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EHPLE Nursing study materials
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EHPLE Nursing practice questions

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Question 1Professional Nursing Practice and Ethics

A nurse working under a code of ethics recognizes that respecting a patient's autonomy most directly requires which action?

  1. Deferring every decision to the patient's family members
  2. Honoring the patient's informed, voluntary decision even when the nurse disagrees with it Correct answer.
  3. Persuading the patient to follow the care team's preferred plan
  4. Documenting the patient's choice only after the physician approves it

Explanation

Autonomy means the patient has the right to make informed, voluntary decisions about their own care, and the nurse must respect those decisions even when they conflict with professional opinion. Persuasion or family deference undermines that right, and physician approval is not a precondition for honoring a competent patient's choice.

Question 2Professional Nursing Practice and Ethics

A patient asks a nurse to explain what a signed advance directive means for future care. Which statement best reflects the purpose of an advance directive?

  1. It becomes active immediately upon hospital admission regardless of capacity
  2. It guarantees the patient will receive every requested intervention
  3. It records the patient's preferences for treatment in case the patient later loses decision-making capacity Correct answer.
  4. It transfers all legal authority over the patient's finances to the hospital

Explanation

An advance directive documents a patient's wishes about future care so they can guide decisions if the patient becomes unable to speak for themselves. It is triggered by loss of capacity, not by admission, and it does not guarantee treatment or transfer financial authority.

Question 3Professional Nursing Practice and Ethics

During a busy shift a nurse realizes a medication was given to the wrong patient. What is the most appropriate immediate professional action?

  1. Assess the patient and report the error through the facility's incident reporting system Correct answer.
  2. Ask a colleague to document the medication as given to the correct patient
  3. Wait to see whether the patient develops symptoms before telling anyone
  4. Record the event only in the nurse's personal notes to avoid blame

Explanation

Patient safety and honesty require the nurse to assess the patient for harm and disclose the error through formal reporting channels. Delaying, hiding, or falsifying documentation violates ethical and legal obligations and endangers the patient.

Question 4Professional Nursing Practice and Ethics

A nurse keeps a patient's diagnosis confidential but learns the patient's employer is asking for details. What principle primarily guides the nurse's response?

  1. Veracity, which requires answering every direct question truthfully and fully
  2. Justice, which requires equal disclosure to all who ask
  3. Beneficence, which requires sharing all information to help the employer
  4. Confidentiality, which limits disclosure to those with a legitimate need to know Correct answer.

Explanation

Confidentiality restricts access to protected health information to parties involved in the patient's care or otherwise authorized. The employer generally has no legitimate need to know, so the nurse should not disclose without proper authorization or legal requirement.

Question 5Professional Nursing Practice and Ethics

A nurse manager notices a colleague consistently arriving impaired. According to professional nursing obligations, what should the manager do first?

  1. Confront the colleague privately and promise to keep the situation secret
  2. Remove the colleague from patient care and follow the facility's impairment reporting policy Correct answer.
  3. Announce the concern to the whole unit to gather opinions
  4. Ignore the behavior until a patient is harmed

Explanation

Protecting patients is paramount, so an impaired nurse must be removed from direct care and the situation handled through established reporting and assistance channels. Secrecy, delay, or public disclosure all fail to protect patients and violate policy.

Question 6Professional Nursing Practice and Ethics

A nurse is asked to witness a patient's signature on a consent form. What is the nurse's primary responsibility in this role?

  1. Guaranteeing the patient understands every risk of the procedure
  2. Explaining the procedure in detail in place of the provider
  3. Deciding whether the procedure is medically indicated
  4. Verifying that the patient received information and signed voluntarily Correct answer.

Explanation

The nurse witnesses that the signature is voluntary and that the patient was informed; the provider is responsible for disclosing risks and benefits and for the medical decision. The nurse supports understanding but does not replace the provider's disclosure or guarantee comprehension.

Question 7Professional Nursing Practice and Ethics

A patient refuses a scheduled dose of medication and is fully alert and oriented. What is the nurse's most appropriate action?

  1. Respect the refusal, document it, and notify the provider of the patient's decision Correct answer.
  2. Skip documentation since no medication was given
  3. Administer the medication covertly in food to ensure treatment
  4. Threaten the patient with discharge to obtain cooperation

Explanation

A competent patient may refuse treatment, and the nurse must honor that decision, document it clearly, and inform the provider so the plan can be reviewed. Covert administration or threats violate autonomy and consent, and refusals must be documented.

