Question 1

While ambulating, a client takes a dose of nitroglycerin spray for angina. What does the nurse do first?

Accepted Answer

Answer reason: Nitroglycerin causes rapid venous and arterial vasodilation, which can acutely lower blood pressure and precipitate dizziness or syncope, especially during ambulation. The immediate priority is preventing a fall by stopping activity and placing the client in a safe seated position while symptoms are addressed. After safety is ensured, the nurse should obtain vital signs (particularly blood pressure) and reassess symptoms/response to the dose. An ECG can be important if pain persists or worsens, but it is not the first action when the client is at immediate risk for injury.

Question 2

These medications have been prescribed for a 9-year-old with deep partial- and full-thickness burns. Which medication is most important to double-check with another licensed nurse before administration?

Accepted Answer

Answer reason: Lorazepam (Ativan) 0.5 mg PO High-alert medications that can cause rapid clinical deterioration require an independent double-check to prevent dosing and administration errors. Benzodiazepines can produce excessive sedation, respiratory depression, and airway compromise, and pediatric patients are particularly vulnerable due to weight-based sensitivity and variable metabolism. A burn patient may also be receiving opioids or other sedatives, increasing the risk of synergistic CNS/respiratory depression if an error occurs. By contrast, topical silver sulfadiazine, famotidine, and a multivitamin generally do not carry the same immediate life-threatening risk from a single routine administration error as a sedative does.

Question 3

A nurse completes administration of a subcutaneous injection to a client. Which action does the nurse take next?

Accepted Answer

Answer reason: Needlestick prevention is the immediate post-injection priority because an exposed needle poses an urgent risk of injury and bloodborne pathogen transmission to staff and others. The safest next step is to activate safety features (if present) and dispose of the uncapped needle directly into an approved sharps container at the point of use. Hand hygiene and documentation are essential but should follow sharps disposal because they do not remove the immediate hazard of an unsecured sharp. Ongoing monitoring for side effects is important but is not the first action once the injection is completed if the sharps risk has not yet been eliminated.

Question 4

A newborn client has a myelomeningocele. The nurse places this client in what position?

Accepted Answer

Answer reason: Placing the newborn prone keeps pressure off the spinal defect and helps maintain integrity of the lesion while awaiting surgical repair. Supine or dorsal recumbent positioning increases direct pressure and friction on the sac, raising the risk of CSF leak and contamination. Fowler’s is not appropriate because it does not reliably offload the lesion and can still allow contact/pressure depending on positioning and supports.

Question 5

A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first?

Accepted Answer

Answer reason: Immediately after knee surgery, restrictions may include bedrest, toe-touch/partial weight bearing, knee immobilizer use, or PT-only first ambulation, making an order check the safest first step. Only after verifying the prescription can the nurse decide whether additional staff, a gait belt/walker, or therapy assistance is required. Premedicating may support comfort, but it does not address the primary safety risk of mobilizing outside ordered limits, and delegation without verification could result in an unsafe transfer.

Question 6

The nurse evaluates morning laboratory results for several clients who were admitted 24 hours earlier. Which laboratory report requires priority follow-up?

Accepted Answer

Answer reason: A value this high is well above typical therapeutic targets, so the nurse should promptly assess for bleeding, verify the infusion/dose, and notify the provider for possible dose adjustment/hold and reversal per protocol. By comparison, a PaCO2 of 52 mm Hg can be an expected chronic finding in COPD, and BNP 800 pg/mL reflects heart failure severity but is not as immediately dangerous. A WBC of 13,000/mm3 suggests infection/inflammation but usually does not represent the same acute, life-threatening complication risk as extreme anticoagulation.

Question 7

The nurse provides client education regarding acupuncture to assist with smoking cessation. When discussing the client’s current medications, which medication indicates a contraindication to the use of acupuncture?

Accepted Answer

Answer reason: An anticoagulant like warfarin can significantly impair clot formation, making even minor punctures more likely to cause clinically relevant bleeding. In contrast, antihypertensives such as ACE inhibitors or calcium channel blockers do not inherently create a bleeding diathesis. The safest nursing teaching is to recognize anticoagulation as a key contraindication/precaution and advise consultation with the prescriber and the acupuncture practitioner before proceeding.

Question 8

A nurse is planning discharge care for a client who had a stroke and now has left-sided weakness. Which of the following interventions should the nurse include in the plan of care?

Accepted Answer

Answer reason: Stroke-related unilateral weakness increases fall risk, especially during toileting and bathing where surfaces are wet and transfers are required. Home safety modifications that provide stable handholds reduce the likelihood of falls and support safer independent mobility during transfers. Crutches are generally inappropriate with hemiparesis because they require bilateral upper-extremity strength and coordination and can worsen instability. Having an aide perform all ADLs can promote learned dependence rather than safe independence, and hospice is not indicated solely for post-stroke weakness without a terminal prognosis.

