Sophomore Review

1. A client in recovery after general anesthesia has snoring respirations and decreasing oxygen saturation. What should the nurse do first?

A. Assess and open the airway

B. Assess the surgical dressing

C. Offer oral fluids

D. Document the findings

A. Assess and open the airway

2. Which finding is most concerning for malignant hyperthermia?

A. Mild nausea

B. Increasing end-tidal CO₂ with muscle rigidity

C. A small amount of expected wound drainage

D. Mild anxiety before surgery

B. Increasing end-tidal CO2 with muscle rigidity

3. A client has questions about the risks of a planned procedure and has not signed the consent. What is the nurse's best action?

A. Explain all surgical risks independently

B. Ask the client to sign immediately

C. Notify the provider responsible for obtaining consent

D. Give a sedative to reduce anxiety

C. Notify the provider responsible for obtaining consent

4. Which interventions help reduce postoperative respiratory complications? Select all that apply.

A. Encourage prescribed incentive spirometry

B. Support early ambulation when safe

C. Provide appropriate pain management

D. Keep the client on strict bed rest without an indication

E. Encourage deep breathing and coughing

A, B, C, E

5. A postoperative client's abdominal incision opens and tissue protrudes. What should the nurse do?

A. Push the tissue back inside

B. Cover it with sterile gauze moistened with sterile saline and call for emergency assistance

C. Apply firm direct pressure to the exposed organs

D. Leave the wound open to air

B. Cover it with sterile gauze moistened with sterile saline and call for emergency assistance

6. A nurse is caring for a client with a suspected Clostridioides difficile (C. diff) infection. Which precaution is most appropriate?

A. Airborne precautions

B. Contact precautions

C. Droplet precautions

D. Standard precautions only

B. Contact precautions

7. Which actions are examples of medical asepsis? Select all that apply.

A. Performing hand hygiene

B. Cleaning reusable equipment

C. Using sterile technique for every routine client interaction

D. Following appropriate infection-control practices

E. Reusing contaminated equipment without cleaning it

A, B, D

8. A nurse discovers a fire in a client's room. According to the RACE protocol, what should the nurse do first?

A. Activate the alarm

B. Contain the fire

C. Rescue the client from immediate danger

D. Extinguish the fire

C. Rescue the client for immediate danger

9. A nurse is caring for a client on prolonged bed rest. Which interventions help prevent complications of immobility? Select all that apply.

A. Encourage range-of-motion exercises as appropriate

B. Reposition the client regularly

C. Encourage mobility as tolerated

D. Keep the client in one position to promote rest

E. Assess for signs of venous thromboembolism (VTE)

A, B, C, E

10. A nurse needs to help a client move from the bed to a chair. Which action demonstrates proper body mechanics?

A. Bend at the waist and keep the knees straight

B. Hold the client as far away from the body as possible

C. Widen the base of support and bend at the hips and knees

D. Twist the torso while lifting the client

C. Widen the base of support and bend at the hips and knees

11. A nurse is providing oral care to an unconscious client. Which actions are appropriate? Select all that apply.

A. Position the client on their side when appropriate

B. Have suction available

C. Position the client flat on their back

D. Take steps to prevent aspiration

E. Pour large amounts of water into the client's mouth

A, B, D

12. A medication is processed by the liver before its components are eliminated from the body. Which pharmacokinetic process describes this liver processing?

A. Absorption

B. Distribution

C. Metabolism

D. Excretion

C. Metabolism

13. The provider prescribes 500 mg of a medication. The available tablets contain 250 mg each. How many tablets should the nurse administer?

A. 0.5 tablet

B. 1 tablet

C. 2 tablets

D. 4 tablets

C. 2 tablets

14. Which actions promote medication safety? Select all that apply.

A. Use two client identifiers before administering medication

B. Check the client's allergies

C. Verify the medication order before administration

D. Use a trailing zero when documenting a dose, such as 5.0 mg

E. Convert units before performing dosage calculations

A, B, C, E

15. A nurse realizes that the wrong medication was administered to a client. What is the priority nursing action?

A. Document that the medication was given correctly

B. Assess the client and address immediate safety needs

C. Wait to see whether the client develops symptoms

D. Delete the medication entry from the record

B. Assess the client and address immediate safety needs

16. A nurse assesses a client's peripheral IV site and observes swelling, coolness, and discomfort. Which complication should the nurse suspect?

A. Phlebitis

B. Infiltration

C. Fluid overload

D. Air embolism

B. Infiltration

17. Which findings and interventions are correctly associated with IV complications? Select all that apply.

A. Infiltration—swelling and coolness at the IV site

B. Phlebitis—redness, warmth, and pain along the vein

C. Extravasation—stop the infusion and avoid flushing unless directed by protocol.

D. Fluid overload—dyspnea and crackles in the lungs

E. Air embolism—continue the infusion and reassess in one hour

A, B, C, D

18. A nurse is administering IV fluids when the client develops shortness of breath and crackles in the lungs. What should the nurse do first?

