1. Which of the following is the primary purpose of an assessment?
A) To diagnose a disease
B) To evaluate a client’s response to treatment
C) To establish a baseline for care
D) To provide therapeutic interventions
Answer: C) To establish a baseline for care
Rationale: The primary purpose of assessment in nursing is to establish a baseline for the
client’s health status and to guide the development of the care plan.
2. Which of the following is the most appropriate nursing intervention for a
client experiencing acute pain?
A) Administer prescribed analgesics
B) Encourage fluid intake
C) Perform passive range of motion exercises
D) Implement stress reduction techniques
Answer: A) Administer prescribed analgesics
Rationale: Acute pain is typically managed with medications, such as analgesics, to reduce pain
and improve the client’s comfort.
3. A nurse is caring for a client who has undergone abdominal surgery. Which of
the following actions should the nurse take to prevent postoperative
complications?
A) Instruct the client to avoid deep breathing exercises
B) Encourage early ambulation
C) Restrict fluid intake
D) Administer opioids frequently for pain
Answer: B) Encourage early ambulation
Rationale: Early ambulation helps prevent postoperative complications like deep vein
thrombosis and pneumonia by improving circulation and respiratory function.
4. Which of the following is an expected outcome of a client’s response to a health
promotion activity?
,A) Decrease in symptoms
B) Increased level of health literacy
C) Immediate relief of pain
D) Absence of all risk factors
Answer: B) Increased level of health literacy
Rationale: Health promotion activities aim to increase a client’s health literacy, empowering
them to make informed decisions about their health.
5. A nurse is assessing a client’s blood pressure. Which of the following findings
indicates a normal blood pressure reading for an adult?
A) 160/100 mmHg
B) 120/80 mmHg
C) 140/90 mmHg
D) 100/60 mmHg
Answer: B) 120/80 mmHg
Rationale: A normal adult blood pressure reading is typically around 120/80 mmHg. Values
above this range may indicate prehypertension or hypertension.
6. What is the purpose of using a nurse’s clinical judgment when making
decisions about patient care?
A) To provide subjective interpretations
B) To apply personal beliefs to the situation
C) To make evidence-based decisions
D) To rely on intuition alone
Answer: C) To make evidence-based decisions
Rationale: Clinical judgment involves integrating evidence, patient preferences, and clinical
expertise to make informed, patient-centered decisions.
7. Which of the following techniques should a nurse use when measuring a
patient’s temperature with a tympanic thermometer?
A) Pull the ear upward and back
B) Insert the thermometer at a 90-degree angle
, C) Press the thermometer against the ear canal for 10 seconds
D) Avoid touching the ear with the thermometer probe
Answer: A) Pull the ear upward and back
Rationale: For adult patients, the ear should be pulled upward and back to straighten the ear
canal before inserting the thermometer to ensure an accurate reading.
8. When performing a wound assessment, which of the following findings should
the nurse report immediately?
A) Redness around the wound
B) Increased drainage from the wound
C) Purulent drainage
D) A dry scab forming
Answer: C) Purulent drainage
Rationale: Purulent drainage may indicate infection, and it should be reported immediately so
appropriate interventions can be implemented.
9. Which of the following is the priority nursing intervention for a client who is
experiencing respiratory distress?
A) Assess the client's vital signs
B) Administer prescribed oxygen therapy
C) Position the client in a supine position
D) Encourage deep breathing and coughing exercises
Answer: B) Administer prescribed oxygen therapy
Rationale: Ensuring adequate oxygenation is the priority in respiratory distress. Administering
oxygen therapy will help stabilize the client's condition.
10. A client is being discharged after a hip replacement. Which of the following
instructions should the nurse include in the discharge teaching?
A) Limit ambulation for 6 weeks
B) Use a walker for the first 2 weeks only
C) Avoid crossing the legs
D) Restrict fluid intake to prevent swelling
A) To diagnose a disease
B) To evaluate a client’s response to treatment
C) To establish a baseline for care
D) To provide therapeutic interventions
Answer: C) To establish a baseline for care
Rationale: The primary purpose of assessment in nursing is to establish a baseline for the
client’s health status and to guide the development of the care plan.
2. Which of the following is the most appropriate nursing intervention for a
client experiencing acute pain?
A) Administer prescribed analgesics
B) Encourage fluid intake
C) Perform passive range of motion exercises
D) Implement stress reduction techniques
Answer: A) Administer prescribed analgesics
Rationale: Acute pain is typically managed with medications, such as analgesics, to reduce pain
and improve the client’s comfort.
3. A nurse is caring for a client who has undergone abdominal surgery. Which of
the following actions should the nurse take to prevent postoperative
complications?
A) Instruct the client to avoid deep breathing exercises
B) Encourage early ambulation
C) Restrict fluid intake
D) Administer opioids frequently for pain
Answer: B) Encourage early ambulation
Rationale: Early ambulation helps prevent postoperative complications like deep vein
thrombosis and pneumonia by improving circulation and respiratory function.
4. Which of the following is an expected outcome of a client’s response to a health
promotion activity?
,A) Decrease in symptoms
B) Increased level of health literacy
C) Immediate relief of pain
D) Absence of all risk factors
Answer: B) Increased level of health literacy
Rationale: Health promotion activities aim to increase a client’s health literacy, empowering
them to make informed decisions about their health.
5. A nurse is assessing a client’s blood pressure. Which of the following findings
indicates a normal blood pressure reading for an adult?
A) 160/100 mmHg
B) 120/80 mmHg
C) 140/90 mmHg
D) 100/60 mmHg
Answer: B) 120/80 mmHg
Rationale: A normal adult blood pressure reading is typically around 120/80 mmHg. Values
above this range may indicate prehypertension or hypertension.
6. What is the purpose of using a nurse’s clinical judgment when making
decisions about patient care?
A) To provide subjective interpretations
B) To apply personal beliefs to the situation
C) To make evidence-based decisions
D) To rely on intuition alone
Answer: C) To make evidence-based decisions
Rationale: Clinical judgment involves integrating evidence, patient preferences, and clinical
expertise to make informed, patient-centered decisions.
7. Which of the following techniques should a nurse use when measuring a
patient’s temperature with a tympanic thermometer?
A) Pull the ear upward and back
B) Insert the thermometer at a 90-degree angle
, C) Press the thermometer against the ear canal for 10 seconds
D) Avoid touching the ear with the thermometer probe
Answer: A) Pull the ear upward and back
Rationale: For adult patients, the ear should be pulled upward and back to straighten the ear
canal before inserting the thermometer to ensure an accurate reading.
8. When performing a wound assessment, which of the following findings should
the nurse report immediately?
A) Redness around the wound
B) Increased drainage from the wound
C) Purulent drainage
D) A dry scab forming
Answer: C) Purulent drainage
Rationale: Purulent drainage may indicate infection, and it should be reported immediately so
appropriate interventions can be implemented.
9. Which of the following is the priority nursing intervention for a client who is
experiencing respiratory distress?
A) Assess the client's vital signs
B) Administer prescribed oxygen therapy
C) Position the client in a supine position
D) Encourage deep breathing and coughing exercises
Answer: B) Administer prescribed oxygen therapy
Rationale: Ensuring adequate oxygenation is the priority in respiratory distress. Administering
oxygen therapy will help stabilize the client's condition.
10. A client is being discharged after a hip replacement. Which of the following
instructions should the nurse include in the discharge teaching?
A) Limit ambulation for 6 weeks
B) Use a walker for the first 2 weeks only
C) Avoid crossing the legs
D) Restrict fluid intake to prevent swelling
