CPNRE Canadian Practical Nurse Registration Exam — Questions and Answers

Question 1: Under the principle of justice in nursing ethics, a PN should:

Give priority care to clients who are most compliant
Focus resources on clients most likely to recover
Provide equal and fair treatment to all clients regardless of background (Correct answer)
Prioritize clients based on the physician's preference

Correct answer: Provide equal and fair treatment to all clients regardless of background

Justice requires fair allocation of resources and non-discriminatory care for all clients.

Question 2: A substitute decision-maker (SDM) holding power of attorney for personal care for a resident with advanced dementia instructs a PN to withhold all information about the resident's declining condition from adult children who visit regularly. The PN knows the resident had clearly expressed, while capable, that 'family should always be kept informed.' What is the PN's most appropriate response?

Comply with the SDM's request, as they hold legal authority over all aspects of the resident's personal care
Continue sharing condition updates with the family, as the resident's prior expressed wishes constitute a binding directive that overrides the SDM
Refuse the SDM's request and document it as an attempt to override the resident's previously stated values
Seek clarification on the scope of the SDM's authority and consult with the interdisciplinary team and, if needed, ethics resources before restricting family communication (Correct answer)

Correct answer: Seek clarification on the scope of the SDM's authority and consult with the interdisciplinary team and, if needed, ethics resources before restricting family communication

An SDM's authority is limited to making healthcare decisions in the incapable person's best interest — it does not automatically extend to controlling what general condition information other family members receive. The resident's previously expressed values are relevant context but do not constitute a legally binding directive that a PN can independently act upon to override an SDM (B). Blindly complying (A) without examining the scope of authority may violate the resident's interests. Unilaterally refusing and documenting it as misconduct (D) is an overreach without proper consultation. The professionally sound approach (C) is to seek clarification through the team and, if needed, ethics or legal resources, before restricting communication.

Question 3: A PN receives a SBAR (Situation-Background-Assessment-Recommendation) handover from a night-shift colleague that is incomplete — the assessment and recommendation sections are missing. The night-shift nurse has already left the unit. Which action reflects the MOST appropriate response under collaborative practice principles?

Proceed with care using the available situation and background information, filling in gaps through independent assessment
Document that handover was incomplete, perform an independent client assessment immediately, and update the care record with current findings before assuming full responsibility (Correct answer)
Contact the night-shift nurse by phone to obtain the missing components before assuming care of the client
Notify the charge nurse and request that care of this client be reassigned until the original nurse returns

Correct answer: Document that handover was incomplete, perform an independent client assessment immediately, and update the care record with current findings before assuming full responsibility

An incomplete handover is a recognized patient safety risk. The PN should document the deficiency, immediately perform an independent assessment to fill the clinical gaps, and update the care record before assuming full responsibility for the client. Contacting the off-shift nurse (B) may be warranted but should not delay client assessment, as the client's status may have changed. Reassigning the client (D) is impractical and delays care. Proceeding without documentation (A) fails to flag the system gap for quality improvement purposes.

Question 4: A nurse is caring for a client who is 48 hours post-liver transplant. The client develops a temperature of 38.9°C, is increasingly jaundiced, and reports right upper quadrant pain. Serum bilirubin has risen from 42 μmol/L yesterday to 118 μmol/L today, and AST/ALT are markedly elevated. The immunosuppression regimen includes tacrolimus and mycophenolate mofetil. Which complication should the nurse prioritize reporting to the physician, and which early assessment finding would most support this suspicion?

Acute cellular rejection; the nurse should assess for a change in bile colour or volume from the T-tube if present
Primary non-function of the graft; the nurse should assess for hypoglycemia and coagulopathy alongside the rising LFTs
Tacrolimus toxicity; the nurse should assess for tremors, headache, and elevated serum tacrolimus trough levels
Hepatic artery thrombosis; the nurse should assess for sudden cessation of bile output and confirm with Doppler ultrasound (Correct answer)

Correct answer: Hepatic artery thrombosis; the nurse should assess for sudden cessation of bile output and confirm with Doppler ultrasound

Hepatic artery thrombosis (HAT) is the most feared early complication after liver transplantation and typically presents within the first 2 weeks post-operatively. Rapid onset of graft dysfunction with rising bilirubin, elevated LFTs, fever, and RUQ pain in the early post-transplant period is classic. HAT causes ischemia to the biliary system (which depends entirely on the hepatic artery for blood supply), leading to biliary necrosis and rapid graft failure. Sudden cessation or significant reduction in bile output from a T-tube is a key clinical sign, and urgent Doppler ultrasound is the immediate diagnostic step. Acute cellular rejection typically presents slightly later (day 5–10) and does not usually cause this rapid a rise in bilirubin. Tacrolimus toxicity and primary non-function have distinct presentations not matching this acute picture.

Question 5: During a nutritional assessment, the practical nurse uses the MUST tool. What does MUST stand for?

Malnutrition Universal Screening Tool (Correct answer)
Minimum Undernutrition Status Test
Malnutrition and Underweight Systematic Tool
Multi-level Undernutrition Scoring Tool

Correct answer: Malnutrition Universal Screening Tool

MUST stands for Malnutrition Universal Screening Tool and is used to identify adults who are malnourished or at risk of malnutrition.

Question 6: While performing a neurological assessment, a practical nurse tests a client's cranial nerve function by asking the client to clench their teeth, palpating the masseter muscles bilaterally, and testing facial sensation with a wisp of cotton. Which cranial nerve is being primarily assessed with this sequence?

Cranial nerve V (Trigeminal) (Correct answer)
Cranial nerve VII (Facial)
Cranial nerve XI (Accessory)
Cranial nerve IX (Glossopharyngeal)

Correct answer: Cranial nerve V (Trigeminal)

Cranial nerve V (Trigeminal) has both motor and sensory components. Its motor branch innervates the muscles of mastication, including the masseter and temporalis (assessed by clenching the jaw). Its sensory branch carries sensation from the face, including touch (tested with cotton), pain, and temperature. CN VII (Facial) controls facial expression muscles and taste on the anterior tongue but does not innervate masticatory muscles. CN IX involves posterior tongue taste and pharyngeal sensation. CN XI controls the trapezius and sternocleidomastoid.

Question 7: When performing a 12-lead ECG, which electrode placement is correct for lead V4?

Fourth intercostal space, left sternal border
Anterior axillary line, same level as V4
Fourth intercostal space, right sternal border
Fifth intercostal space at the midclavicular line (Correct answer)

Correct answer: Fifth intercostal space at the midclavicular line

V4 is placed at the fifth intercostal space at the midclavicular line, corresponding to the apex of the heart.

Question 8: In the context of obtaining informed consent, the practical nurse's role is primarily to:

Ensure the consent form is signed and placed in the client's chart.
Explain the risks and benefits of the medical procedure in detail.
Verify that the client understands the information provided by the primary healthcare provider and advocate for their rights. (Correct answer)
Select the best treatment option for the client.

Correct answer: Verify that the client understands the information provided by the primary healthcare provider and advocate for their rights.

While the physician or other primary healthcare provider is responsible for explaining the procedure, its risks, benefits, and alternatives, the nurse plays a crucial role in the consent process. The nurse must advocate for the client, ensuring they have received adequate information, have had their questions answered, and are making a voluntary and informed choice. Simply witnessing a signature without ensuring understanding does not fulfill this ethical and professional responsibility. The nurse does not provide the primary explanation of medical procedures or choose treatments for the client.

Question 9: A client on lithium carbonate has serum lithium level 1.8 mEq/L with nausea, tremor, and polyuria. How should the practical nurse interpret this?

Subtherapeutic level, dose needs to be increased
Toxic level, notify physician and withhold next dose (Correct answer)
Mildly elevated, monitor more frequently
Therapeutic range, these are normal side effects

Correct answer: Toxic level, notify physician and withhold next dose

Lithium therapeutic range is 0.6-1.2 mEq/L maintenance. A level of 1.8 mEq/L is above therapeutic range indicating toxicity.

Question 10: A practical nurse is asked by a supervisor to falsify a patient's chart to conceal a medication error. The nurse should:

Comply to maintain the employment relationship and avoid conflict
Refuse, as falsifying records is a criminal act and a professional misconduct violation (Correct answer)
Consult a lawyer before deciding whether to comply
Alter only the parts of the chart that cannot be independently verified

Correct answer: Refuse, as falsifying records is a criminal act and a professional misconduct violation

Falsifying medical records constitutes fraud and professional misconduct; a nurse must refuse regardless of who makes the request.

Question 11: A client with left-sided stroke has left hemiplegia and dysphagia. Which meal positioning is most appropriate?

Semi-reclined at 30 degrees
Left lateral position with head elevated
Tilt head back to open the airway
Upright at 90 degrees with head turned toward the weaker side (Correct answer)

Correct answer: Upright at 90 degrees with head turned toward the weaker side

Upright 90 degrees with head turned to the weak side closes that side of the pharynx, directing the food bolus to the stronger side.

Question 12: During the termination phase of a therapeutic relationship, a client with borderline personality disorder begins missing appointments, becoming increasingly hostile, and accusing the nurse of 'abandoning' them. What is the nurse's PRIORITY intervention?

Refer the client immediately to a psychiatrist, as this behaviour indicates decompensation beyond the nurse's scope.
Reduce contact gradually without discussion to help the client adjust to separation incrementally.
Acknowledge the client's feelings, revisit the agreed-upon termination timeline, and collaboratively reinforce transition supports. (Correct answer)
Extend the therapeutic relationship indefinitely to avoid precipitating a mental health crisis.

Correct answer: Acknowledge the client's feelings, revisit the agreed-upon termination timeline, and collaboratively reinforce transition supports.

Behavioural regression during termination is common in clients with borderline personality disorder and represents a testing of the relationship. The nurse should validate the client's feelings of loss, reinforce the pre-established termination plan, and strengthen the post-discharge support plan. Extending the relationship indefinitely (A) reinforces maladaptive dependency. Silent graduated withdrawal (D) is non-transparent and non-therapeutic. Immediate psychiatric referral (C) is premature for an expected termination reaction.

Question 13: A nurse responds to a client's disclosure of abuse by saying, 'That must have been terrifying. I want to make sure you are safe. Can you tell me more about what happened?' This response demonstrates:

Therapeutic communication combining empathy, safety focus, and open-ended exploration. (Correct answer)
A breach of confidentiality by encouraging further disclosure.
Inappropriate questioning that may re-traumatize the client.
Premature problem-solving without gathering information.

Correct answer: Therapeutic communication combining empathy, safety focus, and open-ended exploration.

This response validates feelings, addresses safety, and uses open-ended questions to gather information in a trauma-informed, therapeutic manner.

Question 14: A public health PN is planning a vaccination clinic for an underserved community. Which approach best reflects culturally safe nursing practice?

Translating pamphlets into the dominant local language and partnering with community leaders (Correct answer)
Scheduling the clinic during standard business hours for staff convenience
Offering only English-language education materials as a standardization measure
Focusing education efforts solely on the health risks of not vaccinating

Correct answer: Translating pamphlets into the dominant local language and partnering with community leaders

Culturally safe practice requires acknowledging and responding to the cultural, linguistic, and community context. Partnering with community leaders and providing materials in the local language increases access, trust, and uptake in underserved populations.

Question 15: A PN is working alongside an RN in a long-term care facility. Which statement best describes their collaborative relationship?

The RN delegates all medication administration to the PN
The PN must obtain RN approval before performing any nursing task
The PN functions independently and does not need to communicate with the RN
The RN and PN share responsibility for client care within their respective scopes of practice (Correct answer)

Correct answer: The RN and PN share responsibility for client care within their respective scopes of practice

PNs and RNs collaborate within their respective scopes of practice, sharing accountability for client-centred care outcomes.

Question 16: A practical nurse is providing care to a client in alcohol withdrawal who was admitted 18 hours ago. The client is now exhibiting new-onset visual hallucinations, diaphoresis, and a heart rate of 118 bpm. The nurse assesses the client's Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) score and finds it has risen from 8 to 22. Which action reflects the nurse's best clinical judgment?

Reorient the client calmly, dim the lights, and document the change in status for the oncoming shift
Apply soft restraints to protect the client from injury and request a sitter
Administer the PRN lorazepam ordered for CIWA-Ar ≥ 8 and immediately notify the physician of the escalating score (Correct answer)
Encourage oral fluids, administer thiamine as scheduled, and monitor every 30 minutes

Correct answer: Administer the PRN lorazepam ordered for CIWA-Ar ≥ 8 and immediately notify the physician of the escalating score

A CIWA-Ar score of 22 indicates severe alcohol withdrawal and significant risk for progression to delirium tremens (DTs), which carry a mortality risk. The nurse should administer the ordered PRN benzodiazepine (the cornerstone of symptom-triggered alcohol withdrawal treatment) since the score meets the threshold, and urgently notify the physician because the rapid escalation signals potential deterioration requiring medical reassessment and possible protocol change. Reorientation and comfort measures alone are insufficient at this severity. Restraints are not appropriate as the priority intervention and may worsen agitation. Thiamine administration is important but not the priority action at this moment of acute escalation.

Question 17: Before witnessing a client's advance directive, what must the practical nurse ensure?

The nurse has known the client for at least one year
The attending physician has reviewed and approved it
The document is typed and in proper legal format
The client is competent, signing voluntarily, and understands the document (Correct answer)

Correct answer: The client is competent, signing voluntarily, and understands the document

A witness must ensure the client has capacity, is signing voluntarily without pressure, and understands what they are signing.

Question 18: A client post-total knee replacement reports pain of 7/10 and asks for their analgesic. The nurse notes the last dose was given 3 hours ago and the order states every 4 hours PRN. What is the best action?

Use non-pharmacological measures and reassess before next scheduled dose (Correct answer)
Notify the physician of the client's pain level and request a change in order
Reassess the pain in one hour and administer if still elevated
Administer the medication early given the high pain score

Correct answer: Use non-pharmacological measures and reassess before next scheduled dose

The nurse should respect the prescribed interval, use non-pharmacological comfort measures, and reassess before the next due time, notifying the physician if pain remains uncontrolled.

Question 19: When performing a developmental assessment on a 12-month-old, which milestone would the nurse expect to find?

Speaking in 3-word sentences
Drawing simple shapes
Pulling to stand and saying 1–2 words (Correct answer)
Running steadily without falling

Correct answer: Pulling to stand and saying 1–2 words

At 12 months, infants typically pull to stand, cruise along furniture, and may say 1–2 meaningful words.

Question 20: A client with a known penicillin allergy is prescribed cephalexin 500 mg PO for a wound infection. The prescriber documents awareness of the allergy and confirms the order. What is the practical nurse's BEST action?

Administer the medication and prepare epinephrine at the bedside as a precaution
Clarify with the prescriber the clinical rationale, document the conversation, ensure emergency equipment is available, monitor the client closely after administration, and follow agency policy on cross-reactive allergy orders (Correct answer)
Refuse to administer the medication and document the refusal without further action
Administer the medication as ordered, since the prescriber has acknowledged the allergy and cross-reactivity risk is low with later-generation cephalosporins

Correct answer: Clarify with the prescriber the clinical rationale, document the conversation, ensure emergency equipment is available, monitor the client closely after administration, and follow agency policy on cross-reactive allergy orders

Cephalosporins share a beta-lactam ring structure with penicillins, and cross-reactivity — while estimated at 1–2% — is a real risk. Even when a prescriber knowingly orders a cross-reactive drug, the nurse's professional responsibility does not end at 'the doctor said so.' The nurse must clarify the rationale, document the informed decision, ensure resuscitation equipment is accessible, administer with enhanced monitoring, and follow organizational policy. Simply administering without these steps or refusing without escalation both represent incomplete professional practice.