A. Increase the infusion rate

B. Stop or slow the infusion, assess breathing, and escalate care

C. Encourage the client to drink more fluids

D. Document the findings and continue monitoring routinely

B. Stop or slow the infusion, assess breathing, and escalate care

19. A nurse is developing a care plan for a client at risk for pressure injuries. Which interventions should the nurse include? Select all that apply.

A. Reposition the client regularly

B. Manage moisture and keep the skin clean

C. Assess pressure injury risk using the Braden Scale

D. Massage reddened bony prominences vigorously

E. Reduce prolonged pressure on vulnerable areas

A, B, C, E

20. A nurse identifies a pressure injury with full-thickness skin loss. Which stage is consistent with this finding?

A. Stage 1

B. Stage 2

C. Stage 3

D. Stage 4

C. Stage 3

21. A nurse observes thick, cloudy drainage from a surgical wound. Which type of drainage should the nurse document?

A. Serous

B. Sanguineous

C. Serosanguineous

D. Purulent

D. Purulent

22. Which statements correctly describe wound healing by intention? Select all that apply.

A. Primary intention occurs when wound edges are brought together, such as with sutures

B. Secondary intention involves filling the wound with granulation tissue

C. Tertiary intention involves leaving a wound open initially and closing it later

D. Secondary intention always involves immediate closure with sutures

E. Primary intention requires the wound to remain open until it fills with granulation tissue

A, B, C

23. A nurse observes that a client's abdominal surgical incision has opened and organs are protruding. What is the priority nursing intervention?

A. Gently push the organs back into the abdomen

B. Cover the exposed tissue with sterile gauze moistened with sterile saline

C. Apply a dry dressing and encourage the client to walk

D. Leave the wound uncovered for assessment

D. Leave the wound uncovered for assessment

24. A client weighs 20 kg. The provider prescribes a medication at 5 mg/kg per dose. How many milligrams should the nurse administer per dose?

A. 4 mg

B. 25 mg

C. 100 mg

D. 400 mg

C. 100 mg

25. A nurse is reviewing safety priorities before providing care. Which actions reflect appropriate nursing practice? Select all that apply.

A. Use two identifiers to verify client identity

B. Address pain, noise, and anxiety when promoting sleep

C. Leave an unassessed client who has fallen on the floor until the next scheduled assessment

D. Prioritize sudden chest pain and acute respiratory distress

E. Follow appropriate precautions based on the suspected route of infection transmission

A, B, D, E

26. A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?

A. Obtaining history information from the parents

B. Administering acetaminophen (Tylenol)

C. Instituting droplet precautions

D. Orienting the parents to the pediatric unit

C. Instituting droplet precautions

27. A 10-year-old client contracted severe acute respiratory syndrome (SARS) when traveling abroad with her parents. The nurse knows she must put on personal protective equipment to protect herself while providing care. Based on the mode of SARS transmission, which personal protective equipment should the nurse wear?

A. Gloves

B. Gown and gloves

C. Gown, gloves, and mask

D. Gown, gloves, mask, and eye goggles or eye shield

D. Gown, gloves, mask, and eye goggles or eye sheild

28. A nurse is caring for a patient newly admitted with a confirmed Clostridioides difficile (C. diff) infection. Which of the following hand hygiene methods should the nurse employ after providing direct care to this patient?

A. Perform hand hygiene using soap and water.

B. Use an alcohol-based hand rub vigorously for 20 seconds.

C. Use chlorhexidine gluconate surgical scrub without water.

D. Perform an alcohol rub followed by an antiseptic wipe.

A. Perform hand hygiene using soap and water

29. A nurse is preparing to enter the room of a patient placed on contact precautions due to a Vancomycin-resistant Enterococcus (VRE) wound infection. Which personal protective equipment (PPE) is required upon entry?

A. N95 respirator and face shield

B. Gown and gloves

C. Surgical mask and sterile gloves

D. Shoe covers and hair bonnet

B. Gown and gloves

30. A newly admitted adult patient presents with a chronic cough, night sweats, low-grade fever, and hemoptysis. Active pulmonary tuberculosis (TB) is suspected. Which combination of interventions is essential for this patient?

A. Standard surgical mask and placement in a standard private room.

B. Contact isolation gown and sterile gloves upon entry.

C. Positive pressure airflow room with HEPA filtration.

D. Negative pressure isolation room and an N95 or higher respirator for healthcare personnel.

D. Negative pressure isolation room and an N95 or higher respirator for healthcare personnel

31. According to CDC guidelines, what is the correct sequence for donning personal protective equipment (PPE) before entering an isolation room?

