NURS 330 Practice exam 1 from RR students

1. A nurse is caring for a patient identified as a fall risk. Which of the following interventions should the nurse implement? (Select all that apply.)
a. Keep the bed in the lowest position 

b. Apply all four side rails to prevent falls 

c. Provide non-slip socks for the patient 

d. Ensure the call light is within reach 

e. Perform hourly rounding

a. Keep the bed in the lowest position 

c. Provide non-slip socks for the patient 

d. Ensure the call light is within reach 

e. Perform hourly rounding

2. A nurse is observing a new graduate perform hand hygiene. Which action by the graduate nurse requires intervention?

a. Washing hands with soap and water after removing gloves 

b. Using hand sanitizer after assisting a patient with toileting 

c. Performing hand hygiene before and after patient contact 

d. Keeping artificial nails and nail polish intact while working with patients 

d. Keeping artificial nails and nail polish intact while working with patients 

3. A nurse is preparing to administer a high-risk medication. Which action should the nurse take first? 

a. Double-check the medication with another nurse 

b. Administer the medication to prevent delay 

c. Scan the patient’s identification band 

d. Document the medication administration

c. Scan the patient’s identification band 

4. A nurse is caring for a patient in wrist restraints. Which intervention is appropriate? (Select all that apply.) 

a. Remove the restraints every 2 hours for skin checks 

b. Ensure a physician’s order is obtained and renewed every 24 hours 

c. Tie the restraints to the side rails for quick access 

d. Offer range of motion exercises while restraints are off 

e. Use restraints as a first-line measure to prevent falls 

a. Remove the restraints every 2 hours for skin checks 

b. Ensure a physician’s order is obtained and renewed every 24 hours 

d. Offer range of motion exercises while restraints are off 

5. A fire has started in a hospital room. Which action should the nurse take first? 

a. Contain the fire by closing doors and windows 

b. Activate the fire alarm 

c. Rescue the patient from immediate danger 

d. Extinguish the fire using a fire extinguisher 

c. Rescue the patient from immediate danger 

6. A nurse is reinforcing education on fall prevention with a patient. Which statement indicates understanding? 

a. “I should try to get up on my own first before using the call light.” 

b. “I will make sure to wear my non-slip socks while walking.” 

c. “It’s okay to leave my walker across the room since I won’t be walking much.” 

d. “I can use my bedside table to help me stand up.” 

b. “I will make sure to wear my non-slip socks while walking.” 

7. A nurse is about to enter a patient’s room with airborne precautions. Which personal protective equipment (PPE) should be worn?

a. Gown and gloves 

b. Surgical mask 

c. N95 respirator 

d. Face shield 

c. N95 respirator 

8. A nurse is preparing to administer an oral medication. Which of the following should the nurse verify before administration? (Select all that apply.)

a. Right time 

b. Right route 

c. Right documentation 

d. Right technique 

e. Right patient 

a. Right time 

b. Right route 

c. Right documentation 

e. Right patient 

9. A patient has a history of falls. Which intervention should the nurse implement to ensure safety at night? 

a. Keep the lights off to promote sleep 

b. Assign the patient to a room near the nurses’ station 

c. Raise all four side rails to prevent movement 

d. Allow the patient to use the restroom independently

b. Assign the patient to a room near the nurses’ station 

10. A nurse is assessing a patient in wrist restraints. Which finding requires immediate intervention? 

a. The patient’s skin is intact under the restraints 

b. The patient’s fingers are cool and pale 

c. The patient states they feel frustrated 

d. The patient asks for assistance in repositioning 

b. The patient’s fingers are cool and pale 

1. A nurse is preparing to enter the room of a patient with Clostridium difficile (C. diff). Which of the following precautions should the nurse take?  (Select all that apply.) 

a. Perform hand hygiene using hand sanitizer 

b. Wash hands with soap and water after patient care 

c. Wear a gown and gloves before entering the room 

d. Place the patient in a private or cohort room 

e. Wear an N95 respirator 

b. Wash hands with soap and water after patient care 

c. Wear a gown and gloves before entering the room 

d. Place the patient in a private or cohort room 

2. A nurse receives a needle stick injury after administering an injection. Which of the following actions should the nurse take first?