Question 8Professional Nursing Practice and Ethics

A nurse is caring for a patient whose cultural practices conflict with a scheduled intervention. Which approach best demonstrates culturally competent ethical practice?

  1. Ask the patient to set aside cultural beliefs during hospitalization
  2. Proceed with the intervention because hospital policy overrides personal beliefs
  3. Assign the patient to a nurse who shares the same cultural background as the only solution
  4. Explore the patient's beliefs and negotiate a plan that respects them while addressing safety Correct answer.

Explanation

Culturally competent practice involves eliciting the patient's values and negotiating care that honors those values while safeguarding health. Overriding beliefs, dismissing them, or assuming only a matched nurse can help are not adequate responses.

Question 9Professional Nursing Practice and Ethics

A nurse faces a situation in which two ethical principles appear to conflict. Which action best reflects the use of an ethics committee?

  1. Ask the committee to make the final decision so staff avoid responsibility
  2. Use the committee to punish a clinician who disagrees with the team
  3. Refer every routine care question to the committee
  4. Request a committee consultation to help clarify values and explore options Correct answer.

Explanation

Ethics committees provide consultation, education, and a structured process for clarifying values and exploring options in complex cases. They do not punish staff, and responsibility for decisions remains with the care team and patient, not the committee.

Question 10Professional Nursing Practice and Ethics

A nurse receives a request from a patient's adult child for the patient's test results. The patient is competent and has not authorized disclosure. What should the nurse do?

  1. Provide the results because family members have an automatic right to information
  2. Share only the results the nurse thinks are least sensitive
  3. Ask the child to sign a form giving themselves access
  4. Decline to share results and explain that the patient must authorize disclosure Correct answer.

Explanation

Protected health information may be shared with family only when the competent patient authorizes it or when the patient lacks capacity and disclosure serves the patient's interests. The nurse should decline politely and direct the family member to the patient for authorization.

Question 11Professional Nursing Practice and Ethics

A nurse is documenting care and considers writing a personal opinion about a patient's character in the record. Why should this be avoided?

  1. Personal opinions are acceptable if they are positive
  2. Character notes help future clinicians make treatment decisions
  3. Only physicians are permitted to write in the record
  4. The record is a legal document and should contain objective, clinically relevant information Correct answer.

Explanation

Clinical records are legal documents used for care, communication, and legal review, so entries must be objective, factual, and clinically relevant. Subjective character judgments are unprofessional and can create legal and ethical problems.

Question 12Professional Nursing Practice and Ethics

A nurse is asked to participate in a research study involving patients on the unit. Which action reflects ethical conduct?

  1. Enroll patients who seem confused because they cannot object
  2. Recruit only patients who are unlikely to refuse
  3. Confirm that informed consent was obtained and the study was reviewed by an ethics board Correct answer.
  4. Omit disclosure of risks to avoid worrying participants

Explanation

Ethical research requires voluntary informed consent and independent ethics review before participation. Enrolling patients who cannot consent, targeting likely compliers, or withholding risk information all violate research ethics.

Question 13Professional Nursing Practice and Ethics

A nurse observes a colleague documenting a wound assessment that was not actually performed. What is the most appropriate response?

  1. Address the concern directly and escalate through the chain of command if it continues Correct answer.
  2. Sign the same note to show team solidarity
  3. Report the colleague to patients on the unit
  4. Ignore it because documentation is the colleague's responsibility

Explanation

Falsified documentation endangers patients and is a professional and legal violation, so the nurse should address it directly and escalate if needed. Endorsing or ignoring it makes the nurse complicit, and discussing it with patients breaches confidentiality.

Question 14Professional Nursing Practice and Ethics

A patient with decision-making capacity requests a treatment the care team believes is futile. Which ethical approach best guides the nurse?

  1. Facilitate open discussion of goals and values and involve the ethics consultation process if conflict persists Correct answer.
  2. Tell the patient that futile requests are never honored
  3. Quietly withhold the treatment without discussion
  4. Transfer the patient immediately without explanation

Explanation

Requests for potentially futile treatment require transparent discussion of goals, values, and expected outcomes, with ethics consultation when conflict persists. Unilateral withholding or abrupt transfer without dialogue disrespects the patient and the process.

