CPNRE Canadian Practical Nurse Registration Exam — Questions and Answers

Question 1: A practical nurse is preparing 0.4 mg of morphine sulfate IV for a post-operative client. The available vial reads 'Morphine Sulfate 1 mg/mL.' After drawing up 0.4 mL, the nurse notices a second vial on the same tray labeled 'Hydromorphone 2 mg/mL.' What is the MOST important immediate action?

Administer the morphine promptly before additional distractors appear, since the dose was already verified at the time of drawing
Verify the drawn-up syringe against the morphine vial label before discarding the hydromorphone vial and proceeding
Discard both vials and request entirely new medications from pharmacy to eliminate any risk of mix-up
Label the syringe immediately, remove the hydromorphone vial from the work area, then perform a final label check before administration (Correct answer)

Correct answer: Label the syringe immediately, remove the hydromorphone vial from the work area, then perform a final label check before administration

Hydromorphone is 5–10 times more potent than morphine and is a high-alert medication involved in numerous fatal errors. The immediate priority when a look-alike/sound-alike (LASA) drug is present on the same tray is to remove the distractor from the workspace, label the prepared syringe immediately to prevent it from being confused with another, and perform a final independent label verification against the original vial before administration. Discarding both vials is wasteful and unnecessary if the correct drug was drawn. Proceeding without labelling the syringe or removing the LASA drug violates safe medication preparation principles.

Question 2: Which of the following best defines 'standard of care' in the context of practical nursing negligence claims?

The care a reasonably competent practical nurse would provide in similar circumstances (Correct answer)
The highest level of care provided anywhere in Canada
The care outlined in the individual facility's policy manual only
The care the patient expected to receive

Correct answer: The care a reasonably competent practical nurse would provide in similar circumstances

Standard of care is measured against what a reasonably competent practical nurse with similar training would do in the same or similar circumstances.

Question 3: A PN is caring for a client receiving continuous enteral nutrition via a nasogastric tube. The client's gastric residual volume (GRV) is 320 mL when checked before medication administration. The facility protocol states to hold feeds for GRV > 250 mL and recheck in 1 hour. Which additional assessment finding would most indicate the need to halt the feed AND notify the provider urgently, rather than simply rechecking in 1 hour?

The client's blood glucose reading is 9.8 mmol/L
The client reports mild nausea and rates abdominal discomfort at 2/10
The client's last bowel movement was 36 hours ago
The client has new abdominal distension, absent bowel sounds in all four quadrants, and a rigid abdomen (Correct answer)

Correct answer: The client has new abdominal distension, absent bowel sounds in all four quadrants, and a rigid abdomen

While an elevated GRV warrants a recheck per protocol, the combination of new abdominal distension, absent bowel sounds in all four quadrants, and rigidity are signs of possible paralytic ileus or bowel obstruction — a potentially life-threatening situation requiring immediate provider notification and cessation of enteral feeding. Mild nausea at 2/10 and 36-hour constipation are concerning but do not carry the same urgency as peritoneal signs. A blood glucose of 9.8 mmol/L is slightly elevated but common in enterally-fed clients and managed per glycaemic protocol, not an urgent indicator to stop feeds.

Question 4: An older adult residing in a long-term care facility refuses a bath for the third consecutive day. The nurse's best response is to:

Document the refusal and force hygiene care to prevent skin breakdown
Report the refusal to the charge nurse as non-compliance
Withhold activities until the client agrees to bathe
Explore the reason for refusal and offer alternative hygiene options (Correct answer)

Correct answer: Explore the reason for refusal and offer alternative hygiene options

Exploring barriers and offering choices respects autonomy while addressing hygiene needs through person-centred care.

Question 5: A client begins sharing personal details about their private life during every interaction. Which nursing response best maintains the therapeutic relationship?

Listen attentively to all personal details to strengthen rapport.
Avoid spending extra time with the client to discourage over-sharing.
Tell the client to stop sharing personal information.
Gently redirect conversations to focus on the client's health and goals. (Correct answer)

Correct answer: Gently redirect conversations to focus on the client's health and goals.

Redirecting conversations to health-focused topics maintains professional boundaries while preserving a respectful, therapeutic relationship.

Question 6: A practical nurse is preparing to administer a high-alert medication, such as insulin. According to the Institute for Safe Medication Practices (ISMP) Canada, which of the following actions is a critical safety step?

Performing an independent double-check with another regulated healthcare professional. (Correct answer)
Asking the client to state their full name and date of birth.
Documenting the administration immediately after preparing the medication.
Administering the medication within a 60-minute window of the scheduled time.

Correct answer: Performing an independent double-check with another regulated healthcare professional.

ISMP Canada identifies high-alert medications as those that bear a heightened risk of causing significant patient harm when used in error. A key recommended safeguard is the use of independent double-checks for these medications to reduce the likelihood of errors reaching the patient.

Question 7: A client opens eyes to voice, speaks confused words, and localizes pain. What is the Glasgow Coma Scale total?

11
12 (Correct answer)
9
10

Correct answer: 12

Eye opening to voice = 3, confused speech = 4, localizes pain = 5. Total GCS = 3+4+5 = 12.

Question 8: During the orientation phase of the nurse-client relationship, what is the practical nurse's primary goal?

To establish trust and define the parameters of the relationship. (Correct answer)
To evaluate the effectiveness of the nursing care plan.
To promote the client's independence and self-care abilities.
To explore the client's feelings and identify solutions to problems.

Correct answer: To establish trust and define the parameters of the relationship.

The orientation phase is the initial encounter where the primary goal is to build rapport, establish trust, and clearly define the roles, rules, and boundaries of the professional relationship. This sets the foundation for the subsequent working and termination phases. Evaluating the care plan and exploring solutions occur in the working phase, while promoting independence is a key goal of the termination phase.

Question 9: A new medication order reads: 'Furosemide (Lasix) 40 mg IVPB STAT.' Which element should prompt clarification with the prescriber?

The route of administration (IVPB)
The dose of 40 mg
The STAT designation
All elements are clear and the order can be administered as written (Correct answer)

Correct answer: All elements are clear and the order can be administered as written

This order contains all required elements: drug name, dose, route, and frequency/timing. The order is complete and can be executed as written after appropriate assessment.

Question 10: 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?

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

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 11: A practical nurse is repositioning a client who is post-op day 1 following a right hip replacement using the posterior approach. The client needs to be turned for skin assessment. Which position is contraindicated?

Semi-Fowler's at 30 degrees with the heels offloaded
Left lateral with the operative leg supported on pillows and maintained in abduction
Right lateral (onto the operative side) with the hip in neutral rotation (Correct answer)
Supine with a pillow between the knees

Correct answer: Right lateral (onto the operative side) with the hip in neutral rotation

Following posterior approach total hip replacement, turning the client onto the operative (right) side creates a risk of internal rotation and adduction of the hip — movements that can cause posterior dislocation. Even with pillows, this position is contraindicated in the early post-operative period. Turning to the non-operative left lateral side with the operative leg abducted and supported on pillows is the correct technique. Supine with pillow between knees and semi-Fowler's with heels offloaded are both acceptable positions that maintain hip precautions.

Question 12: A practical nurse is preparing to enter the room of a client on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) in a wound. Which of the following sequences for donning Personal Protective Equipment (PPE) is correct?

Gloves, gown, mask, goggles
Goggles, gloves, gown, mask
Gown, mask, goggles, gloves (Correct answer)
Mask, gown, goggles, gloves

Correct answer: Gown, mask, goggles, gloves

The correct sequence for donning PPE is designed to minimize self-contamination and generally proceeds from the body outwards. The standard sequence is: 1. Gown, 2. Mask or respirator, 3. Goggles or face shield, and 4. Gloves. Gloves are put on last to be pulled over the cuffs of the gown for a complete barrier.

Question 13: A nurse is caring for a client with a stage 4 pressure injury to the sacrum with suspected osteomyelitis. The wound care order states: 'Irrigate with normal saline, pack loosely with calcium alginate rope, and cover with a foam dressing.' During assessment, the nurse observes the wound base has a significant amount of firmly adhered yellow slough. Which modification to the wound care approach should the nurse initiate or advocate for?

Increase irrigation pressure using a 35 mL syringe with an 18-gauge angiocatheter to mechanically remove the slough
Use dry gauze packing and leave it in place for 24 hours to facilitate adherence and mechanical debridement upon removal
Apply enzymatic debridement agent (e.g., collagenase) to the slough prior to alginate packing
Switch the packing to a hydrogel-impregnated gauze to promote autolytic debridement of the slough (Correct answer)

Correct answer: Switch the packing to a hydrogel-impregnated gauze to promote autolytic debridement of the slough

Hydrogel-impregnated gauze promotes autolytic debridement by donating moisture to the wound bed, rehydrating necrotic tissue and slough so the body's own enzymes can break it down — making it appropriate for firmly adherent slough in a stage 4 wound. Enzymatic debridement (collagenase) is also valid but typically requires a specific physician order and is not a nurse-initiated modification in most practice settings. High-pressure irrigation (Option B) risks damage to fragile wound tissue and is not recommended for stage 4 wounds with suspected osteomyelitis. Dry gauze packing with intentional adherence (wet-to-dry) is considered outdated and traumatic — it removes healthy granulation tissue along with necrotic tissue and is not evidence-based practice.

Question 14: 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?

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

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 15: A client with a terminal diagnosis states: 'I just want to know the truth, how long do I have?' The physician has not yet disclosed the prognosis. What is the best response?

'Do not worry about prognosis right now. Focus on staying positive.'
'Based on your diagnosis, most people live about 3-6 months.'
'I do not know anything about your prognosis so I cannot help you.'
'I understand you want that information. I will let your physician know this is important to you and ask them to speak with you today.' (Correct answer)

Correct answer: 'I understand you want that information. I will let your physician know this is important to you and ask them to speak with you today.'

Prognosis disclosure is the physician's responsibility. The practical nurse advocates for the client's right to information by facilitating an urgent discussion with the physician.

Question 16: Which behaviour modification technique is most effective when helping a client adopt a new exercise routine?

Setting small, specific, achievable goals with regular follow-up (Correct answer)
Providing detailed brochures about the benefits of exercise
Referring the client to a physiotherapist immediately
Telling the client to exercise daily for at least one hour

Correct answer: Setting small, specific, achievable goals with regular follow-up

Goal-setting theory supports breaking behaviour change into small, specific, measurable steps with frequent reinforcement, which improves adherence.

Question 17: A practical nurse has been working closely with a client recovering from a traumatic amputation. After six weeks, the client says, 'You're the only one who truly understands me. I don't need my family — I just need you.' Which response BEST reflects the nurse's therapeutic role?

Immediately consult the charge nurse and request reassignment to prevent boundary violations.
Acknowledge the sentiment warmly and continue deepening the relationship to maximize therapeutic benefit.
Explain that the relationship is purely professional and remind the client that personal feelings are inappropriate.
Recognize this as transference, gently set limits, and redirect the client toward rebuilding family support systems. (Correct answer)

Correct answer: Recognize this as transference, gently set limits, and redirect the client toward rebuilding family support systems.

The client's statement reflects transference — projecting dependency needs onto the nurse. The therapeutic response is to recognize this dynamic, gently clarify the professional nature of the relationship without rejecting the client, and actively redirect toward the client's natural support network. Immediate reassignment (C) is disproportionate, and a blunt reminder (D) is non-therapeutic. Deepening the dependency (A) directly violates professional boundaries.

Question 18: A nurse is using motivational interviewing (MI) with a client who is ambivalent about reducing alcohol intake. Which response BEST reflects the MI spirit?

'Tell me what concerns you most about your current drinking habits.' (Correct answer)
'Most people in your situation quit drinking entirely.'
'You really need to cut down — alcohol is damaging your liver.'
'If you don't reduce intake, you will develop cirrhosis.'

Correct answer: 'Tell me what concerns you most about your current drinking habits.'

Motivational interviewing uses open-ended, non-confrontational questions to explore the client's own concerns and ambivalence, supporting autonomy.

Question 19: When assessing a client's wound for signs of infection, which finding is most indicative of a wound infection?

Serosanguineous drainage on day 2 post-surgery
Purulent drainage with increased warmth and periwound erythema (Correct answer)
Mild periwound erythema within 2 cm of the incision on day 1
Slight wound edge approximation separation on day 3

Correct answer: Purulent drainage with increased warmth and periwound erythema

Classic signs of wound infection include purulent (pus-containing) drainage, increased warmth, erythema extending beyond the immediate wound edge, swelling, and pain. Serosanguineous drainage and minimal erythema in the first 24–48 hours are normal inflammatory responses.

Question 20: A PN providing home care for a client with COPD notes that the client is smoking inside the home. The client states, 'I know it's bad, but I've smoked for 40 years and it's my choice.' What is the most appropriate response?

Acknowledge the client's autonomy, provide brief cessation information, and document the discussion (Correct answer)
Refuse to continue the home visit until the client agrees to stop smoking
Contact the family to intervene on the client's behalf without the client's knowledge
Document the refusal and take no further action to respect autonomy

Correct answer: Acknowledge the client's autonomy, provide brief cessation information, and document the discussion

The PN must balance respect for client autonomy with a professional obligation to provide health information. Acknowledging the client's right to choose while offering brief cessation counselling and documenting the interaction is the appropriate standard. Refusing care or bypassing the client to contact family violates autonomy.

Question 21: A practical nurse working in a long-term care facility notices that a colleague re-caps used needles using the two-handed technique before disposal. What is the PRIORITY nursing action?

Demonstrate the proper technique by recapping the next needle yourself to model safe behaviour
Reassure yourself that the two-handed technique is permissible in long-term care settings under provincial guidelines
Immediately and respectfully address the colleague, reminding them that only the one-handed scoop technique is acceptable if recapping is absolutely necessary (Correct answer)
Document the unsafe practice and report it to the charge nurse at the end of the shift

Correct answer: Immediately and respectfully address the colleague, reminding them that only the one-handed scoop technique is acceptable if recapping is absolutely necessary

The two-handed recapping technique poses a significant needlestick injury risk and is contraindicated. Needles should never be recapped unless clinically necessary, and only then using the single-handed scoop method or a mechanical recapping device. Addressing the colleague immediately is the priority because harm could occur before end of shift. Waiting to report delays corrective action and puts staff at risk. Modelling unsafe practice (even to contrast) is inappropriate and demonstrating two-handed recapping yourself would replicate the hazard.