A. Gown, then mask or respirator, then goggles or face shield, then gloves

B. Gloves, then gown, then mask, then goggles

C. Mask or respirator, then gown, then gloves, then goggles

D. Goggles, then mask, then gown, then gloves

A. Gown, then mask or respirator, then goggles or face shield, then gloves

32. A nurse is exiting an isolation room after patient care. According to CDC recommendations, which piece of PPE should be removed first during the doffing process?

A. The isolation gown

B. The gloves

C. The N95 respirator or mask

D. The goggles or face shield

B. The gloves

33. When caring for a patient on airborne precautions using an N95 respirator, where should the nurse safely remove the respirator?

A. Inside the patient's room immediately after removing the gloves and gown.

B. At the nurse's station while charting on the computer.

C. In the hallway right outside the door, while leaving the door propped open.

D. Outside the patient's room, after closing the isolation room door.

D. Outside the patient's room after closing the isolation room door

34. A nurse is admitting a client who has a history of a localized herpes zoster (shingles) infection that is fully crusted over, but the client is currently immunocompromised. What type of isolation precautions should the nurse implement?

A. Airborne and contact precautions until disseminated infection is ruled out.

B. Standard precautions only because the lesions are crusted.

C. Droplet precautions with a private room.

D. Reverse isolation and a protective environment without any masks.

A. Airborne and contact precautions until disseminated infection is ruled out

35. When establishing a sterile field, how large is the unsterile border area around the edges of the drape that is considered contaminated?

A. 1 inch (2.5 cm)

B. 0.5 inch (1.2 cm)

C. 2 inches (5 cm)

D. 3 inches (7.6 cm)

A. 1 inch (2.5 cm)

36. A nurse is preparing a sterile field and notes that the outer wrapper of a sterile supply item is damp. What is the correct action?

A. Dry the outer wrapper thoroughly with a sterile gauze pad before opening

B. Consider the item contaminated and discard or return it

C. Open the package carefully, making sure the inner contents did not get wet

D. Use the item immediately before the moisture spreads further

B. Consider the item contaminated and discard or return it

37. Which action by a nursing student indicates a break in surgical asepsis while managing a sterile field?

A. Keeping sterile hands and items above waist level

B. Facing the sterile field at all times rather than turning one's back

C. Reaching across the center of the sterile field to drop a sterile item

D. Opening a sterile package by pulling the top flap away from the body

C. Reaching across the center of the sterile field to drop a sterile item

38. Under which specific condition is the routine use of an alcohol-based hand rub strictly contraindicated for hand hygiene?

A. Before donning clean non-sterile examination gloves

B. After touching an intact electronic medical record tablet in a patient room

C. Immediately after taking off personal protective gloves

D. When hands are visibly soiled with blood, body fluids, or dirt

D. When hands are visibly soiled with blood, body fluids, or dirt

39. During a traditional surgical hand scrub, in which direction should the cleansing and washing motions consistently proceed?

A. From the elbows down toward the clean fingertips

B. From the clean fingertips up toward the less clean elbows

C. From the mid-forearm outward in a circular motion

D. From the wrist up to the shoulder, then down to the fingers

B. From the clean fingertips up toward the less clean elbows

40. When opening a wrapped sterile package on a table, which flap of the wrapper should the nurse open first to maintain proper technique?

A. The flap on the right side

B. The flap closest to the nurse's body

C. The flap farthest away from the nurse's body

D. The flap on the left side

C. The flap farthest away from the nurse's body

41. A sterile object falls or is positioned relative to a healthcare worker's body. Below what level is an item or sterile field automatically considered unsterile?

A. Chest level

B. Mid-torso level

C. Shoulder level

D. Waist level

D. Waist level

42. A nurse is reviewing the electronic health records of four newly admitted adult patients. Which patient has an appropriate, evidence-based indication for the insertion of an indwelling urinary catheter?

A. A patient with generalized weakness who prefers not to walk to the

bathroom at night.

B. A patient receiving routine post-operative care following an elective total

knee arthroplasty 6 hours ago.

C. A patient admitted with acute urinary retention and bladder outlet

obstruction.

D. A patient who is incontinent of urine and has stage 2 pressure injuries

on the sacrum.

C. A patient admitted with acute urinary retention and blood outlet obstruction

43. What is recognized as the single most effective intervention for reducing the risk of a catheter-associated urinary tract infection (CAUTI)?

A. Administering prophylactic systemic antibiotics daily while the catheter

is in place.

B. Prompt removal of the indwelling urinary catheter as soon as it is no longer clinically indicated.

C. Daily irrigation of the bladder with sterile normal saline solution.

D. Changing the indwelling catheter every 14 days.

B. Prompt removal of the indwelling urinary catheter as soon as it is no longer clinically indicated

44. A nurse is educating a group of nursing students about the chain and progression of infection. Which statement best describes the incubation period of an infectious disease?