Question 15Professional Nursing Practice and Ethics

A nurse is caring for a patient from a culture that values family involvement in decision-making. How should the nurse balance autonomy with cultural values?

  1. Exclude the family to protect the patient's independence
  2. Assume the family should make all decisions without asking the patient
  3. Ask the patient how much family involvement they want and honor that preference Correct answer.
  4. Insist the patient decide alone to avoid undue influence

Explanation

Respecting autonomy includes asking the patient how they wish to involve family and honoring that choice, which may include collective decision-making. Assuming family control or excluding family ignores the patient's own stated preference.

Question 16Professional Nursing Practice and Ethics

A nurse is preparing to administer care and notices a colleague appears to be under the influence of alcohol. Which action best protects patients and supports the colleague?

  1. Remove the colleague from patient care and notify the appropriate supervisor per policy Correct answer.
  2. Wait until the end of the shift to report the concern
  3. Cover for the colleague's shift so no one finds out
  4. Confront the colleague in front of patients

Explanation

Patient safety requires immediate removal from care and notification through proper channels, which also connects the colleague to support resources. Covering up, public confrontation, or delay all leave patients at risk.

Question 17Professional Nursing Practice and Ethics

A nurse receives an order that appears unsafe for the patient. What is the most appropriate professional response?

  1. Ask another nurse to administer it to share liability
  2. Alter the dose independently without discussion
  3. Carry out the order because prescribers are always correct
  4. Clarify the order with the prescribing provider and document the concern before acting Correct answer.

Explanation

Nurses are accountable for safe practice and must clarify questionable orders with the prescriber before implementation, documenting the interaction. Blindly following, shifting liability, or unilaterally changing doses are unsafe and unprofessional.

Question 18Professional Nursing Practice and Ethics

A nurse is asked to delegate a task to unlicensed assistive personnel. Which consideration best reflects ethical delegation?

  1. Matching the task to the person's training and the nurse's responsibility to supervise Correct answer.
  2. Delegating any task to reduce the nurse's workload
  3. Delegating tasks that require clinical judgment to save time
  4. Assuming the delegate will report problems only if asked

Explanation

Ethical delegation requires matching tasks to the delegate's competence and scope, with the nurse retaining accountability and supervision. Delegating judgment-based tasks or failing to ensure reporting endangers patients.

Question 19Professional Nursing Practice and Ethics

A nurse notices that a patient's care plan conflicts with the patient's stated values. What first step best demonstrates advocacy?

  1. Document the conflict and take no further action
  2. Discuss the patient's values with the team and seek a plan aligned with them Correct answer.
  3. Transfer the patient to another unit without discussion
  4. Persuade the patient to accept the existing plan

Explanation

Advocacy means representing the patient's values and preferences in care planning, which begins with bringing the concern to the team and seeking alignment. Persuasion, passive documentation, or unexplained transfer do not advocate for the patient.

Question 20Professional Nursing Practice and Ethics

A nurse is caring for a patient who is terminally ill and requests information about palliative options. Which response best reflects ethical nursing practice?

  1. Refer the patient to a chaplain only and decline discussion
  2. Avoid the topic to prevent distress
  3. Provide accurate information about palliative care and support the patient's exploration of goals Correct answer.
  4. Tell the patient that palliative care means giving up

Explanation

Ethical practice requires honest, accurate information that supports informed decision-making about goals of care. Avoiding the topic, mischaracterizing palliative care, or deflecting to another discipline denies the patient needed information.

Question 21Professional Nursing Practice and Ethics

A patient lacks decision-making capacity and has no advance directive or surrogate. What is the most appropriate ethical approach to treatment decisions?

  1. Delay all care until a family member appears
  2. Make decisions based solely on cost to the facility
  3. Use the best-interest standard with team and ethics input while seeking a surrogate Correct answer.
  4. Ask the patient's roommate what the patient would want

Explanation

When no directive or surrogate exists, decisions should follow the best-interest standard, ideally with multidisciplinary and ethics input while a surrogate is sought. Cost-driven decisions, indefinite delay, or consulting uninvolved parties are not appropriate.

Question 22Professional Nursing Practice and Ethics

A nurse is asked to participate in a procedure that conflicts with the nurse's deeply held moral beliefs. Which approach best reflects professional ethics?