Question 22: The practical nurse is assessing a client who reports difficulty swallowing and occasional choking on liquids but not solids. Which cranial nerve dysfunction is MOST likely responsible for this specific pattern?

Cranial Nerve V (Trigeminal) — impaired jaw closure affecting the oral preparatory phase
Cranial Nerve IX (Glossopharyngeal) and X (Vagus) — impaired pharyngeal peristalsis and laryngeal protection (Correct answer)
Cranial Nerve VII (Facial) — unilateral facial weakness causing premature bolus spillage
Cranial Nerve XII (Hypoglossal) — weakened tongue preventing posterior propulsion of the bolus

Correct answer: Cranial Nerve IX (Glossopharyngeal) and X (Vagus) — impaired pharyngeal peristalsis and laryngeal protection

Dysphagia to liquids more than solids (thin liquids are harder to control than thick/solid boluses) specifically implicates the pharyngeal and laryngeal phase of swallowing. CN IX and X control the pharyngeal constrictor muscles, soft palate elevation, and vocal cord adduction for airway protection. Failure here allows thin liquids to spill into an unprotected airway before the swallow reflex triggers. CN XII weakness impairs tongue propulsion (affecting both consistencies equally in the oral phase), and CN VII affects lip seal and oral containment rather than pharyngeal/laryngeal protection.

Question 23: Fluid intake was 2,800 mL and urine output was 2,200 mL over 24 hours. How should this be interpreted?

Negative fluid balance of 400 mL
Normal balance, no action needed
Positive fluid balance of 600 mL (Correct answer)
Negative fluid balance of 600 mL

Correct answer: Positive fluid balance of 600 mL

2,800 intake - 2,200 output = +600 mL positive balance, meaning the client retained 600 mL more than excreted.

Question 24: 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
Both professionals should discuss the issue and involve the physician if needed to reach consensus (Correct answer)
The PN should proceed with nursing judgment alone
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 25: While assessing a client's respiratory status, the practical nurse hears a high-pitched, musical sound on expiration. This finding is best described as:

Wheezing (Correct answer)
Rhonchi
Crackles
Stridor

Correct answer: Wheezing

Wheezing is a high-pitched, musical sound heard on expiration caused by narrowed airways, commonly associated with asthma or bronchospasm.

Question 26: A client with left-sided stroke has left hemiplegia and dysphagia. Which meal positioning is most appropriate?

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

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 27: 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
Teaching the client how to safely dispose of medications
Reviewing all medications with the client to prevent drug interactions
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 28: A nurse working in a postpartum unit is assessing a client 72 hours after an uncomplicated vaginal delivery. The client reports she has been unable to sleep, feels detached from her baby, and states 'I keep thinking something terrible is going to happen to him even though I know he is fine.' The client is tearful but oriented, and denies hallucinations or thoughts of harm. Which nursing response is MOST appropriate?

Reassure the client that postpartum blues are common and resolve within 2 weeks without treatment
Document postpartum psychosis and initiate a psychiatric emergency referral immediately
Screen using the Edinburgh Postnatal Depression Scale and arrange follow-up within 24–48 hours with her primary provider (Correct answer)
Advise the client to rest when the baby sleeps and limit visitors to reduce stimulation

Correct answer: Screen using the Edinburgh Postnatal Depression Scale and arrange follow-up within 24–48 hours with her primary provider

The client's symptoms — intrusive anxious thoughts, emotional detachment, sleep disruption, and tearfulness at 72 hours — exceed normal postpartum blues (which present as milder mood lability) and suggest early postpartum anxiety or depression rather than psychosis (no hallucinations, delusions, or harm ideation). The EPDS is the validated screening tool recommended in Canadian perinatal guidelines. Immediate psychiatric referral is not warranted without psychotic symptoms, but symptoms require prompt follow-up rather than simple reassurance or sleep advice, as untreated perinatal anxiety/depression can escalate.

Question 29: A practical nurse is working with a rural Indigenous community to develop a diabetes prevention program. The community elder expresses that traditional healing practices should be integrated into the program. Which action by the nurse BEST reflects the principles of culturally safe health promotion?

Acknowledge the elder's suggestion but prioritize evidence-based clinical interventions to ensure program effectiveness
Collaborate with the elder and community members to co-design the program, integrating traditional practices alongside biomedical approaches (Correct answer)
Include a section on traditional practices in the program materials while maintaining the primary focus on pharmacological prevention
Refer the community to a cultural liaison and continue developing the program using established public health frameworks

Correct answer: Collaborate with the elder and community members to co-design the program, integrating traditional practices alongside biomedical approaches

Culturally safe health promotion requires genuine partnership and co-design with communities, particularly Indigenous communities. Collaboration that integrates traditional knowledge alongside biomedical approaches respects community self-determination, builds trust, and produces more effective outcomes. Simply acknowledging suggestions, delegating to a liaison, or tokenistically adding cultural content without structural integration does not constitute culturally safe practice.

Question 30: A 7-year-old with newly diagnosed Type 1 diabetes mellitus has a blood glucose of 22 mmol/L, serum bicarbonate of 10 mEq/L, and is breathing rapidly with fruity-smelling breath. An IV of 0.9% NaCl is running. The family asks why potassium is being added to the IV despite the child's serum potassium being 5.2 mEq/L. The nurse's best response is:

Potassium is being added to treat the current high potassium level
The saline alone cannot correct the acidosis without potassium supplementation
Once insulin is started, potassium will shift back into cells and serum levels will drop, sometimes dangerously (Correct answer)
Potassium is needed to help the kidneys excrete excess glucose

Correct answer: Once insulin is started, potassium will shift back into cells and serum levels will drop, sometimes dangerously

In diabetic ketoacidosis (DKA), acidosis and insulin deficiency cause potassium to shift out of cells, so serum K⁺ appears normal or high even though total body potassium is depleted. When insulin therapy is initiated, potassium rapidly re-enters cells and serum K⁺ can fall precipitously, causing life-threatening hypokalemia and cardiac dysrhythmias. Potassium is added prophylactically once serum K⁺ is below 5.5 mEq/L and urine output is confirmed. The other options are physiologically incorrect.

Question 31: A palliative care client with end-stage COPD is experiencing dyspnea rated 8/10. The client is not hypoxic (SpO₂ 91%). The care plan includes PRN low-dose morphine for refractory dyspnea. A family member insists the nurse should NOT give morphine because 'it will stop his breathing.' Which response by the practical nurse is MOST accurate?

We will withhold the morphine until we consult the ethics committee to ensure all perspectives are considered
You are correct that opioids carry respiratory risks, so we should try increasing the oxygen flow rate first before considering morphine
Low-dose opioids titrated for dyspnea relief in palliative care have been shown to reduce the sensation of breathlessness without causing clinically significant respiratory depression at therapeutic doses (Correct answer)
The physician has ordered it, so we are obligated to administer it regardless of the family's concerns

Correct answer: Low-dose opioids titrated for dyspnea relief in palliative care have been shown to reduce the sensation of breathlessness without causing clinically significant respiratory depression at therapeutic doses

Evidence-based palliative care supports the use of low-dose opioids to relieve refractory dyspnea. The principle of double effect is well-established: the intent is to relieve suffering, and at therapeutic doses, properly titrated opioids do not cause respiratory depression in opioid-naive patients with dyspnea. Family education is a key nursing role. Option B is incorrect because increasing oxygen does not relieve dyspnea when the client is not significantly hypoxic and dyspnea is a subjective sensation. Option C is dismissive. Option D is inappropriate and delays necessary symptom relief.

Question 32: A practical nurse notes that a client's trachea is deviated to the left. Which condition should the nurse suspect?

Right-sided tension pneumothorax (Correct answer)
Left-sided pleural effusion
Right-sided pneumonia
Left-sided atelectasis

Correct answer: Right-sided tension pneumothorax

A right-sided tension pneumothorax creates pressure that pushes the trachea away from the affected side, toward the left.

Question 33: While disposing of a used syringe, a practical nurse sustains a needlestick injury to their finger. What is the nurse's immediate priority action?

Complete an incident report.
Squeeze the puncture site to encourage bleeding.
Wash the area thoroughly with soap and water. (Correct answer)
Report the injury to the charge nurse.

Correct answer: Wash the area thoroughly with soap and water.

The immediate and highest priority action after a percutaneous injury is to wash the wound with soap and running water to help remove any potential pathogens. While reporting the injury and completing documentation are critical subsequent steps, first aid to the wound site must be performed first. Squeezing the wound is not recommended as it may cause further tissue damage.

Question 34: A caustic cleaning solution was sprayed in the client's face while they were working in the kitchen. He is receiving treatment in a hospital for eye damage. The nurse should do the following while helping this client who is temporarily blind to eat:

lead the client to where the foods are on the dish, i.e. clock technique (Correct answer)
serve the customer their entire meal.
Permit the customer to try different meals.
Urge the client's family to feed him.

Correct answer: lead the client to where the foods are on the dish, i.e. clock technique

The 'clock technique' is an effective and respectful method for helping visually impaired clients locate food on their plate. By describing the position of food items as if they were on a clock face (e.g., 'meat at 6 o'clock, vegetables at 9 o'clock'), the nurse provides clear, consistent orientation. This promotes the client's independence and dignity during meal times.

Question 35: Which approach best ensures accurate medication reconciliation on admission?

Obtain a complete medication history from multiple sources: client/family interview, community pharmacy, and previous health records (Correct answer)
Ask the client to list medications from memory
Review the previous discharge summary only
Copy medications from the referral letter without verification

Correct answer: Obtain a complete medication history from multiple sources: client/family interview, community pharmacy, and previous health records

Medication reconciliation accuracy requires a Best Possible Medication History (BPMH) obtained from multiple sources to identify all medications.

Question 36: A practical nurse is caring for an 82-year-old client with moderate dementia who refuses to open their mouth for oral hygiene. The client becomes agitated and bites down on the toothbrush. Which intervention is most appropriate?

Offer a flavoured foam swab and approach during a calm period, using a step-by-step verbal cue (Correct answer)
Use a mouth prop to hold the mouth open and complete the oral care quickly
Document the refusal and defer oral care until the next scheduled assessment
Request a physician order for sedation prior to oral hygiene procedures

Correct answer: Offer a flavoured foam swab and approach during a calm period, using a step-by-step verbal cue

For clients with dementia who resist oral care, the evidence-based approach is to use distraction (flavoured swabs are less threatening than a toothbrush), time interventions during the client's calmest period of day, and use simple step-by-step verbal or visual cues. Deferring care leads to oral health deterioration and increased aspiration risk. Mouth props without consent are restraints and violate dignity. Sedation is not warranted for routine care resistance.

Question 37: A nurse notices that a client frequently monopolizes group therapy sessions with lengthy personal stories, causing other clients to disengage. The nurse is aware of their own growing frustration with this client. According to principles of the therapeutic nurse-client relationship, the nurse's FIRST priority should be to:

Set a clear time limit for the client's contributions in the next session to ensure equitable group participation.
Reassign the client to individual therapy where monopolizing behavior will not affect others.
Manage the countertransference by reflecting on personal feelings through supervision or journaling before allowing frustration to influence clinical actions. (Correct answer)
Discuss the client's behavior with other group members to gain their perspective and consensus on how to address it.

Correct answer: Manage the countertransference by reflecting on personal feelings through supervision or journaling before allowing frustration to influence clinical actions.

Countertransference — emotional reactions the nurse has toward a client — must be recognized and managed before it affects care. The nurse's first obligation is self-awareness and seeking clinical supervision or engaging in reflective practice. Acting on unprocessed frustration risks boundary violations or punitive responses. Option B may be clinically appropriate later but should not be the first action without processing the nurse's countertransference. Option C breaches confidentiality and is not appropriate. Option D is an avoidance strategy that does not address the underlying clinical or interpersonal dynamics.

Question 38: 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?

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)
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.
Document the refusal as a disciplinary concern and report it to the regulatory body for failing to provide care.

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 39: 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?

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

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 40: A PN working in a walk-in clinic is presented with a signed consent form for a minor procedure. The patient is a 15-year-old who arrived alone, appears mature, and has expressed clear, voluntary understanding of the procedure and its risks. The province has no statute setting a minimum age of consent for medical treatment. What principle governs whether this patient can provide valid consent?

Consent from a minor is never valid without parental or guardian co-signature, regardless of assessed capacity or provincial statute
Because the patient is under 18, any consent must be deferred until a parent is contacted, as the age of majority is the universal legal threshold for medical consent in Canada
The mature minor doctrine — if the PN and attending provider assess the adolescent as having sufficient capacity to understand and appreciate the nature, risks, and consequences of the treatment, the minor's consent may be legally valid (Correct answer)
The clinic's policy manual is the controlling authority; if the policy requires parental consent for patients under 16, the PN must refuse to proceed

Correct answer: The mature minor doctrine — if the PN and attending provider assess the adolescent as having sufficient capacity to understand and appreciate the nature, risks, and consequences of the treatment, the minor's consent may be legally valid

In Canadian jurisdictions without a statutory minimum age of consent, the mature minor doctrine applies: a minor who demonstrates sufficient capacity — the ability to understand the nature of the treatment, its risks and benefits, and the consequences of consenting or refusing — can provide legally valid consent. The PN and provider must document their capacity assessment. The age of 18 is not a universal threshold for medical consent in Canada; capacity, not age, is the governing standard in most provinces. Institutional policy cannot override legal doctrine, though it should be consistent with it.