Question 21: A PN working in an outpatient clinic performs a procedure that is within their competency and scope but was not explicitly listed in the facility's approved nursing procedures manual. A complication arises and the client is harmed. Which legal doctrine is MOST likely to be applied to evaluate the PN's conduct?

Strict liability — because the procedure was performed outside the written institutional protocol
The reasonable nurse standard — whether a reasonable PN with similar training would have performed the procedure in the same circumstances (Correct answer)
Respondeat superior — the employer bears sole liability because the procedure was not in the manual
Res ipsa loquitur — the harm itself proves negligence

Correct answer: The reasonable nurse standard — whether a reasonable PN with similar training would have performed the procedure in the same circumstances

Negligence in nursing is assessed using the reasonable nurse standard: what a reasonable, prudent nurse with comparable training and in similar circumstances would have done. The absence of a procedure from an institutional manual does not automatically establish negligence, nor does it assign liability exclusively to the employer. The court would examine whether the PN's decision and technique met the standard of a reasonable PN. Res ipsa loquitur applies only when negligence is obvious from the harm itself, which is not the standard default.

Question 22: A nurse is assessing a client who reports progressive difficulty swallowing solids, then liquids, over the past three months, accompanied by unintentional weight loss of 8 kg. The client is a 67-year-old male with a 40-pack-year smoking history. Which assessment finding would MOST raise the nurse's suspicion for esophageal malignancy over achalasia?

Dysphagia that began with both solids and liquids simultaneously
Nocturnal coughing and aspiration symptoms
Dysphagia that began with solids before progressing to liquids (Correct answer)
Regurgitation of undigested food

Correct answer: Dysphagia that began with solids before progressing to liquids

Progressive dysphagia beginning with solids and then advancing to liquids is a classic hallmark of mechanical obstruction, such as esophageal carcinoma, as the lumen narrows over time. Achalasia, a motility disorder, typically presents with dysphagia for both solids and liquids from the onset because the dysfunction is neuromuscular rather than mechanical. Regurgitation of undigested food and nocturnal aspiration can occur in both conditions. The combination of solid-first progressive dysphagia, significant weight loss, and a heavy smoking history significantly elevates concern for malignancy.

Question 23: A newborn receives a 1-minute Apgar score of 5. Which interpretation and action is correct?

Score of 5 indicates mild to moderate depression requiring stimulation and supplemental oxygen (Correct answer)
Score of 5 is critical requiring immediate intubation
Score of 5 indicates moderate depression requiring full CPR
Score of 5 is normal, no action needed

Correct answer: Score of 5 indicates mild to moderate depression requiring stimulation and supplemental oxygen

Apgar 4-6 indicates mild to moderate depression requiring stimulation (drying, rubbing back) and supplemental oxygen.

Question 24: A PN working in a complex continuing care facility is assigned a client with advanced ALS who uses non-invasive positive pressure ventilation (NIPPV) at night. At 0300, the ventilator alarm sounds and the client is visibly distressed. The mask is in place, but the client is paradoxically breathing — the chest sinks on inspiration. Which interpretation is MOST accurate?

The client has developed a tension pneumothorax on the side opposite to chest sinking
The inspiratory trigger sensitivity is too high, causing the ventilator to cycle with every swallow
The client is experiencing a high-pressure alarm due to secretion buildup in the upper airway
The NIPPV interface has a significant leak, causing the machine to cycle out of synchrony with the client (Correct answer)

Correct answer: The NIPPV interface has a significant leak, causing the machine to cycle out of synchrony with the client

Paradoxical chest movement (chest sinking during what should be an assisted inspiration) in a client on NIPPV most commonly indicates patient-ventilator asynchrony caused by a mask leak. When there is a significant air leak, the ventilator cannot generate adequate pressure, so the client's own inspiratory effort creates negative intrathoracic pressure while the machine fails to deliver flow — causing the chest to sink rather than rise. A tension pneumothorax would present with tracheal deviation, absent breath sounds, and hemodynamic instability. High-pressure alarms occur when resistance increases, not when there's a leak (which causes low-pressure alarms). Trigger sensitivity issues cause double-triggering or auto-cycling, not paradoxical breathing.

Question 25: A practical nurse is performing a functional assessment on an older adult. Which tool is most appropriate for assessing the client's ability to perform basic activities of daily living?

Timed Up and Go Test
Mini-Mental State Examination (MMSE)
Geriatric Depression Scale
Barthel Index (Correct answer)

Correct answer: Barthel Index

The Barthel Index measures a client's performance in ten basic activities of daily living such as feeding, bathing, dressing, and mobility.

Question 26: Which assessment finding indicates early hypoxia in a client?

Decreased respiratory rate
Bradycardia
Restlessness and confusion (Correct answer)
Cyanosis of the lips

Correct answer: Restlessness and confusion

Restlessness and confusion are early signs of hypoxia as the brain is highly sensitive to decreased oxygen levels.

Question 27: A nursing mother reports breast engorgement on postpartum day 2. Which advice should the practical nurse provide?

Supplement with formula between feedings to reduce demand
Apply ice packs continuously and limit feeding frequency
Feed frequently on demand, ensure proper latch, and apply warm compress before feedings (Correct answer)
Stop breastfeeding to allow engorgement to resolve

Correct answer: Feed frequently on demand, ensure proper latch, and apply warm compress before feedings

Frequent, effective breastfeeding with proper latch resolves engorgement; warm compresses before feeding stimulate let-down.

Question 28: A practical nurse is caring for a client who has expressed a desire to refuse further life-sustaining treatment. The client's family is strongly opposed to this decision. Which of the following actions best demonstrates the practical nurse's adherence to ethical principles?

Requesting a psychiatric evaluation to assess the client's decision-making capacity.
Advocating for the client's right to autonomy and informed decision-making. (Correct answer)
Following the family's wishes, as they are the client's support system.
Organizing a meeting with the hospital's ethics committee without the client's knowledge.

Correct answer: Advocating for the client's right to autonomy and informed decision-making.

The core ethical principle of autonomy respects the client's right to make their own decisions about their healthcare, even if those decisions conflict with the views of their family or the healthcare team. The practical nurse's primary responsibility is to the client. Advocating for the client's decision upholds this principle. While assessing capacity is important, requesting a psychiatric evaluation without a clear indication of incapacity could be seen as challenging the client's autonomy. Following the family's wishes or involving the ethics committee without consent would violate the principles of client-centered care and confidentiality.

Question 29: Which instruction about metered-dose inhaler (MDI) technique is correct?

Activate the inhaler before starting to inhale
Inhale rapidly and forcefully to maximize deposition
Breathe in slowly and deeply while activating the inhaler, then hold breath for 10 seconds (Correct answer)
Breathe in and out rapidly 5 times after each puff

Correct answer: Breathe in slowly and deeply while activating the inhaler, then hold breath for 10 seconds

Slow, deep inhalation during MDI activation followed by 10-second breath-hold maximizes medication deposition in the lower airways.

Question 30: A postoperative extremity is pale, cold, and the client reports numbness and tingling. What does this indicate?

Normal postoperative finding
Compromised arterial circulation requiring emergency assessment (Correct answer)
Venous congestion from dependent positioning
Normal inflammatory response

Correct answer: Compromised arterial circulation requiring emergency assessment

Pallor, coolness, and paresthesias indicate compromised arterial circulation requiring emergency evaluation.

Question 31: A practical nurse is preparing to give a client their scheduled dose of metoprolol 50 mg orally. The client's blood pressure is 88/54 mmHg and heart rate is 52 bpm. What is the priority action?

Withhold the medication and notify the prescriber immediately (Correct answer)
Administer the medication and recheck vital signs in 30 minutes
Administer a reduced dose of 25 mg to minimize the hypotensive effect
Encourage the client to drink fluids before administering the medication

Correct answer: Withhold the medication and notify the prescriber immediately

Metoprolol is a beta-blocker that lowers blood pressure and heart rate; administering it with already low BP and bradycardia risks serious hemodynamic compromise.

Question 32: A practical nurse is assessing a client's level of consciousness using the Glasgow Coma Scale (GCS). A client who opens eyes to verbal stimulation, makes confused verbal responses, and localizes pain would receive which score?

12
9
13
11 (Correct answer)

Correct answer: 11

Eyes open to voice = 3, confused verbal response = 4, localizes pain = 5, totaling a GCS score of 12.

Question 33: A client received oral acetaminophen 3 hours ago. The order is for q4h PRN. What is the correct action?

Hold the dose until the full 4-hour interval has elapsed (Correct answer)
Administer since 3 hours is close enough
Administer since q4h allows dosing at any convenient time
Notify the physician that the client is requesting medication early

Correct answer: Hold the dose until the full 4-hour interval has elapsed

A q4h order means a minimum of 4 hours must elapse between doses. Administering before this interval exceeds safe dosing frequency.

Question 34: A practical nurse is assisting with feeding a client who has dysphagia following a stroke. Which intervention is a priority to prevent aspiration?

Positioning the client in an upright, 90-degree angle. (Correct answer)
Encouraging the client to use a straw for all liquids.
Providing a large meal to ensure adequate caloric intake.
Speaking to the client continuously during the meal to check for alertness.

Correct answer: Positioning the client in an upright, 90-degree angle.

Positioning the client fully upright (90-degree angle or high-Fowler's position) is the most critical intervention to prevent aspiration. This position uses gravity to facilitate the passage of food and liquid down the esophagus and away from the trachea. The client should remain upright for at least 30 minutes after the meal.

Question 35: A practical nurse reviews population-level screening data and notes that a cervical cancer screening program has high sensitivity but low specificity. Which statement BEST describes the consequence of this test characteristic for the screened population?

Most individuals who test positive will truly have cervical cancer, reducing unnecessary follow-up
Many individuals with cervical cancer will be missed, leading to delayed diagnoses
The program will identify only the most advanced cases of cervical cancer, skewing prevalence data
A substantial proportion of individuals without cervical cancer will receive positive results, leading to unnecessary follow-up procedures (Correct answer)

Correct answer: A substantial proportion of individuals without cervical cancer will receive positive results, leading to unnecessary follow-up procedures

High sensitivity means the test correctly identifies most true positives (few false negatives — few missed cases). Low specificity means the test also flags many individuals who do not have the disease (high false positive rate). Consequently, a large proportion of people without cervical cancer will receive positive screening results and undergo unnecessary, potentially invasive, and anxiety-inducing follow-up procedures. This is a key trade-off in screening program design that practical nurses must understand when educating clients about screening implications.

Question 36: A practical nurse realizes they made a medication error but the client experienced no harm. What is appropriate?

Say nothing since there was no harm
Complete an incident report, notify the charge nurse, assess the client, and notify the physician (Correct answer)
Tell only the charge nurse verbally
Document in a way that minimizes the description

Correct answer: Complete an incident report, notify the charge nurse, assess the client, and notify the physician

All medication errors must be reported through the incident reporting system regardless of harm, for client safety and regulatory compliance.

Question 37: The patient, who is 17 years old, is being trained to give herself insulin. In the health education, which of the following would a nurse emphasize?

Insulin needs are typically determined without taking meal sizes into account.
Insulin needs are rarely determined by activity levels.
Insulin injections are usually made subcutaneously. (Correct answer)
Playing demanding sports always reduces the requirement for insulin.

Correct answer: Insulin injections are usually made subcutaneously.

Insulin is almost always administered via subcutaneous injection. This route allows for a slower, more consistent absorption of the medication into the bloodstream, which is crucial for effective blood glucose management. Emphasizing the correct injection technique is a fundamental part of insulin education.

Question 38: A client on a medical-surgical unit has a tracheostomy and is receiving enteral nutrition via a PEG tube. During assessment, the PN notices the pilot balloon on the tracheostomy cuff feels flaccid. The client is alert and communicating by mouthing words. What is the PRIORITY nursing action?

Check cuff pressure with a manometer and inflate to maintain 20–30 cmH₂O (Correct answer)
Inject air into the pilot balloon until resistance is felt, then reassess
Temporarily halt the enteral feed and suction the oropharynx before cuff reinflation
Increase the head of bed to 45 degrees and notify the respiratory therapist

Correct answer: Check cuff pressure with a manometer and inflate to maintain 20–30 cmH₂O

A flaccid pilot balloon indicates cuff deflation, which creates aspiration risk especially in a client receiving enteral feeds. The correct intervention is to use a manometer to measure and restore cuff pressure to the therapeutic range of 20–30 cmH₂O. Injecting air without measurement risks overcuffing, which causes tracheal necrosis. Halting feeds is appropriate but is not the priority action — restoring the cuff seal first prevents aspiration of any residual pharyngeal contents.

Question 39: A practical nurse witnesses a colleague falsifying a client's vital signs documentation. What is the ethical and professional obligation?

Report the behavior through appropriate channels (charge nurse, management, regulatory college if required) (Correct answer)
Ignore it since the colleague may have had a valid reason
Counsel privately and give an opportunity to correct the record
Document in the client's chart without notifying management

Correct answer: Report the behavior through appropriate channels (charge nurse, management, regulatory college if required)

Falsifying health records is a serious professional offence requiring mandatory reporting through appropriate channels to protect client safety.

Question 40: While performing a neurological assessment, the practical nurse applies a sternal rub to an unresponsive client. The client's upper extremities internally rotate, wrists flex, and fingers curl. The lower extremities extend and feet plantar flex. Which response is being documented?

Opisthotonus
Spinal cord transection response
Decorticate (abnormal flexion) posturing
Decerebrate (abnormal extension) posturing (Correct answer)

Correct answer: Decerebrate (abnormal extension) posturing

The described pattern — internal rotation of arms, wrist flexion, finger curling WITH lower extremity extension and plantar flexion — is decerebrate posturing. This indicates a lesion at or below the midbrain/upper pons, which disconnects higher cortical control. Decorticate posturing involves arm FLEXION toward the core (elbows bent inward) with lower extremity extension, indicating a lesion above the midbrain (cortex/internal capsule). Opisthotonus is a generalized hyperextension of the back/neck (seen in meningitis or tetanus), not limb posturing.

Question 41: Which action by a practical nurse demonstrates the ethical principle of justice in healthcare delivery?

Prioritizing care based on the client's socioeconomic status
Providing extra care to verbally appreciative clients
Offering emotional support only to clients with serious diagnoses
Advocating for a marginalized client to receive the same quality of care as other clients (Correct answer)

Correct answer: Advocating for a marginalized client to receive the same quality of care as other clients

Justice in healthcare means equitable distribution of care regardless of personal characteristics. Advocating for equal quality care demonstrates this principle.

Question 42: In the ISBAR handoff format, what does the I stand for?

Intervention
Instruction
Investigation
Identification (Correct answer)

Correct answer: Identification

I = Identification: identifying yourself and the client at the start of the handoff report.

Question 43: A practical nurse says 'Your surgery went well' when a client asks how their operation went, but the nurse does not actually know the outcome. This represents which therapeutic communication error?

