ACTUAL EXAM QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES GRADED A+
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1. A nurse enters a client’s room and finds the client lying on the floor. What
is the FIRST action the nurse should take?
A. Notify the healthcare provider
B. Check the client’s airway, breathing, and circulation
C. Ask the client what happened
D. Call for help from the hallway
Correct Answer: B
Rationale: Always assess ABCs first for safety. Determining airway, breathing,
circulation is essential before seeking help or documenting.
2. A client is prescribed a medication that the nurse does not recognize. What
is the most appropriate nursing action?
A. Administer the medication as ordered
B. Ask another nurse what the medication is
C. Look up the medication before administration
D. Call the pharmacy to cancel the medication
Correct Answer: C
Rationale: The nurse is responsible for knowing medications prior to
administration. Independent verification is required.
,3. Which action is an example of secondary prevention?
A. Vaccinations
B. Smoking cessation classes
C. Blood pressure screening at a community fair
D. Rehabilitation after a stroke
Correct Answer: C
Rationale: Secondary prevention = early detection (screening). Primary =
preventing disease; tertiary = reducing disability.
4. A nurse is caring for a client who is Muslim. Which menu option is
culturally appropriate?
A. Pork ribs and vegetables
B. Chicken and rice
C. Beef stew with red wine
D. Ham sandwich
Correct Answer: B
Rationale: Muslims avoid pork and alcohol; chicken is acceptable if halal-
prepared (assumed in exam questions).
5. A nurse gives the wrong medication dose but the client is not harmed. What
should the nurse do FIRST?
A. Document the error in the client’s chart
B. Notify the charge nurse
C. File an incident report
D. Assess the client’s condition
Correct Answer: D
Rationale: Client safety is the priority; assess first, then report.
,6. A nurse is preparing to insert an NG tube. Which action demonstrates
proper procedure?
A. Positioning the client supine
B. Lubricating the tube with petroleum jelly
C. Instructing the client to swallow during advancement
D. Removing the tube at the first gag reflex
Correct Answer: C
Rationale: Swallowing helps guide the tube into the esophagus. The client should
be in high Fowler’s position.
7. A nurse identifies a fire in a patient’s room. According to RACE, what is
the first action?
A. Close all doors
B. Extinguish the fire
C. Activate the alarm
D. Rescue the client
Correct Answer: D
Rationale: RACE = Rescue, Alarm, Contain, Extinguish.
8. The nurse is evaluating a newly admitted client’s orientation. Which
question is most appropriate?
A. “Why are you here?”
B. “Who is the president?”
C. “Can you tell me your name?”
D. “What did you eat for breakfast?”
Correct Answer: C
Rationale: Orientation assessment = person, place, time, situation.
, 9. Which task can the nurse delegate to an unlicensed assistive personnel
(UAP)?
A. Administering oral medications
B. Assessing pain level
C. Ambulating a stable client
D. Developing a care plan
Correct Answer: C
Rationale: UAP can perform non-invasive, routine tasks. Assessment and teaching
cannot be delegated.
10. A postoperative client is at risk for atelectasis. Which intervention helps
prevent this?
A. Increase IV fluids
B. Encourage deep breathing and use of incentive spirometer
C. Limit mobility for 24 hours
D. Reduce opioid use
Correct Answer: B
Rationale: Deep breathing expands alveoli and prevents lung collapse.
11. When prioritizing care, which client should the nurse see FIRST?
A. Client with a fever of 38.9°C
B. Client with new-onset confusion
C. Client with postoperative pain rated 8/10
D. Client requesting assistance to the bathroom
Correct Answer: B
Rationale: Sudden confusion may indicate hypoxia or neurologic compromise →
priority.