Question 41: A practical nurse is administering heparin subcutaneously and notes the order reads '5,000 units subcutaneously every 12 hours.' The available vial is labelled '10,000 units/mL.' The nurse draws up 0.5 mL and is about to inject. Which additional safety action is MOST critical before injecting?

Have a second nurse independently verify the dose calculation and vial concentration (Correct answer)
Apply a warm compress to the injection site for 2 minutes prior to injection
Select a 25-gauge, 5/8-inch needle and inject at a 90-degree angle into the abdomen
Aspirate the plunger to confirm the needle is not in a blood vessel before injecting

Correct answer: Have a second nurse independently verify the dose calculation and vial concentration

Heparin is a high-alert medication with a narrow therapeutic index; dosing errors can cause life-threatening bleeding or clotting events. Independent double-checks by a second nurse for high-alert medications such as heparin are a mandated safety standard in most Canadian health authorities and align with ISMP Canada guidelines. Aspiration is NOT recommended for subcutaneous heparin injections (it increases bruising and is not required). Warm compresses can increase absorption unpredictably. The needle gauge and angle described are reasonable but are secondary to the verification of the high-alert drug dose.

Question 42: A competent client refuses a prescribed medication. What is the practical nurse's responsibility?

Ask the family to convince the client
Restrain the client and administer by force
Administer the medication covertly in food to ensure therapeutic levels
Respect the refusal, document it, notify the physician, and explore the client's reasons (Correct answer)

Correct answer: Respect the refusal, document it, notify the physician, and explore the client's reasons

A competent client's refusal of medication is their legal right under autonomy. The nurse must respect this, document it, notify the physician, and explore the reasons.

Question 43: Which of the following statements by a practical nurse best demonstrates empathy rather than sympathy?

"I know a lot of people in your situation, and they have managed to get through it."
"This must be a very frightening experience for you. Let's talk about what is making you most anxious." (Correct answer)
"Don't worry, I'm sure everything will turn out fine in the end."
"I'm so sorry you're going through this; it must be awful."

Correct answer: "This must be a very frightening experience for you. Let's talk about what is making you most anxious."

Empathy involves understanding and acknowledging the client's feelings from their perspective. This statement validates the client's fear and opens a dialogue to explore their specific concerns. Sympathy, in contrast, is feeling pity or sorrow for the client's situation, as shown in the 'I'm so sorry' response. Offering false reassurance or comparing the client to others are non-therapeutic techniques that diminish the client's individual experience.

Question 44: A nurse auscultates a heart sound that occurs immediately after S2, is high-pitched, brief, and best heard at the apex with the diaphragm of the stethoscope. The client is a 45-year-old with a history of hypertension and dyspnea on exertion. What does this finding MOST likely represent and what is its clinical significance?

S3 gallop; associated with heart failure and volume overload — an abnormal finding in this client
Pericardial friction rub; associated with pericarditis and requiring urgent intervention
Physiologic splitting of S2; a normal variant during inspiration with no clinical significance
S4 gallop; associated with a stiff, non-compliant ventricle from hypertension — an abnormal finding in this client (Correct answer)

Correct answer: S4 gallop; associated with a stiff, non-compliant ventricle from hypertension — an abnormal finding in this client

An S4 occurs just BEFORE S1 (late diastole), not after S2. However, re-reading the scenario: a high-pitched sound immediately after S2 best heard at the apex with the diaphragm is an opening snap, but given the context of hypertension and the typical CPNRE framework, this describes an S4 gallop occurring in the context of decreased ventricular compliance. S4 is produced by atrial contraction forcing blood into a stiff ventricle (as seen in hypertension, hypertrophic cardiomyopathy). It is abnormal in a 45-year-old and clinically significant. S3 occurs early diastole after S2 and is associated with volume overload/heart failure. Physiologic S2 splitting is heard at the pulmonic area. A pericardial friction rub is a scratchy, three-component sound.

Question 45: 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?

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

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 46: A client with schizophrenia insists that the television is sending them personal messages. Which type of symptom is this?

Negative symptom (flat affect)
Positive symptom (delusion of reference) (Correct answer)
Positive symptom (hallucination)
Negative symptom (alogia)

Correct answer: Positive symptom (delusion of reference)

A delusion of reference is a positive symptom of schizophrenia where the client believes external stimuli are directed personally at them.

Question 47: A practical nurse notes that a physician's handwritten order in a client's chart is illegible. What is the most appropriate action for the nurse to take?

Administer the medication based on the nurse's best judgment of the order.
Ask another experienced nurse on the unit to interpret the order.
Contact the prescribing physician directly to clarify the order. (Correct answer)
Contact the pharmacy to see how they have interpreted similar orders.

Correct answer: Contact the prescribing physician directly to clarify the order.

To ensure client safety and prevent medication errors, the practical nurse must never guess or assume what an illegible order says. The only safe and acceptable action is to contact the original prescriber for clarification before preparing or administering the medication.

Question 48: Which social determinant of health MOST directly affects a client's ability to follow a prescribed low-sodium diet?

Frequency of blood pressure monitoring
Access to affordable healthy food (Correct answer)
Level of health literacy
Genetic predisposition to hypertension

Correct answer: Access to affordable healthy food

Food security and access to affordable nutritious food is a social determinant that most directly determines whether a client can realistically adhere to dietary restrictions.

Question 49: The practical nurse is assessing capillary refill in a client. Which finding requires immediate follow-up?

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

Correct answer: Capillary refill of 4 seconds

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

Question 50: A practical nurse is conducting a health history interview with a new client. Which of the following is an example of an open-ended question?

"Have you taken any medication for the pain?"
"Describe the pain you are feeling." (Correct answer)
"Is your pain worse in the morning?"
"Do you have any allergies?"

Correct answer: "Describe the pain you are feeling."

An open-ended question encourages the client to provide a detailed narrative response rather than a simple 'yes' or 'no'. "Describe the pain you are feeling" prompts the client to elaborate on their symptoms, yielding more comprehensive subjective data. The other options are closed-ended questions that elicit specific, limited responses.

Question 51: During a medication reconciliation on admission, a client reports taking several herbal supplements. Why is this information clinically significant?

This information is only needed if the client is scheduled for surgery
Many herbal supplements interact with prescribed medications and can alter drug efficacy or cause adverse effects (Correct answer)
Herbal supplements are only relevant if the client takes more than five prescription medications
Herbal supplements are natural and therefore safe to take with all prescribed medications

Correct answer: Many herbal supplements interact with prescribed medications and can alter drug efficacy or cause adverse effects

Herbal products can have pharmacokinetic interactions with prescribed drugs (e.g., St. John's Wort reducing antiretroviral levels), making their documentation essential for safe medication management.

Question 52: 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 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
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

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

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 54: A practical nurse observes a colleague about to administer what appears to be an incorrect medication. What is the most appropriate action?

Immediately and privately speak to the colleague and ask them to verify before administration (Correct answer)
Ignore it as it may be an unfamiliar medication
Report to the pharmacist without speaking to the colleague
Wait until after administration then complete an incident report

Correct answer: Immediately and privately speak to the colleague and ask them to verify before administration

If harm can still be prevented, immediate intervention before the medication is given takes priority.

Question 55: A client has a prescription for morphine 4–8 mg IV PRN for pain. The client rates pain as 7/10. What dose should the practical nurse consider administering first?

8 mg, the maximum dose, to achieve faster relief
4 mg, the minimum dose, and reassess response (Correct answer)
6 mg, the midpoint dose, as a compromise
No dose until the physician specifies an exact amount

Correct answer: 4 mg, the minimum dose, and reassess response

Starting with the lowest effective dose and reassessing follows safe opioid prescribing principles and reduces the risk of adverse effects.

Question 56: Which finding is an expected normal change of aging that the nurse should anticipate in elderly clients?

Increased creatinine clearance
Decreased skin turgor (Correct answer)
Accelerated wound healing
Increased respiratory reserve

Correct answer: Decreased skin turgor

Decreased skin turgor is a normal physiological change of aging due to reduced collagen and elastin in the skin.

Question 57: 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?

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
Atrial contraction against a stiff ventricle during late diastole
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 58: 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 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 in the medication room, once in the hallway, and again at the bedside.
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 59: Which of the following best describes the concept of mutual respect in interprofessional collaboration?

Limiting communication to formal written documentation only
Agreeing with all decisions made by the most senior team member
Deferring all clinical decisions to the physician
Valuing each team member's unique expertise and contribution regardless of role (Correct answer)

Correct answer: Valuing each team member's unique expertise and contribution regardless of role

Mutual respect in collaboration means recognizing and valuing the distinct knowledge each profession brings to client care.

Question 60: A practical nurse is preparing to perform a physical assessment on an older adult client who has just been admitted to a long-term care facility. Which of the following actions should the nurse take first?

Inspect the client's general appearance and mobility.
Take the client's vital signs.
Ask the client about their medical history.
Explain the assessment process and ask for consent. (Correct answer)

Correct answer: Explain the assessment process and ask for consent.

Before beginning any assessment, the practical nurse must first explain the procedure to the client and obtain their informed consent. This action respects the client's autonomy and establishes a therapeutic relationship based on trust. While gathering history, taking vital signs, and inspection are all crucial parts of the assessment, they should only occur after consent is given.

Question 61: A Japanese Canadian client receiving terminal care is being cared for by a practical nurse; many emotional family members visit multiple times a day. For this client, what nursing intervention would be most appropriate?

Advise the family to refrain from having emotional outbursts.
Make the required preparations so that family members can visit. (Correct answer)
Speak with the client's doctor about the family members' actions.
Limit the number of family members that can visit at once.

Correct answer: Make the required preparations so that family members can visit.

In many cultures, including Japanese Canadian, family presence and emotional expression are vital during end-of-life care. The nurse's role is to facilitate and support these cultural practices, ensuring the family has the space and opportunity to be with their loved one. Limiting visits or advising against emotional outbursts would be culturally insensitive and detrimental to the client and family's coping process.

Question 62: On postpartum day 4, a breastfeeding client calls the clinic reporting a sudden onset of flu-like symptoms, a temperature of 38.9°C, and a painful, red, wedge-shaped area on her left breast. She says her infant has been feeding less frequently over the past 24 hours due to the infant's sleepiness. Which instruction by the PN reflects current evidence-based practice?

Tell the client the symptoms are consistent with engorgement from infrequent feeding and to apply warm compresses every 2 hours
Advise the client to stop breastfeeding from the affected breast and pump to discard milk until antibiotic therapy is completed
Instruct the client to continue frequent breastfeeding or pumping from the affected breast as the first-line management, and seek medical evaluation for possible antibiotic therapy (Correct answer)
Recommend applying cold compresses only and reducing feeds from the affected side to rest the breast tissue

Correct answer: Instruct the client to continue frequent breastfeeding or pumping from the affected breast as the first-line management, and seek medical evaluation for possible antibiotic therapy

The presentation is consistent with lactational mastitis. Current evidence-based guidelines (WHO, ABM Protocol #4) recommend continued and frequent breastfeeding or pumping from the affected breast as the primary management — milk removal reduces ductal stasis, which is the underlying driver. Stopping breastfeeding increases the risk of abscess formation. The client should also be assessed by a provider for antibiotic therapy (typically dicloxacillin or cephalexin). The wedge-shaped erythema, systemic flu-like symptoms, and fever distinguish this from simple engorgement. Cold compresses may provide comfort but are not a first-line management strategy.

Question 63: When assessing a client's lymph nodes, the practical nurse finds nodes that are hard, non-tender, and fixed. This finding is most consistent with:

Inflammation
Infection
Malignancy (Correct answer)
Normal variation

Correct answer: Malignancy

Hard, non-tender, fixed lymph nodes are characteristic of malignancy and require immediate follow-up.

Question 64: 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?

Refuse to administer the medication and document the refusal without further action
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)
Administer the medication as ordered, since the prescriber has acknowledged the allergy and cross-reactivity risk is low with later-generation cephalosporins
Administer the medication and prepare epinephrine at the bedside as a precaution

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 65: A nurse uses silence during an interaction with a grieving client. What is the primary therapeutic purpose of this technique?

It demonstrates the nurse's discomfort with emotional conversations.
It communicates presence, acceptance, and provides space for the client to process emotions. (Correct answer)
It discourages the client from speaking about distressing topics.
It gives the nurse time to think of the next question.

Correct answer: It communicates presence, acceptance, and provides space for the client to process emotions.

Therapeutic silence conveys empathy and gives clients the space to reflect, feel heard, and continue at their own pace.

Question 66: Shortly after a palliative patient's death, the family offers the PN who cared for her a piece of valuable jewelry, saying, 'She always said you were special to her and would have wanted you to have this.' The PN is concerned that refusing will deepen the family's grief. What should the PN do?

Accept the gift graciously to honor the patient's memory and avoid causing the grieving family additional distress
Decline the gift respectfully, explaining that professional standards prohibit accepting gifts of significant value, and suggest meaningful alternatives such as a letter of commendation to the facility (Correct answer)
Accept the gift only if the monetary value is under $50, as most Canadian regulatory bodies permit nominal expressions of gratitude
Accept the gift and donate it to a charity in the patient's name, which balances professional standards with compassion

Correct answer: Decline the gift respectfully, explaining that professional standards prohibit accepting gifts of significant value, and suggest meaningful alternatives such as a letter of commendation to the facility

Provincial practical nursing regulatory standards and codes of ethics consistently prohibit accepting gifts of significant monetary or personal value from patients or families, as this creates real or perceived conflicts of interest and compromises professional boundaries. The PN's discomfort with the family's grief does not override professional obligations (A). Accepting and redirecting (B) still constitutes acceptance of the gift and does not resolve the boundary issue. A $50 threshold (D) is not an established standard in Canadian practical nursing regulatory guidelines — this is a common but inaccurate assumption. The appropriate response (C) is a compassionate but clear decline, paired with a meaningful alternative that still honors the family's wish to express gratitude.

Question 67: A nurse working on an inpatient psychiatric unit notices that a colleague routinely tells clients in distress, 'I understand exactly how you feel — I've been through the same thing myself.' Which therapeutic communication principle does this behaviour most directly violate?