Question 9

A nurse on a medical unit is caring for a client who requires seizure precautions. Which of the following interventions should the nurse contribute to the client’s plan of care?

Accepted Answer

Answer reason: The priority in seizure precautions is preventing injury during an unexpected seizure, especially head and extremity trauma from striking hard surfaces. Padding side rails reduces impact and helps protect the client if tonic-clonic activity occurs. Keeping lights on is not a standard seizure precaution and can worsen sleep disruption without improving safety. A tongue blade should not be kept at bedside for insertion during a seizure because anything placed in the mouth can cause dental injury, aspiration, or airway obstruction.

Question 10

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?

Accepted Answer

Answer reason: A low bed is appropriate, but combining it with all four rails creates an unsafe environment and requires the nurse to intervene to remove/modify the restraint and implement safer fall precautions. Appropriate alternatives include a low bed with two rails (per facility policy), bed alarm, frequent rounding, and keeping needed items within reach. Bed alarms, hourly rounds, and fall-risk identification are standard non-restraint interventions to reduce falls in confused, high-risk clients.

Question 11

A home health nurse is caring for an older adult client who tells the nurse she does not like to leave her home at all anymore. Which of the following would be the Priority assessment?

Accepted Answer

Answer reason: Avoiding leaving home can reflect reduced mobility, fear of falling, deconditioning, or an unsafe home environment, all of which elevate the chance of serious injury. A fall in an older adult can rapidly lead to fractures, head injury, loss of independence, and hospitalization, making it more urgent than social or access barriers. Transportation and socioeconomic status are important contributors to isolation, but they do not typically represent the most immediate physical harm. Bladder incontinence can contribute to falls (urgency, rushing, nighttime toileting), which further supports prioritizing fall-risk assessment.

Question 12

The nurse completes the following drug administrations. Which would require an incident report?

Accepted Answer

Answer reason: MAOIs require an adequate washout period before initiating an SSRI to prevent serotonin syndrome and hypertensive crisis from excessive serotonergic and catecholamine activity. Administering escitalopram the day after stopping phenelzine is a medication error because phenelzine’s MAO inhibition persists for days, and standard guidance is a ~14-day washout. This creates a preventable risk for life-threatening hyperthermia, autonomic instability, agitation, and neuromuscular findings. In contrast, holding a nitrate for marked hypotension is appropriate, and giving warfarin with an INR of 2.5 for PE is within typical therapeutic range.

Question 13

A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100mL/hour?

Accepted Answer

Answer reason: A chest radiograph confirms the catheter tip is in the appropriate central location and helps detect pneumothorax or hemothorax from insertion. Starting IV fluids through a malpositioned catheter can cause infiltration into tissues, vascular injury, or arrhythmias if the tip is too deep. Labs such as osmolality/electrolytes and I&O inform fluid management but do not ensure the catheter is safe to use right after insertion.

Question 14

The nurse discovers an exposed needle at the bedside of the client. The client tells the nurse that the needle was never used. What action does the nurse take?

Accepted Answer

Answer reason: Needlestick injury prevention requires treating any unattended exposed needle as potentially contaminated and disposing of it immediately in an approved sharps container. Activating the safety mechanism reduces the risk of puncture during handling and transport to disposal. Recapping is contraindicated because it increases the risk of accidental sticks and is not an appropriate way to manage found sharps. Using the needle is unsafe because sterility cannot be verified and it creates infection and bloodborne pathogen exposure risk.

Question 15

A 24-year-old primipara is now in her active phase of the first stage of labor. She tells the nurse that she wants general anesthesia to relieve intense pain. The nurse advises the patient that general anesthesia is not preferred for childbirth because?

Accepted Answer

Answer reason: Airway management and ventilation can be more difficult in pregnancy, so hypoventilation or failed intubation can rapidly lead to maternal hypoxia and fetal compromise. Regional techniques (epidural/spinal) typically provide effective analgesia while keeping the mother awake and maintaining airway reflexes. The other options are not the key, common safety-limiting reasons for avoiding general anesthesia in routine vaginal delivery.

Question 16

A school nurse watching elementary students playing on the playground should be most concerned when she sees?

Accepted Answer

Answer reason: Playground nursing surveillance prioritizes preventing high-risk injury from unsafe equipment use and potential falls. Climbing on swing-set supports places the child at significant risk for falling from height and for being struck by moving swings, which can cause head injury or fractures. Heavy breathing after running and squatting after play are common, self-limited post-exertion behaviors in children without other distress signs. An argument is a lower-immediacy safety concern compared with an imminent mechanism of serious physical injury.