Inappropriate use of therapeutic silence
Advising the client
Changing the subject
False reassurance (Correct answer)

Correct answer: False reassurance

Offering reassurance based on uncertain or unknown information is false reassurance. It violates honesty and may damage therapeutic trust when the truth is revealed.

Question 44: A patient's substitute decision-maker (SDM) consents to surgery on behalf of an unconscious patient. Later the patient regains consciousness and refuses the surgery. The practical nurse should:

Seek a court order before stopping the surgical preparation
Recognize that a now-competent patient's refusal supersedes the SDM's prior consent (Correct answer)
Ask the physician to override the patient's refusal to prevent harm
Proceed with surgery prep because the SDM already consented

Correct answer: Recognize that a now-competent patient's refusal supersedes the SDM's prior consent

A patient who regains decision-making capacity immediately reassumes the right to consent or refuse; the SDM's authority ends when the patient is competent.

Question 45: A nurse assesses a client who is 12 hours postpartum and notes the uterine fundus is firm, displaced to the right, and located above the umbilicus. The most appropriate intervention is:

Perform uterine massage until the fundus descends
Assist the client to void or catheterize if unable to void (Correct answer)
Administer oxytocin as ordered
Apply a warm compress to the abdomen to relax the uterus

Correct answer: Assist the client to void or catheterize if unable to void

A displaced, elevated uterine fundus indicates bladder distension; assisting the client to void will allow the uterus to return to the midline.

Question 46: A practical nurse is assessing skin turgor in an elderly client. Which finding is expected due to normal aging?

Skin tents briefly and returns within 3 seconds (Correct answer)
Skin appears moist and returns immediately
Skin returns to place within 1 second
Skin tents and remains elevated for more than 5 seconds

Correct answer: Skin tents briefly and returns within 3 seconds

Decreased skin elasticity in older adults causes mild tenting with a slightly delayed return, which is a normal age-related change rather than a sign of dehydration.

Question 47: In what order should abdominal assessment techniques be performed?

Inspection, percussion, palpation, auscultation
Palpation, auscultation, percussion, inspection
Inspection, auscultation, percussion, palpation (Correct answer)
Auscultation, inspection, percussion, palpation

Correct answer: Inspection, auscultation, percussion, palpation

Abdominal assessment sequence: inspection, auscultation, percussion, palpation. Auscultation precedes palpation to get unaltered bowel sounds.

Question 48: A nurse is caring for a client who is experiencing grief after a significant loss. Which statement by the nurse is most appropriate?

'Everything happens for a reason.'
'You'll feel better in a few weeks.'
'You should join a support group right away.'
'I'm here with you. Tell me what you're experiencing.' (Correct answer)

Correct answer: 'I'm here with you. Tell me what you're experiencing.'

Offering presence and inviting the client to share their experience is the most therapeutic response, demonstrating empathy and active listening without minimizing grief.

Question 49: A practical nurse is assigned to a client diagnosed with influenza. In addition to Routine Practices, which type of transmission-based precautions is required?

Droplet Precautions (Correct answer)
Protective Precautions
Airborne Precautions
Contact Precautions

Correct answer: Droplet Precautions

Influenza is transmitted via large infectious droplets generated when an infected person coughs, sneezes, or talks. Therefore, Droplet Precautions are required in addition to Routine Practices. This typically includes wearing a surgical mask and eye protection when working within 2 meters of the client.

Question 50: A palliative care client rates their pain as 8/10 despite scheduled analgesia. What is the priority nursing action?

Reassess in 30 minutes
Encourage distraction techniques only
Wait until the next scheduled dose
Administer a breakthrough dose as ordered and notify the physician (Correct answer)

Correct answer: Administer a breakthrough dose as ordered and notify the physician

Uncontrolled pain in palliative care requires prompt administration of breakthrough analgesia and physician notification.

Question 51: A practical nurse is caring for a client with chronic kidney disease (CKD) stage 4 who is admitted with heart failure exacerbation. The client's potassium is 5.8 mEq/L, BNP is 1,200 pg/mL, and they are oliguric. The physician orders furosemide 80 mg IV push. Which nursing action is MOST critical before administering this medication?

Confirm the client is not allergic to sulfonamide-based drugs
Assess the client's hearing baseline and recent ototoxic medication use
Ensure the IV rate does not exceed 4 mg/min to prevent ototoxicity (Correct answer)
Withhold the dose because the potassium level contraindicates loop diuretics

Correct answer: Ensure the IV rate does not exceed 4 mg/min to prevent ototoxicity

High-dose IV furosemide administered too rapidly causes sensorineural hearing loss. The maximum safe IV push rate is 4 mg/min; at 80 mg, administration should take at least 20 minutes. While allergy screening and hearing baseline assessment are relevant considerations, the immediate safety action before pushing the medication is ensuring the correct infusion rate. Hyperkalemia does not contraindicate furosemide — in fact, loop diuretics are often used to manage it.

Question 52: A client is prescribed warfarin 5 mg orally daily. Before administering the dose, the practical nurse notes the client's INR is 4.2. What is the most appropriate action?

Administer half the prescribed dose
Hold the dose and notify the physician/NP (Correct answer)
Administer the dose and recheck INR in 2 hours
Administer the dose as prescribed

Correct answer: Hold the dose and notify the physician/NP

An INR of 4.2 is above the therapeutic range (typically 2.0–3.0 for most indications), indicating an increased bleeding risk, so the dose should be withheld and the prescriber notified.

Question 53: A nurse is caring for a client receiving magnesium sulfate for severe preeclampsia. Which assessment finding requires the nurse to stop the infusion immediately?

Urinary output of 35 mL/hour
Respiratory rate of 10 breaths per minute (Correct answer)
Serum magnesium level of 6 mEq/L
Blood pressure of 148/96 mmHg

Correct answer: Respiratory rate of 10 breaths per minute

A respiratory rate of 10 breaths per minute indicates magnesium toxicity and is a critical finding requiring immediate cessation of the infusion.

Question 54: A client tells the nurse, 'I feel like you're the only one who really understands me. Can we be friends after I'm discharged?' How should the nurse respond?

Refer the client to another nurse to manage the boundary issue.
Accept the offer of friendship since it indicates a trusting therapeutic relationship.
Tell the client that feelings of closeness are signs of dependency and must be addressed.
Explain that professional boundaries prevent a personal friendship but that the therapeutic relationship has value. (Correct answer)

Correct answer: Explain that professional boundaries prevent a personal friendship but that the therapeutic relationship has value.

The nurse acknowledges the client's feelings while clearly maintaining professional boundaries and explaining the distinct nature of the therapeutic relationship.

Question 55: A practical nurse is caring for a client receiving enteral nutrition via nasogastric tube at 60 mL/hour. Before administering a medication, the nurse aspirates 280 mL of gastric residual volume (GRV). The client has no nausea, no abdominal distension, and bowel sounds are present in all quadrants. According to current evidence-based practice, what is the most appropriate action?

Return the aspirate, hold the feeding, and notify the physician immediately
Discard the aspirate, reduce the feeding rate by half, and document the finding
Return the aspirate to the client, continue the feeding at the current rate, and reassess GRV in 4 hours (Correct answer)
Hold the feeding for 2 hours, discard the residual, and reassess before resuming

Correct answer: Return the aspirate to the client, continue the feeding at the current rate, and reassess GRV in 4 hours

Current evidence-based guidelines (ASPEN/SCCM) have moved away from routinely holding enteral feeding based solely on GRV thresholds. A GRV of 280 mL in the absence of clinical symptoms (no nausea, no vomiting, no abdominal distension, active bowel sounds) does not warrant stopping feeding. The aspirate should be returned to preserve electrolytes and digestive enzymes. Feeding should continue with close monitoring. Holding feeds based solely on GRV prolongs nutritional deficits without clear clinical benefit. Discarding the aspirate risks metabolic disturbances including hyponatremia and hypokalemia. Automatic physician notification is not required unless clinical signs of intolerance are present.

Question 56: A practical nurse notices a client has stopped making eye contact, gives brief answers, and seems withdrawn after several days of care. What is the most therapeutic response?

'You seem depressed. Should I refer you to a psychiatrist?'
'I notice you seem quieter today. I want you to know I am here if you want to talk.' (Correct answer)
Document and wait to see if it resolves
'You need to communicate more openly with your healthcare team.'

Correct answer: 'I notice you seem quieter today. I want you to know I am here if you want to talk.'

Gently naming the observed change and offering presence without pressure creates a safe opening for the client to share if they choose.

Question 57: A nurse is performing a focused neurological assessment on a post-operative client following a transsphenoidal hypophysectomy. Which finding would require the most immediate intervention?

The client reporting a mild bifrontal headache rated 3/10
Serum sodium of 138 mmol/L
Urine output of 450 mL over the past hour with a urine specific gravity of 1.002
Clear nasal drainage when the client leans forward (Correct answer)

Correct answer: Clear nasal drainage when the client leans forward

Clear nasal drainage after transsphenoidal hypophysectomy may represent a CSF leak (rhinorrhea), which is a serious post-operative complication indicating a breach in the dura. CSF can be differentiated from mucus by testing for glucose (CSF is glucose-positive) or by the 'halo sign' on a tissue. This finding requires immediate reporting as it carries risk of meningitis and tension pneumocephalus. Although large urine output with low specific gravity suggests diabetes insipidus (also a complication), the clear drainage is the most immediately life-threatening finding requiring urgent assessment to rule out CSF leakage.

Question 58: A public health nurse is planning a breast cancer awareness campaign. To reach the greatest number of at-risk women, the nurse should FIRST identify:

Available funding for mammography subsidies
The age group with the highest incidence of breast cancer
Effective communication channels used by the target population (Correct answer)
Community organizations willing to partner in the campaign

Correct answer: Effective communication channels used by the target population

Identifying how the target population receives and exchanges information ensures the campaign messages reach and resonate with the intended audience.

Question 59: A client is asked to name the Prime Minister of Canada and the current season. Which cognitive domain is being tested?

Judgment
Abstract thinking
Memory
Orientation (Correct answer)

Correct answer: Orientation

Naming current political leaders and the season tests orientation to current events and time.

Question 60: A PN working in a long-term care facility discovers that a colleague has been falsifying vital sign records. The PN should:

Ignore it if no client harm has occurred yet
Report the behaviour to the supervisor or appropriate authority (Correct answer)
Confront the colleague privately and warn them to stop
Monitor the situation for several days before acting

Correct answer: Report the behaviour to the supervisor or appropriate authority

Falsifying records is professional misconduct that must be reported to protect client safety and uphold professional integrity.

Question 61: A 76-year-old client with chronic kidney disease (CKD Stage 4) and osteoarthritis is admitted to long-term care. The admitting physician orders celecoxib 200 mg daily for joint pain. The practical nurse reviewing the medication reconciliation should be MOST concerned because:

NSAIDs including COX-2 inhibitors are contraindicated in significant renal impairment as they reduce renal prostaglandin synthesis, worsening GFR and risking acute kidney injury (Correct answer)
Celecoxib requires a loading dose before the maintenance dose can be effective in older adults with reduced absorption
COX-2 inhibitors are safe for renal patients but the concern is that celecoxib interacts with common CKD medications like phosphate binders
The dose of 200 mg is above the maximum recommended daily dose for geriatric patients with osteoarthritis

Correct answer: NSAIDs including COX-2 inhibitors are contraindicated in significant renal impairment as they reduce renal prostaglandin synthesis, worsening GFR and risking acute kidney injury

NSAIDs, including selective COX-2 inhibitors like celecoxib, reduce synthesis of prostaglandins that maintain renal afferent arteriolar dilation. In patients with CKD, this compensatory mechanism is critical for maintaining GFR. Prescribing an NSAID in Stage 4 CKD risks acute-on-chronic kidney injury, fluid retention, hyperkalemia, and accelerated progression to kidney failure. The practical nurse should flag this as a high-risk medication error and consult the prescriber before administration. The Beers Criteria explicitly lists NSAIDs as potentially inappropriate in older adults with reduced renal function.

Question 62: Under Canadian nursing legislation, which term refers to the legally protected activities that only regulated nurses may perform?

Controlled acts
Authorized procedures
Reserved acts (Correct answer)
Licensed functions

Correct answer: Reserved acts

Provincial legislation designates certain nursing activities as 'reserved acts' (or controlled acts in some provinces) that only regulated professionals may perform.

Question 63: A practical nurse is caring for a client with chronic kidney disease who is prescribed both erythropoietin and oral ferrous sulfate. The client reports taking their iron tablet with a glass of milk each morning alongside their other medications. Which response by the nurse is most appropriate?

Instruct the client to take ferrous sulfate on an empty stomach or with orange juice, separated from milk and other medications by at least one hour (Correct answer)
Recommend the client take all medications together in the morning to improve adherence
Reassure the client that taking iron with milk is acceptable as it reduces gastrointestinal upset
Advise the client to switch to IV iron since oral absorption is unreliable in CKD

Correct answer: Instruct the client to take ferrous sulfate on an empty stomach or with orange juice, separated from milk and other medications by at least one hour

Calcium in milk significantly inhibits non-heme iron absorption by competing for the same transport mechanism. Ferrous sulfate should be taken on an empty stomach or with vitamin C (e.g., orange juice), which enhances absorption, and separated from calcium-containing foods, antacids, and other medications by at least one hour. In a CKD patient on erythropoietin, adequate iron stores are critical for the drug to be effective, making proper iron administration especially important.

Question 64: Which high-alert medication requires a two-nurse independent double-check (IDC) per Canadian medication safety standards?

Metformin (Glucophage) 500 mg oral
Concentrated electrolytes (e.g., KCl 40 mEq/100 mL IV) (Correct answer)
Pantoprazole (Pantoloc) 40 mg IV
Acetaminophen (Tylenol) 650 mg oral

Correct answer: Concentrated electrolytes (e.g., KCl 40 mEq/100 mL IV)

Concentrated electrolytes (potassium chloride) are a high-alert medication per ISMP Canada and require independent double-check due to fatal error potential.

Question 65: A practical nurse is performing a routine catheter care on a male client with an indwelling urinary catheter. Which action, if performed by a nursing student being supervised, would require immediate correction?

Positioning the drainage bag on the bed rail at the level of the client's bladder to facilitate drainage (Correct answer)
Cleansing the urethral meatus with a circular motion moving away from the urethral opening
Securing the catheter tubing to the inner thigh with a catheter stabilization device
Wearing clean (non-sterile) gloves for the catheter care procedure

Correct answer: Positioning the drainage bag on the bed rail at the level of the client's bladder to facilitate drainage

The urinary drainage bag must always be kept below the level of the bladder to prevent backflow of urine into the bladder, which can introduce bacteria and cause a catheter-associated urinary tract infection (CAUTI). Placing the bag on the bed rail at bladder level — or above — creates a retrograde flow risk and must be corrected immediately. Cleansing the meatus using outward circular motion is correct technique. Securing the catheter to the inner thigh prevents urethral trauma from traction and is correct practice. Clean gloves are appropriate for catheter care (this is not a sterile procedure after insertion); sterile gloves are only required during catheter insertion.

Question 66: Which of the following best describes healing by secondary intention?