  1. Refuse abruptly and leave the patient without alternative arrangements
  2. Perform the procedure while expressing disapproval to the patient
  3. Notify the supervisor and arrange for another qualified nurse while ensuring the patient's care continues Correct answer.
  4. Persuade the patient to decline the procedure

Explanation

Conscientious objection should be expressed through proper channels so that patient care continues without interruption or abandonment. Abrupt refusal, performing with disapproval, or persuading the patient all harm the patient or breach professionalism.

Question 23Professional Nursing Practice and Ethics

A nurse discovers that a colleague shared a patient's photograph on social media without consent. What is the most appropriate action?

  1. Ask the patient to sign a retroactive consent form
  2. Report the breach through the facility's privacy process and document the concern Correct answer.
  3. Share the post to raise awareness of the issue
  4. Ignore it because the colleague removed the post

Explanation

Unauthorized sharing of patient images is a privacy breach that must be reported through formal channels regardless of later removal. Ignoring it, amplifying it, or seeking retroactive consent does not remedy the violation.

Question 24Professional Nursing Practice and Ethics

A nurse manager is reviewing a case in which staff disagree about disclosing a harmful event to a patient. Which action best aligns with ethical and regulatory expectations?

  1. Wait for the patient to ask before disclosing anything
  2. Disclose only if the harm is permanent
  3. Delegate disclosure to the patient's family instead of the patient
  4. Ensure the patient is informed of the harmful event through the facility's disclosure process Correct answer.

Explanation

Ethical and regulatory standards require that patients be informed of harmful events affecting their care through a structured disclosure process. Waiting to be asked, limiting disclosure to permanent harm, or bypassing the patient all fail those standards.

Question 25Fundamentals of Nursing and Basic Care

A nurse is preparing to insert a peripheral IV catheter. Which action best reflects the principle of medical asepsis during this procedure?

  1. Performing hand hygiene and cleaning the access site with an antiseptic wipe Correct answer.
  2. Using sterile drapes to cover the entire bed surface
  3. Placing the catheter on a sterile drape before insertion
  4. Wearing sterile gloves and a sterile gown throughout the procedure

Explanation

Medical asepsis aims to reduce the number and transmission of microorganisms, and hand hygiene plus skin antisepsis at the access site are core medical-asepsis actions for peripheral IV insertion. Sterile gowns and full draping are surgical-asepsis measures reserved for procedures requiring a sterile field, not routine peripheral cannulation.

Question 26Fundamentals of Nursing and Basic Care

A client is on strict bed rest. Which nursing measure is most important for preventing pressure injury over the sacrum?

  1. Massaging the reddened area vigorously
  2. Keeping the head of the bed elevated at 60 degrees continuously
  3. Repositioning the client at scheduled intervals Correct answer.
  4. Applying a heating pad to the sacral area

Explanation

Pressure injury prevention depends on relieving sustained pressure over bony prominences, so scheduled repositioning is the cornerstone intervention. Massage over a reddened area, prolonged high Fowler positioning, and heat application all increase tissue damage risk rather than reduce it.

Question 27Fundamentals of Nursing and Basic Care

A nurse is to obtain a wound culture from an open surgical wound. Which technique yields the most reliable specimen?

  1. Swabbing the wound surface after it has been cleaned and irrigated Correct answer.
  2. Collecting the specimen from the surrounding intact skin
  3. Collecting the sample from the wound edges without cleansing
  4. Swabbing the wound after applying a topical antibiotic

Explanation

A wound culture should be taken from viable tissue after the wound is cleansed, because surface exudate and debris contain colonizing organisms that can mislead the result. Sampling intact skin or a wound covered with topical antibiotic does not reflect the pathogens within the wound.

Question 28Fundamentals of Nursing and Basic Care

A client reports difficulty swallowing after a stroke. Which nursing action takes priority before oral intake is resumed?

  1. Waiting until the client requests food to begin feeding
  2. Offering thickened fluids immediately to test tolerance
  3. Requesting a swallow evaluation before any oral intake Correct answer.
  4. Encouraging small sips of water to assess cough reflex

Explanation

After a stroke, dysphagia carries a high risk of aspiration, so oral intake should be withheld until a swallow screen or formal evaluation confirms safety. Trial sips or thickened fluids without assessment expose the client to aspiration risk.

