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GNA 10 practice questions

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Question 1Basic Nursing Skills

A nurse is preparing to measure a client's oral temperature. Which action is most appropriate before placing the thermometer?

  1. Wait at least 15 minutes after the client has had a hot drink Correct answer.
  2. Place the probe under the tongue immediately after eating
  3. Ask the client to breathe through the mouth during measurement
  4. Insert the probe against the inner cheek and hold it there

Explanation

Oral temperature readings are distorted by recent intake of hot or cold fluids, so a waiting period of about 15 to 30 minutes is standard practice. The probe belongs in the posterior sublingual pocket, where blood vessels give a reliable core reading. Cheek placement and mouth breathing reduce accuracy.

Question 2Basic Nursing Skills

When counting a client's radial pulse, which technique best supports an accurate result?

  1. Count for a full 60 seconds with two fingers Correct answer.
  2. Use the thumb to feel the artery
  3. Press firmly until the pulse disappears
  4. Count for 15 seconds and multiply by four

Explanation

Counting for a full minute gives the most accurate rate, especially when the rhythm is irregular. Two fingers are used with light pressure over the radial artery on the thumb side of the wrist. The thumb should be avoided because its own pulse can be mistaken for the client's.

Question 3Basic Nursing Skills

A nurse is about to apply a blood pressure cuff to an adult client. Which cuff selection is correct?

  1. A cuff whose bladder encircles about 40 percent of the arm
  2. A cuff chosen by the client's age rather than arm size
  3. A cuff whose bladder encircles about 80 percent of the arm Correct answer.
  4. A cuff that is clearly narrower than the arm

Explanation

Cuff size must match limb circumference; the bladder should encircle roughly 80 percent of the upper arm for adults. A cuff that is too small falsely raises the reading, and one that is too large falsely lowers it. Age alone does not determine cuff size.

Question 4Basic Nursing Skills

A nurse is counting a client's respirations. Which approach supports the most reliable count?

  1. Observe the rise and fall of the chest for a full minute without announcing it Correct answer.
  2. Count for 30 seconds and multiply by two
  3. Tell the client the rate is being counted and ask for slow breathing
  4. Count for 15 seconds and multiply by four

Explanation

Respirations are voluntary to some degree, so clients may alter the rate if they know it is being counted. The nurse should keep the pulse fingers in place and observe chest movement for a full minute. Counting for shorter periods increases error and is not appropriate when accuracy matters.

Question 5Basic Nursing Skills

A nurse is preparing to give a client a bed bath. Which principle should guide the procedure?

  1. Leave the client fully exposed to speed drying
  2. Use the same washcloth section for the whole body
  3. Wash the perineal area first to save time
  4. Wash from the cleanest areas toward the least clean areas Correct answer.

Explanation

Bathing proceeds from cleaner to dirtier regions to limit the spread of microorganisms, so the face and upper body are washed before the perineal area. Exposure should be minimized to preserve warmth, privacy, and dignity. A fresh portion of cloth or a new cloth is used as soiled areas are cleaned.

Question 6Basic Nursing Skills

A client is on bed rest and cannot turn independently. How often should the nurse generally reposition this client?

  1. Only when the client requests it
  2. Once every 24 hours
  3. Once every shift
  4. About every two hours Correct answer.

Explanation

Repositioning about every two hours relieves pressure over bony prominences and helps prevent pressure injury. Clients who cannot move themselves depend entirely on nursing action for this. Shorter or longer intervals may be chosen based on skin condition and support surface.

Question 7Basic Nursing Skills

A nurse is making an occupied bed. Which action protects the client during the procedure?

  1. Roll the client toward the side without rails
  2. Hold the client securely while the linens are changed Correct answer.
  3. Raise the bed to the highest position and leave it there
  4. Keep the side rails down throughout the procedure

Explanation

Safety during an occupied bed change requires the nurse to support and hold the client while linens are being moved, and to keep side rails up on the unoccupied side. The bed should be kept at a safe working height and returned to the lowest position afterward. Leaving rails down or the bed high increases fall risk.

Question 8Basic Nursing Skills

A nurse is assisting a client with a bedpan. Which position best supports elimination?