The wound is left open and heals from the base up through granulation, contraction, and epithelialization (Correct answer)
Wound edges are brought together with adhesive strips within 24 hours of injury
A skin graft is placed over the wound to accelerate closure
Wound edges are approximated with sutures and the wound heals in a straight line

Correct answer: The wound is left open and heals from the base up through granulation, contraction, and epithelialization

Secondary intention healing occurs when wound edges cannot be approximated (e.g., infected wounds, pressure injuries). The wound heals from the base upward by granulation tissue formation, wound contraction, and epithelialization. This process is slower and leaves more scarring than primary intention.

Question 67: A client in palliative care expresses fear about dying alone. What is the most therapeutic nursing response?

Reassure the client that staff will be present as much as possible and discuss their wishes (Correct answer)
Change the subject to focus on positive topics
Suggest the client speak with a physician about their fears
Tell the client they are not dying yet

Correct answer: Reassure the client that staff will be present as much as possible and discuss their wishes

Acknowledging the client's fear and discussing their wishes for presence provides emotional support and practical reassurance.

Question 68: A practical nurse is administering medications to four clients. Which medication requires the nurse to perform an additional safety check by verifying apical pulse before administration?

Pantoprazole 40 mg orally
Metformin 500 mg orally
Digoxin 0.125 mg orally (Correct answer)
Amoxicillin 500 mg orally

Correct answer: Digoxin 0.125 mg orally

Digoxin is a cardiac glycoside; apical pulse must be counted for one full minute before administration and withheld if the rate is below 60 bpm in adults.

Question 69: Which finding in a 2-day-old newborn should the nurse report to the physician immediately?

Jaundice appearing at 48 hours
Respiratory rate of 68 breaths per minute (Correct answer)
Hands and feet that appear bluish (acrocyanosis)
Milia on the nose and cheeks

Correct answer: Respiratory rate of 68 breaths per minute

A respiratory rate of 68 breaths per minute exceeds the normal newborn range of 30–60 breaths per minute and requires immediate physician notification.

Question 70: When assessing the abdomen of a client complaining of abdominal pain, what is the correct sequence of assessment techniques the practical nurse should use?

Inspection, Palpation, Percussion, Auscultation
Inspection, Auscultation, Palpation, Percussion (Correct answer)
Palpation, Auscultation, Inspection, Percussion
Auscultation, Inspection, Palpation, Percussion

Correct answer: Inspection, Auscultation, Palpation, Percussion

The correct order for an abdominal assessment is Inspection, Auscultation, Palpation, and then Percussion. Auscultation is performed before palpation and percussion because physically manipulating the abdomen can alter bowel sounds, leading to an inaccurate assessment.

Question 71: A PN and a respiratory therapist disagree about a client's oxygen therapy plan. What is the best resolution strategy?

Document the disagreement and take no further action
The PN should proceed with nursing judgment alone
Both professionals should discuss the issue and involve the physician if needed to reach consensus (Correct answer)
The respiratory therapist's decision always takes precedence for breathing issues

Correct answer: Both professionals should discuss the issue and involve the physician if needed to reach consensus

Interprofessional disagreements are best resolved through respectful discussion, escalating to the physician when consensus cannot be reached.

Question 72: During assessment of a 58-year-old Indigenous client admitted for an acute exacerbation of COPD, the nurse observes that the client consistently avoids eye contact and gives brief answers. The client's oxygen saturation is 91% on 2L/min, RR is 24, and accessory muscle use is noted. Which action reflects BOTH culturally safe practice AND appropriate clinical prioritization?

Address the immediate respiratory compromise while acknowledging the client's communication style as a cultural norm, adjusting interaction accordingly throughout care (Correct answer)
Pause the assessment to build rapport using indirect conversation before addressing the respiratory findings
Assign a cultural liaison to conduct the full assessment before any nursing intervention to avoid cultural harm
Document refusal to engage and escalate to the care team, prioritizing oxygenation management

Correct answer: Address the immediate respiratory compromise while acknowledging the client's communication style as a cultural norm, adjusting interaction accordingly throughout care

Culturally safe practice does not require deferring urgent clinical care — it requires integrating cultural awareness into all interactions. This client has objective signs of respiratory distress (SpO2 91%, RR 24, accessory muscle use) requiring immediate nursing action. Avoiding eye contact and brevity in some Indigenous cultures reflect respect rather than disengagement or refusal. The nurse should address the clinical emergency while adapting communication style (e.g., not forcing eye contact, using indirect questioning, allowing silence). Delaying intervention to build rapport or reassigning the assessment to a liaison would be clinically unsafe. Documenting it as 'refusal' misinterprets a cultural behaviour.

Question 73: A practical nurse is administering medications via a client's nasogastric (NG) tube. The medication administration record includes sustained-release morphine sulfate (MS Contin) 30 mg. What is the CORRECT action?

Administer the intact tablet by dissolving it in 60 mL of warm water for 10 minutes before instilling
Crush the tablet thoroughly, dissolve in 30 mL of water, and flush the NG tube before and after administration
Open the sustained-release capsule and mix the beads with 15 mL of applesauce before instilling
Contact the prescriber to request a substitute formulation appropriate for NG tube administration (Correct answer)

Correct answer: Contact the prescriber to request a substitute formulation appropriate for NG tube administration

Sustained-release (SR/XR/ER) formulations must NEVER be crushed, split, or altered, as this destroys the time-release matrix and causes immediate release of the entire dose — a potentially fatal morphine overdose. NG tube administration requires an immediate-release liquid or crushable formulation. The nurse must withhold the medication and contact the prescriber for an appropriate order (e.g., immediate-release morphine oral solution or an IV/SC route). This is a patient safety imperative.

Question 74: The apical pulse is 96 bpm but the radial pulse is 78 bpm. How should this be documented?

Bradycardia at 78 bpm
Pulse deficit of 18 beats per minute (Correct answer)
Normal heart rate with peripheral vasoconstriction
Tachycardia with regular rhythm

Correct answer: Pulse deficit of 18 beats per minute

A pulse deficit is the difference between apical and radial rates (96-78=18), indicating some contractions lack sufficient force to produce a peripheral pulse.

Question 75: A PN is employed by a staffing agency and is placed at a hospital where they are asked by the charge RN to perform a task that falls within RN scope but outside PN scope in that province. The charge RN asserts that the hospital policy permits PNs to perform this task. What is the MOST appropriate action?

Decline the task, explaining that provincial nursing legislation and PN scope of practice take precedence over hospital policy (Correct answer)
Perform the task only if the charge RN agrees to co-sign all related documentation
Perform the task because the hospital policy and the charge RN's direction provide sufficient authorization
Contact the staffing agency supervisor to obtain permission before proceeding

Correct answer: Decline the task, explaining that provincial nursing legislation and PN scope of practice take precedence over hospital policy

Scope of practice is defined by provincial nursing legislation and the PN's regulatory body — not by employer or facility policy. A hospital cannot expand a PN's legal scope of practice through internal policy, nor can a supervisor's instruction override provincial law. Performing a task outside one's legislated scope exposes the PN to regulatory discipline and civil liability regardless of who directed them. The PN must decline and escalate appropriately. Contacting the staffing agency is a secondary step, but does not change the legal obligation to decline.

Question 76: During an abdominal assessment, the practical nurse notes a friction rub over the right upper quadrant. Which organ and associated condition does this finding MOST suggest?

Ascending colon, indicating inflammatory bowel disease with serosal involvement
Right kidney, indicating pyelonephritis with perinephric abscess
Gallbladder, indicating acute cholecystitis with pericholecystic inflammation
Liver, indicating hepatic inflammation or tumour with peritoneal involvement (Correct answer)

Correct answer: Liver, indicating hepatic inflammation or tumour with peritoneal involvement

Abdominal friction rubs — a grating sound heard with the stethragm during breathing — indicate peritoneal inflammation of an underlying organ. A friction rub in the right upper quadrant overlies the liver and suggests hepatic pathology such as hepatocellular carcinoma, liver abscess, or hepatitis with capsular/peritoneal inflammation. Splenic friction rubs occur in the left upper quadrant. The gallbladder, though in the RUQ, does not typically produce auscultable friction rubs; acute cholecystitis presents with Murphy's sign instead. Renal pathology is posterolateral, not anterior.

Question 77: During a home visit, a client offers the nurse a gift of homemade cookies as a gesture of gratitude. What is the most appropriate response?

Accept the gift graciously to avoid hurting the client's feelings.
Accept the gift and document it in the client's chart.
Decline and explain the agency's gift policy, acknowledging the client's gratitude verbally. (Correct answer)
Decline without explanation to reinforce professional distance.

Correct answer: Decline and explain the agency's gift policy, acknowledging the client's gratitude verbally.

The nurse follows agency policy on gifts, validates the client's intent, and maintains the therapeutic relationship by acknowledging gratitude in other ways.

Question 78: Six-year-old Anthony frequently gets epistaxis, especially in dry, chilly weather. What first aid advice should Anthony's parents receive from the nurse?

Gently and repeatedly blow your nose until the bleeding stops.
Bend the head back and grasp the nasal bridge.
Close both of your nostrils for approximately five minutes. (Correct answer)
Stuff cotton balls or tissues inside your nose.

Correct answer: Close both of your nostrils for approximately five minutes.

The most effective first aid for a nosebleed is to have the person lean slightly forward (to prevent blood from running down the throat) and firmly pinch both nostrils together for at least five minutes. This direct pressure helps to compress the bleeding blood vessels in the nose, promoting clot formation and stopping the bleeding. Other options are either ineffective or potentially harmful.

Question 79: A PN is floated to an unfamiliar unit and is asked to perform a specific wound care procedure they have not performed in over two years and were never formally assessed on in that practice setting. The charge nurse states there is no one else available. What is the most professionally and legally defensible course of action?

Perform the procedure independently and document only if a complication arises
Refuse the assignment entirely and leave the unit until a qualified nurse is found
Clearly communicate the competency gap to the charge nurse, seek any available supervision or resources, and document the circumstances if asked to proceed (Correct answer)
Perform the procedure, as being a licensed PN implies competence in all general nursing procedures

Correct answer: Clearly communicate the competency gap to the charge nurse, seek any available supervision or resources, and document the circumstances if asked to proceed

Scope of practice includes self-assessment of individual competence. A PN is legally and professionally required to practise only within the limits of their individual knowledge, skill, and judgment — not merely within the broad scope of the profession. The appropriate response is transparent communication of the competency gap to the responsible decision-maker (charge nurse/supervisor), followed by seeking supervision, a skills review, or other resources. Abandoning the patient or unit without ensuring coverage creates patient safety and abandonment liability. Documenting the request and response protects the PN in the event of an adverse outcome.

Question 80: A PN in a home care setting observes that a client is not taking their medications as prescribed. Before concluding the client is non-compliant, which factor should the PN explore first?

Whether the prescribing physician is aware of the client's history
Whether the client understands the consequences of not taking their medications
Whether the client can afford the medications and read the labels (Correct answer)
Whether the client's family agrees with the medication regimen

Correct answer: Whether the client can afford the medications and read the labels

Health literacy and financial barriers are among the most common reasons for medication non-adherence in community settings. Before assuming intentional non-compliance, the PN must assess practical barriers such as cost, ability to read labels, and health literacy.

Question 81: Ankle indentation from pressing disappears within 15 seconds. How should this pitting edema be graded?

+2 pitting edema
+4 pitting edema
+1 pitting edema (Correct answer)
+3 pitting edema

Correct answer: +1 pitting edema

+1 pitting edema: slight indentation (2mm) rebounding within 15 seconds, indicating mild fluid accumulation.

Question 82: A PN working in a correctional facility is instructed by the facility administrator — not a regulated health authority — to withhold prescribed pain medication from an inmate as a disciplinary measure. The PN should:

Comply only if the withholding is for no longer than 24 hours and documented in the health record
Seek a second opinion from another PN on shift before making a decision
Comply, as correctional facility administrators hold legal authority over all personnel within the institution
Refuse and report the instruction through the appropriate professional and regulatory channels, as this constitutes potential patient abuse and violates the standard of care (Correct answer)

Correct answer: Refuse and report the instruction through the appropriate professional and regulatory channels, as this constitutes potential patient abuse and violates the standard of care

Prescribed medications must be administered in accordance with the prescribing order and the standard of care. A non-regulated administrator has no authority to override a prescriber's order or direct a nurse to withhold treatment as punishment — this constitutes a serious ethical and legal violation potentially amounting to deliberate infliction of suffering (a form of abuse). The PN's professional regulatory obligations supersede institutional administrative directives when those directives require unsafe or unethical practice. The PN must refuse, document, and escalate through regulatory and professional reporting mechanisms. Inmates retain the right to receive medically indicated care.

Question 83: A PN is floated to an unfamiliar unit and is asked by the charge nurse to function as the team lead for three unregulated care providers (UCPs) during a short-staffed shift. The PN has not previously coordinated UCPs. What is the BEST response?

Accept the role fully, as PNs are always accountable for UCPs in every practice setting.
Delegate all client care tasks to the UCPs and focus on documentation to manage workload.
Accept care delivery responsibilities but clarify with the charge nurse the specific delegation parameters, available supports, and escalation pathways before the shift begins. (Correct answer)
Refuse the role entirely, as team leadership falls outside the PN scope of practice.

Correct answer: Accept care delivery responsibilities but clarify with the charge nurse the specific delegation parameters, available supports, and escalation pathways before the shift begins.

PNs can assign and monitor tasks performed by UCPs within established organizational frameworks, but effective delegation requires understanding what tasks can be delegated in this specific setting, the competency level of the UCPs, and who to contact when issues arise. Clarifying these parameters before the shift protects clients and ensures the PN functions within a safe, supported scope. Neither blanket acceptance without orientation nor outright refusal reflects sound professional judgment.

Question 84: A nurse is caring for a postoperative client who develops sudden onset chest pain, dyspnea, and SpO2 of 88%. The nurse notes the client had a total hip replacement 3 days ago. What condition is most suspected?

Pulmonary embolism (Correct answer)
Pneumothorax
Acute pulmonary edema
Myocardial infarction

Correct answer: Pulmonary embolism

Sudden onset chest pain, dyspnea, and hypoxia in a post-orthopedic surgery client are classic signs of pulmonary embolism due to venous thromboembolism risk.

Question 85: A 7-year-old post-operative patient following a tonsillectomy repeatedly swallows between assessments. Vital signs are stable and the child denies pain. What is the nurse's priority interpretation of this finding?

Expected post-operative behavior from dry mouth and mouth breathing
Anxiety-related response to the hospital environment
Nausea from residual anesthetic agents
Possible occult hemorrhage with blood being swallowed (Correct answer)

Correct answer: Possible occult hemorrhage with blood being swallowed

Frequent swallowing in a post-tonsillectomy patient is a classic and serious sign of occult hemorrhage — the child is swallowing blood pooling in the posterior pharynx. This can occur even with stable vital signs in the early stages. The nurse must inspect the oropharynx with a light and notify the physician immediately, as this is a surgical emergency. The other explanations are less urgent and do not match the clinical pattern.

Question 86: A practical nurse is assessing a 74-year-old client with heart failure. During auscultation, an S3 gallop is heard at the apex. Which pathophysiological mechanism best explains this finding?