Empathic validation
Non-judgmental acceptance
Active listening
Maintaining professional boundaries through appropriate self-disclosure (Correct answer)

Correct answer: Maintaining professional boundaries through appropriate self-disclosure

While empathy and validation are therapeutic, routine and unsolicited personal disclosure by the nurse shifts the focus from the client to the nurse, blurs the professional therapeutic relationship, and can burden the client with the nurse's experiences. Appropriate self-disclosure in psychiatric nursing is limited, purposeful, and always client-centred. This does not primarily violate active listening (which concerns attending behaviours), empathic validation (acknowledging feelings), or non-judgmental acceptance (avoiding moral judgement).

Question 68: 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?

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

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 69: A PN notices that a colleague consistently documents care before it is provided and has confronted the colleague privately twice without change. What is the MOST appropriate next step within a collaborative practice framework?

Report the behaviour to the provincial regulatory body as the next step after failed peer intervention.
Accept the situation since the colleague's clinical outcomes have not been affected.
Inform the client so they can advocate for accurate documentation of their own care.
Report the pattern to the nurse manager, providing specific documented examples, to initiate a formal process. (Correct answer)

Correct answer: Report the pattern to the nurse manager, providing specific documented examples, to initiate a formal process.

Falsifying documentation is a serious patient safety and professional integrity issue. After direct peer intervention has failed, the PN's professional obligation is to escalate internally to the nurse manager with specific documented examples. Regulatory reporting may follow if internal processes are ineffective, but the manager is the appropriate first formal step. Informing clients would undermine therapeutic trust and is not appropriate.

Question 70: A 14-year-old adolescent with anorexia nervosa is admitted for refeeding. On day 3 of nutritional rehabilitation, the patient develops muscle weakness, cardiac dysrhythmia on the monitor, and paresthesias in the extremities. Serum phosphate is 0.5 mmol/L. Which pathophysiological mechanism BEST explains this cluster of findings?

Hypoglycaemia from insufficient caloric intake in the early refeeding phase causing neuromuscular symptoms
Malnutrition-associated cardiomyopathy exacerbated by increased cardiac demand from refeeding
Refeeding syndrome: insulin release from carbohydrate intake drives phosphate, magnesium, and potassium intracellularly, causing severe serum depletion (Correct answer)
Thiamine deficiency causing Wernicke's encephalopathy and associated cardiac dysfunction

Correct answer: Refeeding syndrome: insulin release from carbohydrate intake drives phosphate, magnesium, and potassium intracellularly, causing severe serum depletion

Refeeding syndrome is a life-threatening metabolic complication occurring when malnourished patients receive nutrition after prolonged starvation. As carbohydrates are introduced, insulin surges and drives phosphate (along with potassium and magnesium) from the bloodstream into cells, causing severe hypophosphatemia. Phosphate is critical for ATP synthesis; without it, neuromuscular function (weakness, paresthesias), cardiac conduction (dysrhythmias), and respiratory muscle function are impaired. Prevention requires slow caloric escalation, pre-refeeding electrolyte correction, and close monitoring of phosphate, magnesium, and potassium. Thiamine deficiency is also important in refeeding but does not directly explain the hypophosphatemia cluster.

Question 71: A PN is screening clients using the AUDIT-C tool at a primary care clinic. A 52-year-old male client scores 6/12. The PN knows his physician plans to prescribe metronidazole for H. pylori eradication. Which secondary prevention action is MOST clinically urgent?

Delay H. pylori treatment until the client's alcohol use is reduced to a low-risk level per AUDIT-C rescreening
Recommend the client attend a community Alcoholics Anonymous group before starting the antibiotic
Report the AUDIT-C score to the prescribing physician and recommend substituting metronidazole with clarithromycin to avoid interaction
Advise the client to abstain from alcohol during metronidazole therapy due to a disulfiram-like reaction risk, and document the counselling (Correct answer)

Correct answer: Advise the client to abstain from alcohol during metronidazole therapy due to a disulfiram-like reaction risk, and document the counselling

An AUDIT-C score of 6 in a male indicates hazardous alcohol use, raising clinically significant risk for a disulfiram-like reaction (flushing, nausea, vomiting, tachycardia) if the client consumes alcohol while taking metronidazole. The most urgent secondary prevention action is clear, documented counselling to abstain from alcohol for the duration of therapy plus 48 hours after the last dose. Delaying H. pylori treatment is not supported — the infection itself poses GI disease risk. Substituting clarithromycin is a prescriber decision and not within the PN's scope, and AA referral, while appropriate as a longer-term intervention, does not address the immediate pharmacological risk.

Question 72: A client post-abdominal surgery reports sudden severe abdominal pain with board-like rigidity. What is the priority nursing action?

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

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 73: 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?

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

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 74: 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 75: 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?

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

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 76: An elderly client tearfully discloses being financially exploited by an adult child. The nurse is a mandatory reporter under provincial elder abuse legislation. What is the correct action?

Provide emotional support, inform the client of their rights and available resources, and report to the appropriate provincial authority (Correct answer)
Counsel the client that family matters are private
Only report if the client gives explicit permission
Document the disclosure and wait for the client to independently seek help

Correct answer: Provide emotional support, inform the client of their rights and available resources, and report to the appropriate provincial authority

Mandatory reporting obligations in elder abuse legislation require reporting regardless of client consent. The process should include support, information, and compassionate communication.

Question 77: A practical nurse (PN) is working a night shift alone in a long-term care facility when a resident becomes acutely confused, febrile, and hypotensive. The on-call physician is unreachable after multiple attempts. Which action best reflects the PN's legal accountability in this situation?

Administer a PRN antipyretic from the resident's medication administration record and continue monitoring until the physician is available
Contact the director of care at home to obtain a verbal order before taking any further clinical action
Wait at the bedside and continue reassessment every 15 minutes, as initiating a transfer exceeds the PN's independent scope
Initiate the facility's emergency transfer protocol and document all attempts to reach the physician, the resident's status, and actions taken (Correct answer)

Correct answer: Initiate the facility's emergency transfer protocol and document all attempts to reach the physician, the resident's status, and actions taken

When a resident's condition is deteriorating and the physician is unreachable, the PN is legally and ethically obligated to activate available emergency systems (e.g., 911 or facility transfer protocols) to prevent patient harm. This falls within the PN's duty to act. Thorough documentation of all attempts, observations, and interventions is both a professional and legal requirement. Waiting passively or limiting action to PRN medications when the resident is hemodynamically unstable would constitute a failure of duty of care.

Question 78: Which situation represents a boundary violation in the nurse-client therapeutic relationship?

Touching a client's hand briefly when delivering difficult news
Asking a client about their cultural food preferences for meal planning
Sharing a brief personal experience with a health issue to build rapport
Accepting a bottle of wine from a client as thanks for excellent care (Correct answer)

Correct answer: Accepting a bottle of wine from a client as thanks for excellent care

Accepting gifts of significant value from clients crosses professional boundaries by creating an inappropriate obligation and blurring the professional relationship.

Question 79: A client recovering from a prolonged hospitalization has significant muscle weakness. Which of the following exercises should the PN initiate first?

Isotonic strengthening exercises
Active range-of-motion (ROM) exercises
Passive range-of-motion (ROM) exercises (Correct answer)
Resistive weight-bearing exercises

Correct answer: Passive range-of-motion (ROM) exercises

Passive range-of-motion exercises are initiated first when the client cannot move independently. The PN moves the joints through their range to maintain flexibility and prevent contractures, with progression to active-assisted and then active ROM as strength returns.

Question 80: A practical nurse is assessing the level of consciousness of a client who has sustained a head injury. Which assessment tool is most appropriate for the nurse to use?

Pain Assessment Scale (PQRST)
Glasgow Coma Scale (GCS) (Correct answer)
Braden Scale
Morse Fall Scale

Correct answer: Glasgow Coma Scale (GCS)

The Glasgow Coma Scale (GCS) is a standardized tool used to objectively assess a client's level of consciousness by evaluating eye-opening, verbal, and motor responses. The Braden Scale assesses risk for pressure ulcers, the Morse Fall Scale assesses fall risk, and PQRST is a mnemonic for pain assessment.

Question 81: The CNA Code of Ethics identifies seven primary values. Which value is demonstrated when a practical nurse ensures a client understands their diagnosis before making a treatment decision?

Health and well-being
Autonomy and self-determination (Correct answer)
Safe, compassionate, competent, and ethical care
Accountability

Correct answer: Autonomy and self-determination

Ensuring a client understands their diagnosis before decision-making demonstrates respect for autonomy and self-determination.

Question 82: When preparing to administer a prefilled subcutaneous enoxaparin (Lovenox) syringe, which action is correct?

Dilute the enoxaparin with normal saline
Administer in the deltoid for fastest absorption
Expel the air bubble from the syringe before injection
Do not expel the air bubble; inject as is from the prefilled syringe (Correct answer)

Correct answer: Do not expel the air bubble; inject as is from the prefilled syringe

The air bubble in prefilled enoxaparin syringes is intentional. It follows the medication to prevent drug leakage from the injection tract and must not be expelled.

Question 83: Parents of a child with a newly placed gastrostomy tube (G-tube) ask what to do if the tube falls out at home. What is the CORRECT nurse teaching?

Insert the tube back in themselves using a clean technique
Do nothing; the stoma will close naturally within 24 hours
Bring the child to the ER immediately and apply a sterile dressing
Cover the stoma with a clean cloth and come to the hospital within 4-6 hours (Correct answer)

Correct answer: Cover the stoma with a clean cloth and come to the hospital within 4-6 hours

A gastrostomy stoma can close within hours, so parents should cover it to prevent closure and bring the child promptly to hospital for replacement.

Question 84: A practical nurse witnesses a colleague administer a medication to the wrong patient. What is the practical nurse's primary legal obligation?

Document the incident and report it to the supervising nurse or manager immediately (Correct answer)
File a complaint directly with the provincial regulatory body
Wait to see if the patient experiences adverse effects before reporting
Confront the colleague privately and ask them to self-report

Correct answer: Document the incident and report it to the supervising nurse or manager immediately

Practical nurses are legally obligated to report medication errors through the facility's incident reporting system promptly to protect patient safety.

Question 85: 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
Withhold the dose because the potassium level contraindicates loop diuretics
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)

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 86: A practical nurse is preparing to administer a cleansing enema to a 70-year-old client with cardiac history prior to a colonoscopy. The client reports feeling faint and the nurse notes the pulse is 48 bpm and irregular during the procedure. What is the priority action?

Stop the enema immediately, remove the rectal tube, place the client supine, and notify the physician (Correct answer)
Continue the enema as planned but apply supplemental oxygen and call for assistance
Stop the enema immediately, position the client in left lateral Sims' position, and notify the physician
Slow the rate of enema instillation and reassess vital signs in 5 minutes

Correct answer: Stop the enema immediately, remove the rectal tube, place the client supine, and notify the physician

Bradycardia (48 bpm) with irregularity and presyncope during rectal stimulation indicates vasovagal response — a potentially life-threatening complication in a cardiac patient. The vagus nerve innervates the rectum; stimulation causes parasympathetic activation leading to bradycardia and hypotension. Priority actions are: (1) stop and remove the rectal tube to eliminate the vagal stimulus, (2) place the client supine to improve cerebral perfusion, and (3) notify the physician immediately. Leaving the tube in place (even while stopping flow) prolongs vagal stimulation. The left lateral Sims' position is used for enema administration, not emergency management of vasovagal response.

Question 87: A PN disagrees with a team decision about a client's care plan. What is the most professional approach?

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

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 88: Which of the following is considered a non-therapeutic communication technique that can block further discussion with a client?

Providing false reassurance by saying "Everything will be just fine." (Correct answer)
Paraphrasing the client's statement to show understanding.
Using silence to allow the client time to reflect.
Asking open-ended questions to encourage elaboration.

Correct answer: Providing false reassurance by saying "Everything will be just fine."

Providing false reassurance is a non-therapeutic technique because it dismisses the client's legitimate feelings and concerns, discouraging them from further expression. It can be perceived as the nurse not taking their situation seriously. Using silence, asking open-ended questions, and paraphrasing are all therapeutic techniques designed to encourage communication.

Question 89: A PN employed by a home care agency is asked by her supervisor to perform wound debridement using sharp instruments on a complex diabetic ulcer. The PN holds a current registration and has completed the agency's competency sign-off for this skill. However, sharp debridement is NOT listed as an authorized act in the provincial legislation governing practical nurses in that jurisdiction. What is the PN's correct course of action?

Contact the provincial college to request a temporary exemption before proceeding
Proceed, because employer competency sign-off is the controlling authority for scope of practice in a home care setting
Perform the debridement once and document it, then seek formal regulatory clarification afterward
Decline to perform the procedure, as performing an act not authorized under provincial legislation constitutes unauthorized practice regardless of employer authorization (Correct answer)

Correct answer: Decline to perform the procedure, as performing an act not authorized under provincial legislation constitutes unauthorized practice regardless of employer authorization

Scope of practice is defined by provincial/territorial legislation and the regulatory college — employer policies and competency sign-offs cannot expand legislated scope. Performing an act that is not authorized under the applicable legislation exposes the PN to regulatory discipline and potential civil or criminal liability, regardless of organizational authorization. The PN must decline, communicate the reason professionally, and if appropriate, advocate for a referral to a clinician whose scope includes the procedure.

Question 90: In the PQRSTU pain assessment tool, what does the U assess?

Where the pain radiates
Urgency of pain management
What makes pain better or worse
Understanding of the client about their pain (Correct answer)

Correct answer: Understanding of the client about their pain

U = Understanding: what the pain means to the client and their knowledge about it.

Question 91: 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?

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

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 92: During a mental status examination, a nurse notes that a client's speech is fluent and grammatically intact but the content is completely unrelated to the questions asked. The client appears unaware of this disconnect. Which specific finding is the nurse documenting?