a. Report the incident to the supervisor 

b. Complete an incident report 

c. Wash the affected area with soap and water 

d. Follow hospital protocol for post-exposure evaluation 

c. Wash the affected area with soap and water 

3. A patient is placed on airborne precautions. Which action should the nurse take? 

a. Wear a surgical mask before entering the room 

b. Place the patient in a negative pressure room 

c. Ensure all visitors wear a gown and gloves 

d. Maintain a distance of 3 feet from the patient 

b. Place the patient in a negative pressure room 

4. A nurse is preparing to set up a sterile field. Which of the following actions would contaminate the field? (Select all that apply.)

a. Allowing sterile gloves to touch the 1-inch border of the sterile drape 

b. Pouring sterile solution from 12 inches above the sterile container 

c. Turning away from the sterile field to grab additional supplies 

d. Holding sterile objects above waist level 

e. Placing sterile gauze 2 inches from the sterile field's edge 

a. Allowing sterile gloves to touch the 1-inch border of the sterile drape 

c. Turning away from the sterile field to grab additional supplies 

5. A nurse is teaching a patient about infection prevention. Which statement by the patient indicates understanding?

a. "I should wash my hands with soap and water for at least 10 seconds." 

b. "I will cover my mouth with my hand when I cough." 

c. "Hand sanitizer is the best option when my hands are visibly dirty." 

d. "I will get my flu shot every year to reduce my risk of infection." 

d. "I will get my flu shot every year to reduce my risk of infection." 

6. A nurse is donning personal protective equipment (PPE) before entering a patient’s room. In what order should the nurse apply PPE?

a. Mask, gloves, gown, goggles 

b. Gloves, gown, mask, goggles 

c. Gown, mask, goggles, gloves 

d. Gown, gloves, mask, goggles 

c. Gown, mask, goggles, gloves 

7. A nurse is caring for a patient with tuberculosis (TB). Which of the following statements indicates proper infection control practices? (Select all that  apply.) 

a. "The patient must wear a surgical mask if leaving the room." 

b. "I will wear an N95 respirator when caring for the patient." 

c. "Visitors must wear gloves and gowns when in the room." 

d. "The patient will be placed in a private room with negative airflow." 

e. "A face shield is required for all staff entering the room." 

a. "The patient must wear a surgical mask if leaving the room." 

b. "I will wear an N95 respirator when caring for the patient." 

d. "The patient will be placed in a private room with negative airflow." 

8. A nurse is removing personal protective equipment (PPE) after caring for a patient on contact precautions. Which action is correct?

a. Remove gloves first, then goggles, gown, and mask 

b. Remove the gown first, then gloves, mask, and goggles 

c. Remove the mask first, then gloves, gown, and goggles 

d. Remove goggles first, then gloves, gown, and mask 

a. Remove gloves first, then goggles, gown, and mask 

9. Which of the following interventions help prevent healthcare-associated infections (HAIs)? (Select all that apply.)

a. Performing hand hygiene before and after patient contact 

b. Wearing gloves for all patient interactions, regardless of exposure risk 

c. Cleaning equipment between patient uses 

d. Using medical asepsis when performing non-sterile procedures 

e. Placing all patients on transmission-based precautions

a. Performing hand hygiene before and after patient contact 

c. Cleaning equipment between patient uses 

d. Using medical asepsis when performing non-sterile procedures 

10. A nurse is teaching a group of nursing students about sharps safety. Which statement by a student requires further teaching?

a. "I will recap the needle using the one-hand scoop technique before disposal." 

b. "I will dispose of used needles immediately in a sharps container." 

c. "If I get a needle stick injury, I will wash the area with soap and water." 

d. "I will report any accidental needle sticks to my supervisor immediately."

a. "I will recap the needle using the one-hand scoop technique before disposal." 

1. A nurse is measuring a patient's blood pressure and notices the cuff is too small for the patient’s arm. How will this affect the reading?

a. The reading will be falsely low 

b. The reading will be falsely high 

c. The reading will be accurate 

d. The reading will not be affected 

b. The reading will be falsely high 

2. A patient with a history of hypertension presents with a BP of 140/90 mmHg. Which of the following interventions should the nurse take? (Select  all that apply.) 

a. Encourage the patient to decrease sodium intake 

b. Check if the patient has been taking prescribed antihypertensive medications 

c. Ask the patient if they are experiencing dizziness or blurred vision 

d. Instruct the patient to drink a glass of water and retake the BP in 5 minutes 

e. Notify the provider immediately as this is a medical emergency 

a. Encourage the patient to decrease sodium intake 

b. Check if the patient has been taking prescribed antihypertensive medications 

c. Ask the patient if they are experiencing dizziness or blurred vision 

3. A nurse is assessing a patient’s oxygen saturation and notes an SpO₂ of 88%. Which action should the nurse take first?

