1. What is the primary purpose of performing hand hygiene in a healthcare
setting?
A) To prevent the spread of infections
B) To remove dirt and grime
C) To reduce patient anxiety
D) To promote staff comfort
Answer: A) To prevent the spread of infections
Rationale: Hand hygiene is critical for preventing healthcare-associated infections by removing
harmful microorganisms.
2. Which of the following is a priority when assessing a patient’s respiratory
status?
A) Heart rate
B) Oxygen saturation
C) Blood pressure
D) Bowel sounds
Answer: B) Oxygen saturation
Rationale: Monitoring oxygen saturation is essential to assess respiratory efficiency and
oxygenation levels in the body.
3. A nurse is preparing to administer a medication via an enteral tube. What is
the first action the nurse should take?
A) Check the patient’s medication record
B) Verify the tube placement
C) Flush the tube with water
D) Administer the medication
Answer: B) Verify the tube placement
Rationale: Verifying the tube placement is crucial to ensure the medication reaches the correct
location and prevents complications like aspiration.
4. A patient is being discharged with a prescription for anticoagulants. What is
the most important teaching point for the nurse to include?
, A) Take the medication with food to reduce stomach irritation.
B) Avoid taking aspirin or NSAIDs without consulting the healthcare provider.
C) Limit fluid intake to prevent fluid retention.
D) Drink at least 8 glasses of water per day.
Answer: B) Avoid taking aspirin or NSAIDs without consulting the healthcare provider.
Rationale: Anticoagulants increase the risk of bleeding, and nonsteroidal anti-inflammatory
drugs (NSAIDs) and aspirin can exacerbate this risk.
5. The nurse is caring for a patient with a new colostomy. Which of the following
is the best way to assess the stoma’s health?
A) Check the color of the stoma and surrounding skin.
B) Ask the patient about the frequency of stool.
C) Palpate the area for firmness.
D) Measure the size of the stoma every day.
Answer: A) Check the color of the stoma and surrounding skin.
Rationale: A healthy stoma should be pink or red, indicating good circulation, and the
surrounding skin should be intact without signs of irritation.
6. A patient with diabetes mellitus is exhibiting signs of hypoglycemia. Which of
the following should the nurse do first?
A) Administer insulin
B) Check the blood glucose level
C) Provide a source of glucose
D) Call the healthcare provider
Answer: C) Provide a source of glucose
Rationale: If hypoglycemia is suspected, the first priority is to provide a fast-acting carbohydrate
(such as glucose tablets or juice) to raise the patient’s blood sugar.
7. Which of the following is the most effective way for a nurse to assess a
patient’s level of consciousness?
A) Perform a Glasgow Coma Scale (GCS) assessment
B) Ask the patient to count backward from 100
C) Check the patient’s vital signs
D) Observe the patient’s ability to follow commands
, Answer: A) Perform a Glasgow Coma Scale (GCS) assessment
Rationale: The GCS is an objective measure of a patient’s level of consciousness and
neurological status.
8. The nurse is caring for a patient after a hip replacement surgery. Which
position is most appropriate for the patient to maintain during the postoperative
period?
A) Supine with the hip externally rotated
B) Prone with the affected leg raised
C) Lying on the unaffected side with a pillow between the legs
D) Semi-Fowler's position with knees flexed
Answer: C) Lying on the unaffected side with a pillow between the legs
Rationale: This position helps prevent dislocation of the new hip joint by keeping the legs in
proper alignment.
9. What is the nurse's priority when providing care for a patient with a chest
tube?
A) Ensuring that the chest tube is connected to suction
B) Maintaining the drainage system below chest level
C) Monitoring for signs of infection at the insertion site
D) Encouraging deep breathing and coughing exercises
Answer: B) Maintaining the drainage system below chest level
Rationale: The drainage system should always be kept below the level of the chest to prevent
backflow of fluid or air into the pleural cavity.
10. A nurse is administering a blood transfusion and notices that the patient is
experiencing chills and a fever. What is the nurse's first action?
A) Slow the infusion rate
B) Stop the transfusion immediately
C) Administer acetaminophen
D) Notify the healthcare provider
Answer: B) Stop the transfusion immediately
Rationale: Chills and fever may indicate a transfusion reaction, so the transfusion should be
stopped immediately to prevent further complications.
setting?
