ATI FUNDAMENTALS PROCTORED CUMULATIVE FINAL EXAM
COMPLETE QNS & ANS FINAL LATEST 2023
1. The nurse is preparing a 4 year old for surgery. Which technique is most appropriate?
a. allow the child to handle safe medical equipment
b. limit the teaching to one 1 hour session
c. explain to the child that she will be put to sleep for the procedure
d. use an anatomically correct doll to explain the procedure
Answer: a. allow the child to handle safe medical equipment
2. The nurse is admitting a patient with a methicillin-resistant Staphylococcus aureus (MRSA)
infection isolated in his stage III pressure ulcer. The nurse places the patient on:
a. contact precautions.
b. airborne precautions.
c. droplet precautions.
d. protective environment.
Answer: a. contact precautions.
3. The nurse is caring for a school-aged child who has injured the right leg after a bicycle
accident. Which signs and symptoms will the nurse assess for to determine if the child is
experiencing a localized inflammatory response?
a. Malaise, anorexia, enlarged lymph nodes, and increased white blood cells
b. Chest pain, shortness of breath, and nausea and vomiting
c. Dizziness and disorientation to time, date, and place
d. Edema, redness, tenderness, and loss of function
Answer: d. Edema, redness, tenderness, and loss of function
4. A diabetic patient presents to the clinic for a dressing change. The wound is located on the
right foot and has purulent yellow drainage. Which action will the nurse take to prevent the
spread of infection?
a. Position the patient comfortably on the stretcher.
b. Explain the procedure for dressing change to the patient.
c. Review the medication list that the patient brought from home.
d. Don gloves and other appropriate personal protective equipment.
Answer: d. Don gloves and other appropriate personal protective equipment.
5. The nurse is caring for a patient in labor and delivery. When near completing an assessment of
the patient’s cervix, the electronic infusion device being used on the intravenous (IV) infusion
alarms. Which sequence of actions is most appropriate for the nurse to take?
a. Complete the assessment, remove gloves, and silence the alarm.
b. Discontinue the assessment, silence the alarm, and assess the intravenous site.
c. Complete the assessment, remove gloves, wash hands, and assess the intravenous infusion.
d. Discontinue the assessment, remove gloves, use hand gel, and assess the intravenous infusion.
Answer: c. Complete the assessment, remove gloves, wash hands, and assess the intravenous
infusion.
6. The nurse is dressed and is preparing to care for a patient in the perioperative area. The nurse
has scrubbed hands and has donned a sterile gown and gloves. Which action will indicate a break
in sterile technique?
a. Touching clean protective eyewear
b. Standing with hands above waist area
c. Accepting sterile supplies from the surgeon
d. Staying with the sterile table once it is open
Answer: a. Touching clean protective eyewear
7. The nurse is caring for a patient with an incision. Which actions will best indicate an
understanding of medical and surgical asepsis for a sterile dressing change?
a. Donning clean goggles, gown, and gloves to dress the wound
b. Donning sterile gown and gloves to remove the wound dressing
c. Utilizing clean gloves to remove the dressing and sterile supplies for the new dressing
d. Utilizing clean gloves to remove the dressing and clean supplies for the new dressing
Answer: c. Utilizing clean gloves to remove the dressing and sterile supplies for the new
dressing
8. The nurse is caring for a patient who has just delivered a neonate. The nurse is checking the
patient for excessive vaginal drainage. Which precaution will the nurse use?
a. Contact
b. Droplet
c. Standard
d. Protective environment
Answer: c. Standard
9. The nurse is performing hand hygiene before assisting a health care provider with insertion of
a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take
next?
a. Inform the health care provider and recruit another nurse to assist.
b. Rinse and dry hands, and begin assisting the health care provider.
c. Extend the handwashing procedure to 5 minutes.
d. Repeat handwashing using antiseptic soap.
Answer: d. Repeat handwashing using antiseptic soap.
10. The nurse is caring for a patient on contact precautions. Which action will be most
appropriate to prevent the spread of disease?
a. Place the patient in a room with negative airflow.
b. Wear a gown, gloves, face mask, and goggles for interactions with the patient.
c. Transport the patient safely and quickly when going to the radiology department.
d. Use a dedicated blood pressure cuff that stays in the room and is used for that patient only .
Answer: d. Use a dedicated blood pressure cuff that stays in the room and is used for that patient
only .
11. The nurse is caring for a patient who has cultured positive for Clostridium difficile. Which
action will the nurse take next?
a. Instruct assistive personnel to use soap and water rather than sanitizer.
b. Wear an N95 respirator when entering the patient room.
c. Place the patient on droplet precautions.
d. Teach the patient cough etiquette.
Answer: a. Instruct assistive personnel to use soap and water rather than sanitizer.
12. The nurse is caring for a patient who has a bloodborne pathogen. The nurse splashes blood
above the glove to intact skin while discontinuing an intravenous (IV) infusion. Which step(s)
will the nurse take next?
a. Obtain an alcohol swab, remove the blood with an alcohol swab, and continue care.
b. Immediately wash the site with soap and running water, and seek guidance from the manager.
c. Do nothing; accidentally getting splashed with blood happens frequently and is part of the job.
d. Delay washing of the site until the nurse is finished providing care to the patient.
Answer: b. Immediately wash the site with soap and running water, and seek guidance from the
manager .
13. The nurse has received a report from the emergency department that a patient with
tuberculosis will be coming to the unit. Which items will the nurse need to care for this patient?
(Select all that apply.)
a. Private room
b. Negative-pressure airflow in room
c. Surgical mask, gown, gloves, eyewear
d. N95 respirator, gown, gloves, eyewear
e. Communication signs for droplet precautions
f. Communication signs for airborne precautions
Answer: a. Private room
b. Negative-pressure airflow in room
d. N95 respirator, gown, gloves, eyewear
f. Communication signs for airborne precautions
14. When providing hygiene for an older-adult patient, the nurse closely assesses the skin. What
is the rationale for the nurse’s action?
a. Outer skin layer becomes more resilient.
b. Less frequent bathing may be required.
c. Skin becomes less subject to bruising.
d. Sweat glands become more active.
Answer: b. Less frequent bathing may be required.
15. The patient has been brought to the emergency department following a motor vehicle
accident. The patient is unresponsive. The driver’s license states that glasses are needed to
operate a motor vehicle, but no glasses were brought in with the patient. Which action should the
nurse take next?
a. Stand to the side of the patient’s eye and observe the cornea.
b. Conclude that the glasses were lost during the accident.
c. Notify the ambulance personnel for missing glasses.
d. Ask the patient where the glasses are.
Answer: a. Stand to the side of the patient’s eye and observe the cornea.
16. The nurse is caring for a patient who is immobile. The nurse frequently checks the patient for
impaired skin integrity. What is the rationale for the nurse’s action?
a. Inadequate blood flow leads to decreased tissue ischemia.
b. Patients with limited caloric intake develop thicker skin.
c. Pressure reduces circulation to affected tissue.
d. Verbalization of skin care needs is decreased
Answer: c. Pressure reduces circulation to affected tissue.
