Nursing Fundamentals — SNLE practice questions

Question 1

A nurse is preparing to reposition a 78-year-old bedbound patient who has a Braden Scale score of 12. Which nursing action best prevents pressure injury development over the sacrum?

Accepted Answer

Reposition the patient onto a 30-degree lateral tilt position

Answer

Massage the sacral area vigorously to stimulate circulation

Answer

Elevate the head of the bed to 60 degrees continuously for comfort

Answer

Place a ring-shaped (donut) foam cushion under the sacrum

Question 2

A nurse measures the vital signs of an adult patient who weighs 70 kg: BP 88/54 mmHg, pulse 118/min, respirations 24/min, temperature 38.9°C. Urine output has been 15 mL/hr for the last three hours. Which of these findings most directly measures perfusion of an end organ?

Accepted Answer

Urine output of 15 mL/hr

Answer

Temperature of 38.9°C

Answer

Respiratory rate of 24/min

Answer

Pulse of 118/min

Question 3

A patient receiving continuous nasogastric enteral feeding suddenly develops coughing, dyspnea, and oxygen saturation falling from 97% to 88%. What is the nurse's first action?

Accepted Answer

Stop the feeding at once and reposition the patient to protect the airway

Answer

Obtain a stat chest radiograph to confirm aspiration before acting

Answer

Check the gastric residual volume before deciding whether to continue

Answer

Flush the feeding tube with 30 mL of water to confirm correct placement

Question 4

A patient receiving intravenous vancomycin develops flushing and erythema of the face, neck, and upper torso 20 minutes into the infusion. Blood pressure is 96/58 mmHg. What is the nurse's most appropriate immediate action?

Accepted Answer

Stop the infusion, give an antihistamine, and resume at a slower rate

Answer

Continue the infusion at the same rate and document the reaction

Answer

Administer intramuscular epinephrine and call the rapid response team

Answer

Permanently document vancomycin as a drug allergy in the record

Question 5

A physician orders 250 mg of an antibiotic to be given orally. The pharmacy supplies a suspension labeled 125 mg per 5 mL. How many milliliters should the nurse administer?

Accepted Answer

10 mL

Answer

5 mL

Answer

12.5 mL

Answer

2.5 mL

Question 6

A patient stabilized on warfarin for atrial fibrillation has an INR of 6.5 with no bleeding. Which action should the nurse anticipate?

Accepted Answer

Withhold the warfarin doses and recheck the INR

Answer

Administer intravenous vitamin K 10 mg immediately

Answer

Administer protamine sulfate to reverse the anticoagulation

Answer

Continue the usual warfarin dose and recheck the INR in one week

Question 7

A nurse is preparing to measure the blood pressure of a patient who has a left arm arteriovenous fistula for hemodialysis. Which of the following actions should the nurse take?

Accepted Answer

Obtain the blood pressure measurement using the right arm.

Answer

Apply the cuff to the left arm directly over the fistula site.

Answer

Place the cuff on the left thigh to avoid both arms entirely.

Answer

Position the cuff on the left forearm below the fistula.

Question 8

A nurse is caring for a patient with a surgical wound infection. After removing the soiled dressing, the nurse notes that her hands are visibly contaminated with wound drainage. Which action should the nurse take next?

Accepted Answer

Wash hands with soap and water.

Answer

Apply an alcohol-based hand rub.

Answer

Put on a clean pair of gloves.

Answer

Use an antiseptic hand wipe.

Question 9

A nurse is providing care for a patient with a confirmed Clostridioides difficile infection. After removing gloves following direct patient contact, which hand hygiene method should the nurse use?

Accepted Answer

Wash hands with soap and water using friction for at least 20 seconds.

Answer

Apply an alcohol-based hand rub to all surfaces of the hands.

Answer

Use an antiseptic hand wash containing chlorhexidine gluconate.

Answer

Rinse hands with water only and dry thoroughly with a paper towel.

Question 10

A nurse is preparing to perform a sterile wound dressing change for a patient with a surgical incision. Which of the following actions should the nurse take first?

Accepted Answer

Perform hand hygiene.

Answer

Apply sterile gloves.

Answer

Open the sterile dressing kit.

Answer

Remove the old dressing.

Question 11

A nurse is preparing to administer a prescribed dose of 10 units of insulin lispro and 20 units of insulin glargine subcutaneously to a patient with diabetes mellitus. Which of the following actions should the nurse take?

Accepted Answer

Administer the insulin lispro and insulin glargine as separate injections.

Answer

Draw up the insulin lispro first, then the insulin glargine in the same syringe.

Answer

Draw up the insulin glargine first, then the insulin lispro in the same syringe.

Answer

Gently roll the insulin glargine vial between the palms before drawing up.

Question 12

A 28-year-old patient with schizophrenia has been taking haloperidol 5 mg twice daily for 2 days. The patient suddenly develops sustained neck twisting, protrusion of the tongue, and difficulty speaking. The patient has a PRN order for benztropine 2 mg IV. Which action should the nurse take first?

Accepted Answer

Administer the prescribed intravenous benztropine.

Answer

Reassure the patient that this is a common, harmless side effect.

Answer

Apply warm compresses to the neck and encourage relaxation.

Answer

Withhold the next dose of haloperidol and notify the physician.

Question 13

A 45-year-old patient is admitted to the medical unit with a persistent cough, night sweats, and hemoptysis. The chest X-ray shows cavitary lesions in the upper lobes. The nurse suspects pulmonary tuberculosis. Which infection control precaution should the nurse implement immediately?

Accepted Answer

Place the patient in a negative-pressure room and wear an N95 respirator when entering the room.

Answer

Place the patient in a private room with the door open and wear a surgical mask when within 3 feet of the patient.