Expressive aphasia (Broca's aphasia)
Receptive aphasia (Wernicke's aphasia) (Correct answer)
Tangentiality
Circumstantiality

Correct answer: Receptive aphasia (Wernicke's aphasia)

Receptive (Wernicke's) aphasia is characterized by fluent, grammatically intact speech that lacks meaningful content and fails to respond relevantly to questions — the client cannot comprehend language input, so responses are semantically disconnected. Clients are typically unaware of the deficit. Tangentiality involves drifting off-topic but with a traceable connection. Circumstantiality involves excessive irrelevant detail but eventually reaches the point. Expressive (Broca's) aphasia produces non-fluent, effortful speech with preserved comprehension.

Question 93: An 82-year-old client with advanced dementia and dysphagia is receiving palliative care. The family insists on nasogastric tube feeding, believing it will prevent aspiration pneumonia and prolong life comfortably. What is the most appropriate nursing response?

Initiate the NG tube as requested, documenting family consent in the chart
Defer the decision entirely to the attending physician without engaging the family further
Recommend a PEG tube instead, as it is safer and more comfortable than NG feeding
Explain that evidence does not support tube feeding in advanced dementia for preventing aspiration or improving comfort, and facilitate a goals-of-care discussion (Correct answer)

Correct answer: Explain that evidence does not support tube feeding in advanced dementia for preventing aspiration or improving comfort, and facilitate a goals-of-care discussion

Current evidence demonstrates that tube feeding in advanced dementia does not reduce aspiration pneumonia, prevent pressure injuries, improve nutrition, or prolong comfortable life. It can actually increase discomfort and agitation. The nurse's role is to provide accurate, evidence-based information to support informed decision-making and facilitate a goals-of-care conversation aligned with the client's palliative plan — not simply comply with family requests or defer responsibility.

Question 94: 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?

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

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 95: A client is prescribed a new antihypertensive medication. After administering the first dose, the practical nurse should prioritize monitoring for which of the following?

The client's understanding of the medication schedule
Therapeutic effect
Adverse effects (Correct answer)
Drug-food interactions

Correct answer: Adverse effects

While all options are important aspects of medication management, the immediate priority after administering the first dose of a new medication is to monitor for any adverse effects, such as orthostatic hypotension with an antihypertensive, which could pose an immediate safety risk to the client. The LPN must have the knowledge to manage adverse reactions.

Question 96: During which phase of the therapeutic nurse-client relationship is a plan of care implemented and the client is encouraged to problem-solve and test new behaviours?

Working phase (Correct answer)
Termination phase
Pre-interaction phase
Orientation phase

Correct answer: Working phase

The working phase is the core of the therapeutic relationship where the nurse and client actively work towards achieving the goals established in the orientation phase. This includes implementing interventions, problem-solving, overcoming resistance, and evaluating progress. The orientation phase is for establishing trust, the termination phase is for ending the relationship, and the pre-interaction phase occurs before the nurse meets the client.

Question 97: A practical nurse is caring for a client with type 1 diabetes who is NPO after midnight for a scheduled colonoscopy at 08:00. At 06:30, the client's capillary blood glucose is 3.1 mmol/L and they report feeling shaky and sweaty. The client's morning insulin (10 units glargine) has not yet been given. What is the most appropriate immediate intervention?

Administer half the usual dose of glargine and reassess glucose in 30 minutes
Administer the glargine insulin as ordered and notify the endocrinology team
Hold all insulin, notify the physician, and administer IV dextrose per hypoglycemia protocol (Correct answer)
Administer 15 g of oral fast-acting carbohydrates and recheck glucose in 15 minutes

Correct answer: Hold all insulin, notify the physician, and administer IV dextrose per hypoglycemia protocol

The client is NPO, symptomatic, and has a blood glucose of 3.1 mmol/L — confirmed hypoglycemia in a patient who cannot safely take anything by mouth due to NPO status and impending procedure. Oral carbohydrates (option A) are contraindicated in an NPO patient scheduled for a procedural sedation. The correct action is to hold insulin (giving glargine to a hypoglycemic NPO patient would worsen the situation), treat via IV dextrose per protocol, and notify the physician — who will also determine whether the procedure timing is affected. Options C and D both involve giving basal insulin to a currently hypoglycemic NPO patient, which is dangerous.

Question 98: A colleague, another practical nurse, is consistently documenting the administration of pain medication to a client, but the client continues to report severe, uncontrolled pain. The practical nurse notices that the colleague appears impaired during their shifts. What is the most appropriate initial action for the practical nurse to take?

Document the colleague's behavior in the client's chart.
Confront the colleague directly and accuse them of diverting medication.
Report the observations and concerns to the nursing supervisor or manager. (Correct answer)
Discuss the situation with other colleagues to see if they have noticed similar behaviors.

Correct answer: Report the observations and concerns to the nursing supervisor or manager.

The primary responsibility of the nurse is to ensure client safety. Reporting suspected impairment or unethical conduct to the appropriate authority (e.g., the nursing supervisor) is a professional and legal obligation. This action protects the client from potential harm and initiates the proper channels for investigation and support for the colleague. Confronting the colleague directly could be unsafe and unprofessional. Discussing with others could be a breach of confidentiality, and documenting suspicions in a client's chart is inappropriate.

Question 99: 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?

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

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 100: When applying seclusion or restraint to a client with acute psychiatric disturbance, which principle guides practice?

Seclusion and restraint may be used routinely for agitation in psychotic clients
Restraints can be applied based on family request
Seclusion and restraint are last resorts used only when all less restrictive de-escalation measures have failed (Correct answer)
Seclusion and restraint are primary therapeutic tools for behavior management

Correct answer: Seclusion and restraint are last resorts used only when all less restrictive de-escalation measures have failed

Seclusion and restraint are last-resort measures when de-escalation has failed and there is imminent risk of harm.

Question 101: A PN is assigned to a client 18 hours post-laparotomy for bowel resection with primary anastomosis. Vital signs are stable. During morning care, the client reports sudden severe abdominal pain rated 9/10, and the abdomen is rigid and board-like. Bowel sounds are absent in all four quadrants. The surgical drain has minimal dark-red output. Which finding is MOST concerning and warrants immediate escalation?

Absent bowel sounds 18 hours post-operatively
Sudden onset of rigid, board-like abdomen with severe pain (Correct answer)
Minimal dark-red drain output in the first 18 hours
Pain rated 9/10 in the immediate post-operative period

Correct answer: Sudden onset of rigid, board-like abdomen with severe pain

A rigid, board-like abdomen with sudden severe pain post-bowel-resection is a hallmark sign of anastomotic leak or bowel perforation causing peritonitis — a surgical emergency. Absent bowel sounds are expected in the first 24–72 hours post-laparotomy due to post-operative ileus and are not acutely alarming in isolation. Minimal dark-red drain output in the early post-operative period is within normal range. Pain in the immediate post-operative period is expected, but the sudden escalation combined with rigidity specifically signals an intra-abdominal catastrophe. The combination of rigidity + sudden severe pain requires immediate physician escalation.

Question 102: Raki comes from a cultural background where mental and emotional disorders are seen as out-of-control behavior that puts the family in disgrace. Given his cultural perspective, which of the following reactions to psychological anguish would Raki be most likely to experience?

Depression
Phobias incorrect
Compulsive-obsessive behavior
Somatization disordercorrect (Correct answer)

Correct answer: Somatization disordercorrect

In cultures where mental and emotional disorders carry significant stigma and shame, individuals may express psychological distress through physical symptoms rather than openly acknowledging mental health issues. Somatization disorder involves experiencing physical symptoms that cannot be fully explained by a medical condition, often as a way to cope with or express underlying emotional distress in a culturally acceptable manner. This is a common presentation in such cultural contexts.

Question 103: A nurse is teaching a parent about febrile seizure management at home. Which statement by the parent indicates understanding?

I will apply cold water all over the body to stop the fever quickly
I will put a spoon in my child's mouth during a seizure to prevent biting
I will give extra doses of acetaminophen during the seizure
I will place my child on their side, protect them from injury, and time the seizure (Correct answer)

Correct answer: I will place my child on their side, protect them from injury, and time the seizure

Positioning the child on their side, ensuring safety, and timing the seizure are correct first aid responses to a febrile seizure.

Question 104: During a therapeutic interaction, a client with borderline personality disorder (BPD) tells the PN, 'You are the only nurse who truly understands me — all the others are cold and don't care.' The MOST therapeutically appropriate response by the PN is:

'Thank you — I do try my best to connect with all my clients.'
'I'm glad you feel supported. Let's also explore how to build those connections with the rest of the team.' (Correct answer)
'It sounds like you've had some difficult interactions with the other nurses.'
'I appreciate that, but I want you to know that all the nurses here care about your well-being.'

Correct answer: 'I'm glad you feel supported. Let's also explore how to build those connections with the rest of the team.'

The client is exhibiting 'splitting,' a core defense mechanism in BPD where individuals perceive people as entirely good or entirely bad. The therapeutic goal is to gently challenge this black-and-white thinking without dismissing the client's feelings. Option D validates the therapeutic relationship while actively redirecting toward reality-based thinking and broader support, which addresses the splitting behavior therapeutically. Option A reinforces the idealization and splitting. Option B colludes with the devaluation of other staff. Option C corrects without building on the therapeutic opportunity the moment presents.

Question 105: A practical nurse discloses to a client, 'I went through a divorce myself, so I know exactly how painful this is.' The client falls silent and appears withdrawn after this statement. What does this scenario MOST likely illustrate?

Counter-transference, where the nurse's unresolved personal experience interfered with the therapeutic focus. (Correct answer)
Appropriate use of self-disclosure that normalized the client's experience but required a follow-up empathic statement.
A therapeutic use of self that deepened rapport but may need to be followed by active listening.
Appropriate boundary maintenance because the nurse demonstrated genuine human connection.

Correct answer: Counter-transference, where the nurse's unresolved personal experience interfered with the therapeutic focus.

This scenario illustrates counter-transference — the nurse imposed her own personal narrative onto the client's experience, shifting the therapeutic focus from client to nurse and implying she 'knows exactly' the client's unique experience, which is presumptuous. The client's withdrawal signals the interaction was not therapeutic. Self-disclosure (A, C) is only appropriate when brief, intentional, and client-focused. This disclosure was self-serving and closed down the client's own expression rather than opening it.

Question 106: A practical nurse discovers they have HIV and is concerned about disclosure obligations to their employer. What is their primary obligation?

No obligation to disclose to anyone
Ceasing all nursing practice immediately
Following provincial occupational health guidelines and regulatory college standards regarding fitness to practice (Correct answer)
Immediate public disclosure to all clients and colleagues

Correct answer: Following provincial occupational health guidelines and regulatory college standards regarding fitness to practice

Specific obligations are outlined in provincial regulatory college standards. Disclosure is context-dependent, not absolute.

Question 107: During a routine audit, an infection control nurse observes a practical nurse donning PPE before entering a room under droplet and contact precautions. The practical nurse puts on the gown first, then the mask, then the goggles, and finally the gloves. The infection control nurse intervenes. What is the correct rationale for the intervention?

The sequence does not matter as long as all PPE is applied before entering the room
Gloves must be donned before the gown to prevent sleeve contamination when pulling on the gown
Goggles must always be the last item applied because they cover the face and secure the mask in place
The mask should be donned before the gown so that face and mucous membrane protection is established before the gown, which requires reaching over the face area to tie at the neck (Correct answer)

Correct answer: The mask should be donned before the gown so that face and mucous membrane protection is established before the gown, which requires reaching over the face area to tie at the neck

The recommended PPE donning sequence per PIDAC and PHAC guidelines is: (1) gown, (2) mask/respirator, (3) eye protection (goggles/face shield), (4) gloves. However, some guidelines and facilities specify that the mask is donned first or second specifically so that tying the mask strings at the back of the head does not require reaching across an already-donned gown and contaminating it, or so the face/airway is protected before handling other PPE. The key principle the auditor is correcting is that the order must be intentional and consistent with the facility's protocol — sequence matters to prevent self-contamination. Gloves are always last to avoid contaminating other PPE during donning. The sequence absolutely matters; entering a room with incorrectly layered PPE can result in self-contamination during doffing.

Question 108: A practical nurse is caring for a client with a known penicillin allergy documented as 'anaphylaxis.' The prescriber has ordered cefazolin 1g IV for surgical prophylaxis. The nurse's best course of action is to:

Substitute cefazolin with vancomycin at the same dose without contacting the prescriber, as this is a safer choice
Withhold the cefazolin and contact the prescriber immediately to clarify and discuss the allergy history before administration (Correct answer)
Administer the cefazolin as ordered because first-generation cephalosporins have no cross-reactivity with penicillin
Administer the cefazolin after performing a bedside skin test using a diluted solution

Correct answer: Withhold the cefazolin and contact the prescriber immediately to clarify and discuss the allergy history before administration

Although the overall cross-reactivity rate between penicillins and cephalosporins is low (approximately 1–2%), a documented history of penicillin-induced anaphylaxis represents a serious risk. First-generation cephalosporins like cefazolin share structural similarities with penicillin and carry a higher cross-reactivity risk than later generations. The nurse must NOT administer the drug on their own judgment, substitute another drug independently, or perform unauthorized allergy testing at the bedside. The safe and professional action is to withhold the dose and immediately contact the prescriber to review the allergy, consider allergy consultation, or select an alternative agent. Substituting medications independently exceeds the practical nurse's scope of practice.

Question 109: 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 110: A practical nurse is caring for an 80-year-old woman in palliative care who has not eaten or drunk anything for 5 days. The family requests IV hydration, believing dehydration is causing her suffering. Current evidence in palliative gerontological nursing most accurately supports which position?

