Mild thirst
D. Slightly elevated heart rate
Answer: B. Blood pressure 80/50 mmHg
Rationale: Hypotension indicates possible hypovolemic shock, which is life-threatening and
requires immediate intervention. Other findings are concerning but not immediately life-
threatening.
Q2: A nurse uses critical thinking when prioritizing care for multiple clients. Which client should
be assessed first?
A. Client with a temperature of 100.4°F
B. Client with sudden shortness of breath
C. Client requesting assistance with ambulation
D. Client with scheduled medication
Answer: B. Client with sudden shortness of breath
Rationale: Airway and breathing take priority according to ABCs (Airway, Breathing,
Circulation).
Q3: During planning care, which action demonstrates proper use of the nursing process?
A. Performing all tasks without considering the client’s needs
B. Prioritizing interventions based on client assessment data
C. Waiting for a physician to decide interventions
D. Documenting only completed tasks
Answer: B. Prioritizing interventions based on client assessment data
Rationale: The nursing process involves assessment, diagnosis, planning, implementation, and
evaluation; interventions are prioritized based on client data.
Q4: A nurse identifies a client at risk for falls. Which intervention is most appropriate?
A. Restrict all mobility
B. Place the client in a high bed
,C. Keep call light within reach and provide assistance
D. Leave the client alone to maintain independence
Answer: C. Keep call light within reach and provide assistance
Rationale: Fall prevention includes maintaining safety while promoting independence; restraints
and high beds increase risk.
Q5: A nurse notices conflicting information in a client’s medical record. What is the best action?
A. Ignore the conflict
B. Report it to the physician only
C. Verify with the client and clarify documentation
D. Assume the most recent entry is correct
Answer: C. Verify with the client and clarify documentation
Rationale: Accuracy and patient safety require clarification of discrepancies before acting.
Topic: Safety & Infection Control
Q6: Which precaution is required when caring for a client with Clostridium difficile?
A. Standard precautions only
B. Contact precautions
C. Droplet precautions
D. Airborne precautions
Answer: B. Contact precautions
Rationale: C. difficile is transmitted via contact with contaminated surfaces or hands; gloves and
gowns are required.
Q7: A nurse is preparing to give medication via NG tube. What is the best practice to prevent
infection?
A. Wash hands before and after administration
B. Wear sterile gloves
C. Use unclean water to flush the tube
D. Skip hand hygiene if gloves are worn
Answer: A. Wash hands before and after administration
Rationale: Hand hygiene is the most effective method to prevent healthcare-associated
infections.
,Q8: Which client action demonstrates understanding of fire safety?
A. Leaving candles burning in the room
B. Using a fire extinguisher incorrectly
C. Knowing the location of the nearest exit
D. Plugging multiple devices into one outlet
Answer: C. Knowing the location of the nearest exit
Rationale: Fire safety includes awareness of evacuation routes and exit locations.
Q9: A nurse is caring for a client with droplet precautions. Which PPE is required?
A. Gloves and gown
B. Mask and gloves
C. Mask within 3 feet of the client
D. N95 respirator
Answer: C. Mask within 3 feet of the client
Rationale: Droplet precautions prevent the spread of pathogens transmitted via large respiratory
droplets; mask use is required when within close contact.
Q10: A client’s lab results show WBC 18,000/mm³. Which action should the nurse take first?
A. Document the results
B. Notify the physician
C. Implement infection control measures
D. Encourage increased fluids
Answer: C. Implement infection control measures
Rationale: High WBC suggests possible infection; protecting other clients and staff from
infection is the immediate priority.
Q11: When assessing a client’s IV site, the nurse observes redness, swelling, and pain. What
should the nurse do first?
A. Document findings
B. Stop the infusion and remove the IV
C. Apply a warm compress
D. Elevate the extremity
Answer: B. Stop the infusion and remove the IV
Rationale: Signs of phlebitis or infiltration require immediate discontinuation to prevent tissue
damage or infection.
, Q12: A nurse is teaching a client how to prevent urinary tract infections. Which instruction is
correct?
A. Wipe from back to front
B. Drink at least 1 liter of fluid per day
C. Void regularly and after sexual intercourse
D. Avoid all bathroom use
Answer: C. Void regularly and after sexual intercourse
Rationale: Regular voiding and post-intercourse voiding reduce the risk of UTI; wiping should
be front to back.
Q13: A client has a latex allergy. Which intervention is appropriate?
A. Use latex gloves for convenience
B. Mark the client’s chart with an allergy alert
C. Assume small latex exposure is safe
D. Do nothing; monitor for symptoms
Answer: B. Mark the client’s chart with an allergy alert
Rationale: Preventing exposure and alerting all staff is essential for safety in latex-allergic
clients.
Q14: A nurse is prioritizing care. Which client is highest priority?
A. Post-op client with mild pain
B. Client with oxygen saturation 82%
C. Client requesting morning care
D. Client with scheduled vital signs
Answer: B. Client with oxygen saturation 82%
Rationale: Airway and oxygenation take priority over comfort and routine care.
Q15: Which action demonstrates proper hand hygiene?
A. Washing hands for 5 seconds
B. Using alcohol-based hand rub when visibly soiled
C. Scrubbing for at least 20 seconds with soap and water
D. Rinsing hands without soap