Question 29Fundamentals of Nursing and Basic Care

Which finding indicates that a client's fall risk requires immediate escalation during a night shift?

  1. The client's bed is in the lowest position with side rails up
  2. The client has an activated call light within reach
  3. The client uses a walker to reach the bathroom with assistance
  4. The client is confused and attempts to climb out of bed unassisted Correct answer.

Explanation

Confusion combined with unassisted climbing out of bed describes an imminent fall and requires immediate intervention such as increased supervision, alarms, or a bed exit system. The other options describe already-implemented safety measures or supported mobility.

Question 30Fundamentals of Nursing and Basic Care

A nurse is teaching a client about the correct technique for using a metered-dose inhaler with a spacer. Which instruction is accurate?

  1. Activate the inhaler several times in rapid succession to ensure full dose delivery
  2. Rinse the spacer with water immediately between each puff
  3. Inhale as quickly and forcefully as possible during activation
  4. Activate the inhaler once while inhaling slowly and deeply, then hold the breath Correct answer.

Explanation

With a spacer, the canister is actuated once during a slow deep inhalation and the breath is held briefly so the medication can deposit in the airways. Rapid repeated actuation, forceful inhalation, and rinsing the spacer between puffs all reduce delivered dose or deposition.

Question 31Fundamentals of Nursing and Basic Care

A client with an indwelling urinary catheter needs routine perineal care. Which practice best reduces catheter-associated infection risk?

  1. Applying antibiotic ointment to the meatus each shift
  2. Disconnecting the catheter from the drainage bag for daily cleaning
  3. Routinely irrigating the catheter with antiseptic solution
  4. Performing routine meatal care with soap and water and maintaining a closed drainage system Correct answer.

Explanation

Standard prevention of catheter-associated urinary tract infection relies on routine hygiene at the meatus and keeping the drainage system closed and dependent. Routine antiseptic irrigation, routine disconnection, and prophylactic ointment are not recommended and increase infection risk.

Question 32Fundamentals of Nursing and Basic Care

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

  1. Administer the medication while the client is lying flat
  2. Flush with 5 mL of water only after the last medication
  3. Verify tube placement and check residual volume before giving the medication Correct answer.
  4. Crush all sustained-release tablets together to ease administration

Explanation

Before giving anything through a nasogastric tube, placement must be verified and residual volume checked to reduce aspiration risk and ensure the tube is in the stomach. Sustained-release forms must not be crushed, the head of bed should be elevated, and flushing is needed before, between, and after medications.

Question 33Fundamentals of Nursing and Basic Care

A client is receiving a blood transfusion. Which assessment finding requires the nurse to stop the transfusion immediately?

  1. Complaint of a mild headache
  2. Sudden onset of fever, chills, and flank pain Correct answer.
  3. Mild itching at the IV site without rash
  4. Temperature rise of 0.3 degrees Celsius from baseline

Explanation

Fever, chills, and flank pain during transfusion suggest an acute hemolytic reaction, which requires stopping the transfusion at once and initiating emergency management. Mild itching, small temperature changes, and headache alone are not the classic presentation of a life-threatening reaction.

Question 34Fundamentals of Nursing and Basic Care

A nurse is caring for a client with a new colostomy. Which observation indicates the stoma is healthy?

  1. The stoma is black with a dry surface
  2. The stoma is pale and dry
  3. The stoma is moist and beefy red Correct answer.
  4. The stoma is dark purple and cool

Explanation

A healthy stoma is moist and beefy red to pink because of its rich blood supply. Pale, dark purple, or black coloration suggests ischemia or necrosis and requires prompt reporting.

Question 35Fundamentals of Nursing and Basic Care

Which action best demonstrates proper body mechanics when a nurse lifts a heavy object from the floor?

  1. Keep the feet together and lift with the back muscles
  2. Bend at the knees and keep the load close to the body Correct answer.
  3. Bend at the waist and hold the load away from the body
  4. Twist the torso while lifting to reposition the load

Explanation

Bending at the knees and keeping the load close to the body reduces spinal load and uses the stronger leg muscles. Bending at the waist, twisting, and lifting with the back all increase the risk of musculoskeletal injury.

Question 36Fundamentals of Nursing and Basic Care

A client has an order for oxygen therapy by nasal cannula at 2 L/min. Which nursing action is appropriate?