a. Increase the patient's oxygen flow rate 

b. Notify the provider immediately 

c. Assess the patient for signs of respiratory distress 

d. Have the patient cough and deep breathe

c. Assess the patient for signs of respiratory distress 

4. A patient is admitted with sepsis. Which of the following vital sign trends would indicate worsening condition? (Select all that apply.)

a. BP: 85/50 mmHg 

b. HR: 120 bpm 

c. Temperature: 99.0°F 

d. RR: 24 breaths per minute 

e. SpO₂: 96% on room air 

a. BP: 85/50 mmHg 

b. HR: 120 bpm 

d. RR: 24 breaths per minute 

5. A nurse is checking the apical pulse of a patient with an irregular radial pulse. Where should the nurse place the stethoscope?

a. Over the carotid artery 

b. At the second intercostal space, right sternal border 

c. At the fifth intercostal space, midclavicular line 

d. Over the brachial artery 

c. At the fifth intercostal space, midclavicular line 

6. A nurse is preparing to assess an older adult patient’s vital signs. Which of the following age-related changes should the nurse anticipate?

a. Increased baseline temperature 

b. Decreased respiratory rate 

c. Increased systolic blood pressure 

d. Increased resting heart rate 

c. Increased systolic blood pressure 

7. A patient reports feeling dizzy when standing up from a seated position. Which action should the nurse take first?

a. Check the patient’s blood pressure in a supine, sitting, and standing position 

b. Instruct the patient to increase their salt intake 

c. Encourage the patient to take slow, deep breaths 

d. Administer IV fluids immediately 

a. Check the patient’s blood pressure in a supine, sitting, and standing position 

8. A nurse is educating a patient with hypertension on how to monitor blood pressure at home. Which of the following statements indicates the  patient understands the teaching? 

a. "I will check my blood pressure right after drinking coffee." 

b. "I will use a smaller cuff if my arm is too large for the regular one." 

c. "I will take my blood pressure at the same time each day." 

d. "I should measure my blood pressure after walking around to ensure accuracy." 

c. "I will take my blood pressure at the same time each day." 

9. A nurse is caring for a patient with bradycardia (HR: 50 bpm). Which of the following symptoms would indicate the need for intervention?  (Select all that apply.) 

a. Dizziness 

b. Fatigue 

c. Normal energy levels 

d. Chest pain 

e. Hypotension 

a. Dizziness 

b. Fatigue 

d. Chest pain 

e. Hypotension 

10. A patient with COPD has an SpO₂ of 91%. What is the nurse’s best action? 

a. Increase the oxygen to 6 L/min via nasal cannula 

b. Document the finding and continue monitoring 

c. Place the patient in a supine position 

d. Notify the provider immediately

b. Document the finding and continue monitoring 

1. A nurse is assessing a patient’s pain using the PQRST method. Which of the following questions should the nurse ask to assess the "S" component?

a. "What does the pain feel like?" 

b. "What makes the pain better or worse?" 

c. "Can you rate your pain on a scale of 0 to 10?" 

d. "Where is your pain located?" 

c. "Can you rate your pain on a scale of 0 to 10?" 

2. A patient with chronic osteoarthritis pain asks about non-pharmacologic pain management options. Which of the following interventions should the  nurse recommend? (Select all that apply.) 

a. Applying heat to the affected joints 

b. Using guided imagery and relaxation techniques 

c. Increasing daily weight-bearing activities 

d. Using cold therapy to reduce inflammation 

e. Performing gentle range-of-motion exercises

a. Applying heat to the affected joints 

b. Using guided imagery and relaxation techniques 

d. Using cold therapy to reduce inflammation 

e. Performing gentle range-of-motion exercises

3. A nurse is caring for a post-operative patient who rates their pain as 8/10. What is the nurse’s priority action? 

a. Encourage deep breathing exercises 

b. Administer prescribed pain medication 

c. Offer a warm compress to the surgical site 

d. Document the pain level and reassess in 30 minutes 

b. Administer prescribed pain medication 

4. A nurse administers hydromorphone (Dilaudid) to a patient for severe pain. Which assessment finding requires immediate intervention?

a. Respiratory rate of 8 breaths per minute 

b. Heart rate of 92 beats per minute 

c. Blood pressure of 118/72 mmHg 

d. Pain score decreased from 9 to 4 out of 10

a. Respiratory rate of 8 breaths per minute 

5. A nurse is educating a patient about acetaminophen (Tylenol) use for pain management. Which statement by the patient indicates a need for further  teaching? 

a. "I should not take more than 4,000 mg of acetaminophen in a day." 

b. "Acetaminophen is safe to take with my warfarin (Coumadin)." 

c. "I will notify my provider if I experience nausea, vomiting, or yellowing of my skin." 

d. "Drinking alcohol while taking acetaminophen can be harmful to my liver." 

b. "Acetaminophen is safe to take with my warfarin (Coumadin)." 

