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NS 660 EXAM 1 (2025-2026) LATEST QUESTIONS
AND ANSWERS GRADED A+
A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states they were busy and did not have a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error?
Diagnosis
Evaluation
Implementation
Assessment
Assessment
A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when
the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process?
Intervention
Evaluation
Planning
Assessment
Assessment
A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient?
Risk for impaired skin integrity
Risk for infection
Spiritual distress
Reflex urinary incontinence
Use of analgesics will eventually lead to addiction.
Pain level and pain tolerance can be assessed using a scale from 0 to 10.
Each client's expression of pain may be different and individualized.
Patient-controlled analgesia (PCA) offers a constant level of opioids within therapeutic range.
Pain level and pain tolerance can be assessed using a scale from 0 to 10.
Each client's expression of pain may be different and individualized.
The nurse is caring for an African American patient with COPD. The nurse knows that the best location to assess for hypoxia is the:
Lower extremities
Abdomen
Earlobes
Oral mucosa
Oral mucosa
What is the most appropriate way to assess the pain of a patient who is oriented and has recently had surgery?
Observe cardiac monitor for increased HR
Ask patient describe the effect of pain on ability to cope
Ask patient to rate level of pain
Assess patients body language
Ask patient to rate level of pain
An assistive personnel reports a client's vital signs as tympanic temperature 37.1° C (98.8° F), pulse 92/min, respiratory rate 18/min, and BP 98/58 mm Hg. Which of the following vital signs should the nurse re-measure?
BP
Temp
Bruit
Murmur
Phlebitis
Bruit
A nurse is caring for a patient with left sided hemiparesis who has developed bronchitis and has a heart rate of 105, blood pressure of 156/90, and a respiration rate of 30. Which nursing diagnosis is the priority for this patient?
Impaired gas exchange
Risk for infection
Activity intolerance
Risk for skin breakdown
Impaired gas exchange
The patient requires temperatures to be taken every two hours. Which of the following cannot be delegated to nursing assistive personnel?
Selecting appropriate route and device
Assessing changes in body temperature
Obtaining temperature measurement at ordered frequency
Being aware of usual values for the patient
Assessing changes in body temperature
When the nurse cleanses the client's leg during a bed bath, it will allow for:
Promotion of social interaction
Increased circulation
Decreased restless leg syndrome
Assessment of pain
Increased circulation
Collect stool and send to laboratory for culture per regular protocol.
Reinstruct the patient on the procedure to collect a stool specimen.
Reinstruct the patient on the procedure to collect a stool specimen.
A nurse is caring for a female patient with diarrhea. What information does the nurse teach the patient about perineal care and self-care?
Wear gloves while performing perineal self-care.
Clean the perineal area from the front to back.
Insert any suppository medication prior to cleaning the perineal area.
Bathe the perineal area with a mild soap and very hot water.
Clean the perineal area from front to back.
A nurse is taking care of an older adult patient who demonstrates good mobility but is unable to stand for long periods of time secondary to muscle weakness. What action will the nurse use to facilitate the patient's self-care and safety?
Assist the patient in taking a stand-up shower
Give the patient a towel or bag bath
Give the patient a bed bath
Obtain a shower chair so the patient can take a sit-down shower
Obtain a shower chair so the patient can take a sit-down shower.
An older adult patient has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which nursing diagnosis?
Social isolation
Impaired memory
Defensive coping
Impaired adjustment
Social isolation
Bathing reduces the possibility of infection.
Bathing reduces the possibility of infection
A student is walking down the hall carrying soiled linen against his/her uniform while taking it to the soiled utility room. What instruction should the nursing instructor provide to the student?
Linen should be held away from the uniform and carried in some type of receptacle to prevent the spread of microorganisms.
Linen should always be handled with gloves and left in the patient's room to prevent spread of microorganisms.
Linen should be changed weekly to prevent the spread of microorganisms
Linens do not spread microorganisms
Linen should be held away from the uniform and carried in some type of receptacle to prevent spread of microorganisms
Upon assessment of the urine in a patient's indwelling urinary catheter drainage bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?
No action is required.
Alert the health care provider of possible infection.
Encourage fluid intake.
Restrict fluid intake.
Encourage fluid intake
Which nursing action demonstrates safe injection practice?
use multiple-dose vials when administering medication to multiple clients
clean injection equipment when dust becomes visible
use sterile single-use disposable syringes for each injection
recap needles if necessary
Use sterile sing-use disposable syringes for each injection
Perform hand hygiene after removing glove
An older adult woman has been in the hospital for more than 1 week. While assessing her intravenous catheter port, the nurse finds a staph infection, which has developed in the past day or so. This infection is an example of which type of infection?
Sexually transmitted infection
Droplet infection
Respiratory infection
Healthcare-associated infection
Healthcare-associated (Noscomial) infection
A nurse prefers to use an alcohol-based hand rub when providing care for patients. In which case is this practice contraindicated?
The nurse finishes patient care and hands are not visibly soiled.
The nurse finishes cleaning a patient's table.
The nurse performs routine care and is moving to another patient.
The nurse is caring for a patient with a C. difficile infection.
The nurse is caring for a patient with C. difficile infection
reasoning:
C diff. is not killed by alcohol, and using alcohol based hand rub will increase risk of spreading infection
The nurse is caring for a patient with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective?
Oxygen saturation 97%
Heart rate 110 beat/minute
Respirations 26 breaths/minute
Clubbing of fingers
Oxygen saturation 97%
Tracheostomy mask
Nasal Cannula
To determine the quality of oxygenation, the nurse performs a physical assessment, an arterial blood gas test, and pulse oximetry. What is the purpose of pulse oximetry test?
Calculate the pressure of carbon dioxide dissolved in plasma.
Monitor the amount of oxygen saturation in the blood.
Measure the volume of air exhaled or inhaled over time.
Monitor the pressure of oxygen dissolved in plasma.
Monitor the amount of oxygen saturation in the blood
Which teaching about the humidifier is important for the nurse to provide to a client using oxygen?
It decreases dry mucous membranes via delivering small water droplets.
It determines whether the client is getting enough oxygen.
It regulates the amount of oxygen received.
It prescribes oxygen concentration.
It decreases dry mucous membranes via delivering small water droplets
What is first component of critical thinking model for clinical decision making
A scientific knowledge base
Rational: Nursing is a science, so everything we do begins with a scientific knowledge base in order to generate nursing process
Nurse enters room to find patient sitting up in bed crying. How would nurse display critical thinking attitude in this situation?
A. Tell patient shell be back in 30 min
B. Set box of tissues at patients bedside
C. Ask why she is crying
D. Limit visitors while patient upset
C. Ask patient why she is crying