17. The nurse is caring for a patient who has diabetes mellitus and circulatory insufficiency, with
peripheral neuropathy and urinary incontinence. On which areas does the nurse focus care?
a. Decreased pain sensation and increased risk of skin impairment
b. Decreased caloric intake and accelerated wound healing
c. High risk for skin infection and low saliva pH level
d. High risk for impaired venous return and dementia
Answer: a. Decreased pain sensation and increased risk of skin impairment
18. The nurse is caring for a patient who has undergone surgery for a broken leg and has a cast in
place. What should the nurse do to prevent skin impairment?
a. Assess surfaces exposed to the edges of the cast for pressure areas.
b. Keep the patient’s blood pressure low to prevent overperfusion of tissue.
c. Do not allow turning in bed because that may lead to redislocation of the leg.
d. Restrict the patient’s dietary intake to reduce the number of times on the bedpan.
Answer: a. Assess surfaces exposed to the edges of the cast for pressure areas.
19. The nurse is providing oral care to an unconscious patient and notes that the patient has
extremely bad breath. Which term will the nurse use when reporting to the oncoming shift?
a. Cheilitis
b. Halitosis
c. Glossitis
d. Dental caries
Answer: b. Halitosis
20. The patient is being treated for cancer with weekly radiation therapy to the head and
chemotherapy treatments. Which assessment is the priority?
a. Feet
b. Nail beds
c. Perineum
d. Oral cavity
Answer: d. Oral cavity
21. The nurse is caring for an older-adult patient with Alzheimer’s disease who is ambulatory but
requires total assistance with activities of daily living (ADLs). The nurse notices that the patient
is edentulous. Which area should the nurse assess?
a. Assess oral cavity.
b. Assess room for drafts.
c. Assess ankles for edema.
d. Assess for reduced sensations.
Answer: a. Assess oral cavity.
22. A nurse is providing perineal care to a female patient. Which washing technique will the
nurse use?
a. Back to front
b. In a circular motion
c. From pubic area to rectum
d. Upward from rectum to pubic area
Answer: c. From pubic area to rectum
23. The patient is reporting an inability to clear nasal passages. Which action will the nurse take?
a. Use gentle suction to prevent tissue damage.
b. Instruct patient to blow nose forcefully to clear the passage.
c. Place a dry washcloth under the nose to absorb secretions.
d. Insert a cotton-tipped applicator to the back of the nose.
Answer: a. Use gentle suction to prevent tissue damage.
24. A nurse is performing an admission assessment on a middle-age patient. A normal change
seen in this age group includes which of the following? (Select all that apply.)
a. A progressive decrease in skin turgor
b. Decreased visual acuity
c. Decreased ability to solve practical problems
d. Decreased strength of abdominal muscles
e. Loss of accommodation
Answer: a. A progressive decrease in skin turgor
b. Decreased visual acuity
d. Decreased strength of abdominal muscles
e. Loss of accommodation
25. A nurse is teaching young adults about health risks. Which statement from a young adult
indicates a correct understanding of the teaching?
a. “It’s probably safe for me to start smoking. At my age, there’s not enough time for cancer to
develop.”
b. “My mother had appendicitis so this increases my chance for developing appendicitis.”
c. “Controlling the amount of stress in my life may decrease the risk of illness.”
d. “I don’t do drugs. I do drink coffee, but caffeine is not a drug.”
Answer: c. “Controlling the amount of stress in my life may decrease the risk of illness.”
26. A nurse is choosing an appropriate topic for a young-adult health fair. Which topic should the
nurse include?
a. Retirement
b. Menopause
c. Climacteric factors
d. Unplanned pregnancies
Answer: d. Unplanned pregnancies
27. During a routine physical assessment, the nurse obtaining a health history notes that a
50year- old female patient reports pain and redness in the right breast. Which action is best for
the nurse to take in response to this finding?
a. Assess the patient as thoroughly as possible.
b. Explain to the patient that breast tenderness is normal at her age.
c. Tell the patient that redness is not a cause for concern and is quite common.
d. Inform her that redness is the precursor to normal unilateral breast enlargement
Answer: a. Assess the patient as thoroughly as possible.
28. A young-adult patient is brought to the hospital by police after crashing the car in a
highspeed chase when trying to avoid arrest for spousal abuse. Which action should the nurse
take?
a. Question the patient about drug use.
b. Offer the patient a cup of coffee to calm nerves.
c. Discretely assess the patient for sexually transmitted infections.
d. Deal with the issue at hand, not asking about previous illnesses
Answer: a. Question the patient about drug use.
29. A nurse is assessing the cognitive changes in a preschooler. Which standard will the nurse
use to determine normal?
a. The ability to think abstractly and deal effectively with hypothetical problems
b. The ability to think in a logical manner about the here and now
c. The ability to assume the view of another person
d. The ability to classify objects by size or color
Answer: d. The ability to classify objects by size or color
30. The nurse is observing a 2-year-old hospitalized patient in the playroom. Which activity will
the nurse most likely observe?
a. Seeking out same sex children to play with
b. Participating as the leader of a small group activity
c. Sitting beside another child while playing with blocks
d. Separating building blocks into groups by size and color
Answer: c. Sitting beside another child while playing with blocks
31. Which action should the nurse take when teaching a 5-year-old patient about a scheduled
surgery?
a. Do not discuss the procedure with the child to decrease anxiety.
b. Let the child know the surgery will be at 9:00 AM in the morning.
c. Insist that the parents wait outside the room to ensure privacy of the child.
d. Allow the child to touch and hold medical equipment such as thermometers.
Answer: d. Allow the child to touch and hold medical equipment such as thermometers.
32. While receiving a shift report on a patient, the nurse is informed that the patient has urinary
incontinence. Upon assessment, which finding will the nurse expect?
a. An indwelling Foley catheter
b. Reddened irritated skin on buttocks
c. Tiny blood clots in the patient’s urine
d. Foul-smelling discharge indicative of infection
Answer: b. Reddened irritated skin on buttocks
33. Which clinical manifestation will the nurse expect to observe in a patient with excessive
white blood cells present in the urine?
a. Reduced urine specific gravity
b. Increased blood pressure
c. Abnormal blood sugar
d. Fever with chills
Answer: d. Fever with chills
34. The nurse will anticipate inserting a Coudé catheter for which patient?
a. An 8-year-old male undergoing anesthesia for a tonsillectomy
b. A 24-year-old female who is going into labor
c. A 56-year-old male with an enlarged prostate
d. An 86-year-old female admitted for a urinary tract infection
Answer: c. A 56-year-old male with an enlarged prostate
35. A nurse is evaluating a nursing assistive personnel’s (NAP) care for a patient with an
indwelling catheter. Which action by the NAP will cause the nurse to intervene?