Atrial contraction against a stiff ventricle during late diastole
Rapid ventricular filling against a non-compliant, volume-overloaded ventricle in early diastole (Correct answer)
Premature closure of the pulmonic valve due to elevated pulmonary pressures
Turbulent blood flow across a stenotic mitral valve during systole

Correct answer: Rapid ventricular filling against a non-compliant, volume-overloaded ventricle in early diastole

An S3 gallop (ventricular gallop) occurs in early diastole (after S2) when blood rushes into a distended, poorly compliant ventricle. In heart failure, the ventricle is volume-overloaded and stiff, causing vibrations during rapid filling — the hallmark of an S3. An S4 (not S3) is associated with atrial contraction against a stiff ventricle. Mitral stenosis produces a different auscultatory profile (opening snap + diastolic rumble), and pulmonic valve changes affect the splitting of S2.

Question 87: A practical nurse is caring for a newborn diagnosed with physiological jaundice. What is the primary rationale for initiating phototherapy?

To prevent hypothermia by keeping the baby warm.
To stimulate the production of new red blood cells.
To convert unconjugated bilirubin into a form that can be excreted. (Correct answer)
To increase the baby's appetite and milk intake.

Correct answer: To convert unconjugated bilirubin into a form that can be excreted.

Phototherapy works by using light to change the chemical structure of unconjugated bilirubin in the skin into a water-soluble form (isomer) called lumirubin. This allows the bilirubin to be excreted in the urine and stool, bypassing the need for conjugation by the immature liver, thus lowering the overall bilirubin level.

Question 88: A practical nurse is caring for a postoperative client 18 hours after an open appendectomy. The client reports sudden onset of severe chest pain radiating to the left shoulder, rated 9/10, with accompanying shortness of breath and diaphoresis. The client's blood pressure is 88/54 mmHg, heart rate 118 bpm, and SpO₂ 91% on room air. Which intervention takes highest priority?

Obtain a 12-lead ECG and administer supplemental oxygen
Administer PRN morphine for pain and reassess in 15 minutes
Place the client in a high Fowler's position and call for the rapid response team (Correct answer)
Increase IV fluid rate to restore blood pressure and notify the surgeon

Correct answer: Place the client in a high Fowler's position and call for the rapid response team

This presentation — severe chest pain, hypotension, tachycardia, diaphoresis, and oxygen desaturation — represents a hemodynamically unstable emergency requiring immediate activation of the rapid response team (RRT). High Fowler's position supports ventilation and reduces cardiac workload. Calling the RRT brings the highest level of rapid intervention. Obtaining an ECG (option A) is important but takes time and does not address the hemodynamic emergency first. Administering morphine (option C) to a hypotensive, desaturating patient is dangerous without immediate medical oversight. Fluid loading alone (option D) is insufficient and delays critical assessment of the likely cause (PE, MI, or internal hemorrhage).

Question 89: Which of the following is considered subjective data in a client's health assessment?

The client's blood pressure is 140/90 mmHg.
The client's respiratory rate is 22 breaths per minute.
The client states, "I feel nauseous." (Correct answer)
The client has a rash on their abdomen.

Correct answer: The client states, "I feel nauseous."

Subjective data is information reported by the client from their own perspective, such as feelings, perceptions, and concerns. The client's statement of feeling nauseous is subjective. Respiratory rate, blood pressure, and the presence of a rash are all objective data that can be observed and measured by the nurse.

Question 90: A practical nurse (PN) is working in a long-term care facility when a resident's family member, who is also a physician, verbally orders a change in the resident's medication dose outside of the facility. The PN cannot reach the resident's attending physician. What is the most legally defensible action?

Administer the original dose but document the family physician's recommendation for the attending to review
Document the family physician's verbal order and administer the new dose, as the family member is a licensed physician
Contact the provincial nursing regulatory body before taking any action
Decline to administer the changed dose, document the situation, and continue to attempt to reach the attending physician or supervisor (Correct answer)

Correct answer: Decline to administer the changed dose, document the situation, and continue to attempt to reach the attending physician or supervisor

A PN must only follow orders from authorized prescribers within the established care relationship and institutional protocols. A family member who is a physician has no prescribing authority over a patient who is not their patient, and a verbal order given outside institutional channels is not legally valid. The PN's accountability requires declining the change, continuing safe care under existing orders, documenting thoroughly, and escalating appropriately.

Question 91: A practical nurse is preparing to transfer a client with left-sided weakness from the bed to a chair. Which action demonstrates the correct technique?

Having the client place their hands on the nurse's shoulders for support.
Instructing the client to pivot on their weaker (left) foot.
Placing the chair on the client's weak (left) side.
Positioning the chair at a 45-degree angle to the bed on the client's strong (right) side. (Correct answer)

Correct answer: Positioning the chair at a 45-degree angle to the bed on the client's strong (right) side.

To ensure safety and maximize client participation, the chair should be placed on the client's stronger side at a 45-degree angle to the bed. This allows the client to pivot on their strong leg and use their strong arm to reach for the chair, providing stability and reducing the risk of falls.

Question 92: A client with major depressive disorder expresses that things will never get better. Which therapeutic communication technique best addresses this hopelessness?

Agree that their situation is very difficult
Change the subject to avoid reinforcing negative thinking
Acknowledge the client's pain while offering realistic hope: 'I hear how painful this is. Many people with depression find that treatment helps.' (Correct answer)
Tell the client to think positively and focus on what they have to live for

Correct answer: Acknowledge the client's pain while offering realistic hope: 'I hear how painful this is. Many people with depression find that treatment helps.'

Acknowledging feelings while offering realistic hope validates the experience without dismissing it and provides therapeutic support.

Question 93: A practical nurse discovers that a colleague has been documenting vital signs without actually taking them, and patients appear clinically stable. The colleague explains they were overwhelmed and promises it will not happen again. What is the nurse's primary professional obligation?

Confront the colleague formally in writing and give them one week to self-report to management
Report the conduct to the nurse manager immediately, as falsifying documentation poses a direct patient safety risk regardless of current patient stability (Correct answer)
Report only if a patient experiences an adverse outcome directly linked to the falsified records
Accept the colleague's explanation and monitor the situation over the next few shifts before escalating

Correct answer: Report the conduct to the nurse manager immediately, as falsifying documentation poses a direct patient safety risk regardless of current patient stability

Falsifying clinical documentation is a serious breach of professional and ethical standards that directly threatens patient safety, as unmonitored changes in condition could go undetected. Current patient stability does not mitigate the risk or the ethical obligation. Waiting, issuing private ultimatums, or conditioning the report on an adverse outcome all delay necessary action. The nurse has a professional duty under the regulatory framework to report unsafe or unethical practice to the appropriate authority without delay.

Question 94: A nurse is conducting a home visit and notices the client has multiple expired medications. Which action reflects tertiary prevention?

Screening the client for polypharmacy-related complications
Reviewing all medications with the client to prevent drug interactions
Teaching the client how to safely dispose of medications
Referring the client to a pharmacist for a comprehensive medication review to manage chronic disease complications (Correct answer)

Correct answer: Referring the client to a pharmacist for a comprehensive medication review to manage chronic disease complications

Tertiary prevention aims to reduce the impact of established disease; a pharmacist review to manage complications of chronic conditions in a medicated client fits this level.

Question 95: A client at 34 weeks gestation is admitted with severe preeclampsia and receiving IV magnesium sulfate. Her respirations drop to 10 breaths/minute and her patellar reflexes are absent. Which action is the nurse's FIRST priority?

Administer calcium gluconate 1 g IV slowly (Correct answer)
Increase the oxygen flow rate and apply a non-rebreather mask
Decrease the magnesium sulfate infusion rate by half
Notify the physician and document the findings

Correct answer: Administer calcium gluconate 1 g IV slowly

Absent patellar reflexes and a respiratory rate below 12 breaths/minute are signs of magnesium sulfate toxicity. Calcium gluconate is the antidote and must be administered immediately to reverse toxicity and prevent respiratory arrest. Notifying the physician is important but not the first action when the client is in immediate danger. Oxygen alone will not reverse the toxicity, and decreasing the infusion rate is insufficient once toxicity has occurred.

Question 96: A family member of a client requests information about the client's prognosis. The client has not consented to share this information. What should the PN do?

Direct the family to ask the physician without explaining why
Share the information to support the family's coping
Explain that client confidentiality prevents sharing information without consent (Correct answer)
Avoid the conversation entirely

Correct answer: Explain that client confidentiality prevents sharing information without consent

Client confidentiality is a fundamental ethical and legal obligation; information cannot be disclosed to family without the client's consent.

Question 97: A client who recently received a terminal diagnosis refuses to discuss advance care planning and instead spends sessions asking the nurse about miracle cures and experimental treatments. The nurse recognizes the client is in the denial stage of grief. Which therapeutic approach is MOST appropriate?

Provide factual information about why experimental treatments are not viable to help move the client toward acceptance.
Avoid the topic of advance care planning entirely until the client raises it spontaneously.
Refer the client to a psychologist, as managing denial and grief is outside the PN's scope of therapeutic practice.
Acknowledge the client's hope while remaining present with the underlying fear, and gently introduce advance care planning as an act of self-determination rather than giving up. (Correct answer)

Correct answer: Acknowledge the client's hope while remaining present with the underlying fear, and gently introduce advance care planning as an act of self-determination rather than giving up.

Denial is a protective mechanism that should not be confronted head-on, as this can rupture rapport and increase distress. The nurse honours the client's hope (meeting them where they are) while also introducing advance care planning in a reframed, empowering way — as control, not concession. Option A is confrontational and dismissive of the defence. Option B is avoidant and may delay necessary planning. Option D unnecessarily limits the PN's therapeutic role; presence and sensitive guidance are within scope.

Question 98: During a medication reconciliation on admission, a client reports taking warfarin 5 mg daily at home. The admission orders read warfarin 2.5 mg daily. The client insists their home dose is 5 mg and becomes agitated when the nurse attempts to give 2.5 mg. What is the MOST appropriate nursing action?

Withhold the dose entirely and wait until morning rounds for the prescriber to clarify
Administer 5 mg as the client states, since the client knows their own medication regimen
Administer 2.5 mg as ordered, document the discrepancy, and immediately contact the prescriber to reconcile the difference before the next dose (Correct answer)
Split the difference and administer 3.75 mg to bridge the gap until the discrepancy is resolved

Correct answer: Administer 2.5 mg as ordered, document the discrepancy, and immediately contact the prescriber to reconcile the difference before the next dose

Nurses must administer medications as prescribed — not as reported by the client — because verbal reports may be inaccurate or reflect a dose that has since been adjusted. However, a discrepancy of this magnitude with a narrow-therapeutic-index drug like warfarin carries serious bleeding risk and must be resolved urgently. The nurse administers the ordered dose (which is safer than the higher unverified dose), documents the discrepancy in detail, and contacts the prescriber immediately so the correct dose can be confirmed or adjusted before the next scheduled administration. Withholding without contact delays necessary anticoagulation.

Question 99: A client who is being discharged at the end of the week tells the practical nurse, "I'm really going to miss our talks. Can I get your phone number so we can keep in touch?" Which of the following responses by the nurse is most appropriate?

"I will miss our talks too. Let's focus on how you will use the skills you've learned once you are discharged." (Correct answer)
"Of course. It's important to have support, and I'd be happy to hear from you."
"It's against hospital policy, but perhaps we can connect on social media instead."
"I'm not allowed to do that, but I can give you the number for the hospital's support line."

Correct answer: "I will miss our talks too. Let's focus on how you will use the skills you've learned once you are discharged."

This response correctly navigates the termination phase by acknowledging the client's feelings while gently redirecting the focus back to the client's progress and future independence, which is the primary goal of this phase. Providing personal contact information or connecting on social media is a breach of professional boundaries. While offering a support line is helpful, the best response also validates the client's feelings about the relationship ending.

Question 100: A client tells the nurse: 'I feel so ashamed. I cannot even manage my own diabetes.' Which therapeutic response is most appropriate?

'You sound really frustrated with managing your diabetes. Can you tell me more about what has been most challenging?' (Correct answer)
'Most people with diabetes struggle too. You are not alone.'
'Diabetes is a difficult disease. You should not be so hard on yourself.'
'Let me review the diabetes management plan with you again.'

Correct answer: 'You sound really frustrated with managing your diabetes. Can you tell me more about what has been most challenging?'

Reflecting the client's emotion and using an open question invites them to share more while validating their experience, which is therapeutic active listening.

Question 101: When assessing a wound for infection, which finding is most concerning?

Increased warmth, redness, purulent drainage, and fever (Correct answer)
Approximated wound edges with mild bruising
Slight pink discoloration at wound edges on day 2
Mild serosanguinous drainage in first 24-48 hours

Correct answer: Increased warmth, redness, purulent drainage, and fever

Warmth, redness, purulent drainage, and fever are classic signs of wound infection requiring prompt reporting and treatment.

Question 102: Which phase of the therapeutic relationship involves establishing trust, clarifying roles, and setting mutual goals?

Working phase
Termination phase
Orientation phase (Correct answer)
Evaluation phase

Correct answer: Orientation phase

The orientation phase focuses on establishing rapport, clarifying the nurse and client roles, and collaboratively setting goals for the relationship.

Question 103: A practical nurse is preparing to administer a nasogastric (NG) tube medication to a client who is also receiving a continuous enteral feed. The medication monograph states it should be given on an empty stomach. Which sequence of actions is MOST appropriate?

Pause the feed briefly, administer the medication mixed into the feed bag, then resume the infusion
Administer the medication without interrupting the feed, as NG medications bypass the stomach's absorptive phase
Crush the tablet, dissolve it in the feed formula, and give the bolus immediately to minimize interruption time
Stop the feed 30–60 minutes before administration, flush the tube, give the medication, flush again, then restart the feed after the required interval (Correct answer)

Correct answer: Stop the feed 30–60 minutes before administration, flush the tube, give the medication, flush again, then restart the feed after the required interval

Medications requiring an empty stomach must not be given concurrently with enteral feeds. The correct practice is to pause the feed for the required time before and after administration, flush the tube with water before and after the medication to prevent tube occlusion and drug-feed interactions, and only resume feeding after the specified hold period. Mixing medication into the feed bag risks incompatibility, inaccurate dosing, and altered absorption. Many medications designated 'empty stomach' are also modified-release and must not be crushed.

Question 104: Which observation in a catheterized client requires immediate reporting?

Urine output 20 mL/hour over the past 3 hours (Correct answer)
Collection bag below the level of the bladder
Urine output 50 mL/hour
Catheter tubing looped below the collection bag

Correct answer: Urine output 20 mL/hour over the past 3 hours

Urine output under 30 mL/hour for 3 hours indicates oliguria and may signal renal insufficiency, dehydration, or obstruction.

Question 105: A nurse is caring for a postoperative client who has not voided in 8 hours. The client reports lower abdominal discomfort. What is the nurse's priority action?

Insert an indwelling urinary catheter immediately
Notify the physician before performing any assessment
Encourage increased oral fluid intake
Palpate and percuss the suprapubic area to assess for bladder distension (Correct answer)

Correct answer: Palpate and percuss the suprapubic area to assess for bladder distension

Assessing for bladder distension by palpation and percussion confirms urinary retention before any intervention is initiated.

Question 106: A client is being prepared for a paracentesis. Which nursing intervention has the highest priority?