6. A patient receiving morphine for pain reports nausea and constipation. Which nursing interventions should be implemented? (Select all that apply.)

a. Encourage fluid and fiber intake 

b. Administer an antiemetic as prescribed 

c. Increase opioid dosage to control symptoms 

d. Encourage early ambulation 

e. Hold the next dose of morphine

a. Encourage fluid and fiber intake 

b. Administer an antiemetic as prescribed 

d. Encourage early ambulation 

7. A nurse is preparing to administer naloxone (Narcan) to a patient with opioid-induced respiratory depression. Which of the following should the  nurse expect after administration? 

a. Increased respiratory rate and improved oxygenation 

b. Increased sedation and pain relief 

c. Decreased blood pressure and bradycardia 

d. Long-term reversal of opioid effects 

a. Increased respiratory rate and improved oxygenation 

8. A nurse is caring for a child who is unable to verbally express pain. Which of the following pain assessment tools is most appropriate?

a. Numeric pain scale 

b. FLACC scale 

c. Verbal pain scale 

d. Glasgow Coma Scale 

b. FLACC scale 

9. A patient reports pain while participating in physical therapy. What is the most appropriate nursing intervention? a. Discontinue the therapy session immediately 

b. Administer pain medication prior to therapy sessions 

c. Advise the patient to push through the pain 

d. Increase the intensity of therapy to build tolerance

b. Administer pain medication prior to therapy sessions 

10. A nurse is evaluating the effectiveness of an opioid pain medication given 30 minutes ago. Which of the following findings indicates a positive  response to the medication? (Select all that apply.) 

a. The patient reports pain decreased from 8 to 3 out of 10 

b. The patient is drowsy but easily arousable 

c. The patient refuses to participate in activities 

d. The patient’s respiratory rate is 10 breaths per minute 

e. The patient is able to reposition in bed with minimal discomfort

a. The patient reports pain decreased from 8 to 3 out of 10 

e. The patient is able to reposition in bed with minimal discomfort

1. During a general survey, a nurse observes that a patient has slurred speech and delayed responses. What is the most appropriate action?

a. Document findings and continue with the assessment 

b. Ask the patient if they are experiencing pain 

c. Assess the patient’s level of consciousness and neurological status 

d. Offer the patient water to determine if hydration is a factor 

c. Assess the patient’s level of consciousness and neurological status 

2. A nurse is assessing a patient’s level of consciousness. The patient only responds to loud verbal stimuli but remains drowsy and slow to respond.  Which term best describes this LOC? 

a. Lethargic 

b. Obtunded 

c. Stuporous 

d. Comatose

b. Obtunded 

3. A patient has a BMI of 32.4. How should the nurse classify this patient’s weight status? 

a. Underweight 

b. Normal weight 

c. Overweight 

d. Obese 

d. Obese 

4. A nurse observes that a patient is using an assistive device while ambulating and has an unsteady gait. Under which component of the general  survey should this be documented? 

a. Physical appearance 

b. Body structure 

c. Mobility 

d. Behavior 

c. Mobility 

5. Which of the following findings during a general survey would require immediate intervention? 

a. A patient with a BMI of 27 

b. A patient who is lethargic but easily arousable 

c. A patient with cyanosis and labored breathing 

d. A patient who appears anxious before an exam 

c. A patient with cyanosis and labored breathing 

6. A nurse is teaching a patient how to obtain an accurate daily weight measurement at home. Which statement by the patient indicates correct  understanding? (Select all that apply.) 

a. "I should weigh myself at the same time each day." 

b. "I should use a different scale each time for accuracy." 

c. "I should wear the same type of clothing for each measurement." 

d. "It’s okay to weigh myself after I eat breakfast for consistency." 

e. "I will record my weight daily and report significant changes to my provider." 

a. "I should weigh myself at the same time each day." 

c. "I should wear the same type of clothing for each measurement." 

e. "I will record my weight daily and report significant changes to my provider." 