IV hydration should always be initiated in the final 72 hours because dehydration causes measurable pain
Oral hydration with a syringe every 2 hours is a safe and equivalent substitute that satisfies both clinical and family concerns
Terminal dehydration in the final days of life does not typically increase suffering and may reduce respiratory secretions and urinary incontinence; IV fluids can sometimes increase discomfort (Correct answer)
The family's request constitutes informed consent and overrides clinical judgment about the benefits of hydration

Correct answer: Terminal dehydration in the final days of life does not typically increase suffering and may reduce respiratory secretions and urinary incontinence; IV fluids can sometimes increase discomfort

Evidence-based palliative care literature consistently shows that terminal dehydration in the active dying phase does not typically cause distress and is part of the normal dying process. Parenteral fluids can increase pulmonary secretions (death rattle), peripheral edema, and ascites — potentially worsening comfort. The nurse's role is to educate the family compassionately, ensure good oral care, and advocate for a goals-of-care discussion with the palliative team.

Question 111: 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
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
Discard the aspirate, reduce the feeding rate by half, and document the finding

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 112: Which alcohol withdrawal assessment finding requires immediate intervention?

Mild diaphoresis and difficulty sleeping
Anxiety and irritability on day 1
Blood pressure 138/88 mmHg
Tonic-clonic seizures and unresponsiveness (Correct answer)

Correct answer: Tonic-clonic seizures and unresponsiveness

Seizures and loss of consciousness indicate severe withdrawal (delirium tremens) requiring emergency intervention.

Question 113: Which medication cannot be crushed for NG tube administration?

Metoprolol tartrate (Lopressor) immediate-release tablet
Acetaminophen (Tylenol) 325 mg tablet
Lactulose oral solution
Metoprolol succinate (Toprol XL) extended-release tablet (Correct answer)

Correct answer: Metoprolol succinate (Toprol XL) extended-release tablet

Extended-release (XL/ER/SR) tablets cannot be crushed as this destroys the slow-release mechanism and causes dose dumping with potential toxicity.

Question 114: A client with a history of childhood sexual abuse discloses to a practical nurse during a wound care visit that the client has been experiencing flashbacks and has begun self-harming. The client pleads, 'Please don't tell anyone — I trust only you.' The nurse is aware that disclosure is legally and ethically required. Which response BEST balances therapeutic relationship principles with professional obligations?

Ask the client to sign a release of information form before the nurse proceeds with any disclosure to respect the client's autonomy.
Acknowledge the client's courage in disclosing, clearly explain the nurse's professional duty to report, describe what will happen next, and remain present to support the client through the process. (Correct answer)
Immediately leave the room to report the self-harm to the charge nurse without explaining anything to the client to avoid a distressed reaction.
Assure the client that the information will remain confidential to preserve trust, then document it as a clinical concern without formally reporting it.

Correct answer: Acknowledge the client's courage in disclosing, clearly explain the nurse's professional duty to report, describe what will happen next, and remain present to support the client through the process.

When confidentiality must be broken due to safety concerns, the therapeutic approach requires transparency: informing the client before or while reporting, explaining the rationale honestly, and maintaining the relationship through the process rather than abandoning the client or deceiving them. Option A violates the duty to report and is legally indefensible. Option B abandons the client and damages trust without therapeutic justification. Option D is clinically inappropriate — reporting a safety risk is a mandatory professional duty that does not require client consent.

Question 115: A nurse is caring for a client prescribed warfarin 5 mg daily for atrial fibrillation. The client's INR today is 4.8, and the client reports no active bleeding. The prescriber's order reads: 'Hold warfarin and repeat INR in 24 hours.' While reviewing the client's chart, the nurse notes a new order for vitamin K 2.5 mg orally was added by the on-call physician. Which action is MOST appropriate?

Clarify the vitamin K order with the prescribing physician and the client's anticoagulation team before administering (Correct answer)
Hold both the warfarin and vitamin K pending clarification of the client's target INR range and supratherapeutic cause
Administer the vitamin K immediately as a supratherapeutic INR of 4.8 always requires reversal
Administer the vitamin K as ordered since it was prescribed by a licensed physician

Correct answer: Clarify the vitamin K order with the prescribing physician and the client's anticoagulation team before administering

An INR of 4.8 without active bleeding does not universally require vitamin K reversal — guidelines (e.g., CHEST) suggest vitamin K is indicated for INR >10 without bleeding, or 4.5–10 with bleeding risk factors. Administering vitamin K can make re-anticoagulation difficult and increase clotting risk. The on-call physician may be unaware of the target INR or the anticoagulation management plan. The nurse must clarify this order with both the prescribing physician and ideally the anticoagulation team before administering, as this is a complex clinical decision requiring reconciliation of conflicting management strategies.

Question 116: A client is to receive amoxicillin (Amoxil) 500 mg. Available is amoxicillin 250 mg/5 mL oral suspension. How many mL should be administered?

7.5 mL
10 mL (Correct answer)
15 mL
5 mL

Correct answer: 10 mL

500 mg divided by 250 mg multiplied by 5 mL = 10 mL.

Question 117: 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
Auscultation, Inspection, Palpation, Percussion
Palpation, Auscultation, Inspection, Percussion
Inspection, Auscultation, Palpation, Percussion (Correct answer)

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 118: A client from a cultural background that uses herbal remedies asks about using them alongside their prescribed medications. What is the culturally competent response?

Dismiss herbal remedies as ineffective
Share personal experience and recommend specific supplements
Acknowledge the cultural practice with respect, educate about potential herb-drug interactions, and encourage discussion with the prescribing physician (Correct answer)
Tell the client to stop all traditional practices while in hospital

Correct answer: Acknowledge the cultural practice with respect, educate about potential herb-drug interactions, and encourage discussion with the prescribing physician

Culturally competent care acknowledges cultural practices respectfully while providing evidence-based safety education about herb-drug interactions and facilitating communication with the prescriber.

Question 119: 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)
Setting the goals and outlining the expected duration of the relationship.
Gathering initial assessment data and establishing a contract for care.

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 120: 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?

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)
Administer the medication without interrupting the feed, as NG medications bypass the stomach's absorptive phase
Pause the feed briefly, administer the medication mixed into the feed bag, then resume the infusion
Crush the tablet, dissolve it in the feed formula, and give the bolus immediately to minimize interruption time

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 121: A client rates pain 8/10 before scheduled medication is due. What is the most appropriate intervention?

Document and continue monitoring
Assess pain fully and notify the physician to review the pain management plan (Correct answer)
Tell the client to wait for the scheduled time
Administer an extra dose immediately

Correct answer: Assess pain fully and notify the physician to review the pain management plan

Severe breakthrough pain requires thorough assessment and physician notification to review the pain plan.

Question 122: During a nutritional assessment, the practical nurse uses the MUST tool. What does MUST stand for?

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

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 123: A practical nurse administers a scheduled oral dose of metoprolol tartrate 50 mg to a client. Fifteen minutes later, the client's heart rate is 42 bpm and blood pressure is 88/54 mmHg. The client is drowsy but arousable. Which intervention reflects the MOST appropriate initial response?

Place the client in Trendelenburg position and administer a 500 mL normal saline bolus immediately
Notify the prescriber immediately, withhold further doses, initiate continuous cardiac monitoring, and prepare for potential reversal with atropine or glucagon per order (Correct answer)
Administer a prescribed PRN dose of epinephrine to rapidly counteract the beta-blockade
Reassess in 30 minutes, as beta-blocker effects peak at 1–2 hours and the current readings may be transient

Correct answer: Notify the prescriber immediately, withhold further doses, initiate continuous cardiac monitoring, and prepare for potential reversal with atropine or glucagon per order

These findings indicate beta-blocker toxicity with hemodynamic compromise (bradycardia + hypotension + altered level of consciousness). The nurse must immediately notify the prescriber, hold further doses, and initiate continuous monitoring. Glucagon is the specific antidote for beta-blocker overdose as it bypasses the blocked receptor; atropine may be ordered for symptomatic bradycardia. Reassessing in 30 minutes is dangerous — the client already shows signs of compromise. Trendelenburg and fluid bolus alone do not address the underlying pharmacological cause. Epinephrine is not a routine beta-blocker reversal agent and could cause rebound hypertension.

Question 124: A practical nurse notices strong feelings of irritation arising during sessions with a long-term client who frequently dismisses the nurse's suggestions. Recognizing this as a countertransference reaction, what is the FIRST priority action?

Disclose the frustration to the client in a controlled way to model authentic communication.
Reflect on the source of the feelings and bring them to clinical supervision to explore how they may be affecting care. (Correct answer)
Request an immediate transfer of the client to another nurse to prevent the therapeutic relationship from being compromised.
Increase session frequency to work through the dynamic directly within the therapeutic relationship.

Correct answer: Reflect on the source of the feelings and bring them to clinical supervision to explore how they may be affecting care.

Countertransference — the nurse's emotional reaction to the client — is inevitable and, if unexamined, can harm the therapeutic relationship. The professional obligation is self-reflection followed by clinical supervision, not avoidance (Option A) or premature disclosure (Option C). Supervision is the appropriate mechanism for processing countertransference without burdening or confusing the client. Option D misses the point; the unaddressed countertransference would persist regardless of session frequency.

Question 125: During a home care visit, a PN notices signs consistent with elder financial abuse perpetrated by the client's legal power of attorney (POA). The client, who has mild cognitive impairment, states they do not want anyone notified. Under most Canadian provincial legislation, what is the PN's obligation?

Report suspicions of elder abuse to the appropriate authority as mandated by provincial adult protection legislation, even without the client's consent (Correct answer)
Notify only the facility's ethics committee and await their determination before taking any further action
Respect the client's wishes and take no action, as the client has the right to privacy and has not consented to disclosure
Document findings and report only if the client later changes their mind or the abuse escalates

Correct answer: Report suspicions of elder abuse to the appropriate authority as mandated by provincial adult protection legislation, even without the client's consent

Most Canadian provinces have mandatory reporting legislation for vulnerable adult abuse (e.g., Ontario's Long-Term Care Homes Act, Nova Scotia's Adult Protection Act). When a PN has reasonable grounds to suspect abuse of a vulnerable adult, they are legally required to report it to the designated authority regardless of the client's consent or wishes. Mild cognitive impairment may also affect the client's capacity to protect themselves, further reinforcing the duty to report. Failure to report is itself a legal violation.

Question 126: During oxytocin infusion, the fetal heart rate drops from 140 to 80 bpm coinciding with each contraction and returning to baseline quickly. How should this be interpreted?

Late decelerations indicating uteroplacental insufficiency
Accelerations indicating fetal well-being
Variable decelerations indicating cord compression
Early decelerations indicating head compression, normal finding (Correct answer)

Correct answer: Early decelerations indicating head compression, normal finding

Decelerations that begin with contraction onset and return to baseline quickly (mirror contractions) are early decelerations from head compression, a benign finding.

Question 127: During a code situation, the team leader assigns a specific task to the PN. The PN is unsure how to perform it. What should the PN do?

Attempt the task without disclosure to avoid slowing the team down
Leave the bedside to consult a policy manual
Perform a different task without informing the leader
Immediately inform the team leader that they need assistance or a task reassignment (Correct answer)

Correct answer: Immediately inform the team leader that they need assistance or a task reassignment

In emergency situations, disclosing limitations immediately allows the team leader to reassign tasks quickly and maintain safe client care.

Question 128: 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
Dysphagia that began with solids before progressing to liquids (Correct answer)
Nocturnal coughing and aspiration symptoms
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 129: A practical nurse has been working closely with a client recovering from a traumatic brain injury for several weeks. The client tells the nurse, 'You're the only one who really understands me. I don't need my family — just you.' Which response BEST demonstrates therapeutic use of self while maintaining appropriate boundaries?

'That means so much to me. I feel the same way — we've built something really special together.'
'I think you should speak with the social worker about these feelings, as this is outside my scope of practice.'
'I'm glad our work together has been meaningful. Part of my role is to help you strengthen your connections with family, who will be your support beyond this setting.' (Correct answer)
'It's normal to feel that way in recovery, but you shouldn't become too dependent on any one nurse.'

Correct answer: 'I'm glad our work together has been meaningful. Part of my role is to help you strengthen your connections with family, who will be your support beyond this setting.'

The therapeutic relationship is purposeful and time-limited. The nurse acknowledges the client's feelings (validating the connection) while redirecting toward the therapeutic goal of rebuilding natural supports. This avoids fostering unhealthy dependency without dismissing the client's experience. Option B represents counter-transference and a boundary violation. Option C deflects unnecessarily. Option D is dismissive and uses the word 'shouldn't,' which is non-therapeutic.

Question 130: A new mother who is 2 days postpartum tells the practical nurse she is concerned because her breasts have become hard, warm, and tender. Which of the following is the most appropriate response by the nurse?

"This is likely breast engorgement, which is common. Applying cold packs after feeding can help." (Correct answer)
"This is a sign of a breast infection; you should stop breastfeeding immediately."
"This means your milk supply is low; you should consider formula supplementation."
"You should limit how often you feed the baby to allow your breasts to rest."

Correct answer: "This is likely breast engorgement, which is common. Applying cold packs after feeding can help."

The symptoms described are characteristic of primary breast engorgement, which occurs as the milk comes in around day 2-5 postpartum. Management includes frequent breastfeeding, ensuring proper latch, applying cold compresses between feedings to reduce swelling, and warm compresses before feeding to facilitate milk flow. Stopping breastfeeding or limiting feedings would worsen the condition. Engorgement indicates a robust milk supply, not a low one.

Question 131: A client on a secure psychiatric unit is prescribed clozapine for treatment-resistant schizophrenia. On day 14 of therapy, routine bloodwork reveals an absolute neutrophil count (ANC) of 1.3 × 10⁹/L. What is the CORRECT nursing action?

