Pain/Safety
A nurse is caring for an older adult with a history of falls. Which intervention is the most effective in preventing falls?
A. Keep all bed rails up at night
B. Encourage the patient to walk independently
C. Place the call light within the patient's reach
D. Turn off the lights at bedtime for rest
Correct Answer: C
Rationale: Easy access to the call light promotes safe communication and reduces fall risk.
A nurse is reviewing the history of a patient suspected of having early-stage rheumatoid arthritis (RA). Which of the following symptoms is most characteristic?
A. Joint pain relieved with activity
B. Unilateral joint inflammation
C. Morning stiffness lasting more than 30 minutes
D. Pain in large weight-bearing joints only
Correct Answer: C
Rationale: Morning stiffness lasting longer than 30 minutes is a hallmark early sign of RA.
A nurse is assessing a client with suspected appendicitis. Which finding is most characteristic?
A. Dull pain in the left lower quadrant
B. Rebound tenderness at McBurney's point
C. Pain relief with deep palpation
D. Decreased white blood cell count
Correct Answer: B
Rationale: Rebound tenderness in the right lower quadrant (McBurney’s point) is a classic sign of appendicitis.
A nurse is assessing a patient for a possible urinary tract infection (UTI). Which of the following is a common physical assessment finding in a client with a UTI?
A. Lower abdominal pain and urgency to urinate
B. Yellow skin and elevated temperature
C. Diarrhea and bloating
D. Severe headache and neck stiffness
Correct Answer: A
Rationale: UTIs commonly present with lower abdominal pain, urinary urgency, and dysuria.
A nurse is assessing an infant with suspected bronchiolitis. Which of the following is the earliest sign of bronchiolitis?
A. Cyanosis
B. Wheezing and cough
C. Chest pain with breathing
D. Hypoxemia
Correct Answer: B
Rationale: Wheezing and a dry cough are early signs of bronchiolitis, usually caused by RSV (respiratory syncytial virus).
Which of the following should the nurse prioritize when assessing a patient’s pain?
A. Objective signs like blood pressure
B. Family report of the patient's pain level
C. The patient’s self-report of pain
D. The provider’s documentation in the chart
Correct Answer: C
Rationale: Pain is subjective; the patient’s self-report is the gold standard in pain assessment.
During a physical assessment of a client with RA, the nurse expects to find which of the following?
A. Cool joints with clear synovial fluid
B. Warm, swollen joints and limited mobility
C. Muscle spasms with decreased tone
D. Bruising around the affected joints
Correct Answer: B
Rationale: RA causes inflammation, leading to warmth, swelling, pain, and limited motion.
Which client is most at risk for complications from hyperthermia?
A. A 42-year-old with asthma
B. A 78-year-old with heart failure
C. A 25-year-old marathon runner
D. A 36-year-old with seasonal allergies
Correct Answer: B
Rationale: Older adults with chronic conditions like heart failure are at higher risk due to decreased thermoregulation.
To reduce the risk of a catheter-associated urinary tract infection (CAUTI), which of the following nursing interventions is most important?
A. Maintain the urinary catheter in a dependent position
B. Encourage the patient to drink large amounts of fluid
C. Clean the urethral meatus with soap and water every 4 hours
D. Change the catheter bag every 24 hours
Correct Answer: A
Rationale: Keeping the catheter in a dependent position helps prevent backflow of urine and reduces CAUTI risk.
Which of the following signs suggests worsening asthma in a patient?
A. Increased expiratory wheezing and inability to complete sentences
B. Clear sputum and decrease in respiratory rate
C. Chest tightness that improves with bronchodilator use
D. Mild cough that improves overnight
Correct Answer: A
Rationale: Increased wheezing and difficulty completing sentences indicate worsening asthma, which requires prompt intervention.
A nurse realizes they administered the wrong dose of medication. What is the nurse’s priority action?
A. Notify the provider and monitor the patient
B. Fill out an incident report and continue care
C. Document the error in the progress notes
D. Inform the charge nurse at the end of the shift
Correct Answer: A
Rationale: Patient safety is always the priority—monitor and notify the provider immediately.
Which nursing intervention is appropriate to help manage joint stiffness in a client with RA?
A. Encourage complete joint rest throughout the day
B. Apply cold packs every morning
C. Assist with warm showers in the morning
D. Limit physical activity to once weekly
Correct Answer: C
Rationale: Warm showers help loosen stiff joints and improve mobility in the morning.
A patient is brought in from the cold with moderate hypothermia. Which assessment finding should the nurse expect?
A. Bounding pulse and flushed skin
B. Shivering and confusion
C. Bradypnea and tachycardia
D. Warm extremities and clear speech
Correct Answer: B
Rationale: Shivering, confusion, and slowed cognition are common in moderate hypothermia.
Which of the following is an essential nursing intervention for preventing surgical site infections (SSIs)?