Establishing IV access
Positioning the client in Fowlers
Ensuring the client has signed the consent form
Instructing the client to void to empty the bladder (Correct answer)

Correct answer: Instructing the client to void to empty the bladder

Having the client void before paracentesis prevents bladder injury during the procedure, as the needle is inserted near the suprapubic region.

Question 107: A PN has been delegated a task by a Registered Nurse (RN) that falls outside the PN's legislated scope in their province. The RN assures the PN that 'delegation covers it.' Which statement MOST accurately reflects the legal position of the PN if they proceed?

The PN remains personally liable for performing an out-of-scope act; delegation by an RN cannot authorize acts that exceed the PN's legislated scope (Correct answer)
The RN assumes full legal liability for the act because she initiated the delegation, shielding the PN from regulatory consequences
The PN is protected if she documents that the task was delegated by the RN and performed under the RN's supervision
Delegation from a regulated professional in a higher scope category legally expands the PN's scope on a task-specific basis

Correct answer: The PN remains personally liable for performing an out-of-scope act; delegation by an RN cannot authorize acts that exceed the PN's legislated scope

Delegation transfers responsibility for a task but does NOT transfer legislated scope of practice. A PN's scope is defined by provincial legislation and their regulatory college standards — an RN cannot legally expand that scope through delegation. If the PN performs an act outside their authorized scope, they are personally accountable to their regulatory college for unauthorized practice, regardless of who asked them to do it or whether supervision was present. Documentation of delegation does not provide legal protection for an out-of-scope act.

Question 108: A client returns from the operating room following general anesthesia. The PN notes oxygen saturation of 91% and the client is difficult to arouse. What is the priority action?

Administer IV fluids to raise blood pressure
Wait 10 minutes and reassess as this is expected post-anesthesia
Document findings and notify the charge nurse at the next opportunity
Reposition the client to a semi-Fowler's position and apply supplemental oxygen (Correct answer)

Correct answer: Reposition the client to a semi-Fowler's position and apply supplemental oxygen

Airway and oxygenation are the priority in the post-anesthetic period. Repositioning to semi-Fowler's opens the airway and applying supplemental oxygen addresses the desaturation. Obtundation and low O2 sat warrant immediate intervention and escalation.

Question 109: A client reports pain that is 8/10 in severity, and the practical nurse observes the client laughing and chatting on the phone. What is the most appropriate nursing action?

Accept the client's self-report as the most reliable pain indicator (Correct answer)
Administer a lower dose of pain medication than ordered
Reassess the client in one hour without intervention
Document the pain rating as inconsistent with behavior

Correct answer: Accept the client's self-report as the most reliable pain indicator

Self-report is the gold standard for pain assessment; behavioral cues do not always correlate with pain intensity, especially in clients using coping strategies.

Question 110: A client on bed rest develops redness over the sacrum that blanches when pressed. How should the nurse document and classify this finding?

Stage I pressure injury with intact skin (Correct answer)
Stage II pressure injury with skin breakdown
Suspected deep tissue injury
Unstageable pressure injury

Correct answer: Stage I pressure injury with intact skin

Redness that blanches indicates intact skin with a reactive hyperemic response, classified as a Stage I pressure injury.

Question 111: A 10-month-old with a known peanut allergy receives their first dose of MMR vaccine. Fifteen minutes later, the nurse observes urticaria, inspiratory stridor, and a heart rate of 178 bpm. The child weighs 9 kg. What is the correct epinephrine dose and route?

0.09 mg IM of 1:10,000 concentration into the deltoid
0.09 mg IM of 1:1,000 concentration into the anterolateral thigh (Correct answer)
0.9 mg IV of 1:10,000 concentration via peripheral IV
0.45 mg subcutaneously of 1:1,000 concentration

Correct answer: 0.09 mg IM of 1:1,000 concentration into the anterolateral thigh

Epinephrine for anaphylaxis is dosed at 0.01 mg/kg using the 1:1,000 (1 mg/mL) concentration given IM. For a 9 kg infant: 9 × 0.01 = 0.09 mg. The anterolateral thigh (vastus lateralis) is the preferred IM site for fastest absorption. IV epinephrine 1:10,000 is reserved for cardiac arrest scenarios and carries severe dysrhythmia risk. The subcutaneous route has slower, less reliable absorption during anaphylaxis. The deltoid has inadequate muscle mass in infants.

Question 112: An outbreak of norovirus is declared on a medical unit. Which measure is most effective?

Strict hand hygiene with soap and water and cohort nursing for affected clients (Correct answer)
Closing the unit and discharging all clients
Universal masking regardless of symptoms
Administering antivirals prophylactically to all staff

Correct answer: Strict hand hygiene with soap and water and cohort nursing for affected clients

Soap and water hand washing combined with cohorting infected clients are the most effective norovirus outbreak control measures.

Question 113: A client who delivered vaginally 6 hours ago has a fundal height at the umbilicus, deviated to the right, and a boggy uterus. What should the practical nurse suspect?

Retained placental fragment
Postpartum hemorrhage from uterine atony
Bladder distension causing uterine displacement and atony (Correct answer)
Normal postpartum uterine involution

Correct answer: Bladder distension causing uterine displacement and atony

A boggy uterus deviated to the right 6 hours postpartum typically indicates bladder distension preventing effective uterine contraction.

Question 114: A practical nurse is assessing deep tendon reflexes and documents a '4+' response. What does this indicate?

Normal reflex response
Absent reflex
Hyperreflexia with clonus (Correct answer)
Diminished reflex

Correct answer: Hyperreflexia with clonus

A 4+ reflex response indicates hyperreflexia with clonus, which may suggest an upper motor neuron disorder.

Question 115: A nurse is preparing to administer digoxin to a 2-year-old with heart failure. The child's apical pulse is 88 bpm. What is the appropriate action?

Recheck the pulse in 30 minutes before giving
Administer the dose and document the heart rate
Administer half the dose as a precaution
Withhold the dose and notify the physician (Correct answer)

Correct answer: Withhold the dose and notify the physician

The threshold for withholding digoxin in children under 2 years is an apical pulse below 90 bpm; 88 bpm means the dose should be held and the physician notified.

Question 116: A client refuses to take their prescribed morning dose of an oral medication, stating, "I don't want to take that pill today." What is the practical nurse's most appropriate initial action?

Notifying the charge nurse and the prescriber immediately.
Documenting the refusal and discarding the medication.
Exploring the client's reason for the refusal. (Correct answer)
Informing the client that the medication is essential for their health.

Correct answer: Exploring the client's reason for the refusal.

Clients have the right to refuse medication. The nurse's first responsibility is to assess the situation by exploring the client's reasons for refusal. This demonstrates respect for client autonomy and allows the nurse to identify and address any misunderstandings, concerns, or adverse effects the client may be experiencing before taking further action.

Question 117: A practical nurse has been working with a client recovering from a traumatic brain injury for 8 weeks. The client tells the nurse, 'You are the only one who truly understands me. I don't need anyone else as long as I have you.' Which response by the nurse BEST addresses this statement therapeutically?

Acknowledge the client's feelings while gently reinforcing that the relationship has defined boundaries and that building connections beyond the therapeutic setting is an important goal of recovery. (Correct answer)
Consult with the charge nurse immediately to arrange a transfer of the client's care to another nurse to prevent unhealthy attachment.
Thank the client for the trust placed in the nurse and assure the client that the therapeutic relationship will continue as long as needed.
Explain to the client that nurses are not allowed to form close bonds with clients and redirect the conversation to physical care.

Correct answer: Acknowledge the client's feelings while gently reinforcing that the relationship has defined boundaries and that building connections beyond the therapeutic setting is an important goal of recovery.

The client is displaying signs of overdependence, which can occur in the working phase of the therapeutic relationship. The nurse's role is to validate feelings without reinforcing dependency, and to redirect the client toward the therapeutic goal of fostering independence and broader social support. Option B reinforces the dependency. Option C is dismissive and not therapeutically appropriate. Option D is an extreme measure not warranted at this stage and avoids rather than addresses the therapeutic issue.

Question 118: A practical nurse receives a telephone order from a physician for a client. Which of the following actions by the nurse best ensures accuracy and client safety?

Waiting for the physician to enter the order into the electronic system later.
Repeating the order back to the physician for verification before ending the call. (Correct answer)
Asking a colleague to listen to the voicemail to confirm the order.
Writing the order down and administering it immediately to ensure timely care.

Correct answer: Repeating the order back to the physician for verification before ending the call.

To prevent errors with verbal or telephone orders, the best practice is to write the order down verbatim and then read it back to the prescriber for confirmation. This "read-back" process is a crucial safety check to ensure the nurse heard and transcribed the order correctly before administration. If an order is unclear or incomplete, the LPN must contact the authorized prescriber for clarification.

Question 119: An interdisciplinary team meeting is planned for a client whose family is present and insists on participating in all care decisions. The client, who is cognitively intact, privately tells the PN they do not want their family involved in the meeting. How should the PN handle this within the team?

Brief the team before the meeting that the client has invoked their right to confidentiality and family participation should be excluded, unless the client changes their decision. (Correct answer)
Document the client's preference but allow the team leader to make the final decision on family inclusion.
Inform the family privately so they can discuss it with the client before the meeting.
Invite the family anyway to avoid conflict and maintain team-family rapport.

Correct answer: Brief the team before the meeting that the client has invoked their right to confidentiality and family participation should be excluded, unless the client changes their decision.

A cognitively intact adult client has the autonomous right to control who participates in their care discussions. The PN must communicate this clearly to the team prior to the meeting to protect client confidentiality and autonomy. Disclosing the client's wishes to the family or deferring the decision to a team leader would violate the client's right to self-determination.

Question 120: The practical nurse is administering an oral liquid medication to a client with dysphagia. Which action best promotes safe administration?

Mix the medication in a large glass of water to thin it further
Administer the medication rapidly to minimize aspiration time
Instruct the client to tilt their head back while swallowing
Position the client upright or at a 45-degree angle before administration (Correct answer)

Correct answer: Position the client upright or at a 45-degree angle before administration

Upright or semi-upright positioning uses gravity to facilitate swallowing and significantly reduces the risk of aspiration.

Question 121: Informed consent for a surgical procedure is primarily the responsibility of:

The PN, who explains the procedure in plain language
The charge nurse on the unit
The hospital's consent coordinator
The surgeon performing the procedure (Correct answer)

Correct answer: The surgeon performing the procedure

The physician or surgeon performing the procedure is responsible for obtaining informed consent; the PN may witness the signature and reinforce information.

Question 122: A practical nurse feels personally uncomfortable caring for a client seeking a legal medical procedure that conflicts with their religious beliefs. What is the ethical course of action?

Refuse to care for the client and ask them to request a different nurse
Continue to provide safe and ethical care and, if conscientious objection exists, follow the facility's policy while ensuring client care is not compromised (Correct answer)
Share personal religious beliefs with the client to explain limitations
Provide care but withhold information about the procedure

Correct answer: Continue to provide safe and ethical care and, if conscientious objection exists, follow the facility's policy while ensuring client care is not compromised

Conscientious objection is recognized in Canadian nursing ethics, but the nurse must ensure client care is not compromised and must follow the facility's policy for proper transfer of care.

Question 123: A client tells the PN they feel their concerns are being ignored by the medical team. What is the PN's most appropriate response?

Acknowledge the client's feelings and advocate by communicating concerns to the team on the client's behalf (Correct answer)
Reassure the client that the team always knows best
Tell the client to raise the concern directly with administration only
Document the statement and take no further action

Correct answer: Acknowledge the client's feelings and advocate by communicating concerns to the team on the client's behalf

Advocacy is a core nursing role; PNs must communicate clients' concerns to the team and ensure clients feel heard and supported.

Question 124: A nurse is caring for a client with systemic lupus erythematosus (SLE) who is admitted for a disease flare. The client is on hydroxychloroquine and high-dose prednisone. The client develops sudden onset dyspnea, pleuritic chest pain, and oxygen saturation of 91% on room air. The nurse suspects pulmonary embolism. After calling the physician, what is the MOST appropriate immediate nursing intervention?

Apply supplemental oxygen and position the client in high Fowler's position (Correct answer)
Place the client in the left lateral Trendelenburg position to improve venous return
Administer the client's next scheduled dose of prednisone to reduce pulmonary inflammation
Prepare the client for immediate anticoagulation by drawing a full blood panel and starting a peripheral IV

Correct answer: Apply supplemental oxygen and position the client in high Fowler's position

The immediate priority for suspected PE with hypoxemia is to correct hypoxia by applying supplemental oxygen and optimizing respiratory mechanics with high Fowler's positioning, which reduces diaphragm pressure and improves tidal volume. While preparing for anticoagulation (labs and IV access) is important and will follow, correcting the acute hypoxia takes precedence as the first nursing action. Administering prednisone does not address a thromboembolic event. Trendelenburg positioning is contraindicated in PE because it increases venous return to an already-compromised right ventricle and worsens dyspnea.

Question 125: A 78-year-old client is prescribed multiple medications. Which age-related pharmacokinetic change most increases the risk of drug toxicity in older adults?

Faster hepatic metabolism
Increased total body water
Increased gastric acid production
Decreased renal clearance (Correct answer)

Correct answer: Decreased renal clearance

Declining glomerular filtration rate reduces renal clearance, causing drug accumulation and elevated risk of toxicity in older adults.

Question 126: A nurse is teaching a client about warning signs to report after discharge at 48 hours postpartum. Which symptom warrants immediate medical attention?

Lochia rubra changing to lochia serosa
Calf pain, redness, and swelling in one leg (Correct answer)
Mild perineal discomfort relieved by ice packs
Mild breast tenderness when breastfeeding

Correct answer: Calf pain, redness, and swelling in one leg

Unilateral calf pain, redness, and swelling are signs of deep vein thrombosis (DVT), a serious postpartum complication requiring immediate evaluation.

Question 127: A practical nurse is assigned to care for a client whose cultural and religious beliefs differ significantly from their own. The client is refusing a specific medical procedure recommended by the physician due to these beliefs. The nurse's first response should be to:

Request to be reassigned to another client to avoid a conflict of values.
Document the refusal and proceed with other aspects of the care plan.
Explain to the client why the procedure is medically necessary and attempt to change their mind.
Respect the client's decision and explore their beliefs and values with cultural sensitivity. (Correct answer)

Correct answer: Respect the client's decision and explore their beliefs and values with cultural sensitivity.

Ethical nursing practice requires respecting the rights of all individuals, regardless of their diverse values, beliefs, and cultures. The nurse's first action should be to seek understanding and demonstrate respect for the client's perspective. This client-centered approach promotes trust and opens a dialogue where the client's needs and wishes can be properly understood and advocated for. Attempting to change their mind disrespects their autonomy. Simply documenting the refusal without trying to understand the reasoning is a missed opportunity for holistic care. While re-assignment is a last resort in a true conflict of conscience, the initial step is always to engage respectfully with the client.

Question 128: The practical nurse is assessing capillary refill in a client. Which finding requires immediate follow-up?

Capillary refill of 2 seconds
Capillary refill of 1 second
Capillary refill that varies between fingers
Capillary refill of 4 seconds (Correct answer)

Correct answer: Capillary refill of 4 seconds

Capillary refill greater than 3 seconds indicates poor peripheral perfusion and requires immediate assessment and intervention.