A. The interval between the pathogen's invasion of the body and the

appearance of the first general symptoms.

B. The period when early, nonspecific symptoms such as fatigue and low-grade fever begin to appear.

C. The phase during which acute, pathogen-specific clinical manifestations

reach their peak.

D. The time when acute symptoms begin to subside and the body returns

to its baseline state of health.

A. The interval between the pathogen's invasion of the body and the appearance of the first general symptoms

45. A patient presents to the clinic reporting generalized fatigue, a mild headache, and a scratchy throat for the past 24 hours following a known exposure to influenza. The nurse recognizes that the patient is most likely in which stage of infection?

A. Incubation period

B. Prodromal stage

C. Acute illness stage

D. Convalescent stage

B. Prodromal stage

46. Which statement by the patient indicates a correct understanding of this phase?

A. "I might still feel unusually tired for a while as my body continues to repair tissues."

B. "Since I feel better today, I can stop taking my remaining antibiotic pills."

C. "I am no longer capable of shedding or transmitting any microbes to my family members."

D. "My symptoms and tissue inflammation are at their absolute worst right now."

A. "I might still feel unusually tired for a while as my body continues to repair tissues."

47. Which action is most appropriate when caring for a client with a localized MRSA wound infection?

A. Place the client in a negative-pressure airflow room

B. Wear a gown and gloves upon entering the room

C. Wear a surgical mask within 3 feet of the client

D. Restrict all family visitors indefinitely

B. Wear a gown and gloves upon entering the room

48. A nurse is assisting a client with right-sided weakness to ambulate using a cane. Which instruction should the nurse provide?

A. Hold the cane directly in front and move both legs together.

B. Hold the cane on the left side and move the left leg first.

C. Hold the cane on the left side and move it forward with the right leg.

D. Hold the cane on the right side and move it with the left leg.

C. Hold the cane on the left side and move it forward with the right.

49. A client reports dizziness when getting out of bed. The nurse notes a significant drop in blood pressure when the client stands. What should the nurse do first?

A. Assist the client back to a lying or sitting position.

B. Encourage the client to walk slowly.

C. Restrict all oral fluids.

D. Have the client stand for another blood pressure reading.

A. Assist the client to a lying or sitting position.

50. A nurse is administering prescribed ophthalmic medication. Where should the nurse place the eye drops?

A. Directly onto the cornea.

B. Into the conjunctival sac of the lower eyelid.

C. Against the upper eyelid.

D. Directly onto the eyelashes.

B. Into the conjunctival sac of the lower eyelid.

51. The provider prescribes 500 mg of a medication. The medication available is 250 mg per tablet. How many tablets should the nurse administer?

A. 1.5 tablets

B. 2.5 tablets

C. 1 tablet

D. 2 tablets

D. 2 tablets

52. The nurse assesses a client with a pressure injury that has partial thickness skin loss with exposed dermis. Which stage should the nurse document?

A. Stage 1

B. Stage 3

C. Stage 2

D. Stage 4

C. Stage 2

53. A nurse administers an oral medication to a client. The medication travels through the gastrointestinal tract and enters the bloodstream. Which pharmacokinetic process is occurring?

A. Distribution

B. Metabolism

C. Absorption

D. Excretion

C. Absorption

54. A client with severe liver disease is prescribed a medication that is primarily metabolized by the liver. What should the nurse anticipate?

A. The medication will be eliminated more quickly.

B. The medication will be excreted entirely through the lungs.

C. The medication may accumulate and increase the risk of toxicity.

D. The medication will not be absorbed.

C. The medication may accumulate and increase the risk of toxicity.

55. A nurse is caring for an older adult with decreased kidney function. Which medication-related complication is the client at increased risk for?

A. reduced medication absorption

B. increased first pass metabolism

C. decreased medication distribution

D. medication accumulation and toxicity

D. Medication accumulation and toxicity

56. A nurse is preparing a client for surgery. The client states, 'I signed the consent form, but I still do not understand what the surgeon will be doing.' What should the nurse do?

A. Notify the surgeon that the client needs additional explanation.

B. Explain the surgical procedure in detail

C. Ask the family to explain the procedure.

D. Continue preparing the client because the consent form is signed

A. Notify the surgeon that the client needs additional explanation.

57. A nurse is completing a preoperative assessment. Which findings should be reported to the surgical team? Select all that apply.

A. The client wears prescription eyeglasses.

B. The client takes an anticoagulant medication.

C. The client has a history of smoking.

D. The client reports a previous allergic reaction to anesthesia.

Select all that apply.

B,CD

58. A postoperative client has shallow respirations and diminished breath sounds at the lung bases. Which complication should the nurse suspect?

A. Postoperative Ileus

B. Atelectasis

C. Deep Vein Thrombosis

D. Urinary Retention

B. atelectasis