7. A nurse is assessing a patient who is alert and oriented to person, place, and time but is unsure why they are in the hospital. How should the nurse  document this finding? 

a. AAOx1 

b. AAOx2 

c. AAOx3 

d. AAOx4 

c. AAOx3 

8. A nurse is completing a general survey on an older adult patient. Which of the following findings would require further evaluation?

a. The patient has a flat affect and avoids eye contact 

b. The patient has a BMI of 22 

c. The patient is alert and oriented to person, place, time, and situation 

d. The patient’s speech is clear and appropriate 

a. The patient has a flat affect and avoids eye contact 

9. A nurse notes that a patient has experienced a sudden, fluctuating change in mental status with periods of confusion and inattention. The nurse  recognizes this as: 

a. Dementia 

b. Delirium 

c. Lethargy 

d. Stupor 

b. Delirium 

10. A nurse is reviewing a patient’s general survey documentation. Which of the following should be included in the general survey report? (Select all  that apply.) 

a. Patient’s hygiene and grooming 

b. Patient’s blood glucose level 

c. Patient’s gait and mobility status 

d. Patient’s level of consciousness 

e. Patient’s affect and behavior

a. Patient’s hygiene and grooming 

c. Patient’s gait and mobility status 

d. Patient’s level of consciousness 

e. Patient’s affect and behavior

1. A nurse is delegating tasks to a nursing assistant. Which task is appropriate for delegation? 

a. Administering oral pain medication 

b. Assessing a patient’s lung sounds 

c. Measuring and recording a patient’s urine output 

d. Providing discharge education 

c. Measuring and recording a patient’s urine output 

2. A nurse is prioritizing care for multiple clients. Which client should the nurse assess first? 

a. A client with chronic heart failure who reports 2+ pitting edema 

b. A client with pneumonia and an oxygen saturation of 88% on room air 

c. A client requesting pain medication for postoperative discomfort (4/10) 

d. A client due for a scheduled dressing change in 30 minutes

b. A client with pneumonia and an oxygen saturation of 88% on room air 

3. A charge nurse is reviewing delegation principles with a newly licensed nurse. Which statement by the new nurse requires further teaching?

a. "I can delegate feeding assistance to a nursing assistant." 

b. "I should provide clear instructions when delegating a task." 

c. "I can delegate a sterile dressing change to a licensed practical nurse (LPN)." 

d. "Once I delegate a task, I am no longer responsible for it." 

d. "Once I delegate a task, I am no longer responsible for it." 

4. A nurse is using the SBAR technique to report a change in a client’s condition to the provider. Which statement represents the ‘A’ in SBAR? a. "The client’s oxygen saturation has dropped to 85%." 

b. "The client has a history of COPD and hypertension." 

c. "I assessed the client and noted increased respiratory distress." 

d. "I recommend initiating oxygen therapy at 2 L/min via nasal cannula." 

c. "I assessed the client and noted increased respiratory distress." 

5. A nurse is organizing care for four clients. Which of the following interventions should be completed first? 

a. Administering insulin to a client with a blood glucose of 250 mg/dL 

b. Changing a dry sterile dressing for a client with a pressure ulcer 

c. Administering IV antibiotics to a client with sepsis 

d. Assisting a client to the bathroom who reports needing to void 

c. Administering IV antibiotics to a client with sepsis 

6. A nurse is planning care for a group of clients. Which actions demonstrate effective time management? (Select all that apply.)

a. Prioritizing care based on the severity of client conditions 

b. Clustering care activities to minimize client disruptions 

c. Completing documentation at the end of the shift to save time 

d. Using a checklist to track completed and pending tasks 

e. Delaying non-urgent tasks until the end of the shift 

a. Prioritizing care based on the severity of client conditions 

b. Clustering care activities to minimize client disruptions 

d. Using a checklist to track completed and pending tasks 

7. A nurse is assigning tasks to an LPN. Which of the following tasks is appropriate to delegate? 

a. Initiating a blood transfusion 

b. Administering IV push pain medication 

c. Monitoring a client receiving IV antibiotics 

d. Completing a new admission assessment

c. Monitoring a client receiving IV antibiotics 

8. A nurse is caring for four clients. Using Maslow’s hierarchy of needs, which client should the nurse attend to first?

a. A client who is feeling anxious before a scheduled procedure 

b. A client who is having difficulty swallowing after a stroke 

c. A client who needs assistance getting dressed for the day 

d. A client who is upset about a diagnosis of diabetes 

b. A client who is having difficulty swallowing after a stroke 

9. A nurse is supervising a nursing assistant. Which of the following actions by the assistant requires intervention? a. Recording a client’s vital signs in the electronic health record 

b. Assisting a client to ambulate after surgery 

c. Providing discharge teaching about wound care 

d. Emptying a client’s urinary catheter drainage bag 

c. Providing discharge teaching about wound care 

10. A nurse is reporting to the provider about a client’s worsening condition. Which statement demonstrates effective communication using SBAR?  (Select all that apply.) 