a. Emptying the drainage bag when half full
b. Kinking the catheter tubing to obtain a urine specimen
c. Placing the drainage bag on the side rail of the patient’s bed
d. Securing the catheter tubing to the patient’s thigh
Answer: c. Placing the drainage bag on the side rail of the patient’s bed
36. Which nursing actions will the nurse implement when collecting a urine specimen from a
patient? (Select all that apply.)
a. Growing urine cultures for up to 12 hours
b. Labeling all specimens with date, time, and initials
c. Allowing the patient adequate time and privacy to void
d. Wearing gown, gloves, and mask for all specimen handling
e. Transporting specimens to the laboratory in a timely manner
f. Collecting the specimen from the drainage bag of an indwelling catheter
Answer: b. Labeling all specimens with date, time, and initials
c. Allowing the patient adequate time and privacy to void
e. Transporting specimens to the laboratory in a timely manner
37. The nurse is obtaining a 24-hour urine specimen collection from the patient. Which actions
should the nurse take? (Select all that apply.)
a. Keeping the urine collection container on ice when indicated
b. Withholding all patient medications for the day
c. Irrigating the sample as needed with sterile solution
d. Testing the urine sample with a reagent strip by dipping it in the urine
e. Asking the patient to void and discarding that urine to start the collection
Answer: a. Keeping the urine collection container on ice when indicated
e. Asking the patient to void and discarding that urine to start the collection
38. The nurse is planning care for a group of patients. Which task will the nurse assign to the
nursing assistive personnel?
a. Measuring capillary blood glucose level
b. Measuring nasoenteric tube for insertion
c. Measuring pH in gastrointestinal aspirate
d. Measuring the patient’s risk for aspiration
Answer: a. Measuring capillary blood glucose level
39. In teaching mothers-to-be about infant nutrition, which instruction should the nurse provide?
a. Supplement breast milk with corn syrup.
b. Give cow’s milk during the first year of life.
c. Add honey to infant formulas for increased energy.
d. Provide breast milk or formula for the first 4 to 6 months.
Answer: d. Provide breast milk or formula for the first 4 to 6 months.
40. The patient is admitted with facial trauma, including a broken nose, and has a history of
esophageal reflux and of aspiration pneumonia. With which tube will the nurse most likely
administer the feeding?
a. Nasogastric tube
b. Jejunostomy tube
c. Nasointestinal tube
d. Percutaneous endoscopic gastrostomy (PEG) tube
Answer: b. Jejunostomy tube
41. The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To
determine the length of the tube needed to be inserted, how should the nurse measure the tube?
a. From the tip of the nose to the earlobe
b. From the tip of the earlobe to the xiphoid process
c. From the tip of the earlobe to the nose to the xiphoid process
d. From the tip of the nose to the earlobe to the xiphoid process
Answer: d. From the tip of the nose to the earlobe to the xiphoid process
42. A small-bore feeding tube is placed. Which technique will the nurse use to best verify tube
placement?
a. X-ray
b. pH testing
c. Auscultation
d. Aspiration of contents
Answer: a. X-ray
43. The patient has just started on enteral feedings, and the patient is reporting abdominal
cramping. Which action will the nurse take next?
a. Slow the rate of tube feeding.
b. Instill cold formula to “numb” the stomach.
c. Change the tube feeding to a high-fat formula.
d. Consult with the health care provider about prokinetic medication
Answer: a. Slow the rate of tube feeding.
44. The nurse is providing home care for a patient diagnosed with acquired immunodeficiency
syndrome (AIDS). Which dietary intervention will the nurse add to the care plan?
a. Provide small, frequent nutrient-dense meals for maximizing kilocalories.
b. Prepare hot meals because they are more easily tolerated by the patient.
c. Avoid salty foods and limit liquids to preserve electrolytes.
d. Encourage intake of fatty foods to increase caloric intake.
Answer: a. Provide small, frequent nutrient-dense meals for maximizing kilocalories.
45. The nurse is preparing to lift a patient. Which action will the nurse take first?
a. Position a drawsheet under the patient.
b. Assess weight and determine assistance needs.
c. Delegate the task to a nursing assistive personnel.
d. Attempt to manually lift the patient alone before asking for assistance.
Answer: b. Assess weight and determine assistance needs.
46. The nurse is caring for an older-adult patient who has been diagnosed with a stroke. Which
intervention will the nurse add to the care plan?
a. Encourage the patient to perform as many self-care activities as possible.
b. Provide a complete bed bath to promote patient comfort.
c. Coordinate with occupational therapy for gait training.
d. Place the patient on bed rest to prevent fatigue.
Answer: a. Encourage the patient to perform as many self-care activities as possible.
47. The patient is being admitted to the neurological unit with a diagnosis of stroke. When will
the nurse begin discharge planning?
a. At the time of admission
b. The day before the patient is to be discharged
c. When outpatient therapy will no longer be needed
d. As soon as the patient’s discharge destination is known
Answer: a. At the time of admission
48. The nurse is caring for a patient with impaired physical mobility. Which potential
complications will the nurse monitor for in this patient? (Select all that apply.)
a. Footdrop
b. Somnolence
c. Hypostatic pneumonia
d. Impaired skin integrity
e. Increased socialization
Answer: a. Footdrop
c. Hypostatic pneumonia
d. Impaired skin integrity
49. A nurse is teaching a health promotion class about isotonic exercises. Which types of
exercises will the nurse give as examples? (Not exact question, but very similar)
a. Swimming, jogging, and bicycling
b. Tightening or tensing of muscles without moving body parts
c. Quadriceps set exercises and contraction of the gluteal muscles
d. Push-ups, hip lifting, pushing feet against a footboard on the bed
Answer: a. Swimming, jogging, and bicycling
50. A nurse is teaching a community group of school-aged parents about safety. Which safety
item is most important for the nurse to include in the teaching session?
a. Proper fit of a bicycle helmet
b. Proper fit of soccer shin guards
c. Proper fit of swimming goggles
d. Proper fit of baseball sliding shorts
Answer: a. Proper fit of a bicycle helmet
51. The nurse is caring for a patient who suddenly becomes confused and tries to remove an
intravenous (IV) infusion. Which priority action will the nurse take?
a. Assess the patient.
b. Gather restraint supplies.
c. Try alternatives to restraint.
d. Call the health care provider for a restraint order.
Answer: a. Assess the patient.
52. The nurse is monitoring for the four categories of risk that have been identified in the health
care environment. Which examples will alert the nurse that these safety risks are occurring? (Not
exact question, but very similar)
a. Tile floors, cold food, scratchy linen, and noisy alarms
b. Dirty floors, hallways blocked, medication room locked, and alarms set
c. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach
d. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient, and alarms
not function properly
Answer: d. Wet floors unmarked, patient pinching fingers in door, failure to use lift for patient,
and alarms not function properly
53. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and
family about fall precautions. Which action will the nurse take? (Not exact question, but very
similar)
a. Check on the patient once a shift.
b. Encourage visitors in the early evening.
c. Place all four side rails in the “up” position.
d. Keep the patient on fall risk until discharge.
