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Question 1. Which of the following documents specifically designates a surrogate decision‑maker for health care when the client becomes incapacitated? A) Living will B) Durable power of attorney for health care C) Do‑not‑resuscitate (DNR) order D) Advance directive checklist Answer: B Explanation: A durable power of attorney for health care legally appoints another person to make health‑care decisions on the client’s behalf if the client is unable to do so. Question 2. A client refuses a blood transfusion based on religious beliefs. The nurse’s most appropriate action is to: A) Report the refusal to the attending physician immediately B) Document the refusal and respect the client’s autonomy C) Persuade the client to accept the transfusion for safety D) Withhold the transfusion and proceed with alternative therapy without documentation Answer: B Explanation: Respecting autonomy requires honoring the client’s informed refusal and documenting it clearly in the record. Question 3. Which ethical principle is primarily concerned with doing good and promoting the client’s welfare? A) Autonomy B) Beneficence C) Non‑maleficence D) Justice Answer: B Explanation: Beneficence obligates nurses to act in ways that benefit the client and promote health. Question 4. When triaging patients in a mass‑casualty incident using the “Survival Potential” model, which category receives the highest priority?
A) Immediate (red) – life‑threatening injuries but treatable B) Delayed (yellow) – serious injuries, can wait C) Minimal (green) – minor injuries D) Expectant (black) – injuries unlikely to survive regardless of treatment Answer: A Explanation: The “Immediate” category includes patients who need rapid intervention to survive. Question 5. According to the Five Rights of Delegation, which right ensures that the task assigned is appropriate for the delegatee’s scope of practice? A) Right task B) Right circumstance C) Right person D) Right communication Answer: C Explanation: “Right person” confirms that the delegatee is qualified, licensed, and competent for the specific task. Question 6. In assigning clients to a LPN, which factor is most important to consider? A) The LPN’s personal preferences for client types B) The client’s need for complex medication administration requiring independent assessment C) The LPN’s shift length D) The client’s insurance status Answer: B Explanation: LPNs can administer many medications but cannot perform independent assessments for complex conditions; tasks must match scope. Question 7. Which interdisciplinary team member is primarily responsible for assessing mobility limitations and prescribing therapeutic exercises? A) Dietitian B) Physical therapist
Question 11. The most appropriate ergonomic technique for transferring a client from a bed to a wheelchair is: A) Using a slide sheet and a team lift B) Pulling the client by the arms C) Twisting the client’s torso while lifting D) Allowing the client to stand unsupported Answer: A Explanation: Slide sheets reduce shear forces and, combined with a team lift, protect both client and nurse. Question 12. Which standard precaution is essential before any patient contact? A) Wearing a gown B) Hand hygiene with soap and water or alcohol‑based sanitizer C) Donning an N95 respirator D) Placing the patient in isolation Answer: B Explanation: Hand hygiene is the cornerstone of standard precautions for all patient interactions. Question 13. A client with confirmed active tuberculosis requires which transmission‑based precaution? A) Contact precautions only B) Droplet precautions only C) Airborne precautions with N95 respirator and negative‑pressure room D) Standard precautions only Answer: C Explanation: TB spreads via airborne particles; N95 respirators and negative‑pressure isolation are required. Question 14. For a client with influenza, the nurse should implement:
A) N95 respirator and negative‑pressure room B) Surgical mask and droplet precautions C) Gown and gloves only D) No additional precautions beyond standard Answer: B Explanation: Influenza is transmitted by large droplets; surgical masks and droplet precautions are appropriate. Question 15. When caring for a client colonized with MRSA, which precaution is indicated? A) Airborne precautions B) Droplet precautions C) Contact precautions with gown and gloves D) No additional precautions needed Answer: C Explanation: MRSA spreads by direct contact; gown and gloves prevent transmission. Question 16. The sterile field must be maintained during which of the following procedures? A) Inserting a peripheral IV catheter B) Performing a bedside blood glucose check C) Changing a urinary catheter D) Applying a non‑sterile wound dressing Answer: A Explanation: Peripheral IV insertion is a sterile procedure requiring a sterile field. Question 17. An infant who is exclusively breastfed should receive which immunization at 2 months of age? A) Hepatitis B (first dose) B) Rotavirus (first dose) C) Varicella (first dose)
Question 21. Current guidelines recommend mammography screening for average‑risk women begin at what age? A) 30 years B) 40 years C) 45 years D) 50 years Answer: C Explanation: The USPSTF recommends biennial screening mammography starting at age 40‑49 (optional) and routinely at 50; many protocols now start at 45. Question 22. Which lifestyle counseling technique is most effective for smoking cessation? A) Providing a pamphlet only B) Motivational interviewing combined with nicotine replacement therapy C) Telling the client to “just quit” D) Using hypnosis without follow‑up Answer: B Explanation: Motivational interviewing engages the client’s readiness, and nicotine replacement addresses physiological dependence. Question 23. A client in early labor has a “boggy” uterus on assessment. The nurse’s immediate action is to: A) Administer oxytocin infusion B) Massage the fundus to stimulate contraction C) Encourage the client to ambulate D) Apply a warm compress to the abdomen Answer: B Explanation: Uterine massage stimulates contraction and helps firm a boggy uterus postpartum.