  1. Supine with the legs fully extended
  2. High Fowler position with the client leaning forward Correct answer.
  3. Sims position with the head of bed flat
  4. Prone with the face turned to one side

Explanation

A Fowler or semi-Fowler position uses gravity to assist elimination and is more natural for the client. Some clients may raise the head of the bed and lean forward slightly. Flat or prone positions make elimination difficult and are uncomfortable.

Question 9Basic Nursing Skills

A nurse is collecting a midstream urine specimen from a client. Which step is essential?

  1. Collect the specimen from the bedpan after voiding
  2. Have the client void directly into a clean container without cleansing
  3. Collect the first portion of the voided urine
  4. Cleanse the meatus before the client begins to void Correct answer.

Explanation

A midstream specimen requires cleansing of the meatus first, then catching urine after the initial flow has begun. The first portion flushes the urethra and is discarded. Collecting from a bedpan or skipping cleansing contaminates the sample.

Question 10Basic Nursing Skills

A nurse is applying a condom catheter to a male client. Which action is correct?

  1. Roll the sheath onto the penis with the adhesive side out
  2. Tape the catheter tubing to the client's thigh under tension
  3. Apply the device over pubic hair for better adhesion
  4. Leave a small space between the tip of the penis and the catheter end Correct answer.

Explanation

A small space at the tip prevents irritation and allows urine to drain without pressure on the glans. The condom is rolled on with adhesive outward so it adheres to the shaft. Pubic hair should be kept clear, and tubing is secured without tension to prevent injury.

Question 11Basic Nursing Skills

A nurse is teaching a client about using a metered-dose inhaler. Which instruction is correct?

  1. Hold the breath for one second after inhaling
  2. Breathe in slowly and deeply while pressing the canister Correct answer.
  3. Take several quick breaths after each puff
  4. Exhale fully into the mouthpiece before activating

Explanation

The medication is delivered best when the client inhales slowly and deeply while the dose is released, then holds the breath for about ten seconds. Exhaling into the mouthpiece adds moisture and contaminates the device. Rapid breaths deposit drug in the mouth rather than the airways.

Question 12Basic Nursing Skills

A nurse is preparing to administer an intramuscular injection into the ventrogluteal site. How is this site located?

  1. By dividing the buttock into four equal quadrants
  2. By measuring three fingerbreadths below the acromion
  3. By placing the palm on the greater trochanter and the index finger on the anterior iliac spine Correct answer.
  4. By locating the midpoint of the posterior thigh

Explanation

The ventrogluteal site is found by placing the palm on the greater trochanter with the index finger on the anterior superior iliac spine and the middle finger along the iliac crest. The injection goes into the center of the V formed by the fingers. This site avoids major nerves and blood vessels.

Question 13Basic Nursing Skills

A nurse must give an intradermal injection, such as a tuberculin skin test. Which technique is correct?

  1. Insert the needle at a 15-degree angle with the bevel down
  2. Insert the needle nearly parallel to the skin with the bevel up Correct answer.
  3. Insert the needle at a 90-degree angle deep into muscle
  4. Insert the needle at a 45-degree angle into fat

Explanation

Intradermal injections use a fine needle inserted almost parallel to the skin, bevel up, until the bevel is just under the epidermis. A small wheal should form as fluid enters the dermis. Deeper angles and bevel-down insertion deliver the fluid to the wrong layer.

Question 14Basic Nursing Skills

A nurse is calculating a client's intake and output. Which item should be recorded as intake?

  1. Urine collected in a bedpan
  2. Ice chips that the client has eaten Correct answer.
  3. Drainage from a surgical wound
  4. Emesis in an emesis basin

Explanation

Intake includes anything taken into the body by mouth or tube, including ice chips, which are recorded as part of fluid volume. Output includes urine, emesis, wound drainage, and stool. Separating intake from output correctly is essential for accurate fluid balance records.

Question 15Basic Nursing Skills

A nurse is caring for a client with an indwelling urinary catheter. Which action helps prevent catheter-associated infection?

