1. A nurse is caring for a client who has a new tracheostomy. Which of the following
actions should the nurse take?
A. Suction the tracheostomy tube every 2 hours
B. Cleanse the stoma site with hydrogen peroxide
C. Change the tracheostomy ties when they become soiled
D. Inflate the cuff to 30 mmHg
Answer: C - Tracheostomy ties should be changed when soiled or loose. Suctioning
should be done only when needed (not routinely). Hydrogen peroxide is not
recommended for stoma care (use normal saline). Cuff pressure should be 15-25
mmHg.
---
2. A nurse is preparing to administer a blood transfusion. Which of the
following actions should the nurse take first?
A. Obtain the client's vital signs
B. Verify the blood product with another nurse
,C. Prime the blood tubing with normal saline
D. Check the client's identification band
Answer: D - Always verify client identification FIRST using two identifiers before any
other step in the blood administration process.
---
3. A nurse is caring for a client who is receiving continuous enteral feedings. Which
of the following findings should the nurse identify as requiring immediate
intervention?
A. Gastric residual volume of 150 mL
B. Absent bowel sounds in all four quadrants
C. The feeding bag is empty
D. The client is in a semi-Fowler's position
Answer: B - Absent bowel sounds may indicate a paralytic ileus or bowel
obstruction, which requires immediate intervention before continuing feedings.
---
4. A nurse is implementing contact precautions for a client who has
Clostridium difficile infection. Which of the following actions should the
nurse take?
A. Wear a surgical mask when entering the room
B. Place the client in a negative-pressure room
C. Use soap and water for hand hygiene after removing gloves
D. Keep the door to the client's room closed at all times
,Answer: C - C. difficile spores are not killed by alcohol-based hand sanitizers.
Soap and water must be used. Contact precautions require gloves and gown, not
necessarily mask or negative pressure.
---
5. A nurse is assessing a client following a fall. Which of the following findings
should the nurse identify as an indication of a possible fracture?
A. Swelling at the injury site
B. Ecchymosis at the injury site
C. Crepitus at the injury site
D. Redness at the injury site
Answer: C - Crepitus (a grating sound or sensation) is a classic sign of a fracture
and requires immediate immobilization and further assessment.
---
HEALTH PROMOTION & MAINTENANCE
6. A nurse is providing teaching to the parent of a 2-month-old infant
about immunizations. Which of the following statements by the parent
indicates an understanding of the teaching?
A. "My baby will receive the hepatitis B vaccine at this visit."
B. "My baby will receive the MMR vaccine at this visit."
C. "My baby will receive the varicella vaccine at this visit."
D. "My baby will receive the polio vaccine at this visit."
, Answer: D - At 2 months, the infant receives DTaP, IPV (polio), Hib, PCV13, Hep B (if
not already completed), and RV (rotavirus). MMR and varicella are given at 12
months.
---
7. A nurse is performing a developmental screening on a 4-year-old child. Which of
the following behaviors should the nurse expect the child to demonstrate?
A. Hop on one foot
B. Tie shoelaces
C. Draw a person with six body parts
D. Write their first name
Answer: C - A 4-year-old can typically draw a person with 3-6 body parts, hop on
one foot, and copy a circle. Tying shoelaces and writing their name are expected at
age 5-6.
---
8. A nurse is providing dietary teaching to a client who is pregnant and has gestational
diabetes. Which of the following statements by the client indicates an understanding
of the teaching?
A. "I should eat three large meals per day."
B. "I should limit my carbohydrate intake to 50% of total calories."
C. "I should avoid all fruits during my pregnancy."
D. "I should skip breakfast to keep my blood sugar low."
Answer: B - Carbohydrates should be limited to 40-50% of total calories, distributed
in small, frequent meals throughout the day. Skipping meals can cause hypoglycemia
or ketosis.
actions should the nurse take?
A. Suction the tracheostomy tube every 2 hours
B. Cleanse the stoma site with hydrogen peroxide
C. Change the tracheostomy ties when they become soiled
D. Inflate the cuff to 30 mmHg
Answer: C - Tracheostomy ties should be changed when soiled or loose. Suctioning
should be done only when needed (not routinely). Hydrogen peroxide is not
recommended for stoma care (use normal saline). Cuff pressure should be 15-25
mmHg.
---
2. A nurse is preparing to administer a blood transfusion. Which of the
following actions should the nurse take first?
A. Obtain the client's vital signs
B. Verify the blood product with another nurse
,C. Prime the blood tubing with normal saline
D. Check the client's identification band
Answer: D - Always verify client identification FIRST using two identifiers before any
other step in the blood administration process.
---
3. A nurse is caring for a client who is receiving continuous enteral feedings. Which
of the following findings should the nurse identify as requiring immediate
intervention?
A. Gastric residual volume of 150 mL
B. Absent bowel sounds in all four quadrants
C. The feeding bag is empty
D. The client is in a semi-Fowler's position
Answer: B - Absent bowel sounds may indicate a paralytic ileus or bowel
obstruction, which requires immediate intervention before continuing feedings.
---
4. A nurse is implementing contact precautions for a client who has
Clostridium difficile infection. Which of the following actions should the
nurse take?
A. Wear a surgical mask when entering the room
B. Place the client in a negative-pressure room
C. Use soap and water for hand hygiene after removing gloves
D. Keep the door to the client's room closed at all times
,Answer: C - C. difficile spores are not killed by alcohol-based hand sanitizers.
Soap and water must be used. Contact precautions require gloves and gown, not
necessarily mask or negative pressure.
---
5. A nurse is assessing a client following a fall. Which of the following findings
should the nurse identify as an indication of a possible fracture?
A. Swelling at the injury site
B. Ecchymosis at the injury site
C. Crepitus at the injury site
D. Redness at the injury site
Answer: C - Crepitus (a grating sound or sensation) is a classic sign of a fracture
and requires immediate immobilization and further assessment.
---
HEALTH PROMOTION & MAINTENANCE
6. A nurse is providing teaching to the parent of a 2-month-old infant
about immunizations. Which of the following statements by the parent
indicates an understanding of the teaching?
A. "My baby will receive the hepatitis B vaccine at this visit."
B. "My baby will receive the MMR vaccine at this visit."
C. "My baby will receive the varicella vaccine at this visit."
D. "My baby will receive the polio vaccine at this visit."
, Answer: D - At 2 months, the infant receives DTaP, IPV (polio), Hib, PCV13, Hep B (if
not already completed), and RV (rotavirus). MMR and varicella are given at 12
months.
---
7. A nurse is performing a developmental screening on a 4-year-old child. Which of
the following behaviors should the nurse expect the child to demonstrate?
A. Hop on one foot
B. Tie shoelaces
C. Draw a person with six body parts
D. Write their first name
Answer: C - A 4-year-old can typically draw a person with 3-6 body parts, hop on
one foot, and copy a circle. Tying shoelaces and writing their name are expected at
age 5-6.
---
8. A nurse is providing dietary teaching to a client who is pregnant and has gestational
diabetes. Which of the following statements by the client indicates an understanding
of the teaching?
A. "I should eat three large meals per day."
B. "I should limit my carbohydrate intake to 50% of total calories."
C. "I should avoid all fruits during my pregnancy."
D. "I should skip breakfast to keep my blood sugar low."
Answer: B - Carbohydrates should be limited to 40-50% of total calories, distributed
in small, frequent meals throughout the day. Skipping meals can cause hypoglycemia
or ketosis.