Question 17

The school nurse is speaking with the parent of a fourth grade student about a bed bug that was found on the child's sweater. The parent confirms that their home is infested but that the issue is being resolved. Which is the best action by the nurse?

Accepted Answer

Answer reason: Heat from laundering/drying and isolation in sealed bags are practical, evidence-based steps that reduce live bugs and prevent transfer in backpacks/lockers. Asking school staff to apply insecticides is unsafe and outside typical school nursing scope, with unnecessary chemical exposure risk. Broad notification or excluding the child is not the least restrictive approach and can increase stigma without meaningfully improving safety compared with targeted containment measures.

Question 18

Unlicensed assistive personnel report 4 situations to the registered nurse. Which situation warrants the nurse's intervention first?

Accepted Answer

Answer reason: This requires prompt nursing action to remove/replace the container and prevent improper disposal or forced insertion of sharps. The discarded 24-hour urine specimen affects test accuracy but is not an immediate physical danger. A glucose of 80 mg/dL is within normal range for many adults and warrants routine monitoring rather than urgent intervention, while the clergy request is important but not a safety emergency.

Question 19

The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client’s central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change?

Accepted Answer

Answer reason: Preventing air embolism is a key safety priority when changing central line tubing because negative intrathoracic pressure can draw air into the venous system. Holding a deep breath and bearing down (Valsalva) increases intrathoracic and central venous pressure, reducing the pressure gradient that could entrain air. This maneuver is especially relevant with a subclavian central line, where the risk is higher due to its location above the heart. Normal breathing or slow exhalation can create periods of lower venous pressure and does not provide the same protection against air entry.

Question 20

The client is prescribed a fentanyl patch for persistent severe pain. Which client behavior most urgently requires correction?

Accepted Answer

Answer reason: This creates an immediate risk for life-threatening respiratory depression, excessive sedation, and overdose, making it the most urgent safety issue. In contrast, placing the patch on the upper anterior chest can be acceptable if it is an appropriate, intact, hairless site and rotated per instructions. Extending the interval to every 4 days risks inadequate analgesia and withdrawal, and reusing patches is unsafe and inappropriate, but neither is as immediately capable of precipitating acute overdose as external heat.

Question 21

A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the delivery room table and the nurse positions the client?

Accepted Answer

Answer reason: A lateral uterine displacement using a wedge achieves a left tilt that relieves vena cava compression while maintaining a practical operative position for anesthesia and surgical prep. This improves maternal hemodynamic stability and helps maintain fetal oxygenation during preparation for cesarean birth. Trendelenburg can worsen respiratory mechanics and venous congestion, and prone positioning is not feasible/safe for term pregnancy on an OR table.

Question 22

A client with right-sided weakness becomes dizzy, loses balance and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?

Accepted Answer

Answer reason: Extending one leg creates a controlled “slide” surface so the client can be guided down gradually without sudden impact or twisting. Standing slightly behind with feet apart reduces the chance the nurse is pulled forward and allows controlled lowering rather than catching the full weight. Options involving bracing knees/feet or lifting under the axillae increase risk of nurse injury and client shoulder/nerve injury and can destabilize both during the descent.

Question 23

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?

Accepted Answer

Answer reason: Immediate nursing actions include stopping the infusion, assessing the extremity (pain, blanching, coolness), elevating the limb, and applying appropriate compresses per the infusate and policy, with restart at a new site as needed. A DNR order only limits resuscitative measures during cardiopulmonary arrest and does not change the urgency of treating preventable harm. The other findings are time-based or low-risk (slightly overdue flush, low-rate infusion with fluid remaining) and can be addressed after stabilizing the potentially injurious IV complication.

Question 24

A 1 5-year-old parent brings a 4-month-old infant for a well-baby checkup. The parent tells the nurse that the baby cries all the time. The parent is doing everything to keep the infant quieter, but nothing works. What is the priority nursing action?

Accepted Answer

Answer reason: The key priority is infant safety by identifying any potentially harmful soothing practices and assessing risk for abusive head trauma when a caregiver reports persistent crying and ineffective calming. Clarifying exactly what the caregiver is doing can reveal dangerous actions (e.g., shaking, unsafe sleep positioning, inappropriate medications) and allows immediate safety teaching and intervention. This approach also assesses caregiver coping and escalating frustration, which are strong predictors of unsafe responses to crying. Compared with immediately calling the provider or focusing first on crying patterns/support system, screening for unsafe behaviors addresses the most imminent preventable harm.