  1. Routinely irrigating the catheter every shift
  2. Disconnecting the tubing to obtain urine samples
  3. Keeping the drainage bag below the level of the bladder Correct answer.
  4. Changing the catheter every 24 hours

Explanation

Gravity drainage is maintained by keeping the bag below bladder level so urine cannot flow back into the bladder. Routine irrigation, frequent catheter changes, and breaking the closed system all increase infection risk. Samples are obtained with a sterile syringe from the sampling port.

Question 16Basic Nursing Skills

A nurse is performing a sterile dressing change. Which action maintains the sterile field?

  1. Turning away from the field to pick up supplies
  2. Holding sterile items above waist level at all times Correct answer.
  3. Touching the sterile drape edges with sterile gloves
  4. Reaching across the sterile field with the arm

Explanation

Sterile items and the nurse's gloved hands must remain above waist level and within view to stay sterile. Edges of sterile drapes are considered unsterile, and reaching across a field risks contamination. The nurse should never turn away from a sterile field.

Question 17Basic Nursing Skills

A nurse is preparing to insert a nasogastric tube. Which action is essential before insertion?

  1. Measure the tube from the nose to the earlobe to the xiphoid Correct answer.
  2. Verify tube placement by auscultating the abdomen
  3. Ask the client to breathe deeply during insertion
  4. Insert the tube while the client is fully supine

Explanation

Measuring from the nose to the earlobe to the xiphoid estimates the length needed to reach the stomach. The client is usually positioned upright with the head slightly flexed, and swallowing water helps advance the tube. Auscultation alone is not reliable for confirming placement.

Question 18Basic Nursing Skills

A nurse is providing mouth care to an unconscious client. Which action is safest?

  1. Give small sips of water to rinse the mouth
  2. Swab the mouth with the client flat on the back
  3. Use a toothbrush with a large head and plenty of water
  4. Place the client in a side-lying position and use suction Correct answer.

Explanation

An unconscious client cannot swallow or protect the airway, so a side-lying position allows fluids to drain and suction should be available. Small amounts of solution are used, and the mouth is not rinsed with free water. Flat positioning and oral fluids risk aspiration.

Question 19Basic Nursing Skills

A nurse is checking a client for orthostatic hypotension. Which sequence of measurements is correct?

  1. Measure blood pressure while the client is lying, then sitting, then standing Correct answer.
  2. Measure blood pressure after the client has exercised
  3. Measure blood pressure only while the client is standing
  4. Measure blood pressure once while the client is seated

Explanation

Orthostatic vital signs compare readings taken with the client lying, then sitting, and then standing, allowing time between position changes. A drop in systolic pressure or symptoms such as dizziness supports the finding. A single reading or a reading after exercise does not assess orthostatic change.

Question 20Basic Nursing Skills

A nurse is assisting a client to walk who has been on bed rest. Which action is most important?

  1. Apply a gait belt and stand at the client's side Correct answer.
  2. Have the client stand quickly to test strength
  3. Leave the client alone once standing
  4. Walk ahead of the client to lead the way

Explanation

A gait belt gives the nurse a secure hold to support the client if weakness or dizziness occurs, and the nurse stays at the client's side. Rising slowly helps prevent orthostatic symptoms. Walking ahead or leaving the client alone removes needed support.

Question 21Basic Nursing Skills

A nurse is transferring a client who can bear weight from the bed to a chair. Where should the chair be placed?

  1. On the client's stronger side, angled toward the bed Correct answer.
  2. Behind the bed out of the walking path
  3. At the foot of the bed facing away
  4. On the client's weaker side, parallel to the bed

Explanation

Placing the chair on the stronger side lets the client pivot and use the stronger leg for support. The chair should be angled toward the bed so the client can sit down with a controlled movement. The weaker side provides less stability for the transfer.

Question 22Basic Nursing Skills

A nurse is caring for a client receiving oxygen by nasal cannula. Which safety measure is appropriate?

  1. Adjust the flow rate without an order
  2. Store the oxygen cylinder lying flat on the floor
  3. Keep the client's petroleum-based ointment near the oxygen source
  4. Post no-smoking signs and keep oxygen away from open flames Correct answer.

Explanation

Oxygen supports combustion, so no-smoking signs and removal of ignition sources are essential safety measures. Petroleum products should be kept away from oxygen because they are flammable. Flow rates are set according to a prescriber's order.