a. "The client’s blood pressure has dropped to 82/50 mmHg." 

b. "The client has a history of hypertension and chronic kidney disease." 

c. "I think the client would benefit from a fluid bolus." 

d. "The client’s daughter was very upset during the visit." 

e. "The client has been increasingly confused and disoriented since this morning." 

a. "The client’s blood pressure has dropped to 82/50 mmHg." 

b. "The client has a history of hypertension and chronic kidney disease." 

c. "I think the client would benefit from a fluid bolus." 

e. "The client has been increasingly confused and disoriented since this morning." 

1. A nurse is assessing four clients. Which client should be the nurse’s priority? 

a. A client with a history of hypertension reporting a mild headache 

b. A client with pneumonia and an oxygen saturation of 88% 

c. A client with a stage 2 pressure ulcer needing a dressing change 

d. A client with chronic back pain requesting pain medication 

b. A client with pneumonia and an oxygen saturation of 88% 

2. A nurse is applying Maslow’s Hierarchy of Needs when prioritizing care. Which client need should the nurse address first?

a. A client who is feeling lonely after a prolonged hospital stay 

b. A client who needs assistance to the bathroom due to incontinence 

c. A client expressing frustration about not being able to work 

d. A client requesting a visit from a chaplain for emotional support 

b. A client who needs assistance to the bathroom due to incontinence 

3. A nurse is caring for multiple clients. Which situation requires immediate intervention using the ABC priority framework?

a. A client with asthma who is audibly wheezing and has labored breathing 

b. A client with diabetes who has a blood glucose of 180 mg/dL 

c. A client with a femur fracture requesting pain medication 

d. A client with a fever of 101.2°F receiving IV antibiotics

a. A client with asthma who is audibly wheezing and has labored breathing 

4. A nurse receives a shift report. Which of the following clients should the nurse assess first? 

a. A client with end-stage renal disease who missed one dialysis session 

b. A client with an irregular pulse rate of 98 bpm and no other symptoms 

c. A client who suddenly develops slurred speech and facial drooping 

d. A client with a hemoglobin level of 10.5 g/dL reporting mild fatigue 

c. A client who suddenly develops slurred speech and facial drooping 

5. A nurse is triaging clients in the emergency department. Which client should receive care first? 

a. A client with a sprained ankle and moderate swelling 

b. A client with a deep laceration actively bleeding 

c. A client with a productive cough and mild fever 

d. A client with nausea and vomiting for the past two hours

b. A client with a deep laceration actively bleeding 

6. A nurse is reviewing client cases to determine priority using the systemic vs. local approach. Which client should be seen first? a. A client with localized cellulitis and a temperature of 99°F 

b. A client with sepsis and a blood pressure of 85/50 mmHg 

c. A client with a skin rash after taking a new medication 

d. A client with a left leg deep vein thrombosis (DVT) 

b. A client with sepsis and a blood pressure of 85/50 mmHg 

7. A nurse is caring for a client with a suspected airway obstruction. Which intervention should the nurse perform first?

a. Check the client’s gag reflex 

b. Apply oxygen via nasal cannula 

c. Perform the Heimlich maneuver 

d. Attempt to suction the airway 

d. Attempt to suction the airway 

8. A nurse is prioritizing care for four clients. Which of the following clients should be assessed first? 

a. A client who is post-op day 1 from knee replacement and requesting pain medication 

b. A client receiving IV antibiotics for pneumonia with increased work of breathing 

c. A client with a new diagnosis of diabetes needing insulin administration teaching 

d. A client scheduled for a dressing change in 30 minutes 

b. A client receiving IV antibiotics for pneumonia with increased work of breathing 

9. A nurse is caring for a client with an acute myocardial infarction (MI). Which intervention should the nurse prioritize? a. Provide emotional support to the client and family 

b. Educate the client about lifestyle modifications 

c. Monitor cardiac enzymes and obtain an ECG 

d. Administer oxygen and prepare for emergency interventions 

d. Administer oxygen and prepare for emergency interventions 

10. A nurse is using the acute vs. chronic framework to determine client priorities. Which client should be attended to first? (Select all that apply.)