Answer: d. Keep the patient on fall risk until discharge.
54. The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion
tubing. Which nursing diagnosis will the nurse add to the care plan?
a. Impaired home maintenance
b. Deficient knowledge
c. Risk for poisoning
d. Risk for injury
Answer: d. Risk for injury
55. A confused patient is restless and continues to try to remove the oxygen cannula and urinary
catheter. What is the priority nursing diagnosis and intervention to implement for this patient?
a. Risk for injury: Check on patient every 15 minutes.
b. Risk for suffocation: Place “Oxygen in Use” sign on door.
c. Disturbed body image: Encourage patient to express concerns about body.
d. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter.
Answer: a. Risk for injury: Check on patient every 15 minutes.
56. The nurse is caring for a patient in restraints. Which essential information will the nurse
document in the patient’s medical record to provide safe care? (Select all that apply.)
a. One family member has gone to lunch.
b. Patient is placed in bilateral wrist restraints at 0815.
c. Bilateral radial pulses present, 2+, hands warm to touch
d. Straps with quick-release buckle attached to bed side rails
e. Attempts to distract the patient with television are unsuccessful.
f. Released from restraints, active range-of-motion exercises completed
Answer: b. Patient is placed in bilateral wrist restraints at 0815.
c. Bilateral radial pulses present, 2+, hands warm to touch
e. Attempts to distract the patient with television are unsuccessful.
f. Released from restraints, active range-of-motion exercises completed
57. A nurse is assisting a patient in making dietary choices that promote healthy bowel
elimination. Which menu option should the nurse recommend?
a. Broccoli and cheese soup with potato bread
b. Turkey and mashed potatoes with brown gravy
c. Grape and walnut chicken salad sandwich on whole wheat bread
d. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing
Answer: c. Grape and walnut chicken salad sandwich on whole wheat bread
58. Which nursing intervention is most effective in promoting normal defecation for a patient
who has muscle weakness in the legs?
a. Administer a soapsuds enema every 2 hours.
b. Use a mobility device to place the patient on a bedside commode.
c. Give the patient a pillow to brace against the abdomen while bearing down.
d. Elevate the head of the bed 20 degrees 60 minutes after breakfast while on bedpan.
Answer: b. Use a mobility device to place the patient on a bedside commode.
59. A nurse is checking orders. Which order should the nurse question?
a. A normal saline enema to be repeated every 4 hours until stool is produced
b. A hypertonic solution enema for a patient with fluid volume excess
c. A Kayexalate enema for a patient with severe hypokalemia
d. An oil retention enema for a patient with constipation
Answer: c. A Kayexalate enema for a patient with severe hypokalemia
60. A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing
action is most important?
a. Ensuring that the patient does not eat or drink 2 hours before the examination.
b. Administering a colon cleansing product 6 hours before the examination.
c. Obtaining an order for a pain medication before the test is performed.
d. Removing all of the patient’s metallic jewelry.
Answer: d. Removing all of the patient’s metallic jewelry.
61. A patient had an ileostomy surgically placed 2 days ago. Which diet will the nurse
recommend to the patient to ease the transition of the new ostomy?
a. Eggs over easy, whole wheat toast, and orange juice with pulp
b. Chicken fried rice with fresh pineapple and iced tea
c. Turkey meatloaf with white rice and apple juice
d. Fish sticks with sweet corn and soda
Answer: c. Turkey meatloaf with white rice and apple juice
62. The nurse is caring for a patient with Clostridium difficile. Which nursing actions will have
the greatest impact in preventing the spread of the bacteria?
a. Appropriate disposal of contaminated items in biohazard bags
b. Monthly in-services about contact precautions
c. Mandatory cultures on all patients
d. Proper hand hygiene techniques
Answer: d. Proper hand hygiene techniques
63. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should
report which assessment finding immediately?
a. Stoma is protruding from the abdomen.
b. Stoma is flush with the skin.
c. Stoma is purple.
d. Stoma is moist.
Answer: c. Stoma is purple.
64. A patient is receiving opioids for pain. Which bowel assessment is a priority?
a. Clostridium difficile
b. Constipation
c. Hemorrhoids
d. Diarrhea
Answer: b. Constipation
65. Which finding for a 19-year-old female who is a vegan may indicate the need for cobalamin
supplementation?
a. Paresthesias
b. Ecchymoses
c. Dry, scaly skin
d. Gingival swelling
Answer: a. Paresthesias
66. The nurse knows that urinary tract infection (UTI) is the most common health careassociated infection because
a. Catheterization procedures are performed more frequently than indicated.
b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures.
c. Perineal care is often neglected by nursing staff.
d. Bedpans and urinals are not stored properly and transmit infection.
Answer: b. Escherichia coli pathogens are transmitted during surgical or catheterization
procedures.
67. When caring for a patient with urinary retention, the nurse would anticipate an order for
a. Limited fluid intake.
b. A urinary catheter.
c. Diuretic medication.
d. A renal angiogram
Answer: b. A urinary catheter.
68. A nurse notifies the provider immediately if a patient with an indwelling catheter
a. Complains of discomfort upon insertion of the catheter.
b. Places the drainage bag higher than the waist while ambulating.
c. Has not collected any urine in the drainage bag for 2 hours.
d. Is incontinent of stool and contaminates the external portion of the catheter.
Answer: c. Has not collected any urine in the drainage bag for 2 hours.
69. The nurse would question an order to insert a urinary catheter on which patient?
a. A 26-year-old patient with a recent spinal cord injury at T2
b. A 30-year-old patient requiring drug screening for employment
c. A 40-year-old patient undergoing bladder repair surgery
d. An 86-year-old patient requiring monitoring of urinary output for renal failure
Answer: b. A 30-year-old patient requiring drug screening for employment
70. The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.)
a. Asking the patient to void and to discard the first sample.
b. Keeping the urine collection container on ice.
c. Withholding all patient medications for the day.
d. Asking the patient to notify the staff before and after every void.
Answer: a. Asking the patient to void and to discard the first sample.
b. Keeping the urine collection container on ice.
71. A young adult with extensive facial injuries from a motor vehicle crash is receiving tube
feedings through a percutaneous endoscopic gastrostomy (PEG). Which action will the nurse
include in the plan of care?
a. Keep the patient positioned on the left side.
b. Check the gastric residual volume every 4 to 6 hours.
c. Avoid giving bolus tube feedings through the PEG tube.
d. Obtain a daily abdominal radiographs to verify tube placement.
Answer: b. Check the gastric residual volume every 4 to 6 hours.
72. A patient's capillary blood glucose level is 120 mg/dL 6 hours after the nurse initiated a
parenteral nutrition (PN) infusion. The appropriate action by the nurse is to
a. obtain a venous blood glucose specimen.
b. slow the infusion rate of the PN infusion.
c. recheck the capillary blood glucose level in 4 to 6 hours.
d. contact the health care provider for infusion rate changes.
Answer: c. recheck the capillary blood glucose level in 4 to 6 hours.
