Mobility and safety
A nurse prepares a client to ambulate. What is the priority assessment?
A. Lung sounds
B. Muscle strength and balance
C. Skin turgor
D. Appetite
B) muscle strength and balance
Which intervention prevents pressure injuries?
A. Massage bony areas
B. Turn every 2 hours
C. Keep HOB elevated
D. Limit fluids
B) Turn every 2 hours
Which precaution is used for TB?
A. Contact
B. Droplet
C. Airborne
D. Standard
C) airborne
Best position for feeding dysphagia patient?
A. Supine
B. High Fowler’s
C. Trendelenburg
D. Side-lying flat
B. High Fowler’s
Where is cyanosis best assessed in dark-skinned clients?
A. Arms
B. Lips and mucous membranes
C. Legs
D. Back
B. Lips and mucous membranes
A nurse finds a client on the floor. What is the first action?
A. Help client to bed
B. Document incident
C. Assess for injuries
D. Notify provider
C) Assess for injuries
Which finding indicates wound infection?
A. Pale tissue
B. Redness and warmth
C. Dry edges
D. Clear drainage
B) Redness and Warmth
Which PPE is required for droplet precautions?
A. N95 respirator
B. Surgical mask
C. Gloves only
D. Gown only
B) surgical mask
Which indicates dehydration?
A. Moist skin
B. Dark urine
C. Bradycardia
D. Weight gain
B) dark urine
Alternative site for pulse oximetry?
A. Abdomen
B. Earlobe
C. Back
D. Thigh
B) Earlobe
Which instruction is correct for cane use?
A. Hold cane on weak side
B. Move cane with stronger leg
C. Move cane with weaker leg
D. Keep cane behind body
C) move cane with the weaker leg
Dehiscence is defined as:
A. Organ protrusion
B. Wound reopening
C. Infection spread
D. Tissue death
B) wound reopening
Which disease requires contact precautions?
A. Influenza
B. TB
C. C. diff
D. Measles
C) C-diff
Before tube feeding, nurse checks:
A. Pulse
B. NG tube placement
C. Temperature
D. Blood pressure
B) NG tube placement
Crackles indicate:
A. Airway obstruction
B. Fluid in lungs
C. Normal finding
D. Muscle strain
B) Fluid in lungs
Which action best prevents falls?
A. Bed in high position
B. Call light within reach
C. Restrain client
D. Restrict ambulation
B) Call light within reach
Priority action for evisceration?
A. Apply dry dressing
B. Cover with saline-moistened sterile dressing
C. Push organs back in
D. Elevate HOB
B. Cover with saline-moistened sterile dressing
Which hand hygiene method is required for C. diff?
A. Alcohol sanitizer
B. Soap and water
C. Chlorhexidine
D. None
B) soap and water
Which electrolyte is commonly lost with gastric suction?
A. Calcium
B. Sodium
C. Potassium
D. Magnesium
C) Potassium
Which client should be seen first?
A. Pain 8/10
B. SpO₂ 88%
C. Fever 101°F
D. Request for water
B. SpO₂ 88%
Which is a complication of immobility?
A. Increased appetite
B. Pressure injury
C. Hyperactivity
D. Hypertension
B) Pressure Injury
Which factor delays wound healing?
A. Good nutrition
B. Adequate oxygen
C. Diabetes
D. Hydration
C) diabetes
Which stage of infection has full symptoms?
A. Incubation
B. Prodromal
C. Illness
D. Convalescence
C) Illness
Which finding is common in elderly with UTI?
A. Weight gain
B. Confusion
C. Bradycardia
D. Increased appetite
B) confusion
Which lab requires immediate action?
A. Na 140
B. K 6.2
C. Ca 9.0
D. Mg 1.9
B) K 6.2