a. A client with a new onset of confusion and agitation 

b. A client with a history of COPD reporting mild shortness of breath 

c. A client with newly diagnosed hypertension and no symptoms 

d. A client with acute abdominal pain rated 9/10 

e. A client with osteoarthritis needing assistance ambulating 

a. A client with a new onset of confusion and agitation 

d. A client with acute abdominal pain rated 9/10 

1. A nurse is performing a respiratory assessment. Which finding requires immediate intervention? 

a. Bilateral vesicular breath sounds 

b. Asymmetrical chest expansion 

c. Clear lung sounds in all fields 

d. Respiratory rate of 18 breaths per minute

b. Asymmetrical chest expansion 

2. A nurse auscultates a patient’s lungs and hears high-pitched, musical sounds during expiration. This finding is most consistent with which condition?

a. Pneumonia 

b. Pulmonary edema 

c. Asthma 

d. Pleural effusion

c. Asthma 

3. A nurse is caring for a client with suspected fluid overload. Which of the following assessments would support this diagnosis? (Select all that apply.)

a. Presence of jugular vein distention (JVD) 

b. Bounding peripheral pulses 

c. Capillary refill greater than 3 seconds 

d. Fine crackles auscultated in the lung bases 

e. Weak, thready radial pulses

a. Presence of jugular vein distention (JVD) 

b. Bounding peripheral pulses 

d. Fine crackles auscultated in the lung bases 

4. A nurse assesses a patient’s lower extremities and notes pale, cool skin with diminished dorsalis pedis pulses. These findings are most consistent with:

a. Venous insufficiency 

b. Arterial insufficiency 

c. Deep vein thrombosis (DVT) 

d. Congestive heart failure

b. Arterial insufficiency 

5. A nurse is auscultating heart sounds and hears a low-pitched extra sound immediately after S2. This finding is best described as:

a. A pericardial friction rub 

b. An S3 heart sound 

c. A systolic murmur 

d. An S4 heart sound 

b. An S3 heart sound 

6. A nurse is assessing a client with chronic venous insufficiency. Which of the following findings are expected? (Select all that apply.)

a. Brown discoloration of lower legs 

b. Ulcers on the toes 

c. Warm skin temperature 

d. Diminished pedal pulses 

e. Pitting edema 

a. Brown discoloration of lower legs 

c. Warm skin temperature 

e. Pitting edema 

7. A client’s pulse oximetry reading is 89%. Which of the following interventions should the nurse perform first? 

a. Administer oxygen at 4 L/min via nasal cannula 

b. Reassess the reading after repositioning the client’s hand 

c. Notify the healthcare provider immediately 

d. Prepare for endotracheal intubation 

b. Reassess the reading after repositioning the client’s hand 

8. A nurse auscultates a patient’s lung sounds and hears coarse, low-pitched sounds that clear after coughing. What is the most likely cause?

a. Wheezing 

b. Rhonchi 

c. Crackles 

d. Stridor 

b. Rhonchi 

9. A nurse is assessing a patient’s apical pulse at the fifth intercostal space, midclavicular line. What is the expected normal finding?

a. A rate of 90 beats per minute with a regular rhythm 

b. A systolic murmur noted over the mitral valve 

c. An S4 heart sound with an irregular pulse 

d. No audible heart sounds in this location 

a. A rate of 90 beats per minute with a regular rhythm 

10. A nurse is assessing a client for signs of early hypoxia. Which of the following would the nurse expect? 

a. Cyanosis and bradycardia 

b. Restlessness and tachycardia 

c. Hypotension and confusion 

d. Decreased respiratory rate and clubbing

b. Restlessness and tachycardia 

11. A nurse is performing a cardiac assessment and notes a client has +3 pitting edema in both lower extremities. This finding is most likely associated with:

a. Pulmonary embolism 

b. Right-sided heart failure 

c. Left-sided heart failure 

d. Peripheral artery disease 

b. Right-sided heart failure 

12. A client is admitted with suspected pneumonia. Which assessment finding would support this diagnosis? 

a. Bilateral vesicular breath sounds 

b. Hyperresonance on percussion 

c. Dullness on percussion over the affected lung 

d. Inspiratory wheezing throughout all lung fields 

c. Dullness on percussion over the affected lung 

1. A nurse is assessing a client with early signs of hypoxia. Which of the following findings should the nurse expect? 

a. Cyanosis 

b. Bradycardia 

c. Restlessness 

d. Hypotension 

c. Restlessness 

2. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) receiving oxygen therapy. Which intervention is most appropriate? a. Administering oxygen at 6 L/min via nasal cannula 

b. Increasing the oxygen flow rate to maintain SpO₂ at 100% 

c. Keeping the oxygen flow rate at or below 2 L/min 

d. Using a non-rebreather mask to ensure adequate oxygenation

c. Keeping the oxygen flow rate at or below 2 L/min 

3. A nurse is reinforcing teaching to a patient about using an incentive spirometer. Which of the following instructions should be included? (Select all that apply.)