Question 23Basic Nursing Skills

A nurse is preparing to perform a fingerstick blood glucose test. Which action is correct?

  1. Cleanse the site with alcohol and let it dry completely Correct answer.
  2. Cleanse the site with alcohol and test before it dries
  3. Use the first drop of blood without cleansing the site
  4. Squeeze the fingertip firmly to obtain a large drop

Explanation

The puncture site is cleansed with an alcohol swab and allowed to dry so the alcohol does not dilute the sample or sting. The first drop may be wiped away to avoid contamination. Excessive squeezing adds tissue fluid and alters the reading.

Question 24Basic Nursing Skills

A nurse is caring for a client with a new colostomy. Which observation should be reported promptly?

  1. A small amount of gas in the pouch
  2. A stoma that appears dark and dusky Correct answer.
  3. Stool in the ostomy pouch
  4. A stoma that is pink and moist

Explanation

A healthy stoma is pink to red and moist, so a dark, dusky, or black stoma may indicate compromised blood flow and must be reported. Gas and stool in the pouch are expected findings. Stoma color is a key indicator of tissue perfusion.

Question 25Basic Nursing Skills

A nurse is applying sequential compression devices to a client's legs. Which action is correct?

  1. Place the sleeves only on the leg with a known clot
  2. Leave the sleeves in place during ambulation
  3. Wrap the sleeves snugly and check skin under them regularly Correct answer.
  4. Apply the sleeves over the client's clothing

Explanation

Compression sleeves are wrapped snugly but not tightly, and the skin beneath is inspected regularly for pressure or irritation. Devices are removed during ambulation and are not applied to a leg with a suspected clot. Sleeves are placed against the skin, not over clothing.

Question 26Basic Nursing Skills

A nurse is preparing to administer a subcutaneous injection of insulin. Which angle of insertion is correct for a client with a normal body build?

  1. 90 degrees Correct answer.
  2. 30 degrees
  3. 45 degrees
  4. 15 degrees

Explanation

Subcutaneous injections are typically given at a 90-degree angle for clients with adequate subcutaneous tissue. A 45-degree angle is used for clients who are thin or have little subcutaneous fat. Insulin is given subcutaneously, and the standard angle is 90 degrees unless the client is very thin.

Question 27Basic Nursing Skills

A nurse is caring for a client who has a new prescription for a clear liquid diet. Which item should the nurse expect to be allowed on this diet?

  1. Strained cream of wheat
  2. Vanilla ice cream
  3. Apple juice Correct answer.
  4. Cream of tomato soup

Explanation

A clear liquid diet includes liquids that are transparent and liquid at room temperature, such as apple juice, clear broth, and gelatin. Foods that are opaque or contain milk products or solids are not allowed. Apple juice meets the criteria for a clear liquid.

Question 28Basic Nursing Skills

A nurse is measuring a client's blood pressure manually. Which action is correct to ensure an accurate reading?

  1. Place the cuff over the client's clothing.
  2. Use a cuff that is too small for the client's arm.
  3. Position the client's arm at heart level. Correct answer.
  4. Deflate the cuff rapidly at 10 mm Hg per second.

Explanation

For an accurate blood pressure reading, the client's arm should be supported at heart level. This prevents hydrostatic pressure effects that can alter the reading. The cuff should be placed on bare skin, sized appropriately, and deflated at a rate of 2 to 3 mm Hg per second.

Question 29Basic Nursing Skills

A nurse is preparing to administer a medication through a nasogastric tube. Which action is essential to maintain tube patency and ensure medication delivery?

  1. Flush the tube with 30 mL of water before and after each medication. Correct answer.
  2. Clamp the tube for 5 minutes after each medication.
  3. Use a syringe to instill medications rapidly.
  4. Mix all medications together before instilling them.

Explanation

Flushing the nasogastric tube with water before and after medication administration helps prevent clogging and ensures the medication reaches the stomach. Medications should be given separately to avoid interactions and to maintain their individual effects. Rapid instillation can cause discomfort and does not improve delivery.

Question 30Basic Nursing Skills

A nurse is caring for a client who is receiving continuous enteral feedings through a nasogastric tube. Which action is most important to prevent aspiration?