  1. Set the flow rate higher if the client reports discomfort
  2. Assess the nares and skin behind the ears for irritation Correct answer.
  3. Apply petroleum jelly to the nares to prevent dryness
  4. Tape the cannula tightly to both cheeks

Explanation

Oxygen by nasal cannula can cause dryness and skin breakdown at the nares and ears, so regular assessment of these areas is essential. Petroleum products near oxygen create a fire hazard, taping tightly impairs circulation, and flow rates are changed only per order.

Question 37Fundamentals of Nursing and Basic Care

A nurse is measuring a client's blood pressure. Which technique is correct?

  1. Place the cuff over a long-sleeved shirt
  2. Position the cuff over the antecubital fossa
  3. Deflate the cuff rapidly to finish the measurement quickly
  4. Place the cuff over the bare upper arm at heart level Correct answer.

Explanation

Accurate blood pressure measurement requires the cuff on bare skin at the level of the heart. Clothing under the cuff, incorrect cuff placement over the antecubital fossa, and rapid deflation all introduce measurement error.

Question 38Fundamentals of Nursing and Basic Care

A client is admitted with dehydration. Which assessment finding supports this diagnosis?

  1. Bounding pulse and neck vein distention
  2. Weight gain of 2 kg over 24 hours
  3. Dry mucous membranes and decreased skin turgor Correct answer.
  4. Crackles auscultated in the lung bases

Explanation

Dehydration reduces intravascular and interstitial fluid, producing dry mucous membranes and decreased skin turgor. Bounding pulses, neck vein distention, crackles, and rapid weight gain reflect fluid overload instead.

Question 39Fundamentals of Nursing and Basic Care

A nurse is caring for a client receiving intravenous potassium chloride. Which safety measure is essential?

  1. Verify that the infusion is diluted and given via a controlled pump Correct answer.
  2. Administer the dose as a rapid IV push
  3. Give the dose undiluted through a peripheral line
  4. Withhold monitoring of the infusion site to reduce disturbances

Explanation

Potassium chloride must be diluted and infused at a controlled rate because rapid or concentrated administration can cause fatal cardiac dysrhythmias. IV push administration and undiluted delivery are unsafe, and the site should be monitored for infiltration.

Question 40Fundamentals of Nursing and Basic Care

Which nursing action best prevents a needlestick injury during a subcutaneous injection?

  1. Activating the safety device and disposing of the needle in a sharps container immediately Correct answer.
  2. Placing the used needle on the medication tray until the shift ends
  3. Bending the needle before placing it in the trash
  4. Recapping the needle with one hand before disposal

Explanation

Immediate activation of the safety device and disposal in a puncture-resistant sharps container is the most effective way to prevent needlestick injury. Recapping, leaving used needles on trays, and bending needles all increase exposure risk.

Question 41Fundamentals of Nursing and Basic Care

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

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

Explanation

Ice chips melt to a measurable volume of water and therefore count as intake. Urine, emesis, and wound drainage are outputs and are recorded as such.

Question 42Fundamentals of Nursing and Basic Care

A client on complete bed rest is at risk for deep vein thrombosis. Which intervention is most appropriate?

  1. Apply firm pressure to the calves each shift
  2. Keep the legs dependent for long periods
  3. Perform active or passive range-of-motion exercises as ordered Correct answer.
  4. Massage the calves vigorously twice daily

Explanation

Range-of-motion exercises promote venous return and reduce venous stasis in immobilized clients. Vigorous calf massage, prolonged dependency, and firm calf pressure do not prevent thrombosis and may be harmful.

Question 43Fundamentals of Nursing and Basic Care

A nurse is preparing to give an intramuscular injection to an adult. Which site and technique are correct?

  1. Dorsogluteal site with the needle inserted at a 30-degree angle
  2. Ventrogluteal site with the needle inserted at a 90-degree angle Correct answer.
  3. Deltoid site with the needle inserted at a 15-degree angle
  4. Vastus lateralis site with the needle inserted at a 45-degree angle

Explanation

For adult intramuscular injections, the ventrogluteal site is preferred and the needle is inserted at a 90-degree angle into muscle. Angles less than 90 degrees deposit medication in subcutaneous tissue, and the dorsogluteal site carries greater risk to the sciatic nerve.