73. When caring for a patient with a history of a total gastrectomy, the nurse will monitor for
a. constipation.
b. dehydration.
c. elevated total serum cholesterol.
d. cobalamin (vitamin B12) deficiency.
Answer: d. cobalamin (vitamin B12) deficiency.
74. Which nursing actions could the nurse delegate to a licensed practical/vocational nurse
(LPN/LVN) who is part of the team caring for a patient with Alzheimer's disease (select all that
apply)?
a. Develop a plan to minimize difficult behavior.
b. Administer the prescribed memantine (Namenda).
c. Remove potential safety hazards from the patient's environment
d. Refer the patient and caregivers to appropriate community resources.
e. Help the patient and caregivers choose memory enhancement methods.
f. Evaluate the effectiveness of the prescribed enteral feedings on patient nutrition.
Answer: b. Administer the prescribed memantine (Namenda).
c. Remove potential safety hazards from the patient's environment
75. Which information will the nurse include when teaching a patient how to avoid chronic
constipation (select all that apply)?
a. Many over-the-counter (OTC) medications can cause constipation.
b. Stimulant and saline laxatives can be used regularly.
c. Bulk-forming laxatives are an excellent source of fiber.
d. Walking or cycling frequently will help bowel motility.
e. A good time for a bowel movement may be after breakfast.
Answer: a. Many over-the-counter (OTC) medications can cause constipation.
c. Bulk-forming laxatives are an excellent source of fiber.
d. Walking or cycling frequently will help bowel motility.
e. A good time for a bowel movement may be after breakfast.
76. The nurse is caring for a patient with the diagnosis of Impaired physical mobility. The nurse
needs to be alert for which of the following potential complications? (Select all that apply.)
a. Pulmonary emboli
b. Pneumonia
c. Impaired skin integrity Somnolence
d. Increased socialization
Answer: a. Pulmonary emboli
b. Pneumonia
c. Impaired skin integrity Somnolence
77. A nurse is providing discharge teaching for a patient who is going home with a guaiac test.
Which statement by the patient indicates the need for further education?
a. "If I get a positive result, I have gastrointestinal bleeding."
b. "I should not eat red meat before my examination."
c. "I should schedule to perform the examination when I am not menstruating."
d. "I will need to perform this test three times if I have a positive result."
Answer: a. "If I get a positive result, I have gastrointestinal bleeding."
78. A 48-year-old man who has just been started on tube feedings of full-strength formula at 100
mL/hr has 6 diarrhea stools the first day. Which action should the nurse plan to take?
a. Slow the infusion rate of the tube feeding.
b. Check gastric residual volumes more frequently.
c. Change the enteral feeding system and formula every 8 hours.
d. Discontinue administration of water through the feeding tube.
Answer: a. Slow the infusion rate of the tube feeding.
79. After change-of-shift report, which patient will the nurse assess first?
a. A 40-year-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left
b. A 40-year-old man with continuous enteral feedings who has developed pulmonary crackles
c. A 30-year-old man with 4+ generalized pitting edema and severe protein-calorie malnutrition
d. A 30-year-old woman whose gastrostomy tube is plugged after crushed medications were
administered.
Answer: a. A 40-year-old woman whose parenteral nutrition infusion bag has 30 minutes of
solution left
80. The nurse is using a preoperative checklist to assist in preparing a patient on the day of
surgery. What will the checklist include? (Select all that apply.)
a. Vital signs
b. Laboratory data
c. Living will
d. NPO
e. Identification (ID) band on
f. Family location
Answer: a. Vital signs
b. Laboratory data
d. NPO
e. Identification (ID) band on
81. A patient is scheduled for a computed tomography (CT) scan of the chest with contrast
media. Which assessment findings should the nurse report to the health care provider before the
patient goes for the CT (select all that apply)?
a. Allergy to shellfish
b. Patient reports claustrophobia
c. Elevated serum creatinine level
d. Recent bronchodilator inhaler use
e. Inability to remove a wedding band
Answer: a. Allergy to shellfish
c. Elevated serum creatinine level
82. A 35-year-old female is admitted for an elective surgical procedure. Which information
obtained by the nurse during the preoperative assessment is most important to report to the
anesthesiologist before surgery?
a. The patient’s lack of knowledge about postoperative pain control measures
b. The patient’s statement that her last menstrual period was 8 weeks previously
c. The patient’s history of a postoperative infection following a prior cholecystectomy
d. The patient’s concern that she will be unable to care for her children postoperatively
Answer: b. The patient’s statement that her last menstrual period was 8 weeks previously
83. The surgical unit nurse has just received a patient with a history of smoking from the
postanesthesia care unit. Which action is most important at this time?
a. Auscultate for adventitious breath sounds.
b. Obtain the patient's blood pressure and temperature.
c. Remind the patient about harmful effects of smoking.
d. Ask the health care provider about prescribing a nicotine patch.
Answer: a. Auscultate for adventitious breath sounds.
84. The outpatient surgery nurse reviews the complete blood cell (CBC) count results for a
patient who is scheduled for surgery in a few days. The results are white blood cell (WBC) count
10.2 × 103/µL; hemoglobin 15 g/dL; hematocrit 45%; platelets 150 × 103/µL. Which action
should the nurse take?
a. Call the surgeon and anesthesiologist immediately.
b. Ask the patient about any symptoms of a recent infection.
c. Discuss the possibility of blood transfusion with the patient.
d. Send the patient to the holding area when the operating room calls.
Answer: d. Send the patient to the holding area when the operating room calls.
85. Which statement, if made by a new circulating nurse, is appropriate?
a. "I will assist in preparing the operating room for the patient."
b. "I will remain gloved while performing activities in the sterile field."
c. "I will assist with suturing of incisions and maintaining hemostasis as needed."
d. "I must don full surgical attire and sterile gloves while obtaining items from the unsterile
field."
Answer: a. "I will assist in preparing the operating room for the patient."
86. While in the holding area, a patient reveals to the nurse that his father had a high fever after
surgery. What action by the nurse is a priority?
a. Place a medical alert sticker on the front of the patient's chart.
b. Alert the anesthesia care provider of the family member's reaction to surgery.
c. Reassure the patient that there will be close monitoring during and after surgery.
d. Administer 650 mg of acetaminophen (Tylenol) per rectum as a preventive measure.
Answer: b. Alert the anesthesia care provider of the family member's reaction to surgery.
87. In the postanesthesia care unit (PACU), a patient's vital signs are blood pressure 116/72,
pulse 74, respirations 12, and SpO2 91%. The patient is sleepy but awakens easily. Which action
should the nurse take first?
a. Place the patient in a side-lying position.
b. Encourage the patient to take deep breaths.
c. Prepare to transfer the patient to a clinical unit.
d. Increase the rate of the postoperative IV fluids.
Answer: b. Encourage the patient to take deep breaths.