Question 129: During a team huddle, a registered nurse (RN) assigns a task to the PN that falls outside the PN's defined scope of practice in that jurisdiction. The PN has performed similar tasks in a previous province. What should the PN do?

Ask the client whether they are comfortable with the PN performing the task before proceeding.
Perform the task because prior experience demonstrates competency.
Perform the task under the direct supervision of the RN to remain within scope.
Decline the task, explain that it falls outside their current jurisdictional scope, and collaborate with the RN to reassign it appropriately. (Correct answer)

Correct answer: Decline the task, explain that it falls outside their current jurisdictional scope, and collaborate with the RN to reassign it appropriately.

Scope of practice is jurisdiction-specific and is not transferable based on prior experience in another province. The PN must decline, clearly communicate the reason, and work collaboratively with the RN to ensure the task is safely reassigned to a team member who is within scope. Client consent does not override regulatory boundaries.

Question 130: A practical nurse is caring for a client who has been taking a first-generation antipsychotic medication for several years. The nurse observes the client exhibiting involuntary, repetitive facial movements, including lip-smacking and grimacing. The nurse recognizes these signs as being consistent with which condition?

Neuroleptic malignant syndrome
Acute dystonia
Akathisia
Tardive dyskinesia (Correct answer)

Correct answer: Tardive dyskinesia

Tardive dyskinesia is a serious, often irreversible side effect of long-term antipsychotic use, characterized by involuntary and repetitive movements of the face, limbs, and trunk. Akathisia is motor restlessness, acute dystonia involves sudden muscle spasms, and neuroleptic malignant syndrome is a life-threatening reaction involving fever and rigidity.

Question 131: A female patient, age 68, is brought to the hospital due to a stage III decubitus ulcer located above her right ischial tuberosity. There are multiple instances of chronic obstructive pulmonary disease (COPD) in the client's past medical history. For the client, the following is the best position:

Lying on one's right side with cushions between the knees
Lie on one's left side with cushions in between the knees (Correct answer)
Lying down with cushions beneath the knees
With a cushion beneath the client's knees, recline

Correct answer: Lie on one's left side with cushions in between the knees

A stage III decubitus ulcer over the right ischial tuberosity means there is significant tissue damage in that area. Positioning the client on their left side with cushions between the knees effectively redistributes pressure away from the affected right side. This helps prevent further skin breakdown and promotes healing by avoiding direct pressure on the ulcerated area.

Question 132: A nurse is working with a client from a different cultural background. Which action best demonstrates cultural sensitivity within the therapeutic relationship?

Ask the client about their cultural values and preferences related to care. (Correct answer)
Avoid discussing cultural differences to prevent discomfort.
Assume the client shares the same health beliefs as the nurse.
Provide care based on standard protocols without customization.

Correct answer: Ask the client about their cultural values and preferences related to care.

Inquiring about cultural values demonstrates respect and ensures care is individualized and culturally sensitive within the therapeutic relationship.

Question 133: A nurse is assessing a client's readiness to change using the Transtheoretical Model. The client says, 'I know I need to exercise, but I'm not planning to start for at least six months.' The client is in which stage?

Preparation
Precontemplation
Maintenance
Contemplation (Correct answer)

Correct answer: Contemplation

Contemplation is the stage where individuals acknowledge a need to change but are not planning to act within the next 30 days; thinking about change in 6 months fits this stage.

Question 134: When assessing a palliative client for dehydration at end of life, the nurse should understand that:

Dehydration always causes suffering in dying clients
IV fluids must always be initiated to prevent dehydration
Nasogastric tube feeding prevents end-of-life complications
Reduced fluid intake is a natural part of the dying process (Correct answer)

Correct answer: Reduced fluid intake is a natural part of the dying process

Reduced food and fluid intake is a normal and expected part of the dying process and does not necessarily cause suffering.

Question 135: A practical nurse is caring for an Indigenous client who has requested a traditional healing ceremony in their hospital room. How should the nurse respond?

Decline since ceremonial activities are not permitted in hospital settings
Allow the ceremony only if no medical interventions are scheduled
Document the request was declined and proceed with standard care
Support the request by facilitating the ceremony with the care team, following hospital policy on traditional healing (Correct answer)

Correct answer: Support the request by facilitating the ceremony with the care team, following hospital policy on traditional healing

Indigenous clients have the right to access traditional healing practices as part of culturally safe care. The nurse should facilitate the ceremony by coordinating with the care team.

Question 136: A practical nurse is in the working phase of a therapeutic relationship with a client recovering from major surgery. Which action is the priority for the nurse during this phase?

Summarizing the progress made and preparing the client for discharge.
Assisting the client to actively problem-solve and practice new coping skills. (Correct answer)
Gathering initial assessment data and establishing a contract for care.
Setting the goals and outlining the expected duration of the relationship.

Correct answer: Assisting the client to actively problem-solve and practice new coping skills.

The working phase is where the bulk of the therapeutic work occurs. The priority is to actively engage the client in exploring their problems, trying new solutions, and learning new skills to promote change and recovery. Gathering data and setting goals occur in the orientation phase, and summarizing progress is characteristic of the termination phase.

Question 137: A practical nurse is assigned to care for a patient whose religious beliefs the nurse finds morally repugnant. The nurse is not in a remote or under-resourced setting, and other staff are available. What is the most professionally appropriate action?

Provide full care without any disclosure, suppressing personal values entirely as professional duty requires
Immediately refuse care, inform the patient their beliefs are incompatible with the nurse's practice, and leave the room
Provide care for urgent needs only and document that further care was withheld due to a values conflict
Invoke conscientious objection by privately notifying the supervisor, arranging a seamless transfer of care to another qualified nurse, and ensuring the patient experiences no gap in service (Correct answer)

Correct answer: Invoke conscientious objection by privately notifying the supervisor, arranging a seamless transfer of care to another qualified nurse, and ensuring the patient experiences no gap in service

Nurses may exercise conscientious objection when personal moral values conflict with a patient's beliefs or requested care, provided doing so does not abandon the patient and does not interfere with access to care. The ethical pathway is to notify a supervisor discreetly, ensure a qualified replacement is in place before withdrawing, and maintain professional non-judgmental communication with the patient throughout the handover. Refusing without arranging continuity abandons the patient; withholding non-urgent care without a proper handover also violates the duty of care. Suppressing values entirely indefinitely is not a sustainable or required standard.

Question 138: A woman at 32 weeks gestation reports painless, bright red vaginal bleeding. Which condition does this presentation most suggest?

Cervical polyp
Placental abruption
Placenta previa (Correct answer)
Normal bloody show

Correct answer: Placenta previa

Painless bright red vaginal bleeding in the third trimester is the classic presentation of placenta previa.

Question 139: A frail older adult is admitted with dehydration. Which assessment finding best supports a nursing diagnosis of fluid volume deficit in this population?

Dry oral mucous membranes and elevated serum sodium (Correct answer)
Pitting oedema in the lower extremities
Bilateral crackles on lung auscultation
Blood pressure 140/90 mmHg

Correct answer: Dry oral mucous membranes and elevated serum sodium

Dry mucous membranes combined with elevated serum sodium are reliable indicators of fluid volume deficit in older adults.

Question 140: Which action when applying antiembolic stockings (TEDs) requires correction?

Measuring leg dimensions before applying
Applying while the client is recumbent
Removing and reapplying every 8 hours per policy
Applying stockings over a wound dressing (Correct answer)

Correct answer: Applying stockings over a wound dressing

TEDs must not be applied over wound dressings as this disrupts dressing integrity and may impair wound perfusion.

Question 141: A heart failure client being discharged home states: 'I can add extra salt to my food to maintain energy levels.' What does this indicate?

Appropriate discharge readiness
Understanding of fluid and sodium balance
Correct understanding of diet and activity balance
Need for further teaching: extra salt is contraindicated in heart failure (Correct answer)

Correct answer: Need for further teaching: extra salt is contraindicated in heart failure

Adding extra salt is contraindicated in heart failure as sodium causes fluid retention worsening cardiac workload and edema.

Question 142: A practical nurse is preparing to administer insulin glargine 20 units subcutaneously at 2200h as ordered. Upon drawing up the dose, the nurse notices the insulin solution appears slightly cloudy. The nurse's MOST appropriate action is:

Gently roll the vial between the palms to mix the insulin before drawing up the correct dose
Administer the insulin as drawn, as some cloudiness is expected with long-acting basal insulin formulations
Warm the vial under running water for 60 seconds to re-dissolve any precipitate before use
Discard the vial and obtain a new one, as insulin glargine should always be a clear, colourless solution (Correct answer)

Correct answer: Discard the vial and obtain a new one, as insulin glargine should always be a clear, colourless solution

Insulin glargine (Lantus, Basaglar, Toujeo) is a clear, colourless solution — unlike NPH insulin, it should NEVER be cloudy, as cloudiness indicates contamination, precipitation, or degradation. Administering compromised insulin glargine is unsafe and will not provide predictable glycemic control. The nurse must discard the vial and obtain a new one. This is a critical distinction from NPH or pre-mixed insulins, which are intentionally cloudy and require gentle mixing — confusing these properties is a common and dangerous error.

Question 143: A PN receives a gift of significant value from a grateful client upon discharge. The most professional response is to:

Accept it and share it with the care team
Accept it but report it to the manager afterward
Accept it graciously to avoid offending the client
Decline politely and explain professional boundaries regarding gifts (Correct answer)

Correct answer: Decline politely and explain professional boundaries regarding gifts

Accepting gifts of significant value can compromise professional boundaries and create real or perceived conflicts of interest.

Question 144: A child is brought to the clinic with a barking cough, inspiratory stridor, and low-grade fever. The nurse suspects:

Bronchiolitis
Croup (laryngotracheobronchitis) (Correct answer)
Epiglottitis
Pneumonia

Correct answer: Croup (laryngotracheobronchitis)

A barking seal-like cough with inspiratory stridor and low-grade fever are classic signs of croup caused by parainfluenza virus.

Question 145: A nurse is assigned to care for a client who was convicted of child sexual abuse. The nurse tells the charge nurse: 'I can provide basic physical care, but I cannot engage therapeutically with this person — my values won't allow it.' How should the charge nurse BEST respond?

Document the refusal as a disciplinary concern and report it to the regulatory body for failing to provide care.
Remind the nurse that personal values have no place in professional practice and insist they provide full therapeutic care.
Reassign the client immediately to a nurse without personal conflicts to ensure quality care.
Acknowledge the nurse's values, explore whether they can separate personal feelings from professional obligations, and if not, facilitate reassignment without stigmatizing the nurse. (Correct answer)

Correct answer: Acknowledge the nurse's values, explore whether they can separate personal feelings from professional obligations, and if not, facilitate reassignment without stigmatizing the nurse.

Nurses may hold deeply held personal values that create genuine conflict with caring for certain clients. The ethical and professional response is to acknowledge the nurse's self-awareness (which is itself a professional strength), assess whether the nurse can bracket personal feelings enough to provide non-judgmental therapeutic care, and facilitate a non-punitive reassignment if not. Insisting the nurse suppress values entirely (C) is unrealistic and may harm the client. Immediate reassignment without discussion (A) misses a supervisory opportunity. Disciplinary action (D) is disproportionate when the nurse proactively disclosed a conflict — this is responsible professional behaviour.

Question 146: A nurse working in an Indigenous community wants to incorporate cultural safety into health promotion activities. Which action BEST demonstrates cultural safety?

Providing transportation to the nearest urban health clinic
Translating all written materials into the local Indigenous language
Inviting community Elders to co-design and lead health sessions (Correct answer)
Displaying Indigenous artwork in the community health centre

Correct answer: Inviting community Elders to co-design and lead health sessions

Cultural safety goes beyond translation or décor by actively sharing power — co-designing programs with Elders ensures the community's values and knowledge shape the intervention.

Question 147: A client expresses anger and frustration about a delayed diagnostic test, stating, "No one here cares about what happens to me!" Which response by the practical nurse best maintains the therapeutic relationship?

"I can see you are very upset. Let's talk about what is frustrating you the most." (Correct answer)
"You shouldn't feel that way; we are all working hard to help you."
"The staff is very busy, but I'm sure the doctor is doing what's best for you."
"Why are you getting so angry? It won't make the test happen any faster."

Correct answer: "I can see you are very upset. Let's talk about what is frustrating you the most."

This response uses the therapeutic techniques of acknowledging the client's feelings and offering to explore the source of their frustration. This validates their experience and keeps communication open. Defending the staff, telling the client how to feel, and asking 'why' questions are all non-therapeutic techniques that can make the client defensive and block further communication.

Question 148: During the working phase of the therapeutic nurse-client relationship, what is the primary focus?

Completing documentation of nursing assessments for legal purposes
Identifying problems, collaborating on goals, and implementing strategies to promote health and coping (Correct answer)
Establishing trust and explaining the nurse's role
Reviewing progress and preparing the client for independent functioning

Correct answer: Identifying problems, collaborating on goals, and implementing strategies to promote health and coping

The working phase is the active therapeutic phase where problems are identified, goals are set, and interventions are implemented to achieve health outcomes.

Question 149: During end-of-life care, an 84-year-old man on a continuous subcutaneous morphine infusion for pain management develops Cheyne-Stokes respirations, mottled skin to the knees, and is unresponsive. His daughter arrives and insists the nurse increase the morphine dose to 'speed things up.' What is the most appropriate nursing response?

Increase the rate modestly, as the patient's comfort is the only priority at this stage
Explain that the current infusion is titrated for comfort and that hastening death intentionally falls outside the nurse's scope; offer to facilitate a palliative care physician consult (Correct answer)
Reduce the infusion rate to demonstrate that the medication is not causing death and reassure the daughter
Contact the physician to request a bolus dose because the family's distress constitutes a clinical indication

Correct answer: Explain that the current infusion is titrated for comfort and that hastening death intentionally falls outside the nurse's scope; offer to facilitate a palliative care physician consult

Intentionally hastening death at a family member's request — rather than for symptom relief — falls outside nursing scope and is ethically distinct from palliative sedation titrated for comfort. The nurse must uphold the doctrine of double effect while clearly explaining the distinction, declining to act outside scope, and facilitating appropriate medical consultation. Adjusting the dose for non-clinical reasons, in either direction, is inappropriate.

Question 150: A 3-year-old with known glucose-6-phosphate dehydrogenase (G6PD) deficiency is admitted with a urinary tract infection. Which antibiotic should the practical nurse flag as contraindicated and report to the physician before administration?

Cephalexin
Amoxicillin
Nitrofurantoin (Correct answer)
Azithromycin

Correct answer: Nitrofurantoin

Nitrofurantoin is an oxidant drug that can trigger acute hemolytic anemia in patients with G6PD deficiency. G6PD is essential for protecting red blood cells from oxidative damage; without it, oxidant drugs cause rapid RBC destruction. Amoxicillin, cephalexin, and azithromycin are not classified as oxidant drugs and are generally safe in G6PD deficiency.

Question 151: Which of the following scenarios constitutes a breach of client confidentiality by a practical nurse?

Discussing a client's difficult diagnosis with a spouse who is not the designated substitute decision-maker, without the client's consent. (Correct answer)
Informing the pharmacist about a client's allergy before dispensing a new medication.
Sharing client information with the oncoming nurse during a shift report.
Collaborating with the physiotherapist about a client's mobility status and care plan.