Administer the dose as scheduled but increase monitoring frequency to twice-weekly ANC checks
Permanently discontinue clozapine per protocol and arrange for hematology consultation
Withhold the next dose and notify the prescriber immediately, as this represents mild neutropenia (Correct answer)
Document the result and continue clozapine; recheck the ANC in one week as scheduled

Correct answer: Withhold the next dose and notify the prescriber immediately, as this represents mild neutropenia

An ANC between 1.0–1.5 × 10⁹/L indicates mild neutropenia (Grade 2) under clozapine monitoring protocols. At this threshold, the current dose should be withheld and the prescriber notified immediately. Clozapine can cause agranulocytosis, a potentially fatal drop in neutrophils, requiring vigilant ANC monitoring. Permanent discontinuation is required at ANC < 1.0 × 10⁹/L (Grade 3 or worse). Continuing without intervention (Options A and D) is unsafe at this ANC level. The correct action is to withhold and escalate — not to permanently discontinue yet, as this ANC level may be reversible with dose adjustment or temporary suspension.

Question 132: A client with chronic lung illness who is getting oxygen through a nasal cannula is being cared for by a practical nurse. Which of the following outcomes is the nurse expected to expect?

The patient will remain bedridden.
Oral intake for the client will be limited.
Every two hours, arterial blood gases will be obtained.
Three L/minute or fewer will be the oxygen flow rate. (Correct answer)

Correct answer: Three L/minute or fewer will be the oxygen flow rate.

Clients with chronic lung diseases, such as COPD, often rely on a hypoxic drive to breathe. Administering high flow rates of oxygen can suppress this drive, leading to hypoventilation and increased carbon dioxide retention. Therefore, a low oxygen flow rate (typically 3 L/minute or less) is crucial to maintain adequate oxygenation without compromising the client's respiratory effort.

Question 133: A nurse is assessing a 3-year-old for signs of epiglottitis. Which finding would prompt immediate emergency action?

Mild respiratory congestion and runny nose
Barking cough and hoarse voice
High fever, drooling, tripod positioning, and inspiratory stridor (Correct answer)
Low-grade fever and mild throat discomfort

Correct answer: High fever, drooling, tripod positioning, and inspiratory stridor

High fever, drooling, tripod position, and stridor are signs of epiglottitis, a life-threatening emergency requiring immediate action.

Question 134: In which situation would a practical nurse be legally justified in breaching patient confidentiality without consent?

A family member requests information because they are paying for treatment
The patient discloses they intend to seriously harm an identifiable person (Correct answer)
The patient's employer calls asking about the reason for the patient's hospital stay
A journalist claims to be writing a story about patient safety issues

Correct answer: The patient discloses they intend to seriously harm an identifiable person

The duty to warn applies when there is a serious, credible, and imminent threat of harm to an identifiable third party, justifying disclosure to prevent that harm.

Question 135: A client has a chest tube connected to water seal drainage. The water in the water seal chamber stops oscillating (tidaling). What does this indicate?

The suction setting is too high
There is a significant air leak requiring intervention
The lung has fully re-expanded, expected end-point
Either the lung has re-expanded or the tube is kinked/blocked, assess further (Correct answer)

Correct answer: Either the lung has re-expanded or the tube is kinked/blocked, assess further

Cessation of tidaling can mean the lung has re-expanded (normal) or the tube is kinked/blocked. Further assessment is needed.

Question 136: During the working phase of the therapeutic nurse-client relationship, what is the primary focus?

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

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 137: A practical nurse is preparing to administer methotrexate 15 mg orally to a client with rheumatoid arthritis. The pharmacy has dispensed methotrexate 2.5 mg tablets. The nurse calculates a dose of 6 tablets. Before administering, which action is MOST critical given methotrexate's high-alert status?

Split the dose into two administrations two hours apart to reduce GI side effects
Contact the prescriber to verify whether the order is a weekly dose before administering (Correct answer)
Administer the dose as calculated and document the administration immediately after
Crush the tablets and mix with juice to ensure complete absorption

Correct answer: Contact the prescriber to verify whether the order is a weekly dose before administering

Methotrexate for non-oncologic indications (e.g., rheumatoid arthritis) is prescribed WEEKLY, not daily. Daily administration of methotrexate in this context is a known, potentially fatal medication error. The nurse must verify the dosing frequency with the prescriber before administering 6 tablets, as this dose given daily could cause severe toxicity. Independent double-checking and clarification of high-alert medications is a mandatory safety step.

Question 138: A practical nurse is caring for a client with chronic kidney disease who is receiving a continuous heparin infusion for a deep vein thrombosis. The client's aPTT result comes back at 180 seconds (therapeutic range: 60–100 seconds). The client is alert and oriented with no signs of active bleeding. What is the priority nursing action?

Reduce the infusion rate by 25% per protocol and reassess aPTT in 6 hours
Administer protamine sulfate as an antidote
Continue the current infusion rate and recheck aPTT in 4 hours
Hold the heparin infusion and notify the physician immediately (Correct answer)

Correct answer: Hold the heparin infusion and notify the physician immediately

An aPTT of 180 seconds is nearly double the upper therapeutic limit, representing a critical supratherapeutic level that significantly increases hemorrhage risk. The priority action is to hold the infusion and notify the physician so the dose can be safely adjusted or protamine sulfate considered. Simply reducing the rate (option B) without physician direction is outside the PN scope for a critically abnormal value. Protamine sulfate (option C) is reserved for confirmed or life-threatening overdose with active bleeding, not a standing nursing decision. Continuing the infusion (option D) risks serious harm.

Question 139: A nurse is performing a comprehensive pain assessment on a postoperative client who is non-verbal and has moderate cognitive impairment. The client cannot self-report pain. Which assessment approach is MOST valid for this population?

Administer a standard 0–10 numeric rating scale verbally and document the response
Infer pain absence because the client is not crying or guarding the surgical site
Rely solely on proxy reporting from family members as the gold standard substitute
Use a behavioural observation tool such as the Abbey Pain Scale, incorporating physiological and behavioural cues (Correct answer)

Correct answer: Use a behavioural observation tool such as the Abbey Pain Scale, incorporating physiological and behavioural cues

For non-verbal clients with cognitive impairment, validated behavioural observation tools such as the Abbey Pain Scale, PAINAD, or CPOT are the standard of care. These tools assess facial expressions, body language, vocalizations, consolability, and physiological indicators. The numeric rating scale requires self-report capacity the client lacks. Absence of overt distress does not rule out pain, particularly in cognitively impaired individuals who may have blunted expression. Family proxy reporting alone is not validated as a gold standard and must be combined with direct behavioural observation.

Question 140: Which statement best describes the recovery model of mental health care as applied in Canadian mental health nursing?

Recovery means complete elimination of all mental illness symptoms
Recovery is a personal journey toward living a meaningful life despite the challenges of mental illness (Correct answer)
Recovery requires compliance with all prescribed treatments without question
Recovery is only possible with strong family support

Correct answer: Recovery is a personal journey toward living a meaningful life despite the challenges of mental illness

The recovery model emphasizes personal meaning, hope, and quality of life rather than symptom elimination, centered on the client's goals and strengths.

Question 141: 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:

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

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 142: A practical nurse is applying the Stages of Change (Transtheoretical) Model when counselling a client about smoking cessation. The client says, 'I know I should quit, but I'm not planning to do anything about it for now.' The nurse MOST accurately identifies this client as being in which stage, and which intervention is MOST appropriate?

Contemplation; prescribe nicotine replacement therapy to begin physiological preparation for quitting
Precontemplation; provide unsolicited educational pamphlets about the harms of smoking to increase knowledge
Preparation; assist the client in setting a quit date and identifying cessation supports
Contemplation; explore ambivalence using motivational interviewing and help the client weigh pros and cons (Correct answer)

Correct answer: Contemplation; explore ambivalence using motivational interviewing and help the client weigh pros and cons

The client acknowledges a need to quit ('I know I should') but has no immediate intention to act ('not planning to do anything about it for now'), which places them in the Contemplation stage — aware of the problem, ambivalent, but not committed to action. Motivational interviewing to explore ambivalence and weigh pros and cons is the evidence-based approach for this stage. Precontemplation involves no awareness of the need to change; Preparation involves active planning. Prescribing NRT without readiness is premature and nurse practitioners/physicians, not practical nurses, prescribe.

Question 143: 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 144: While reviewing a fellow team member's documentation, a PN notices that a colleague has been consistently charting vital signs at times when the PN knows the colleague was on break. The documentation appears to have been fabricated. Under professional accountability standards, what is the PN's PRIMARY obligation?

Report the concern to the nurse manager or employer, and if the issue is not addressed, escalate to the provincial regulatory college (Correct answer)
Confront the colleague privately and give them an opportunity to self-correct before involving management
Document personal observations in a private log and wait to see if a patient harm event occurs before reporting
Report directly to the provincial regulatory college, bypassing the employer, to ensure regulatory bodies are immediately informed

Correct answer: Report the concern to the nurse manager or employer, and if the issue is not addressed, escalate to the provincial regulatory college

Falsifying documentation is a serious breach of professional standards that directly endangers patient safety and constitutes professional misconduct. The PN has a duty to report. The correct sequence is to first report to the employer/manager — facilities have processes to investigate and address this. If the employer fails to act or the situation poses ongoing risk, the PN is obligated to escalate to the regulatory college. Bypassing the employer entirely as a first step is generally not appropriate; however, inaction or private logging while harm is ongoing is never acceptable.

Question 145: A nurse is assessing a newborn at 36 hours of life. Total serum bilirubin is 195 µmol/L. The infant is 38 weeks gestational age, exclusively breastfed, and blood type A positive while the mother is O negative. Direct Coombs test is positive. Which complication is this newborn MOST at risk for if phototherapy is not initiated promptly?

Polycythemia causing hyperviscosity syndrome and renal vein thrombosis
Kernicterus leading to sensorineural hearing loss and choreoathetoid cerebral palsy (Correct answer)
Hypothyroidism from bilirubin-induced thyroid suppression
Neonatal sepsis secondary to bilirubin-mediated immunosuppression

Correct answer: Kernicterus leading to sensorineural hearing loss and choreoathetoid cerebral palsy

A positive direct Coombs test in a newborn with O-negative mother and A-positive infant confirms ABO incompatibility with active hemolysis. Rapidly rising unconjugated bilirubin crosses the blood-brain barrier and deposits in the basal ganglia and brainstem nuclei (kernicterus/bilirubin encephalopathy), causing irreversible sensorineural hearing loss, choreoathetoid cerebral palsy, upward gaze palsy, and intellectual disability. At 38 weeks gestation, the threshold for phototherapy is lower than term, making prompt intervention critical.

Question 146: When preparing an intramuscular injection, the practical nurse accidentally contaminates the needle by touching the syringe barrel. What should the nurse do?

Replace only the needle before administration
Administer the medication and document the contamination
Discard the entire syringe and prepare a new one (Correct answer)
Wipe the needle with an alcohol swab and proceed

Correct answer: Discard the entire syringe and prepare a new one

Once sterility is compromised, the entire syringe and needle must be discarded and a new preparation made to prevent infection.

Question 147: A boy, eighteen, is brought to the hospital to receive treatment for partial thickness burns on both legs. He is not eating much. What dish would be suitable to serve this customer?

crackers and chicken soup
shake heavy in protein (Correct answer)
Jell-O mixed with cream cheese
Two dollops of banana flavored ice cream

Correct answer: shake heavy in protein

Burn patients have significantly increased metabolic demands due to the extensive tissue damage, inflammation, and healing process. They require a high-calorie and high-protein diet to support tissue repair, prevent muscle wasting, and maintain immune function. A protein-heavy shake is an excellent choice as it is nutrient-dense, easy to consume, and often more palatable for clients with a decreased appetite.

Question 148: A client admitted with severe neutropenia (ANC < 500 cells/µL) is placed on protective (reverse) isolation. A practical nurse is assigned to this client. Which action by the nurse requires immediate correction?

Performing hand hygiene with ABHR before donning gloves to enter the room
Wearing a surgical mask when entering the room
Bringing a potted flowering plant sent by the client's family into the room (Correct answer)
Using dedicated equipment such as a stethoscope that remains in the room

Correct answer: Bringing a potted flowering plant sent by the client's family into the room

Potted plants and fresh flowers are contraindicated in the rooms of severely immunocompromised (neutropenic) clients because the soil and standing water in plant pots harbour Aspergillus species and Pseudomonas aeruginosa, which can cause life-threatening opportunistic infections in neutropenic patients. This is a well-established infection control restriction in oncology and transplant settings. Wearing a mask, using dedicated equipment, and proper hand hygiene before gloving are all appropriate protective measures for this population.

Question 149: In the ISBAR handoff format, what does the I stand for?

Investigation
Instruction
Identification (Correct answer)
Intervention

Correct answer: Identification

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

Question 150: A practical nurse is caring for an 82-year-old client with moderate dementia who refuses to open their mouth for oral hygiene. The client becomes increasingly agitated when approached with a toothbrush. Which intervention is most appropriate?

Document the refusal and defer oral care until the next shift when the client may be more cooperative
Request a physician's order to administer a mild sedative before oral care to ensure compliance
Delegate oral hygiene to the family and remove it from the nursing care plan
Use a chlorhexidine swab during a moment of calm, timing the intervention with the client's natural mouth opening during speech or yawning (Correct answer)

Correct answer: Use a chlorhexidine swab during a moment of calm, timing the intervention with the client's natural mouth opening during speech or yawning

For clients with dementia who resist care, best practice involves using therapeutic timing — capitalizing on natural opportunities (speaking, yawning) — and using less threatening tools like swabs instead of toothbrushes. Chlorhexidine gluconate swabs reduce oral bacteria and aspiration pneumonia risk effectively. Deferring care increases risk of aspiration pneumonia, a leading cause of death in dementia. Sedation for routine hygiene is not ethically or clinically appropriate. Delegating entirely to family without nursing oversight is an abandonment of professional responsibility.

Question 151: During the termination phase, which client response indicates the relationship is ending therapeutically?

The client denies having any feelings about the relationship ending
The client expresses realistic summary of progress and demonstrates coping strategies for ongoing needs (Correct answer)
The client regresses to behaviors from the orientation phase
The client becomes increasingly dependent and requests more contact

Correct answer: The client expresses realistic summary of progress and demonstrates coping strategies for ongoing needs

Realistic review of progress and independent coping strategies indicate healthy therapeutic termination. The client has internalized gains from the relationship.

