Foundations
Which task is appropriate to delegate to a CNA?
A. Teaching incentive spirometry
B. Initial admission assessment
C. Administering PO antihypertensives
D. Feeding a stable client with aspiration precautions after RN sets up
D. Feeding a stable client with aspiration precautions after RN sets up
A client is found on the floor. What is the nurse’s PRIORITY?
A. Notify the provider
B. Assess for injury and vital signs
C. Complete an incident report
D. Call the family
B. Assess for injury and vital signs
Appropriate daily fluid intake for most adults without restriction is:
A. 500–1000 mL
B. 1–1.5 L
C. 2–3 L
D. 3–4 L
C. 2–3 L
Which PPE is required for a client with suspected TB?
A. Surgical mask and gloves
B. N95 respirator in negative‑pressure room
C. Gown and gloves only
D. Face shield and gown only
B. N95 respirator in negative‑pressure room
Enteric‑coated tablets should:
A. Be crushed for easier swallowing
B. Be split in half
C. Not be crushed or chewed
D. Be dissolved in hot water
C. Not be crushed or chewed
Which response demonstrates therapeutic communication?
A. “Why are you upset?”
B. “It sounds like you’re feeling worried. Tell me more.”
C. “Don’t worry; everything will be fine.”
D. “Calm down and take deep breaths.”
B. “It sounds like you’re feeling worried. Tell me more.”
Which action should the nurse take FIRST when a client reports new shortness of breath?
A. Apply oxygen at 2 L/min via nasal cannula
B. Notify the healthcare provider
C. Assess respiratory rate, effort, and SpO₂
D. Raise the head of bed to High Fowler’s
C. Assess respiratory rate, effort, and SpO₂
Signs of fluid volume overload include:
A. Hypotension and dry mucosa
B. Tachycardia and flat neck veins
C. Edema and crackles in lungs
D. Weight loss and concentrated urine
C. Edema and crackles in lungs
Which action prevents catheter‑associated UTI?
A. Maintain a dependent drainage bag below the bladder
B. Break the closed system for sampling
C. Routine irrigation each shift
D. Place bag on bed during transfer
A. Maintain a dependent drainage bag below the bladder
Before administering an antibiotic, the nurse should FIRST:
A. Check culture and sensitivity orders and allergies
B. Offer yogurt
C. Start IV fluids
D. Give with antacid
A. Check culture and sensitivity orders and allergies
A client requires an enema. The best position is:
A. High Fowler’s
B. Sims’ (left lateral)
C. Supine
D. Prone
B. Sims’ (left lateral)
Which client should the nurse see FIRST?
A. New onset confusion and restlessness
B. Post‑op day 1 reporting incisional pain 6/10
C. Needs assistance to the bathroom
D. Requesting discharge instructions
A. New onset confusion and restlessness
Which lab result is most concerning?
A. Na⁺ 134 mEq/L
B. WBC 10,800/mm³
C. Hgb 11.5 g/dL
D. K⁺ 2.9 mEq/L
D. K⁺ 2.9 mEq/L
A client on contact precautions requests to walk in the hallway. The nurse should:
A. Allow and remove PPE before leaving the room
B. Allow after ensuring gown/gloves for staff and cleaning of equipment
C. Disallow hallway ambulation
D. Require an N95 respirator
B. Allow after ensuring gown/gloves for staff and cleaning of equipment
What is the best way to measure a liquid medication dose?
A. Estimate in the cup
B. Measure at eye level on a calibrated device
C. Use a tablespoon
D. Ask client preference
B. Measure at eye level on a calibrated device
Which client is best assignment for an LPN?
A. Newly admitted with acute GI bleed
B. Stable client requiring wound care and PO meds
C. Unstable COPD client with new confusion
D. Post‑op client needing complex IV titration
B. Stable client requiring wound care and PO meds
Which finding requires immediate follow‑up?
A. Temp 99°F (37.2°C)
B. BP 100/60 mmHg
C. Respirations 10/min and shallow
D. Pulse 92 bpm regular
C. Respirations 10/min and shallow
Which electrolyte imbalance is associated with muscle cramps and Trousseau sign?
A. Hypernatremia
B. Hypocalcemia
C. Hyperkalemia
D. Hypomagnesemia
B. Hypocalcemia
Which finding suggests infection?
A. WBC 9,000/mm³
B. Clear lung sounds
C. Temperature 101.5°F (38.6°C)
D. BP 118/72 mmHg
C. Temperature 101.5°F (38.6°C)
The nurse verifies the 6 rights of medication to ensure:
A. Client safety
B. Cost‑effective care
C. Documentation efficiency
D. Pharmacy accuracy
A. Client safety
Which client is at greatest risk for dehydration?
A. Adult with pneumonia drinking well
B. Elderly client with fever and diarrhea
C. Teen with sprained ankle
D. Post‑op client on IV fluids
B. Elderly client with fever and diarrhea
The FIRST action after a needlestick injury is to:
A. Wash the area with soap and water
B. Report to employee health
C. Notify the unit manager
D. Complete incident documentation
A. Wash the area with soap and water
For a client with chest pain, which task can be delegated to a CNA?
A. Obtain a STAT ECG
B. Administer nitroglycerin
C. Obtain vital signs and report
D. Complete focused cardiac assessment
C. Obtain vital signs and report
Which client can be placed in the same room (cohort) with a client who has influenza?
A. Client with MRSA wound
B. Asymptomatic client post‑op day 1
C. Client with influenza‑like illness
D. Client receiving chemotherapy
C. Client with influenza‑like illness
Which order should the nurse question?
A. Digoxin 0.25 mg PO daily
B. Acetaminophen 650 mg PO q6h PRN pain
C. Heparin 5,000 units subcut q8h
D. Morphine 2–4 mg IV push now
D. Morphine 2–4 mg IV push now