  1. Check the residual volume every 8 hours.
  2. Elevate the head of the bed to 30 to 45 degrees. Correct answer.
  3. Flush the tube with 10 mL of water every 4 hours.
  4. Change the feeding container every 48 hours.

Explanation

Elevating the head of the bed to 30 to 45 degrees during and after enteral feedings helps prevent aspiration by reducing the risk of reflux. Residual volume checks are done per policy, but elevation is a key preventive measure. Flushing and container changes are important for tube maintenance but do not directly prevent aspiration.

Question 31Basic Nursing Skills

A nurse is performing a sterile procedure and needs to add sterile items to the sterile field. Which action is correct?

  1. Hold the item over the field and open the package with sterile gloves.
  2. Place the item on the edge of the sterile field.
  3. Turn away from the sterile field to open the package.
  4. Open the package and drop the item onto the field from 6 inches above. Correct answer.

Explanation

When adding sterile items to a sterile field, the nurse should open the package and drop the item onto the field from a safe distance (about 6 inches) to avoid contamination. Holding the item over the field or touching the field with non-sterile objects can contaminate it. The edges of the sterile field are considered contaminated.

Question 32Basic Nursing Skills

A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which action is correct?

  1. Discard the first voiding and collect all urine for the next 24 hours. Correct answer.
  2. Collect only the urine voided during the daytime.
  3. Collect all urine for 24 hours, including the first voiding.
  4. Collect the first voiding and discard all subsequent urine.

Explanation

For a 24-hour urine collection, the client should void and discard the first specimen, then collect all urine for the next 24 hours, including the final voiding at the end of the period. This ensures that the collection reflects exactly 24 hours of urine output. Collecting the first voiding would include urine formed before the start time.

Question 33Basic Nursing Skills

A nurse is preparing to administer a rectal suppository to an adult client. Which action is correct?

  1. Insert the suppository with the pointed end first.
  2. Ask the client to bear down during insertion.
  3. Lubricate the suppository with a water-soluble lubricant. Correct answer.
  4. Insert the suppository 1 inch into the rectum.

Explanation

Rectal suppositories should be lubricated with a water-soluble lubricant to ease insertion and reduce discomfort. They are inserted past the internal sphincter, about 3 to 4 inches for an adult, with the rounded end first unless otherwise specified. Asking the client to bear down can help relax the sphincter but is not the primary action for insertion.

Question 34Basic Nursing Skills

A nurse is caring for a client who is at risk for pressure injuries. Which action is most effective in preventing pressure injuries?

  1. Massage reddened areas every 4 hours.
  2. Keep the head of the bed elevated at 60 degrees.
  3. Reposition the client at least every 2 hours. Correct answer.
  4. Use a donut-shaped cushion when sitting.

Explanation

Repositioning the client at least every 2 hours relieves pressure on vulnerable areas and is a key preventive measure for pressure injuries. Massaging reddened areas can cause further damage, and donut cushions can impair circulation. Elevating the head of the bed increases shear and pressure on the sacrum.

Question 35Basic Nursing Skills

A nurse is performing a physical assessment on a client. Which technique is correct for auscultating the lungs?

  1. Use the bell of the stethoscope to listen for high-pitched breath sounds.
  2. Place the stethoscope over the client's clothing.
  3. Use the diaphragm of the stethoscope and listen over bare skin. Correct answer.
  4. Ask the client to breathe rapidly through the mouth.

Explanation

The diaphragm of the stethoscope is best for hearing high-pitched breath sounds, and it should be placed directly on bare skin to avoid muffling. The bell is used for low-pitched sounds. Asking the client to breathe rapidly can cause hyperventilation and is not standard technique.

Question 36Basic Nursing Skills

A nurse is preparing to administer eye drops to a client. Which action is correct?

  1. Apply pressure to the inner canthus after instillation. Correct answer.
  2. Instill the drops directly onto the cornea.
  3. Have the client look up during instillation.
  4. Touch the dropper tip to the eyelid.

Explanation

Applying pressure to the inner canthus (punctal occlusion) after instilling eye drops helps prevent systemic absorption and increases the medication's local effect. The drops should be placed in the lower conjunctival sac, not directly on the cornea. The dropper should never touch the eye or eyelid to avoid contamination.