Question 24. Which defense mechanism involves redirecting unacceptable impulses toward a socially acceptable activity? A) Denial B) Sublimation C) Projection D) Regression Answer: B Explanation: Sublimation channels unacceptable urges into constructive actions. Question 25. In crisis intervention, the nurse’s first priority is to: A) Provide detailed counseling about the trauma B) Ensure the client’s safety and basic needs are met C) Encourage the client to recount the event fully D) Schedule a follow‑up therapy session Answer: B Explanation: Immediate safety and stabilization precede therapeutic processing. Question 26. According to the Kübler‑Ross model, which stage is characterized by feelings of disbelief and numbness? A) Denial B) Anger C) Bargaining D) Acceptance Answer: A Explanation: Denial is the initial response to loss, marked by disbelief. Question 27. Active listening in therapeutic communication includes all EXCEPT: A) Summarizing the client’s statements B) Maintaining eye contact
Answer: A Explanation: Rotating injection sites prevents lipohypertrophy and ensures consistent absorption. Question 31. An IV infusion shows swelling, coolness, and pain at the site. The nurse should first: A) Increase the infusion rate B) Apply a warm compress C) Stop the infusion and assess for infiltration D) Change the IV solution bag Answer: C Explanation: Swelling, coolness, and pain suggest infiltration; the infusion must be stopped immediately. Question 32. A client undergoing cardiac catheterization requires which pre‑procedure nursing action? A) Encourage a high‑protein breakfast two hours before B) Administer a beta‑blocker without physician order C) Verify the presence of a signed informed consent D) Place the client in a supine position only after the procedure Answer: C Explanation: Informed consent ensures the client understands risks and agrees to the procedure. Question 33. An ABG result shows pH 7.28, PaCO₂ 55 mmHg, HCO₃⁻ 24 mEq/L. The primary acid‑base disturbance is: A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis Answer: B Explanation: Low pH with elevated PaCO₂ indicates primary respiratory acidosis.
Question 34. Which electrolyte abnormality is most likely to cause tall, peaked T‑waves on an ECG? A) Hyperkalemia B) Hypokalemia C) Hypercalcemia D) Hyponatremia Answer: A Explanation: Elevated serum potassium produces characteristic tall, peaked T‑waves. Question 35. The normal range for INR in a client on warfarin for atrial fibrillation is: A) 0.8‑1. B) 1.0‑1. C) 2.0‑3. D) 3.5‑4. Answer: C Explanation: Therapeutic INR for most indications, including atrial fibrillation, is 2.0‑3.0. Question 36. A client’s blood pressure drops to 80/50 mmHg, pulse 120/min, and skin is cool and clammy. The nurse should first suspect: A) Hypertensive crisis B) Hypovolemic shock C) Anaphylactic reaction D) Neurogenic shock Answer: B Explanation: Hypotension with tachycardia and cool, clammy skin is classic for hypovolemic shock. Question 37. Which of the following is a hallmark sign of acute pulmonary embolism? A) Bradycardia B) Painless hematuria C) Sudden onset dyspnea and pleuritic chest pain
Explanation: A low‑sodium renal diet typically limits sodium to ≤ 2 g (≈ 2000 mg) per day. Question 41. When providing education on insulin administration, the nurse should advise the client to: A) Inject insulin into a scarred area for better absorption B) Rotate injection sites within the same region only C) Store insulin in the refrigerator after each use D) Inspect the insulin vial for particulate matter before use Answer: D Explanation: Inspecting for particles ensures the insulin is not contaminated; other options are incorrect practices. Question 42. Which of the following lab values indicates hypernatremia? A) Na⁺ 125 mEq/L B) Na⁺ 138 mEq/L C) Na⁺ 150 mEq/L D) Na⁺ 115 mEq/L Answer: C Explanation: Normal serum sodium is 135‑ 145 mEq/L; 150 mEq/L reflects hypernatremia. Question 43. A client receiving potassium chloride IV infusion develops muscle weakness and peaked T‑waves. The nurse’s immediate action is to: A) Increase the infusion rate B) Stop the infusion and notify the provider C) Administer calcium gluconate rapidly D) Encourage the client to ambulate Answer: B Explanation: Signs of potassium toxicity require immediate cessation of the infusion and provider notification.