88. A patient who is just waking up after having hip replacement surgery is agitated and
confused. Which action should the nurse take first?
a. Administer the prescribed opioid.
b. Check the oxygen (O2) saturation.
c. Take the blood pressure and pulse.
d. Apply wrist restraints to secure IV lines.
Answer: b. Check the oxygen (O2) saturation.
89. While caring for a patient who has been admitted with a pulmonary embolism, the nurse
notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. Which action should
the nurse take next?
a. Increase the oxygen flow rate.
b. Suction the patient's oropharynx.
c. Instruct the patient to cough and deep breathe.
d. Help the patient to sit in a more upright position.
Answer: a. Increase the oxygen flow rate.
90. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency
department complaining of shortness of breath and dyspnea on minimal exertion. Which
assessment finding by the nurse is most important to report to the health care provider?
a. The patient has bibasilar lung crackles.
b. The patient is sitting in the tripod position.
c. The patient's respirations have decreased from 30 to 10 breaths/minute.
d. The patient's pulse oximetry indicates an O2 saturation of 91%.
Answer: c. The patient's respirations have decreased from 30 to 10 breaths/minute.
91. A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of
impaired breathing pattern related to anxiety. Which nursing action is most appropriate to
include in the plan of care?
a. Titrate oxygen to keep saturation at least 90%.
b. Discuss a high-protein, high-calorie diet with the patient.
c. Suggest the use of over-the-counter sedative medications.
d. Teach the patient how to effectively use pursed lip breathing.
Answer: d. Teach the patient how to effectively use pursed lip breathing.
92. The nurse is encouraging the postoperative patient to utilize diaphragmatic breathing. Which
priority goal is the nurse trying to achieve?
a. Manage pain
b. Prevent atelectasis
c. Reduce healing time
d. Decrease thrombus formation
Answer: b. Prevent atelectasis
93. The nurse is reviewing the surgical consent with the patient during preoperative education.
The patient indicates that he does not understand what procedure will be completed. What is the
nurses best next step?
a. Notify the physician about the patients question.
b. Explain the procedure that will be completed.
c. Ask the patient to sign the form.
d. Continue with preoperative education.
Answer: a. Notify the physician about the patients question.
94. The nurse is preparing a patient for a surgical procedure on the right great toe. Which of the
following actions would be most important to include in this patients preparation?
a. Ascertain that the surgical site has been correctly marked.
b. Ascertain where the family will be located during the procedure.
c. Place the patient in a clean surgical gown.
d. Ask the patient to remove all hairpins and cosmetics.
Answer: a. Ascertain that the surgical site has been correctly marked.
95. Which statement by the patient indicates an understanding of atelectasis?
a. It is important to do breathing exercises every hour to prevent atelectasis.
b. If I develop atelectasis, I will need a chest tube to drain excess fluid.
c. Atelectasis affects only those with chronic conditions such as emphysema.
d. Hyperventilation will open up my alveoli, preventing atelectasis.
Answer: a. It is important to do breathing exercises every hour to prevent atelectasis.
96. Which nursing intervention is most effective in preventing hospital-acquired pneumonia in
an elderly patient?
a. Assist patient to cough, turn, and deep breathe every 2 hours.
b. Encourage patient to drink through a straw to prevent aspiration.
c. Discontinue humidification delivery device to keep excess fluid from lungs.
d. Monitor oxygen saturation, and frequently assess lung bases.
Answer: a. Assist patient to cough, turn, and deep breathe every 2 hours.
97. The P wave is represented by which portion of the conduction system?
a. SA node
b. AV node
c. Bundle of HIS
d. Purkinje network
Answer: a. SA node
98. What assessment finding is the earliest sign of hypoxia?
a. Restlessness
b. Decreased blood pressure
c. Cardiac dysrhythmias
d. Cyanosis
Answer: a. Restlessness
99. A nurse caring for a patient with COPD knows that which oxygen delivery device is most
appropriate?
a. Nasal cannula
b. Simple face mask
c. Partial non-rebreather mask
d. Non-rebreather mask
Answer: a. Nasal cannula
100. A patient with COPD asks the nurse why he is having increased difficulty with his fine
motor skills, such as buttoning his shirt. Which response by the nurse is most therapeutic?
a. "Your body isn't receiving enough oxygen to send down to your fingers; this causes them to
club and makes dexterity difficult."
b. "Your disease process makes even the smallest tasks seem exhausting. Try taking a nap before
getting dressed."
c. "Often patients with your disease lose mental status and forget how to perform daily tasks."
d. "Your disease affects both your lungs and your heart, and not enough blood is being pumped.
So you are losing sensory feedback in your extremities."
Answer: a. "Your body isn't receiving enough oxygen to send down to your fingers; this causes
them to club and makes dexterity difficult."
101. The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is
most effective in promoting effective airway clearance?
a. Suctioning respiratory secretions several times every hour
b. Administering humidified oxygen through a tracheostomy collar
c. Instilling normal saline into the tracheostomy to thin secretions before suctioning
d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions
Answer: b. Administering humidified oxygen through a tracheostomy collar
102. The nurse is educating a student nurse on caring for a patient with a chest tube. The nurse
knows that teaching has been effective when the student states
a. "I should strip the drains on the chest tube every hour to promote drainage."
b. "If the chest tube becomes dislodged, the first thing I should do is notify the physician."
c. "I should clamp the chest tube when giving the patient a bed bath."
d. "I should report if I see continuous bubbling in the water-seal chamber."
Answer: d. "I should report if I see continuous bubbling in the water-seal chamber."
103. The nurse knows that a closed suction device would be most appropriate for which patient?
a. A 5-year-old with an asthma attack following severe allergies
b. A 24-year-old with a right pneumothorax following a motor vehicle accident
c. A 50-year-old with pulmonary edema following a myocardial infarction
d. A 75-year-old with aspiration pneumonia following a stroke
Answer: d. A 75-year-old with aspiration pneumonia following a stroke
104. A patient with acute shortness of breath is admitted to the hospital. Which action should the
nurse take during the initial assessment of the patient?
a. Ask the patient to lie down to complete a full physical assessment.
b. Briefly ask specific questions about this episode of respiratory distress.
c. Complete the admission database to check for allergies before treatment.
d. Delay the physical assessment to first complete pulmonary function tests.
Answer: b. Briefly ask specific questions about this episode of respiratory distress.
105. While caring for a patient with respiratory disease, the nurse observes that the patient's
SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority
action of the nurse?
a. Notify the health care provider.
b. Document the response to exercise.
c. Administer the PRN supplemental O2.
d. Encourage the patient to pace activity.
Answer: c. Administer the PRN supplemental O2.
106. A patient who is experiencing an acute asthma attack is admitted to the emergency
department. Which assessment should the nurse complete first?
a. listen to breath sounds
b. ask about inhaled corticosteroid use
c. determine when the dyspnea started
d. obtain the forced expiratory volume (FEV) flow rate
Answer: a. listen to breath sounds
107. A patient who is complaining of a "racing" heart and feeling "anxious" comes to the
emergency department. The nurse places the patient on a heart monitor and obtains the following
electrocardiographic (ECG) tracing. Which action should the nurse take next?
a. Prepare to perform electrical cardioversion.
b. Have the patient perform the Valsalva maneuver.
c. Obtain the patient's vital signs including oxygen saturation.
d. Prepare to give a β-blocker medication to slow the heart rate.