A. Administer broad-spectrum antibiotics routinely before all surgeries
B. Ensure proper hand hygiene and sterile technique during the procedure
C. Allow patients to shower within 24 hours postoperatively
D. Encourage patients to cough and deep breathe within the first hour after surgery
Correct Answer: B
Rationale: Proper hand hygiene and sterile technique are critical to prevent surgical site infections.
Which of the following interventions is most effective in preventing pneumonia in an older adult patient hospitalized after surgery?
A. Administering antipyretics regularly
B. Encouraging deep breathing exercises and incentive spirometry
C. Providing daily antibiotics as a preventive measure
D. Limiting fluid intake to reduce aspiration risk
Correct Answer: B
Rationale: Deep breathing exercises and incentive spirometry help expand the lungs and prevent atelectasis, reducing pneumonia risk.
Which situation requires the use of restraints as a last resort?
A. A confused patient who removes their oxygen mask
B. A patient with expressive aphasia who shouts
C. A patient wandering in the hallway with supervision
D. A patient refusing to eat lunch
Correct Answer: A
Rationale: Restraints may be used if the patient is at risk of harming themselves and all alternatives have failed.
A nurse is teaching a client with RA about disease-modifying antirheumatic drugs (DMARDs). Which of the following best explains the goal of this medication class?
A. Provide immediate pain relief
B. Promote cartilage regeneration
C. Reduce joint inflammation and prevent further damage
D. Cure the underlying autoimmune disease
Correct Answer: C
Rationale: DMARDs slow disease progression and help prevent permanent joint damage.
Which laboratory result would support a diagnosis of acute appendicitis?
A. Decreased neutrophil count
B. Elevated white blood cell (WBC) count
C. Decreased C-reactive protein
D. Elevated red blood cell count
Correct Answer: B
Rationale: A high WBC count often indicates infection and inflammation, consistent with appendicitis.
A nurse is educating a female patient on how to prevent recurrent urinary tract infections (UTIs). Which of the following instructions is most important?
A. Avoid drinking caffeinated beverages
B. Empty the bladder completely when urinating
C. Use vaginal deodorant sprays after urination
D. Wear tight-fitting underwear to prevent irritation
Correct Answer: B
Rationale: Emptying the bladder completely helps flush bacteria from the urinary tract, reducing UTI risk.
A patient with dyspnea and an SpO2 of 88% is receiving oxygen via nasal cannula. What is the nurse's priority intervention?
A. Increase the flow rate of oxygen
B. Check the oxygen delivery system for obstructions
C. Administer a bronchodilator via nebulizer
D. Monitor the patient for signs of respiratory distress
Correct Answer: B
Rationale: Ensuring the oxygen system is functioning properly is critical before increasing flow rates or administering medications.
A nurse witnesses a surgical procedure being performed on the wrong limb. What type of event is this, and what is the immediate nursing responsibility?
A. It is a near miss; document it in the nurse’s notes.
B. It is an error of omission; inform the family.
C. It is a sentinel event; complete an incident report and follow facility protocol.
D. It is an error of execution; alert the patient’s insurance provider.
Correct Answer: C
Rationale: Wrong-site surgery is a sentinel event requiring full reporting and review.
Which statement made by a client taking methotrexate for RA indicates a need for further teaching?
A. "I will avoid crowds and sick people."
B. "I will have regular blood tests while on this drug."
C. "I can take this medication during pregnancy."
D. "It may take a few weeks before I feel better."
Correct Answer: C
Rationale: Methotrexate is teratogenic—it should not be taken during pregnancy.
Which is the priority nursing intervention for a client experiencing heat stroke?
A. Offer cool oral fluids
B. Apply warm compresses to extremities
C. Begin active cooling with ice packs to the axillae and groin
D. Administer antipyretics like acetaminophen
Correct Answer: C
Rationale: Active cooling is critical in heat stroke—targeting large vessels like the axillae and groin improves cooling efficiency.
What is the most effective prevention strategy to reduce the risk of central line-associated bloodstream infections (CLABSI)?
A. Using a subclavian or internal jugular site for insertion
B. Changing the dressing over the catheter site every week
C. Performing hand hygiene before and after patient contact
D. Replacing central line catheters every 3 days
Correct Answer: C
Rationale: Hand hygiene is the most effective way to prevent CLABSI, followed by proper catheter care and maintenance.
For a patient experiencing a severe asthma attack, what is the priority intervention?
A. Administer a corticosteroid via IV
B. Provide supplemental oxygen and a short-acting beta agonist (SABA) inhaler
C. Administer systemic antibiotics
D. Monitor the patient's peak flow rate every hour
Correct Answer: B
Rationale: Oxygen therapy and a short-acting beta agonist (SABA) inhaler are the first-line treatments for acute asthma attacks, improving oxygenation and relieving bronchospasm.