Question 37Basic Nursing Skills

A nurse is preparing to administer a medication via a metered-dose inhaler with a spacer. Which action is correct?

  1. Shake the inhaler vigorously for 10 seconds before use.
  2. Wait 5 minutes between puffs of the same medication.
  3. Have the client exhale fully before actuating the inhaler. Correct answer.
  4. Instruct the client to inhale rapidly after actuation.

Explanation

The client should exhale fully before actuating the inhaler to allow for maximum inhalation of the medication. The inhaler should be shaken well, but vigorous shaking for 10 seconds is not necessary. The client should inhale slowly and deeply, and wait at least 30 to 60 seconds between puffs.

Question 38Basic Nursing Skills

A nurse is caring for a client who requires a wound culture. Which action is correct?

  1. Collect the specimen from the wound edges.
  2. Collect the specimen after cleansing the wound with normal saline. Correct answer.
  3. Use a dry swab to collect the specimen.
  4. Swab the wound bed before cleansing.

Explanation

Wound cultures should be collected after cleansing the wound with normal saline to remove surface contaminants and obtain a specimen from the actual wound bed. Swabbing before cleansing can yield misleading results. The specimen should be taken from the wound bed, not the edges, and the swab should be moistened with sterile saline if needed.

Question 39Basic Nursing Skills

A nurse is caring for a client who has a new colostomy. Which observation should the nurse report to the health care provider immediately?

  1. The stoma is beefy red and moist.
  2. There is a small amount of bleeding from the stoma.
  3. The stoma is dark purple and dry. Correct answer.
  4. The client reports mild cramping.

Explanation

A healthy stoma should be beefy red and moist. A dark purple, dry stoma indicates ischemia and requires immediate notification of the health care provider. Small amounts of bleeding and mild cramping can be normal postoperatively.

Question 40Basic Nursing Skills

A nurse is preparing to administer a medication via a nasogastric tube. Which action is correct?

  1. Flush the tube with 30 mL of water before and after each medication. Correct answer.
  2. Use a syringe to instill the medication rapidly.
  3. Clamp the tube for 5 minutes after each medication.
  4. Mix all medications together before instilling them.

Explanation

Flushing the nasogastric tube with water before and after medication administration helps prevent clogging and ensures the medication reaches the stomach. Medications should be given separately to avoid interactions. Rapid instillation can cause discomfort and does not improve delivery.

Question 41Basic Nursing Skills

A nurse is caring for a client who is receiving oxygen therapy. Which action is correct to prevent oxygen toxicity?

  1. Use a nonrebreather mask for all clients.
  2. Administer oxygen continuously regardless of the client's condition.
  3. Keep the oxygen flow rate at 10 L/min or higher.
  4. Administer oxygen at the lowest effective flow rate. Correct answer.

Explanation

Oxygen toxicity can occur with high concentrations or prolonged oxygen therapy. The nurse should administer oxygen at the lowest effective flow rate to maintain adequate oxygenation. High flow rates and nonrebreather masks are used only when specifically indicated.

Question 42Basic Nursing Skills

A nurse is preparing to administer a subcutaneous injection of heparin. Which action is correct?

  1. Do not aspirate and do not massage the site. Correct answer.
  2. Use a 45-degree angle for insertion.
  3. Aspirate before injecting the medication.
  4. Massage the injection site after injection.

Explanation

Heparin is administered subcutaneously, and the nurse should not aspirate before injecting or massage the site afterward to avoid tissue damage and hematoma. The injection is given at a 90-degree angle into the fatty tissue of the abdomen. Aspiration and massage are not recommended for heparin injections.

Question 43Basic Nursing Skills

A nurse is preparing to insert an indwelling urinary catheter into a female client. Which action is correct to reduce the risk of urinary tract infection?

  1. Irrigate the catheter routinely every shift
  2. Use sterile technique and maintain a closed drainage system Correct answer.
  3. Inflate the balloon before confirming urine return
  4. Cleanse the perineum with antiseptic solution before insertion

Explanation

Catheter-associated urinary tract infection is prevented chiefly by strict sterile technique at insertion and by keeping the drainage system closed and dependent. Routine irrigation and antiseptic perineal scrubbing are not recommended practices and may introduce organisms.