Answer

Place the patient in a private room and wear gloves and a gown for all patient contact.

Answer

Place the patient in a standard room and wear a surgical mask only during aerosol-generating procedures.

Question 14

A nurse is preparing to perform a sterile dressing change for a patient with a surgical wound. Which of the following actions by the nurse indicates a need for further education regarding infection control?

Accepted Answer

Places sterile items on the 1-inch border of the sterile field

Answer

Performs hand hygiene before donning sterile gloves

Answer

Opens the sterile dressing kit by first opening the flap farthest from the body, then the side flaps, and finally the flap nearest to the body

Answer

Places the sterile glove package on a clean, dry surface before opening it

Question 15

A nurse is preparing to administer a prescribed mixture of NPH and regular insulin to a patient with type 1 diabetes. Which action should the nurse take first?

Accepted Answer

Gently roll the NPH vial between the palms to resuspend the insulin.

Answer

Inject air into the NPH vial before injecting air into the regular vial.

Answer

Draw up the regular insulin into the syringe before the NPH insulin.

Answer

Shake the NPH vial vigorously to ensure the insulin is well mixed.

Question 16

A nurse is preparing to administer a prescribed mixture of NPH insulin and regular insulin to a patient with diabetes mellitus. The mixture is not available as a premixed formulation, so the nurse must mix the insulins from separate vials. Which action should the nurse take?

Accepted Answer

Draw up the regular insulin first, then the NPH insulin.

Answer

Draw up the NPH insulin first, then the regular insulin.

Answer

Shake the NPH insulin vial vigorously before drawing up the dose.

Answer

Wait at least 30 minutes after mixing before administering the injection.

Question 17

A nurse is changing the dressing of a patient with a surgical wound infection. After removing the soiled dressing and discarding it in the appropriate bin, the nurse removes gloves and performs hand hygiene. Which of the WHO '5 Moments for Hand Hygiene' indicates the need for this action?

Accepted Answer

After body fluid exposure risk

Answer

Before touching a patient

Answer

After touching a patient

Answer

After touching patient surroundings

Question 18

A nurse is preparing to administer the first enteral feeding through a newly inserted nasogastric (NG) tube. Which action should the nurse take to confirm correct tube placement before starting the feeding?

Accepted Answer

Obtain an abdominal x-ray to visualize tube tip location.

Answer

Inject 10 mL of air while auscultating over the epigastrium.

Answer

Measure the pH of gastric aspirate obtained from the tube.

Answer

Mark and record the external tube length at the naris.

Question 19

A nurse is performing a peripheral vascular assessment on a patient who reports chronic leg pain. Which finding would the nurse interpret as most indicative of arterial insufficiency?

Accepted Answer

Dependent rubor of the foot when lowered below heart level

Answer

Brownish hyperpigmentation around the medial malleolus

Answer

Pitting edema extending from the foot to the calf

Answer

Irregularly shaped ulcer with moderate to heavy exudate

Question 20

A nurse is assessing a 65-year-old patient who is 3 days post-operative following a total hip replacement. The patient reports pain in the right calf. Which assessment finding would most strongly suggest the presence of a deep vein thrombosis (DVT)?

Accepted Answer

Unilateral swelling of the right calf

Answer

Positive Homan's sign

Answer

Bilateral pitting edema in the lower extremities

Answer

Diminished pedal pulses in the affected leg

Question 21

A nurse is assessing a patient admitted with dyspnea and bilateral lower extremity edema. To accurately evaluate for jugular venous distention, which action should the nurse take?

Accepted Answer

Elevate the head of the bed to 30-45 degrees.

Answer

Position the patient supine with the head of the bed flat.

Answer

Have the patient sit upright and lean forward.

Answer

Ask the patient to stand and turn the head to the left.

Question 22

A nurse is preparing to administer the morning dose of digoxin to a patient with heart failure. The patient reports feeling nauseated and anorexic since yesterday and mentions seeing 'yellow halos' around lights. The nurse notes a heart rate of 58 beats/min. Which action should the nurse take first?

Accepted Answer

Withhold the digoxin and notify the prescriber.

Answer

Administer the digoxin and document the patient's symptoms.

Answer

Administer an antiemetic and reassess the patient in 30 minutes.

Answer

Check the patient's serum digoxin level before administering the dose.

Question 23

A 68-year-old patient with a history of chronic obstructive pulmonary disease (COPD) is admitted with increased dyspnea and confusion. Arterial blood gas results on room air are: pH 7.29, PaCO₂ 58 mm Hg, HCO₃⁻ 26 mEq/L. Which acid-base imbalance does the nurse interpret?

Accepted Answer

Uncompensated respiratory acidosis

Answer

Metabolic acidosis with partial respiratory compensation

Answer

Compensated respiratory alkalosis

Answer

Mixed metabolic and respiratory acidosis

Question 24

A patient is receiving intravenous gentamicin for a severe infection. The medication is infused over 30 minutes. The nurse is scheduled to draw a peak serum gentamicin level. At what time should the nurse obtain the blood sample?

Accepted Answer

30 minutes after the infusion ends

Answer

30 minutes after starting the infusion

Answer

1 hour before the next dose is due

Answer

Immediately before the next dose

Question 25

A nurse is caring for a patient with a known seizure disorder. The patient suddenly begins to have a generalized tonic-clonic seizure. Which action should the nurse take first?

Accepted Answer

Protect the patient's head and clear the immediate area of hazardous objects.

Answer

Insert a padded tongue blade into the patient's mouth to prevent tongue injury.

Answer

Restrain the patient's arms and legs to prevent injury from flailing.

Answer

Administer the prescribed intravenous antiepileptic medication immediately.