A) To prevent the spread of infections
B) To remove dirt and grime
C) To reduce patient anxiety
D) To promote staff comfort
Answer: A) To prevent the spread of infections
Rationale: Hand hygiene is critical for preventing healthcare-associated infections by removing
harmful microorganisms.
2. Which of the following is a priority when assessing a patient’s respiratory
status?
A) Heart rate
B) Oxygen saturation
C) Blood pressure
D) Bowel sounds
Answer: B) Oxygen saturation
Rationale: Monitoring oxygen saturation is essential to assess respiratory efficiency and
oxygenation levels in the body.
3. A nurse is preparing to administer a medication via an enteral tube. What is
the first action the nurse should take?
A) Check the patient’s medication record
B) Verify the tube placement
C) Flush the tube with water
D) Administer the medication
Answer: B) Verify the tube placement
Rationale: Verifying the tube placement is crucial to ensure the medication reaches the correct
location and prevents complications like aspiration.
4. A patient is being discharged with a prescription for anticoagulants. What is
the most important teaching point for the nurse to include?
, A) Take the medication with food to reduce stomach irritation.
B) Avoid taking aspirin or NSAIDs without consulting the healthcare provider.
C) Limit fluid intake to prevent fluid retention.
D) Drink at least 8 glasses of water per day.
Answer: B) Avoid taking aspirin or NSAIDs without consulting the healthcare provider.
Rationale: Anticoagulants increase the risk of bleeding, and nonsteroidal anti-inflammatory
drugs (NSAIDs) and aspirin can exacerbate this risk.
5. The nurse is caring for a patient with a new colostomy. Which of the following
is the best way to assess the stoma’s health?
A) Check the color of the stoma and surrounding skin.
B) Ask the patient about the frequency of stool.
C) Palpate the area for firmness.
D) Measure the size of the stoma every day.
Answer: A) Check the color of the stoma and surrounding skin.
Rationale: A healthy stoma should be pink or red, indicating good circulation, and the
surrounding skin should be intact without signs of irritation.
6. A patient with diabetes mellitus is exhibiting signs of hypoglycemia. Which of
the following should the nurse do first?
A) Administer insulin
B) Check the blood glucose level
C) Provide a source of glucose
D) Call the healthcare provider
Answer: C) Provide a source of glucose
Rationale: If hypoglycemia is suspected, the first priority is to provide a fast-acting carbohydrate
(such as glucose tablets or juice) to raise the patient’s blood sugar.
7. Which of the following is the most effective way for a nurse to assess a
patient’s level of consciousness?
A) Perform a Glasgow Coma Scale (GCS) assessment
B) Ask the patient to count backward from 100
C) Check the patient’s vital signs
D) Observe the patient’s ability to follow commands
, Answer: A) Perform a Glasgow Coma Scale (GCS) assessment
Rationale: The GCS is an objective measure of a patient’s level of consciousness and
neurological status.
8. The nurse is caring for a patient after a hip replacement surgery. Which
position is most appropriate for the patient to maintain during the postoperative
period?
A) Supine with the hip externally rotated
B) Prone with the affected leg raised
C) Lying on the unaffected side with a pillow between the legs
D) Semi-Fowler's position with knees flexed
Answer: C) Lying on the unaffected side with a pillow between the legs
Rationale: This position helps prevent dislocation of the new hip joint by keeping the legs in
proper alignment.
9. What is the nurse's priority when providing care for a patient with a chest
tube?
A) Ensuring that the chest tube is connected to suction
B) Maintaining the drainage system below chest level
C) Monitoring for signs of infection at the insertion site
D) Encouraging deep breathing and coughing exercises
Answer: B) Maintaining the drainage system below chest level
Rationale: The drainage system should always be kept below the level of the chest to prevent
backflow of fluid or air into the pleural cavity.
10. A nurse is administering a blood transfusion and notices that the patient is
experiencing chills and a fever. What is the nurse's first action?
A) Slow the infusion rate
B) Stop the transfusion immediately
C) Administer acetaminophen
D) Notify the healthcare provider
Answer: B) Stop the transfusion immediately
Rationale: Chills and fever may indicate a transfusion reaction, so the transfusion should be
stopped immediately to prevent further complications.