Answer: c. Obtain the patient's vital signs including oxygen saturation.
108. The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of
tissue will the nurse expect to observe when the wound is healing?
a. Eschar
b. Slough
c. Granulation
d. Purulent drainage
Answer: c. Granulation
109. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For
which type of healing will the nurse focus the care plan?
a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention
Answer: d. Primary intention
110. A nurse is assessing a patient’s wound. Which nursing observation will indicate the wound
healed by secondary intention?
a. Minimal loss of tissue function
b. Permanent dark redness at site
c. Minimal scar tissue
d. Scarring that may be severe
Answer: d. Scarring that may be severe
111. A patient presents to the emergency department with a laceration of the right forearm caused
by a fall. After determining that the patient is stable, what is the next best step for the nurse to
take?
a. Inspect the wound for foreign bodies.
b. Inspect the wound for bleeding.
c. Determine the size of the wound.
d. Determine the need for a tetanus antitoxin injection.
Answer: b. Inspect the wound for bleeding.
112. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain
and a dressing that needs changing. Which action should the nurse take first?
a. Provide analgesic medications as ordered.
b. Avoid accidentally removing the drain.
c. Don sterile gloves.
d. Gather supplies.
Answer: a. Provide analgesic medications as ordered.
113. The nurse is caring for a patient who has a wound drain with a collection device. The nurse
notices that the collection device has a sudden decrease in drainage. Which action will the nurse
take next?
a. Call the health care provider; a blockage is present in the tubing.
b. Chart the results on the intake and output flow sheet.
c. Do nothing, as long as the evacuator is compressed.
d. Remove the drain; a drain is no longer needed.
Answer: a. Call the health care provider; a blockage is present in the tubing.
114. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black.
Which next step will the nurse anticipate?
a. Monitor the wound.
b. Document the wound.
c. Debride the wound.
d. Manage drainage from wound.
Answer: c. Debride the wound.
115. The nurse is caring for a surgical patient. Which intervention is most important for the nurse
to complete to decrease the risk of pressure ulcers and encourage the patient’s willingness and
ability to increase mobility?
a. Explain the risks of immobility to the patient.
b. Turn the patient every 3 hours while in bed.
c. Encourage the patient to sit up in the chair.
d. Provide analgesic medication as ordered.
Answer: d. Provide analgesic medication as ordered.
116. The nurse is caring for a patient with a Stage II pressure ulcer and has assigned a nursing
diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is
completing the plan of care and is writing goals for the patient. Which is the best goal for this
patient?
a. The patient will state what to look for with regard to an infection.
b. The patient’s family will demonstrate specific care of the wound site.
c. The patient’s family members will wash their hands when visiting the patient.
d. The patient will remain free of odorous or purulent drainage from the wound.
Answer: d. The patient will remain free of odorous or purulent drainage from the wound.
117. The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit
up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse
schedule the patient to sit in the chair?
a. At least 3 hours
b. Less than 2 hours
c. No longer than 30 minutes
d. As long as the patient remains comfortable
Answer: b. Less than 2 hours
118. The nurse is cleansing a wound site. As the nurse administers the procedure, which
intervention should be included?
a. Allow the solution to flow from the most contaminated to the least contaminated.
b. Scrub vigorously when applying noncytotoxic solution to the skin.
c. Cleanse in a direction from the least contaminated area.
d. Utilize clean gauze and clean gloves to cleanse a site.
Answer: c. Cleanse in a direction from the least contaminated area.
119. The nurse is caring for a patient who will have both a large abdominal bandage and an
abdominal binder. Which actions will the nurse take before applying the bandage and binder?
(Select all that apply.)
a. Cover exposed wounds.
b. Mark the sites of all abrasions.
c. Assess the condition of current dressings.
d. Inspect the skin for abrasions and edema.
e. Cleanse the area with hydrogen peroxide.
f. Assess the skin at underlying areas for circulatory impairment.
Answer: a. Cover exposed wounds.
c. Assess the condition of current dressings.
d. Inspect the skin for abrasions and edema.
f. Assess the skin at underlying areas for circulatory impairment.
120. A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient
is becoming malnourished because nothing tastes good. Which recommendation by the nurse
will be most appropriate for this patient?
a. “Rinse your mouth several times a day to hydrate your taste buds.”
b. “Avoid adding spices or lemon juice to food to prevent nausea.”
c. “Blend foods together in interesting flavor combinations.”
d. “Eat soft foods that are easy to chew and swallow.”
Answer: a. “Rinse your mouth several times a day to hydrate your taste buds.”
121. The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis
will the nurse include in the care plan to address a safety complication of the sensory deficit?
a. Body image disturbance
b. Social isolation
c. Risk for falls
d. Fear
Answer: c. Risk for falls
122. The nurse is caring for a group of patients and is monitoring for sensory deprivation.
Which patient will the nurse monitor most closely?
a. A patient in the ICU under constant monitoring following a myocardial infarction
b. A patient on the unit with tuberculosis on airborne precautions
c. A patient who recently had a stroke and has left-sided weakness
d. A patient receiving hospice care for end-stage lung cancer
Answer: b. A patient on the unit with tuberculosis on airborne precautions
123. nurse is caring for an older-adult patient on bed rest with potential sensory deprivation.
Which action will the nurse take?
a. Offer the patient a back rub.
b. Hang a “Do not disturb” sign on patient’s door.
c. Ask the patient “Would you like a newspaper to read?”
d. Place the patient in the room farthest from the nurses’ station.
Answer: a. Offer the patient a back rub.
124. The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse
notices the patient becoming more agitated and withdrawn with each group of surgeon visitors.
The nurse and patient agree to place a “Do not disturb” sign on the door. A few hours later, the
nurse notices a surgeon who is not involved in the patient’s care attempting to enter the room.
Which response by the nurse is most appropriate?
a. Call for security to remove the surgeon.
b. Allow the surgeon to enter.
c. Firmly explain that the patient does not wish to have visitors at this time.
d. Scold the surgeon for not obeying the sign and respecting the patient’s wishes.
Answer: c. Firmly explain that the patient does not wish to have visitors at this time.
125. The patient has just been diagnosed with narcolepsy. The nurse teaches the patient about
management of the condition. Which information from the patient will cause the nurse to
intervene?
a. Takes antidepressant medications
b. Naps shorter than 20 minutes
c. Sits in hot, stuffy rooms
d. Chews gum
Answer: c. Sits in hot, stuffy rooms
126. A 2-year-old child is ordered to have eardrops daily. Which action will the nurse take?
a. Pull the auricle down and back to straighten the ear canal.
b. Pull the auricle upward and outward to straighten the ear canal.
c. Sit the child up for 2 to 3 minutes after instilling drops in ear canal.
d. Sit the child up to insert the cotton ball into the innermost ear canal.