Question 44Basic Nursing Skills

A nurse is caring for a client who is receiving a blood transfusion. Which finding should the nurse report immediately as a possible transfusion reaction?

  1. A temperature rise of 1.5 degrees Celsius with chills Correct answer.
  2. Mild itching at the intravenous site
  3. Urine output of 50 mL in the past hour
  4. A hemoglobin level drawn before the transfusion

Explanation

Fever with chills during a transfusion is a classic sign of a hemolytic or febrile transfusion reaction and requires stopping the transfusion and notifying the provider at once. Vital signs are monitored before, during, and after transfusion specifically to detect such changes early.

Question 45Basic Nursing Skills

A nurse is performing hand hygiene with an alcohol-based hand rub. Which action is correct?

  1. Apply the product to dry hands and rub until the hands are dry Correct answer.
  2. Apply the product only to the palms of the hands
  3. Use the rub when the hands are visibly soiled with blood
  4. Rinse the hands with water after rubbing the product in

Explanation

Alcohol-based hand rubs are effective only when applied to dry hands and rubbed until completely dry, allowing adequate contact time. Visible soiling with blood or body fluids requires soap and water washing because alcohol rubs do not remove organic material.

Question 46Basic Nursing Skills

A nurse is caring for a client who has an order for strict intake and output monitoring. Which action is correct?

  1. Record all oral fluids, intravenous fluids, and emesis as output
  2. Estimate output volumes rather than measuring them
  3. Count only liquids the client drinks by mouth as intake
  4. Measure and record all fluids taken in and all urine, vomitus, and drainage Correct answer.

Explanation

Strict intake and output monitoring requires measuring and recording every fluid entering the body and every fluid leaving it, including urine, emesis, and wound or tube drainage. Accurate measurement, not estimation, is essential for assessing fluid balance.

Question 47Basic Nursing Skills

A nurse is repositioning a client who is unable to assist. Which action is correct to protect both the nurse and the client?

  1. Twist the torso while pulling the client toward the head of the bed
  2. Raise the bed to waist height and use a friction-reducing device Correct answer.
  3. Keep the bed in the lowest position during the transfer
  4. Pull the client by the arms to move them up in bed

Explanation

Raising the bed to about waist height and using a friction-reducing slide sheet reduces the force required and protects the nurse's back from injury. Good body mechanics also include keeping the client close and avoiding twisting during the move.

Question 48Basic Nursing Skills

A nurse is caring for a client who has an order for a cleansing enema. Which action is correct?

  1. Hang the solution bag 90 cm above the client
  2. Insert the tubing tip while pointing it toward the client's spine
  3. Instill the solution rapidly to shorten the procedure
  4. Position the client in the left lateral position with the knees flexed Correct answer.

Explanation

The left lateral position allows the solution to flow along the natural curve of the descending colon and sigmoid, improving retention and effectiveness. The solution should be instilled slowly at a height of about 30 to 45 cm to avoid cramping.

Question 49Basic Nursing Skills

A nurse is teaching a client how to use a cane. Which instruction is correct for a client who has left leg weakness?

  1. Hold the cane on the left side and advance it before the right leg
  2. Hold the cane on the right side and keep it still while stepping
  3. Hold the cane on the right side and advance it with the weak left leg Correct answer.
  4. Hold the cane on the left side and move it with the left leg

Explanation

The cane is held on the stronger side so it can widen the base of support and bear weight opposite the weak leg. The cane and the weak leg advance together, followed by the stronger leg.

Question 50Basic Nursing Skills

A nurse is caring for a client who has a new prescription for oxygen at 2 L per minute by nasal cannula. Which action is correct?

  1. Place the cannula tubing under the client's chin
  2. Set the flow rate before placing the cannula on the client Correct answer.
  3. Increase the flow rate if the client reports shortness of breath
  4. Apply petroleum jelly to the nares to prevent dryness

Explanation

The flow rate must be set and checked before the cannula is applied so the client receives the prescribed amount from the start and is not exposed to a sudden burst. Petroleum-based products are avoided near oxygen because they are flammable.