Correct answer: Discussing a client's difficult diagnosis with a spouse who is not the designated substitute decision-maker, without the client's consent.

Licensed Practical Nurses have a legal and ethical duty to protect the privacy and confidentiality of a client's personal health information. Disclosing information to anyone outside the immediate circle of care, including a spouse, without the client's explicit consent is a breach of this duty. Sharing information during shift report, with the pharmacist for medication safety, or with other members of the interdisciplinary team for care planning are all appropriate and necessary communications for providing safe care.

Question 152: A practical nurse assesses a client with chronic liver disease and notes asterixis. Which assessment technique is used to elicit this sign, and what does it indicate?

Asking the client to extend the arms and wrists with fingers spread and observing for a flapping tremor; indicates hepatic encephalopathy (Correct answer)
Asking the client to dorsiflex both feet and observing for calf pain; indicates deep vein thrombosis
Percussing the abdomen in all four quadrants and listening for fluid shifts; indicates ascites
Applying pressure to the nail bed and observing capillary refill; indicates peripheral vascular disease

Correct answer: Asking the client to extend the arms and wrists with fingers spread and observing for a flapping tremor; indicates hepatic encephalopathy

Asterixis ("liver flap") is elicited by asking the client to hold arms outstretched with wrists dorsiflexed. A flapping, non-rhythmic tremor results from the inability to maintain sustained postures due to metabolic disturbances — most notably the accumulation of ammonia in hepatic encephalopathy. It can also occur in renal failure (uremic encephalopathy) and CO2 narcosis, but in the context of liver disease it strongly suggests hepatic encephalopathy requiring urgent intervention.

Question 153: A practical nurse is reviewing the hand hygiene practices on the unit. Which clinical scenario represents an indication for handwashing with soap and water rather than alcohol-based hand rub (ABHR)?

After providing perineal care to a patient with Clostridioides difficile infection (Correct answer)
Before administering oral medications to a patient with no known infections
After removing gloves following a blood pressure assessment on a patient with MRSA
Before inserting a urinary catheter using sterile technique

Correct answer: After providing perineal care to a patient with Clostridioides difficile infection

Soap and water handwashing is specifically indicated over ABHR when caring for patients with C. difficile infection. C. diff produces spores that are NOT killed by alcohol-based hand rubs — physical removal by friction and water is required to mechanically remove spores from the hands. This is one of the critical exceptions to the general preference for ABHR. MRSA, blood pressure assessments, medication administration, and catheter insertions are all appropriate contexts for ABHR unless hands are visibly soiled.

Question 154: A client post-abdominal surgery reports sudden severe abdominal pain with board-like rigidity. What is the priority nursing action?

Administer analgesic and reassess in 30 minutes
Document and report at end of shift
Apply warm compress and continue monitoring
Position in semi-Fowlers and notify the physician immediately (Correct answer)

Correct answer: Position in semi-Fowlers and notify the physician immediately

Sudden severe pain with abdominal rigidity post-surgery suggests peritonitis or anastomotic leak requiring immediate medical intervention.

Question 155: Which scenario best illustrates transference in the nurse-client relationship?

The client agrees with everything the nurse says to avoid conflict.
The nurse shares personal experiences to help the client feel less alone.
The client treats the nurse as an authority figure similar to a strict parent from their past. (Correct answer)
The nurse feels irritated by a demanding client.

Correct answer: The client treats the nurse as an authority figure similar to a strict parent from their past.

Transference occurs when the client unconsciously redirects feelings from past significant relationships onto the nurse.

Question 156: A nurse is meeting a newly admitted client for the first time. The client is a refugee who recently experienced political persecution and is reluctant to answer questions or make eye contact. The nurse identifies a language barrier but no interpreter is currently available. Which action demonstrates the HIGHEST therapeutic use of self in this situation?

Ask a bilingual staff member from a different department to interpret to allow the assessment to proceed immediately.
Proceed with the full admission assessment using simple English and gestures, completing all required documentation to avoid care delays.
Postpone all non-urgent assessment, sit quietly near the client at a non-threatening distance, and use calm non-verbal presence while arranging for an interpreter before continuing. (Correct answer)
Explain to the client in simple terms that the questions are mandatory and that cooperation is required for appropriate care.

Correct answer: Postpone all non-urgent assessment, sit quietly near the client at a non-threatening distance, and use calm non-verbal presence while arranging for an interpreter before continuing.

Therapeutic use of self involves conscious, purposeful use of the nurse's personality, presence, and communication style to facilitate healing. For a trauma-affected refugee client with a language barrier, the most therapeutic immediate action is to establish psychological safety through calm, non-pressuring presence while ensuring a qualified interpreter is arranged before proceeding. Option A risks retraumatization and violates informed consent. Option C uses an ad hoc interpreter, which is inadequate for mental health and trauma-sensitive assessment. Option D is coercive and damages trust.

Question 157: When a practical nurse is performing the three checks of medication administration, which of the following is the correct procedure?

Check the medication label against the MAR in the medication room, once in the hallway, and again at the bedside.
Check the medication label against the MAR when removing it from the dispenser, when preparing it, and at the bedside before administering it. (Correct answer)
Check the medication label against the MAR when selecting it, at the bedside before opening, and when documenting.
Check the medication label against the MAR when selecting it, before pouring it, and after administering it.

Correct answer: Check the medication label against the MAR when removing it from the dispenser, when preparing it, and at the bedside before administering it.

The three checks of medication administration are a fundamental safety protocol. The nurse must check the medication against the Medication Administration Record (MAR) three times: 1) when taking the medication from its storage location, 2) when preparing or pouring the medication, and 3) at the client's bedside just before administering it.

Question 158: A nurse working in a mental health unit is in the termination phase of a therapeutic relationship with a long-term client. The client begins showing increased anxiety and regression to earlier maladaptive behaviors seen at admission. The nurse recognizes this as a potential indicator of:

A psychotic break requiring immediate psychiatric re-evaluation and possible medication adjustment.
The client's conscious manipulation to extend the therapeutic relationship beyond its appropriate endpoint.
A normal but clinically significant response to impending loss that warrants acknowledgment and therapeutic processing rather than extension of the relationship. (Correct answer)
Treatment failure indicating that the goals of the therapeutic relationship were never adequately established.

Correct answer: A normal but clinically significant response to impending loss that warrants acknowledgment and therapeutic processing rather than extension of the relationship.

Regression and anxiety during the termination phase is a well-recognized phenomenon that reflects the client's emotional response to the loss of the therapeutic relationship. It does not necessarily indicate treatment failure or a psychiatric emergency. The appropriate response is to acknowledge and therapeutically process these feelings, reinforcing the progress made, rather than extending or prematurely ending the relationship. Assuming manipulation (Option B) is a judgmental interpretation without clinical basis. Option D misattributes regression to goal-setting failure without supporting evidence.

Question 159: A nurse is caring for a client from a cultural background where prolonged direct eye contact is considered disrespectful. The nurse notices the client avoids eye contact during every interaction. Which interpretation is MOST clinically sound?

The client is demonstrating resistance to the therapeutic process and requires motivational interviewing.
The client is exhibiting a sign of clinical depression that warrants further psychiatric assessment.
The client has low self-esteem and the nurse should use therapeutic techniques to build confidence.
The client's behaviour is likely a culturally normative communication style, and the nurse should adapt accordingly. (Correct answer)

Correct answer: The client's behaviour is likely a culturally normative communication style, and the nurse should adapt accordingly.

In many cultural contexts, avoiding direct eye contact is a sign of respect, not psychopathology. Applying Western communication norms universally is ethnocentric and can lead to incorrect clinical assumptions. The nurse must distinguish between cultural communication differences and psychologically significant behaviours. Interpreting avoidance as depression (A), resistance (B), or low self-esteem (D) without further individualized assessment imposes cultural bias and may harm the therapeutic alliance.

Question 160: When inserting a peripheral IV line, which action breaks sterile technique?

Touching the needle tip after skin prep is complete (Correct answer)
Applying a transparent dressing over the insertion site
Using a new sterile catheter from packaging
Cleaning the site with chlorhexidine using friction

Correct answer: Touching the needle tip after skin prep is complete

Touching the needle tip after skin preparation contaminates the sterile field, directly increasing infection risk.

Question 161: Which behavior best demonstrates the nurse's use of empathy in the therapeutic relationship?

Saying, 'It sounds like this situation has been very overwhelming for you.' (Correct answer)
Assuring the client that everything will be fine.
Telling the client, 'I know exactly how you feel because I went through the same thing.'
Changing the subject when the client becomes emotional.

Correct answer: Saying, 'It sounds like this situation has been very overwhelming for you.'

Empathy involves reflecting the client's emotional experience accurately without projecting personal feelings or offering false reassurance.

Question 162: A PN disagrees with a team decision about a client's care plan. What is the most professional approach?

Report the disagreement to the client to gain support
Implement care according to personal judgment without telling the team
Express concerns respectfully during the team meeting and document the discussion (Correct answer)
Comply silently and avoid raising the issue

Correct answer: Express concerns respectfully during the team meeting and document the discussion

PNs are accountable to voice professional concerns respectfully within the team to advocate for client safety and quality care.

Question 163: Which technique is correct when performing shoulder ROM exercises?

Focus only on the affected side
Perform ROM only when requested by the client
Support the joint above and below and move within the pain-free range (Correct answer)
Move the joint as far as possible to maximize benefit

Correct answer: Support the joint above and below and move within the pain-free range

Supporting above and below the joint while staying within the pain-free range prevents injury during ROM.

Question 164: A practical nurse is administering insulin using a pen device shared on the unit for multiple clients. A colleague mentions this is acceptable because individual pen needles are changed between clients. What is the MOST accurate response by the nurse?

The practice is acceptable only if the pen contains a cartridge type rather than a pre-filled pen
The practice is safe because changing the needle between clients prevents cross-contamination of the needle itself
The practice is unsafe — insulin pens are single-client devices; reusing the pen body between clients risks backflow contamination of the medication reservoir regardless of needle changes (Correct answer)
The practice is safe as long as the nurse confirms the client's blood type before administration to check compatibility

Correct answer: The practice is unsafe — insulin pens are single-client devices; reusing the pen body between clients risks backflow contamination of the medication reservoir regardless of needle changes

Insulin pens — including the pen body and medication cartridge — are single-patient-use devices. When a needle is attached and the pen is used, blood can be drawn back into the cartridge through capillary action (backflow), contaminating the medication reservoir with bloodborne pathogens (HIV, hepatitis B, hepatitis C). Changing the needle does not eliminate this risk because the contamination is in the cartridge, not just the needle. Health Canada, ISMP Canada, and all provincial nursing regulatory bodies explicitly prohibit sharing insulin pen devices between clients. This has been associated with real-world bloodborne pathogen transmission events.

Question 165: A client is scheduled for elective surgery in 2 hours. The PN notes the client drank a full glass of water 30 minutes ago. What is the most appropriate action?

Reassure the client that a small amount of water is acceptable
Notify the surgeon and anesthesiologist immediately (Correct answer)
Administer a prescribed antiemetic to reduce aspiration risk
Document the finding and proceed with pre-op preparation

Correct answer: Notify the surgeon and anesthesiologist immediately

NPO (nothing by mouth) status is critical to prevent aspiration during anesthesia. Any oral intake within the pre-operative window must be reported to the surgeon and anesthesiologist immediately, as the case may need to be postponed.

Question 166: A practical nurse overhears a colleague making demeaning comments about an elderly client based on cognitive impairment. What is the primary professional obligation?

Ignore it since it did not directly affect care
Address the behavior with the colleague and report through appropriate professional channels (Correct answer)
Mention it informally to a friend without formal reporting
Document the incident in the client's chart

Correct answer: Address the behavior with the colleague and report through appropriate professional channels

Demeaning behavior toward clients requires immediate addressing and reporting. All clients have the right to be treated with dignity.

Question 167: Which principle underpins the practical nurse's obligation to obtain informed consent?

Autonomy (Correct answer)
Justice
Beneficence
Non-maleficence

Correct answer: Autonomy

Informed consent is fundamentally an expression of patient autonomy, the right to make informed decisions about one's own healthcare.

Question 168: During a therapeutic interaction, a client with borderline personality disorder says, 'You're the best nurse I've ever had — unlike that other nurse who is absolutely terrible and doesn't care about patients at all.' Recognizing this as a manifestation of splitting, what is the nurse's MOST appropriate initial response?

Acknowledge the client's feelings and, without validating the split perception, calmly restate that all team members are committed to the client's care. (Correct answer)
Tell the client it is not therapeutic to speak negatively about other nurses and set a firm limit on this type of conversation.
Agree that care quality varies among nurses and validate the client's positive experience with the current nurse.
Immediately document the client's complaint about the other nurse and initiate a formal incident review.

Correct answer: Acknowledge the client's feelings and, without validating the split perception, calmly restate that all team members are committed to the client's care.

Splitting — viewing people as entirely good or entirely bad — is a hallmark defense mechanism in borderline personality disorder. The therapeutic response is to neither validate the idealization nor the devaluation, and to reinforce the consistency and collective commitment of the team. Option A reinforces the split by agreeing. Option C misidentifies a psychological defense as a formal complaint. Option D is confrontational and shuts down communication, damaging the therapeutic relationship.

Question 169: A nurse working in a community mental health clinic has developed a strong therapeutic alliance with a client over 14 months. The client asks the nurse to attend their graduation ceremony 'just as a friend.' The nurse feels that refusing will damage the trust built over the long relationship. What is the MOST appropriate action?

Consult the care team and attend only if the team agrees it falls within acceptable therapeutic practice.
Accept the invitation because long-term therapeutic relationships evolve naturally into friendship.
Decline and use the request as a therapeutic opportunity to explore the client's relationship needs and boundaries. (Correct answer)
Attend briefly to honour the relationship milestone, then process the boundary crossing in supervision.

Correct answer: Decline and use the request as a therapeutic opportunity to explore the client's relationship needs and boundaries.

Attending a personal social event constitutes a boundary crossing that compromises professional objectivity and the therapeutic frame, regardless of relationship duration. The nurse's discomfort about 'damaging trust' by declining reflects counter-transference. Rather than attending, the nurse should decline clearly and use the request therapeutically — exploring what it means to the client, what needs it reflects, and reinforcing the professional relationship's value. Long-term therapeutic relationships do not naturally evolve into friendships (D), and peer endorsement does not make a boundary crossing appropriate (C).

Question 170: Which nursing intervention best supports the rehabilitation principle of 'restorative care'?

Restricting activity until the client is fully recovered to prevent injury
Delegating all rehabilitation activities to the physiotherapist
Completing tasks for the client to ensure efficiency and reduce fatigue
Encouraging the client to do as much as possible for themselves with guidance and support (Correct answer)

Correct answer: Encouraging the client to do as much as possible for themselves with guidance and support

Restorative care promotes the client's independence and functional ability by encouraging self-care with appropriate support. 'Doing for' the client when they are capable of doing themselves undermines recovery and prolongs dependence.

CPNRE Canadian Practical Nurse Registration Exam

The CPNRE certifies practical nurses in Canada with 170 questions over 4 hours, assessing professional practice, nurse-client partnerships, health alterations, and collaborative care.

170

Questions

240 min

Time Limit

60%

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