1. A nurse is preparing to insert an indwelling urinary catheter for a female patient.
Which of the following actions should the nurse take first?
A. Lubricate the catheter tip
B. Open the sterile catheter kit
C. Place a drape under the patient’s buttocks
D. Perform hand hygiene
Correct Answer: D
Rationale: Hand hygiene is the first step in any aseptic procedure to reduce infection
risk. The other steps come after.
2. A patient is receiving a continuous enteral feeding via nasogastric tube. Which of the
following positions is most appropriate?
A. Supine
B. Semi-Fowler’s (30–45°)
C. Prone
D. Trendelenburg
Correct Answer: B
Rationale: Semi-Fowler’s reduces risk of aspiration. Supine and Trendelenburg increase
reflux risk.
, 3. A nurse notes a small area of non-blanchable erythema over a patient’s sacrum. How
should this be staged?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep tissue injury
D. Unstageable
Correct Answer: A
Rationale: Stage 1 = intact skin with non-blanchable redness. Stage 2 involves partial-
thickness skin loss.
4. A nurse is providing discharge teaching to a patient with a new colostomy. Which of
the following statements indicate understanding? (Select all that apply)
A. “I should empty my pouch when it is one-third to one-half full.”
B. “I can take a bath or shower with the pouch on or off.”
C. “I will change my pouch daily to prevent infection.”
D. “I should avoid carbonated beverages to reduce gas.”
E. “I will clean the stoma with alcohol wipes.”
Correct Answers: A, B, D
Rationale:
A – Prevents leakage and skin breakdown.
B – Water won’t hurt stoma; showering without pouch is fine.
C – Change every 3–7 days unless leaking.
D – Carbonated drinks increase gas.
E – Alcohol damages skin; use mild soap and water.
5. Which of the following are correct actions when applying anti-embolism stockings
(TED hose)? (Select all that apply)
A. Apply after the patient has been sitting for 10 minutes
B. Measure the patient’s leg length and calf circumference
C. Turn the stocking inside out to apply
D. Roll the stocking up the leg to avoid creases
E. Remove stockings once per shift for skin assessment
, Correct Answers: B, C, E
Rationale:
A – Apply with patient supine, not sitting.
B – Correct sizing prevents tourniquet effect.
C – Inside-out application helps smooth application.
D – Rolling creates wrinkles and impairs circulation.
E – Remove daily to check skin and circulation.
A nurse on a medical-surgical unit receives report on a 78-year-old patient admitted 2
days ago with pneumonia.
Current data:
HR 110 bpm
BP 98/62 mm Hg
RR 24/min
SpO₂ 89% on room air
Temp 38.9°C (102°F)
Lethargic, confused to time and place
IV fluids at 75 mL/hr
Oxygen at 2 L/min via nasal cannula ordered but not applied.
6. Recognize Cues – Which findings are abnormal? (Select all that apply)
A. HR 110 bpm
B. BP 98/62 mm Hg
C. RR 24/min
D. SpO₂ 89%
E. Temp 38.9°C
F. Lethargy/confusion
Correct Answers: A, C, D, E, F
Rationale:
A – Tachycardia (>100)
C – Tachypnea (>20)
D – Hypoxemia (<90%)
E – Fever (>38°C)
F – Altered mental status
Which of the following actions should the nurse take first?
A. Lubricate the catheter tip
B. Open the sterile catheter kit
C. Place a drape under the patient’s buttocks
D. Perform hand hygiene
Correct Answer: D
Rationale: Hand hygiene is the first step in any aseptic procedure to reduce infection
risk. The other steps come after.
2. A patient is receiving a continuous enteral feeding via nasogastric tube. Which of the
following positions is most appropriate?
A. Supine
B. Semi-Fowler’s (30–45°)
C. Prone
D. Trendelenburg
Correct Answer: B
Rationale: Semi-Fowler’s reduces risk of aspiration. Supine and Trendelenburg increase
reflux risk.
, 3. A nurse notes a small area of non-blanchable erythema over a patient’s sacrum. How
should this be staged?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Deep tissue injury
D. Unstageable
Correct Answer: A
Rationale: Stage 1 = intact skin with non-blanchable redness. Stage 2 involves partial-
thickness skin loss.
4. A nurse is providing discharge teaching to a patient with a new colostomy. Which of
the following statements indicate understanding? (Select all that apply)
A. “I should empty my pouch when it is one-third to one-half full.”
B. “I can take a bath or shower with the pouch on or off.”
C. “I will change my pouch daily to prevent infection.”
D. “I should avoid carbonated beverages to reduce gas.”
E. “I will clean the stoma with alcohol wipes.”
Correct Answers: A, B, D
Rationale:
A – Prevents leakage and skin breakdown.
B – Water won’t hurt stoma; showering without pouch is fine.
C – Change every 3–7 days unless leaking.
D – Carbonated drinks increase gas.
E – Alcohol damages skin; use mild soap and water.
5. Which of the following are correct actions when applying anti-embolism stockings
(TED hose)? (Select all that apply)
A. Apply after the patient has been sitting for 10 minutes
B. Measure the patient’s leg length and calf circumference
C. Turn the stocking inside out to apply
D. Roll the stocking up the leg to avoid creases
E. Remove stockings once per shift for skin assessment
, Correct Answers: B, C, E
Rationale:
A – Apply with patient supine, not sitting.
B – Correct sizing prevents tourniquet effect.
C – Inside-out application helps smooth application.
D – Rolling creates wrinkles and impairs circulation.
E – Remove daily to check skin and circulation.
A nurse on a medical-surgical unit receives report on a 78-year-old patient admitted 2
days ago with pneumonia.
Current data:
HR 110 bpm
BP 98/62 mm Hg
RR 24/min
SpO₂ 89% on room air
Temp 38.9°C (102°F)
Lethargic, confused to time and place
IV fluids at 75 mL/hr
Oxygen at 2 L/min via nasal cannula ordered but not applied.
6. Recognize Cues – Which findings are abnormal? (Select all that apply)
A. HR 110 bpm
B. BP 98/62 mm Hg
C. RR 24/min
D. SpO₂ 89%
E. Temp 38.9°C
F. Lethargy/confusion
Correct Answers: A, C, D, E, F
Rationale:
A – Tachycardia (>100)
C – Tachypnea (>20)
D – Hypoxemia (<90%)
E – Fever (>38°C)
F – Altered mental status