Question 44. Which nursing diagnosis is most appropriate for a client with chronic pain secondary to osteoarthritis? A) Impaired gas exchange B) Acute confusion C) Chronic pain related to joint degeneration D) Risk for infection Answer: C Explanation: The diagnosis directly addresses the persistent pain caused by joint degeneration. Question 45. A client with a new urinary catheter complains of burning on urination. The most likely cause is: A) Catheter‑associated urinary tract infection B) Normal post‑insertion irritation that resolves in 24 hours C) Allergic reaction to catheter material D) Dehydration Answer: A Explanation: Burning suggests a catheter‑associated UTI; early detection and treatment are essential. Question 46. Which of the following is a sign of dehydration in an older adult? A. Hypertension B. Decreased skin turgor over the abdomen C. Warm, flushed skin D. Polyuria Answer: B Explanation: Older adults often show decreased skin turgor, especially over the abdomen, as a dehydration indicator. Question 47. A client with a known allergy to latex requires a dressing change. The nurse should: A) Use standard latex gloves B) Request a latex‑free dressing kit
D. Decreased heart rate Answer: B Explanation: Mydriasis, yawning, and gooseflesh are classic opioid withdrawal signs, indicating the taper may be too rapid. Question 51. When delegating a vital‑signs check to a certified nursing assistant (CNA), which “right” must the RN verify? A. Right task – CNA is trained to assess vital signs B. Right circumstance – client is stable and does not require RN assessment C. Right person – CNA holds a valid license for medication administration D. Right communication – RN must write a detailed order in the chart Answer: B Explanation: The RN must ensure the client’s condition allows the CNA to perform the task safely (right circumstance). Question 52. Which of the following best describes the “Maslow hierarchy” priority for a client with an open fracture? A. Self‑actualization B. Safety and security C. Physiological needs – airway, breathing, circulation D. Belongingness and love Answer: C Explanation: Physiological needs, especially hemorrhage control and perfusion, are the most urgent. Question 53. A client with a new diagnosis of type 2 diabetes asks about diet. The nurse should recommend: A. High‑protein, low‑carbohydrate diet without portion control B. Balanced meals with controlled carbohydrate portions and fiber C. Unlimited fruit intake because it is natural sugar D. No change; medication alone controls glucose
Answer: B Explanation: Balanced meals with regulated carbohydrate portions and fiber help maintain glycemic control. Question 54. Which of the following is a contraindication to the use of a nasogastric tube? A. Decreased level of consciousness without airway protection B. Presence of a gastric ulcer C. Need for enteral nutrition D. Post‑operative ileus Answer: A Explanation: An unconscious patient who cannot protect the airway is at risk for aspiration with an NG tube. Question 55. A client on warfarin therapy presents with a sudden nosebleed. The most appropriate nursing action is to: A. Apply a cold compress and monitor B. Increase the warfarin dose C. Hold the next dose and notify the provider D. Give vitamin K orally without order Answer: C Explanation: Bleeding may indicate an elevated INR; the dose should be held and the provider notified. Question 56. Which assessment finding would indicate a client is in the “early” stage of shock? A. Warm, flushed skin and bounding pulse B. Cool, clammy skin with weak peripheral pulses C. Bradycardia and hypertension D. Normal blood pressure and heart rate Answer: A Explanation: Early (compensated) shock presents with peripheral vasoconstriction causing warm extremities and a strong pulse; later stages show cool, clammy skin.
A. Deep vein thrombosis B. Surgical site infection C. Atelectasis D. Pulmonary embolism Answer: C Explanation: Atelectasis is the most common cause of low‑grade fever early after surgery. Question 61. Which of the following is a sign of hypokalemia? A. Peaked T‑waves on ECG B. Muscle weakness and constipation C. Elevated blood pressure D. Nausea and vomiting Answer: B Explanation: Low potassium causes muscle weakness and decreased gastrointestinal motility leading to constipation. Question 62. A client with a new pressure ulcer is placed on a low‑air‑flow mattress. The primary purpose of this intervention is to: A. Increase heat loss from the wound B. Decrease shear forces on the skin C. Provide continuous moisture to the ulcer D. Reduce friction during transfers Answer: B Explanation: Low‑air‑flow mattresses redistribute pressure and minimize shear, promoting ulcer healing. Question 63. Which of the following is an example of a “right circumstance” in delegation? A. Assigning a complex medication calculation to a nursing student B. Delegating a routine blood pressure check to an LPN for a stable client C. Having a CNA administer IV antibiotics without order
D. Allowing a PT to perform wound dressing without RN oversight Answer: B Explanation: The client’s stable condition makes the task appropriate for delegation to an LPN. Question 64. A client with chronic heart failure is prescribed spironolactone. The nurse should monitor which laboratory value most closely? A. Serum calcium B. Serum potassium C. Serum magnesium D. Serum phosphate Answer: B Explanation: Spironolactone is a potassium‑sparing diuretic; hyperkalemia is a major risk. Question 65. Which of the following is the most accurate statement regarding the “right medication” principle? A. The medication must be administered at the correct time only B. The medication must be appropriate for the client’s diagnosis and allergies C. The medication must be given by any staff member present D. The medication must be documented after administration only Answer: B Explanation: “Right medication” includes ensuring the drug is appropriate for the client’s condition and allergies. Question 66. A client with severe COPD is receiving oxygen therapy. The nurse notes a PaO₂ of 65 mmHg on ABG. The appropriate nursing action is to: A. Increase the oxygen flow to 8 L/min B. Decrease the oxygen flow to avoid CO₂ retention C. Maintain the current flow and re‑check ABG in 2 hours D. Switch to a non‑rebreather mask immediately Answer: C