a. "Exhale forcefully into the device to clear secretions." 

b. "Inhale deeply and slowly through the mouthpiece." 

c. "Hold your breath for at least 3 seconds before exhaling." 

d. "Repeat the exercise 10 times per hour while awake." 

e. "Use pursed-lip breathing immediately after using the device."

b. "Inhale deeply and slowly through the mouthpiece." 

c. "Hold your breath for at least 3 seconds before exhaling." 

d. "Repeat the exercise 10 times per hour while awake." 

4. A patient receiving 10 L/min oxygen via a simple face mask is complaining of dry nasal passages. What is the nurse’s best action?

a. Decrease the oxygen flow rate to 4 L/min 

b. Switch the patient to a nasal cannula 

c. Add humidification to the oxygen delivery system 

d. Apply petroleum jelly to the patient’s nostrils

c. Add humidification to the oxygen delivery system 

5. A nurse notes a patient with COPD sitting in a tripod position and using pursed-lip breathing. What is the purpose of these actions?

a. To eliminate the need for supplemental oxygen 

b. To increase exhalation time and reduce air trapping 

c. To improve circulation and decrease heart rate 

d. To encourage hyperventilation and lower CO₂ levels

b. To increase exhalation time and reduce air trapping 

6. A nurse is caring for a client with pneumonia who has an SpO₂ of 89%. Which of the following interventions should the nurse take first?

a. Notify the provider 

b. Reassess the SpO₂ after repositioning the client’s hand 

c. Administer oxygen and elevate the head of the bed 

d. Document the finding as expected for pneumonia

c. Administer oxygen and elevate the head of the bed 

7. Which of the following are expected findings in a patient experiencing late-stage hypoxia? (Select all that apply.) 

a. Cyanosis 

b. Tachycardia 

c. Bradycardia 

d. Restlessness 

e. Hypotension

a. Cyanosis 

c. Bradycardia

e. Hypotension

8. A nurse is preparing to apply a non-rebreather mask to a client in severe respiratory distress. Which of the following actions should be taken first?

a. Ensure that the reservoir bag is fully inflated before placing the mask on the client 

b. Set the oxygen flow rate to 4 L/min 

c. Apply the mask tightly to prevent any CO₂ retention 

d. Encourage the client to breathe through their nose instead of their mouth

a. Ensure that the reservoir bag is fully inflated before placing the mask on the client 

9. A nurse is caring for a client with thick respiratory secretions. Which interventions should the nurse implement to help thin the secretions? (Select all that apply.)

a. Encourage oral fluid intake 

b. Administer nebulizer treatments as prescribed 

c. Perform chest physiotherapy 

d. Decrease oxygen flow to prevent airway irritation 

e. Encourage pursed-lip breathing

a. Encourage oral fluid intake 

b. Administer nebulizer treatments as prescribed 

c. Perform chest physiotherapy 

10. A patient receiving oxygen therapy begins showing signs of oxygen toxicity. Which symptom should the nurse anticipate?

a. Hypotension 

b. Altered level of consciousness 

c. Cyanosis 

d. Increased respiratory rate

b. Altered level of consciousness 

11. A nurse is educating a patient on effective coughing and deep breathing techniques. Which of the following statements indicates correct understanding? a. "I should take shallow breaths to prevent lung strain." 

b. "I should lean backward to promote deep inhalation." 

c. "I should perform deep breathing exercises every hour while awake." 

d. "I should hold my breath for at least 10 seconds before exhaling."

c. "I should perform deep breathing exercises every hour while awake." 

12. A nurse is assisting a patient in respiratory distress. Which of the following interventions should be implemented first? 

a. Obtain an arterial blood gas (ABG) sample 

b. Encourage fluid intake to prevent dehydration 

c. Position the patient in High Fowler’s position 

d. Apply humidified oxygen at 4 L/min via nasal cannula

c. Position the patient in High Fowler’s position