Question 44Fundamentals of Nursing and Basic Care

A client reports pain rated 8 out of 10 one hour after receiving an opioid analgesic. Which action should the nurse take first?

  1. Document the pain score and wait for the next scheduled dose
  2. Administer another full dose of the same opioid immediately
  3. Tell the client that the medication should have worked by now
  4. Reassess the client and evaluate the pain characteristics and response to the medication Correct answer.

Explanation

When a client reports unrelieved pain, the nurse first reassesses the pain and the response to the medication before deciding on further intervention. Giving another dose without assessment, waiting, or dismissing the report are unsafe or nontherapeutic.

Question 45Fundamentals of Nursing and Basic Care

A nurse is teaching a client about a low-sodium diet. Which food choice indicates the client understands the teaching?

  1. Processed deli ham with pickles
  2. Canned soup with crackers
  3. Frozen dinner with soy sauce
  4. Fresh chicken breast seasoned with lemon and herbs Correct answer.

Explanation

Fresh unprocessed meat seasoned with lemon and herbs is low in sodium. Canned soup, processed deli meats, pickles, and soy sauce are all high-sodium foods that should be limited on a low-sodium diet.

Question 46Fundamentals of Nursing and Basic Care

Which action demonstrates correct sterile technique when a nurse dons sterile gloves?

  1. Reaching across an unsterile surface to pick up a sterile item
  2. Touching the outside of the sterile glove with the bare hand
  3. Turning the back to the sterile field to adjust the gown
  4. Keeping the hands above the waist and away from the body after gloving Correct answer.

Explanation

After donning sterile gloves, the hands must remain above waist level and within the nurse's field of vision to avoid contamination. Touching the outside of the glove, reaching over unsterile areas, and turning away from the field all break sterile technique.

Question 47Fundamentals of Nursing and Basic Care

A client with a new tracheostomy requires routine care. Which action is appropriate?

  1. Instill normal saline routinely before each suction pass
  2. Reuse the suction catheter without cleaning for the shift
  3. Suction routinely every hour regardless of secretions
  4. Suction only when clinically indicated, using sterile technique Correct answer.

Explanation

Suctioning should be performed only when indicated, such as visible secretions or signs of airway obstruction, because unnecessary suctioning traumatizes the mucosa and depletes oxygen. Routine saline instillation, fixed hourly suctioning, and catheter reuse are not recommended.

Question 48Fundamentals of Nursing and Basic Care

A nurse is assessing a client for signs of hypoxia. Which cluster of findings is most consistent with this condition?

  1. Deep sleep, slow respirations, and pink mucous membranes
  2. Bradycardia, warm dry skin, and hypertension
  3. Restlessness, tachycardia, and decreased oxygen saturation Correct answer.
  4. Increased appetite, polyuria, and weight loss

Explanation

Early hypoxia commonly presents with restlessness, tachycardia, and falling oxygen saturation as the body attempts to compensate. Bradycardia with warm skin, deep sleep with slow respirations, and polyuria with weight loss do not fit the hypoxia picture.

Question 49Fundamentals of Nursing and Basic Care

A client has an order for a cleansing enema. Which position is generally recommended during administration?

  1. High Fowler position with feet flat
  2. Left lateral position with the head slightly elevated Correct answer.
  3. Right lateral position with the head flat
  4. Prone position with knees flexed

Explanation

The left lateral position with the head slightly elevated follows the natural course of the descending colon and sigmoid, improving solution retention and distribution. High Fowler, prone, and right lateral positions are less effective for a cleansing enema.

Question 50Fundamentals of Nursing and Basic Care

A nurse is preparing to insert a small-bore nasogastric tube for a client. Which action best confirms that the tube tip has reached the stomach before the first feeding?

  1. Check that the tube marking sits at the naris
  2. Observe the client for coughing during insertion
  3. Measure the pH of fluid aspirated from the tube Correct answer.
  4. Auscultate an injected air bolus over the epigastrium

Explanation

Aspirated gastric fluid is normally acidic (pH below about 5.5), while respiratory placement yields fluid with a pH above 6, so measuring aspirate pH is the most reliable bedside confirmation. Auscultating air is unreliable because gurgling can be transmitted from the esophagus or lung, and it is no longer accepted as verification. Radiography remains the definitive check when pH results are equivocal.