Answer: a. Pull the auricle down and back to straighten the ear canal.
127. A patient has an order to receive 0.3 mL of U-500 insulin. Which syringe will the nurse
obtain to administer the medication?
a. 3-mL syringe
b. U-100 syringe
c. Needleless syringe
d. Tuberculin syringe
Answer: d. Tuberculin syringe
128. When the nurse administers an IM corticosteroid injection, the nurse aspirates. What is the
rationale for the nurse aspirating?
a. Prevent the patient from choking.
b. Increase the force of the injection.
c. Ensure proper placement of the needle.
d. Reduce the discomfort of the injection.
Answer: c. Ensure proper placement of the needle.
129. The nurse is giving an IM injection. Upon aspiration, the nurse notices blood return in the
syringe. What should the nurse do?
a. Administer the injection at a slower rate.
b. Withdraw the needle and prepare the injection again.
c. Pull the needle back slightly and inject the medication.
d. Give the injection and hold pressure over the site for 3 minutes.
Answer: b. Withdraw the needle and prepare the injection again.
130. The nurse is planning to administer a tuberculin test with a 27-gauge, -inch needle. At
which angle will the nurse insert the needle?
a. 15 degree
b. 30 degree
c. 45 degree
d. 90 degree
Answer: a. 15 degree
131. A patient is in need of immediate pain relief for a severe headache. Which medication will
the nurse administer to be absorbed the quickest?
a. Acetaminophen 650 mg PO
b. Hydromorphone 4 mg IV
c. Ketorolac 8 mg IM
d. Morphine 6 mg SQ
Answer: b. Hydromorphone 4 mg IV
132. An order is written for phenytoin 500 mg IM q3-4h prn for pain. The nurse recognizes that
treatment of pain is not a standard therapeutic indication for this drug. The nurse believes that
the health care provider meant to write hydromorphone. What should the nurse do?
a. Call the health care provider to clarify the order.
b. Give the patient hydromorphone, as it was meant to be written.
c. Administer the medication and monitor the patient frequently.
d. Refuse to give the medication and notify the nurse supervisor.
Answer: a. Call the health care provider to clarify the order.
133. A patient needs assistance in eliminating an anesthetic gaseous medication (nitrous oxide).
Which action will the nurse take?
a. Encourage the patient to cough and deep-breathe.
b. Suction the patient’s respiratory secretions.
c. Suggest voiding every 2 hours.
d. Increase fluid intake.
Answer: a. Encourage the patient to cough and deep-breathe.
134. A nurse has withdrawn a narcotic from the medication dispenser and must waste a portion
of the medication. What should the nurse do?
a. Have another nurse witness the wasted medication.
b. Return the wasted medication to the medication dispenser.
c. Place the wasted portion of the medication in the sharps container.
d. Exit the medication room to call the health care provider to request an order that matches the
dosages
Answer: a. Have another nurse witness the wasted medication.
135. A patient refuses medication. Which is the nurse’s first action?
a. Educate the patient about the importance of the medication.
b. Discreetly hide the medication in the patient’s favorite gelatin.
c. Agree with the patient’s decision and document it in the chart.
d. Explore with the patient reasons for not wanting to take the medication
Answer: d. Explore with the patient reasons for not wanting to take the medication
136. A patient who is being discharged today is going home with an inhaler. The patient is to
administer 2 puffs of the inhaler twice daily. The inhaler contains 200 puffs. When should the
nurse appropriately advise the patient to refill the medication?
a. 6 weeks from the start of using the inhaler
b. As soon as the patient leaves the hospital
c. When the inhaler is half empty.
d. 50 days after discharge.
Answer: a. 6 weeks from the start of using the inhaler
137. The supervising nurse is watching nurses prepare medications. Which action by one of the
nurses will the supervising nurse stop immediately?
a. Rolls insulin vial between hands
b. Administers a dose of correction insulin
c. Draws up glargine (Lantus) in a syringe by itself
d. Prepares NPH insulin to be given intravenously (IV)
Answer: d. Prepares NPH insulin to be given intravenously (IV)
138. The prescriber wrote for a 40-kg child to receive 25 mg of medication 4 times a day. The
therapeutic range is 5 to 10 mg/kg/day. What is the nurse’s priority?
a. Change the dose to one that is within range.
b. Administer the medication because it is within the therapeutic range.
c. Notify the health care provider that the prescribed dose is in the toxic range.
d. Notify the health care provider that the prescribed dose is below the therapeutic range
Answer: d. Notify the health care provider that the prescribed dose is below the therapeutic
range
139. The supervising nurse is observing several different nurses. Which action will cause the
supervising nurse to intervene?
a. A nurse administers a vaccine without aspirating.
b. A nurse gives an IV medication through a 22-gauge IV needle without blood return.
c. A nurse draws up the NPH insulin first when mixing a short-acting and intermediate acting
insulin.
d. A nurse calls the health care provider for a patient with nasogastric suction and orders for oral
meds.
Answer: c. A nurse draws up the NPH insulin first when mixing a short-acting and intermediate
acting insulin.
140. The nurse is preparing to administer medications to two patients with the same last name.
After the administration, the nurse realizes that did not check the identification of the patient
before administering medication. Which action should the nurse complete first?
a. Return to the room to check and assess the patient.
b. Administer the antidote to the patient immediately.
c. Alert the charge nurse that a medication error has occurred.
d. Complete proper documentation of the medication error in the patient’s chart.
Answer: a. Return to the room to check and assess the patient.
141. A patient prefers not to take the daily allergy pill this morning because it causes drowsiness
throughout the day. Which response by the nurse is best?
a. “The physician ordered it; therefore, you must take your medication every morning at the
same time when you’re drowsy or not.”
b. “Let’s see if we can change the time you take your pill to 9 PM, so the drowsiness occurs
when you would normally be sleeping.”
c. “You can skip this medication on days when you need to be awake and alert.”
d. “Try to get as much done as you can before you take your pill, so you can sleep in the
afternoon.”
Answer: b. “Let’s see if we can change the time you take your pill to 9 PM, so the drowsiness
occurs when you would normally be sleeping.”
142. An older-adult patient needs an IM injection of antibiotic. Which site is best for the nurse to
use?
a. Deltoid
b. Dorsal gluteal
c. Ventrogluteal
d. Vastus lateralis
Answer: c. Ventrogluteal
143. A nurse is following safety principles to reduce the risk of needlestick injury. Which actions
will the nurse take? (Select all that apply.)
a. Recap the needle after giving an injection.
b. Remove needle and dispose in sharps box.
c. Never force needles into the sharps disposal.
d. Use clearly marked sharps disposal containers.
e. Use needleless devices whenever possible.
Answer: c. Never force needles into the sharps disposal.
d. Use clearly marked sharps disposal containers.
e. Use needleless devices whenever possible.