Question 152: A practical nurse is assessing pain in an 88-year-old resident with severe Alzheimer's disease who is unable to verbalize. The nurse notices the resident grimacing, clenching fists, and resisting repositioning. The family states 'she never complains so she must be fine.' Which assessment approach is MOST appropriate?

Use a validated behavioral pain assessment tool such as the PACSLAC or PAINAD scale to objectively quantify pain indicators (Correct answer)
Request a physiotherapy consult to determine if the behaviors are related to musculoskeletal stiffness rather than pain
Administer a PRN analgesic empirically and document the behavioral response as an indirect pain measure
Accept the family's report as reliable since they know the resident best and document 'no pain per family'

Correct answer: Use a validated behavioral pain assessment tool such as the PACSLAC or PAINAD scale to objectively quantify pain indicators

Cognitively impaired older adults are at high risk for undertreated pain because they cannot self-report. Behavioral pain scales like PAINAD (Pain Assessment in Advanced Dementia) and PACSLAC are validated tools for this population and assess indicators such as facial expressions, body language, vocalizations, and resistance to care. Family report alone is insufficient and often unreliable for pain intensity in advanced dementia. While empirical analgesic trials can be part of a stepwise approach, beginning with a validated tool ensures objective documentation and clinical defensibility.

Question 153: Moments before a patient is transported to the OR for an elective laparoscopic cholecystectomy, she tells the PN, 'I've changed my mind — I don't want to go ahead today.' The surgeon tells the PN, 'She's just pre-op anxiety — take her in, we'll sort it out in there.' The patient looks directly at the PN and asks, 'What should I do?' What is the PN's most appropriate immediate action?

Reassure the patient that pre-operative anxiety is common and encourage her to proceed, as the surgeon is best positioned to assess her readiness
Inform the patient that because the consent form has already been signed, the procedure will proceed as scheduled, but offer to remain with her in the OR for emotional support
Remain neutral and defer to the surgical team's clinical judgment, documenting the patient's statement for the record
Stop the transport to the OR, clearly communicate the patient's withdrawal of consent to the entire surgical team, and advocate for the patient to have adequate time and privacy to discuss her concerns before any decision is made (Correct answer)

Correct answer: Stop the transport to the OR, clearly communicate the patient's withdrawal of consent to the entire surgical team, and advocate for the patient to have adequate time and privacy to discuss her concerns before any decision is made

A patient retains the absolute right to withdraw consent at any point, including immediately before a procedure — this is a foundational principle of Canadian healthcare law and patient rights. The PN's role as patient advocate requires them to stop the process immediately and ensure the withdrawal of consent is formally recognized by the entire team. Deferring to the surgeon's opinion that the patient is 'just anxious' (A, B) dismisses the patient's autonomous decision and could expose all team members to liability for assault or battery if the procedure proceeds. Telling the patient that the signed consent is irrevocable (D) is factually and legally incorrect. The PN must act decisively and immediately (C), even under significant pressure from senior team members, to protect the patient's fundamental rights.

Question 154: A practical nurse discovers a medication error made by another nurse on the previous shift. The harmed patient is stable. What documentation is required?

A chart entry describing the patient's current status and an incident report filed per facility policy (Correct answer)
Verbal notification to the charge nurse with no written documentation
An incident report only; no chart entry is needed to avoid legal risk
A note in the outgoing nurse's personnel file

Correct answer: A chart entry describing the patient's current status and an incident report filed per facility policy

Both a factual, objective chart entry about the patient's condition and an incident report are required to ensure continuity of care and proper quality-improvement processes.

Question 155: A PN is part of a quality improvement committee reviewing fall prevention. What role does the PN play in this committee?

Focus only on medication-related quality indicators
Observe only, since quality improvement is the manager's responsibility
Contribute frontline observations and nursing expertise to inform evidence-based changes (Correct answer)
Implement whatever changes are decided without providing input

Correct answer: Contribute frontline observations and nursing expertise to inform evidence-based changes

PNs bring valuable frontline clinical knowledge to quality improvement initiatives and are expected to actively contribute.

Question 156: A PN documents in the electronic health record (EHR) that a dressing change was completed at 1400h. At 1430h, the PN realizes the dressing was actually applied incorrectly and a second nurse redressed the wound. The PN should:

Add a late entry or addendum with the correct information, the time of correction, and a brief explanation — never alter or delete the original entry (Correct answer)
Ask the charge nurse to correct the record under their own credentials to protect the PN from liability
Leave the original entry unchanged to avoid creating the appearance of tampering
Delete the original entry and replace it with a corrected entry to keep the record accurate and unambiguous

Correct answer: Add a late entry or addendum with the correct information, the time of correction, and a brief explanation — never alter or delete the original entry

Altering or deleting health record entries — even to correct a genuine error — constitutes falsification of a legal document and is a serious professional offence in all Canadian jurisdictions. The legally and professionally correct approach is to make an addendum or late entry that clearly identifies the error, the correction, the time, and the author's credentials, while leaving the original entry intact and visible. This preserves the integrity of the record, ensures continuity of care, and demonstrates transparency. Asking another clinician to record under their credentials to obscure the original nurse's involvement would be an additional ethical and regulatory violation.

Question 157: A client with heart failure is prescribed a fluid restriction of 1,200 mL per 24 hours. At 1400h, the intake record shows: morning medications with 180 mL water, breakfast juice 120 mL, IV piggyback antibiotics in 100 mL NS (completed at 1200h), lunch soup 150 mL, and oral intake of 240 mL since lunch. How many millilitres remain for the rest of the shift and night?

370 mL
410 mL (Correct answer)
510 mL
310 mL

Correct answer: 410 mL

Total intake so far: 180 (medications) + 120 (juice) + 100 (IV piggyback) + 150 (soup) + 240 (oral since lunch) = 790 mL. Remaining: 1,200 − 790 = 410 mL. IV piggyback fluid counts toward fluid intake in clients with restrictions. Errors in fluid restriction management are a common cause of fluid overload and hospital readmission in heart failure clients, making meticulous inclusion of all fluid sources essential.

Question 158: Under the principle of self-regulation, Practical Nurses are accountable for:

Ensuring the profitability of their employing healthcare facility.
Following physician's orders without question.
Supervising the work of all unregulated care providers.
Maintaining their own competence and fitness to practice. (Correct answer)

Correct answer: Maintaining their own competence and fitness to practice.

Self-regulation is a privilege granted to professions, and it comes with the responsibility for its members to govern themselves. A key component of this is individual accountability for maintaining continuing competence, professional development, and ensuring one's own physical, mental, and emotional fitness to provide safe and ethical care.

Question 159: A practical nurse is performing a respiratory assessment on a client with a suspected right-sided pleural effusion. Which combination of assessment findings is most consistent with this condition?

Increased tactile fremitus, dullness on percussion, and bronchial breath sounds over the right base
Decreased tactile fremitus, hyperresonance on percussion, and absent breath sounds over the right base
Decreased tactile fremitus, dullness on percussion, and diminished breath sounds over the right base (Correct answer)
Increased tactile fremitus, resonance on percussion, and crackles over the right base

Correct answer: Decreased tactile fremitus, dullness on percussion, and diminished breath sounds over the right base

Pleural effusion (fluid in the pleural space) produces a classic triad: decreased tactile fremitus (fluid dampens vibration transmission), dullness to percussion (fluid is dense), and diminished or absent breath sounds over the affected area. Increased fremitus with bronchial sounds suggests consolidation (pneumonia). Hyperresonance suggests pneumothorax, not effusion. Crackles suggest fluid within alveoli (pulmonary edema), not pleural fluid.

Question 160: A Practical Nurse is documenting care provided to a client. Which of the following documentation entries is most legally sound?

"Client was uncooperative and difficult during the morning assessment."
"Client appeared to be in a better mood today."
"Performed wound care as per protocol. Dressing changed. No signs of infection noted."
"Administered pain medication for client's complaint of abdominal pain. Client reports pain level decreased from 8/10 to 3/10, 45 minutes post-administration." (Correct answer)

Correct answer: "Administered pain medication for client's complaint of abdominal pain. Client reports pain level decreased from 8/10 to 3/10, 45 minutes post-administration."

Legally sound documentation should be objective, specific, and factual. This entry includes the reason for the intervention (complaint of pain), the specific action taken (administered medication), the client's subjective report using a pain scale, the time frame for evaluation, and the outcome. It avoids vague terms, subjective judgments, and generalizations.

Question 161: A PN is assessing a client's sacral wound and observes a shallow open ulcer with a red-pink wound bed and no slough. How should this wound be staged?

Stage IV
Stage I
Stage II (Correct answer)
Stage III

Correct answer: Stage II

A Stage II pressure injury presents as a shallow open ulcer with a pink or red wound bed. There is partial-thickness loss of skin with no slough or eschar. Stage I involves intact skin with non-blanchable erythema; Stage III involves full-thickness tissue loss.

Question 162: 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?

Contact the physician to request a bolus dose because the family's distress constitutes a clinical indication
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)
Increase the rate modestly, as the patient's comfort is the only priority at this stage
Reduce the infusion rate to demonstrate that the medication is not causing death and reassure the daughter

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 163: 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 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)
The client is demonstrating resistance to the therapeutic process and requires motivational interviewing.

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 164: A client with dementia becomes agitated and refuses their morning medication. The Practical Nurse documents the refusal and informs the charge nurse. Later, the client's family insists the medication must be given. What is the PN's most appropriate legal and ethical response?

Explain to the family that a competent client has the right to refuse treatment. (Correct answer)
Administer the medication discreetly in the client's food.
Request the family to sign a waiver before administering the medication.
Inform the family that since the client has dementia, their refusal is not valid.

Correct answer: Explain to the family that a competent client has the right to refuse treatment.

Even with a diagnosis of dementia, a client may still have the capacity to make decisions. The fundamental ethical and legal principle is the client's right to autonomy and informed refusal of treatment. Forcing medication would be considered battery. The PN's responsibility is to respect the client's decision, document it, and communicate this to the family and the healthcare team.

Question 165: A PN working in a long-term care facility disagrees with a care decision made by the most responsible physician regarding a resident's pain management. The PN believes the current order is inadequate based on their ongoing assessment. After raising the concern with the RN team lead and receiving no change, what is the most appropriate next step?

Document the concern in the chart and follow the established escalation pathway, such as contacting the unit manager or using a structured advocacy tool (Correct answer)
Notify the provincial licensing body that inadequate care is being provided
Contact the resident's family to advise them to request a second physician opinion
Administer a higher dose than ordered based on the PN's clinical judgment

Correct answer: Document the concern in the chart and follow the established escalation pathway, such as contacting the unit manager or using a structured advocacy tool

When a PN believes a client's needs are not being met, the professional obligation is to escalate through the facility's established channels — such as the unit manager or a structured communication tool like SBAR or a formal escalation protocol — while documenting the concern. This upholds both client advocacy and professional accountability. Administering a higher dose (A) is unsafe and outside the PN's authority. Contacting the family to orchestrate a physician change (C) oversteps the PN's role and bypasses proper process. Reporting to the licensing body (D) is reserved for serious professional misconduct, not a single unresolved clinical disagreement.

Question 166: Which concept describes the legal responsibility a practical nurse holds when delegating a task to an unregulated care provider?

Respondeat superior
Contributory negligence
Accountability for delegation (Correct answer)
Vicarious liability

Correct answer: Accountability for delegation

The practical nurse retains accountability for delegation decisions, including assessing whether the task is appropriate for the unregulated care provider's competency.

Question 167: During a focused respiratory assessment, the practical nurse auscultates high-pitched musical sounds on exhalation. How are these best described?

Wheezes (Correct answer)
Stridor
Rhonchi
Crackles

Correct answer: Wheezes

Wheezes are high-pitched musical sounds from narrowed airways, heard primarily on exhalation, associated with asthma and COPD.

Question 168: When performing a mental status assessment, which component does the practical nurse evaluate by asking the client to subtract serial 7s from 100?

Concentration and calculation (Correct answer)
Orientation
Abstract reasoning
Memory

Correct answer: Concentration and calculation

Serial 7 subtraction tests concentration and calculation ability, which is a component of cognitive function in a mental status exam.

Question 169: A practical nurse is conducting a community needs assessment using Precede-Proceed model principles. During the epidemiological assessment phase, the nurse identifies that a rural First Nations community has a cervical cancer incidence rate three times the provincial average. Which finding would MOST directly inform the educational and ecological assessment (Phase 3) of the model?

The community lacks a local colposcopy clinic, requiring clients to travel 300 km for follow-up
The age-standardized cervical cancer mortality rate has increased 15% over five years
HPV vaccination uptake among girls aged 9–14 in the community is 28% compared to 72% provincially
Cultural mistrust of the healthcare system due to intergenerational trauma from residential schools reduces health-seeking behaviour (Correct answer)

Correct answer: Cultural mistrust of the healthcare system due to intergenerational trauma from residential schools reduces health-seeking behaviour

The educational and ecological assessment (Phase 3 of Precede-Proceed) identifies predisposing, enabling, and reinforcing factors that influence health behaviours. Cultural mistrust rooted in historical trauma is a predisposing factor — an attitudinal/belief factor that directly affects willingness to engage with screening. Lack of a colposcopy clinic is an enabling factor (access barrier) relevant to Phase 3 but is less foundational than the predisposing cultural factor. Low vaccination rates and mortality data belong to the epidemiological assessment (Phase 2). The correct answer is D because it is the most direct predisposing determinant shaping behaviour.

Question 170: 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.
Decline without explanation to reinforce professional distance.
Decline and explain the agency's gift policy, acknowledging the client's gratitude verbally. (Correct answer)
Accept the gift and document it in the client's chart.

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.

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%

To Pass

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These practice questions were written with AI tools. They are not real exam questions. Exam facts are checked against the official sources listed below. Not reviewed by a subject-matter expert. Editorial policy

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