Question 25

The nurse working in an intensive care unit cares for a client with a left triple lumen subclavian central venous catheter (CVC). The nurse should call the primary health care provider (HCP) for clarification prior to implementation when recognizing that which prescription is an error?

Accepted Answer

Answer reason: A routine order to instill 1000 units of heparin into unused CVC lumens is unsafe and atypical for standard triple-lumen central venous catheters, which are commonly maintained with saline (and, if ordered, very low-dose heparin per facility/policy and catheter type). Such a high heparin dose increases risk of systemic anticoagulation, bleeding, and heparin-induced thrombocytopenia, especially if inadvertently flushed into circulation. The other prescriptions are consistent with typical care: TPN can be infused via a dedicated lumen, occlusive dressings are often changed every 7 days if clean/intact, and the distal lumen is used for CVP monitoring.

Question 26

The nurse in an outpatient clinic is supervising student nurses administering influenza vaccinations. The nurse should question the administration of the vaccine to which of the following clients?

Accepted Answer

Answer reason: Vaccines should be given after screening for acute illness because moderate-to-severe intercurrent infection with systemic symptoms can confound adverse-event assessment and may warrant postponement. A sore throat can represent an active infectious process (e.g., influenza-like illness) requiring further assessment (fever, severity, systemic signs) before proceeding. In contrast, shellfish allergy is not a contraindication to influenza vaccination, and high-risk clients (older adults, congregate living, and heart failure) are priority candidates for immunization. The safest nursing action is to pause and assess illness severity rather than vaccinate immediately without clarification.

Question 27

The nurse does rounds on clients midway through the evening shift. Which situation requires a priority intervention by the nurse?

Accepted Answer

Answer reason: Priority nursing care follows the principle of preventing immediate physiologic harm and preserving perfusion. Crossing the legs at the knee can further impede already compromised arterial blood flow in PAD, increasing ischemia and risk of pain, pallor, coolness, and tissue breakdown. This is a modifiable positioning issue that requires prompt teaching and repositioning to avoid worsening circulation. In contrast, the GERD client sipping a carbonated beverage may worsen symptoms but is unlikely to cause acute harm, and the dementia feeding assistance is an appropriate safety support if aspiration precautions are followed.

Question 28

The nurse is performing an assessment of a child who is to receive a measles, mumps, and rubella (MMR) vaccine. The nurse notes that the child is allergic to eggs. Which intervention has priority?

Accepted Answer

Answer reason: Egg allergy is not a routine contraindication to MMR (it is grown in chick embryo fibroblasts and contains negligible egg protein), so the priority is assessment and communication rather than withholding the vaccine or premedicating. Prophylactic epinephrine is inappropriate and suggests treating a reaction before it occurs; emergency medications should be available but not routinely given. Antihistamines/acetaminophen can mask early symptoms or be unnecessary and do not replace proper pre-vaccine evaluation and provider notification when allergy history is concerning.

Question 29

A newly registered nurse is caring for a school-aged child with cerebral palsy under the supervision of a senior nurse. Which action by the new RN would warrant the senior nurse to intervene?

Accepted Answer

Answer reason: Feeding a child with neuromuscular impairment increases aspiration risk due to poor oropharyngeal coordination and weak protective reflexes. Safe feeding requires upright positioning (typically high Fowler’s ~60–90°) with head/neck alignment to reduce choking and aspiration. Elevating the bed only 30° is closer to semi-Fowler’s and is generally insufficient for safe oral intake in a high-risk child. In contrast, lowering the bed, assisting mobility via wheelchair, and gentle range-of-motion are routine safety and comfort measures when done with appropriate assessment and supervision.

Question 30

A 42-year-old woman was admitted to the hospital with a hemoglobin of 6.5 g/dL. She is experiencing signs and symptoms of cerebral tissue hypoxia. Which of the following should the nurse prioritize?

Accepted Answer

Answer reason: The immediate nursing priority is preventing injury from a predictable safety hazard while the underlying cause is being treated. Hot water exposure can cause burns, and a hypoxic client may not accurately perceive temperature or react quickly enough to avoid injury. Rest periods and OT referral support longer-term energy conservation, and assisted ambulation is helpful, but burn prevention is a more direct, high-risk, immediate safety intervention for an at-risk client in the bathroom setting.

Question 31

A community mental health nurse visits a client diagnosed with paranoid schizophrenia. When she arrives at his house, he calls her Satan, shouts at her, and tells her to back away. Which intervention should be performed first?

Accepted Answer

Answer reason: When a client is actively paranoid, shouting, and directing the nurse to back away, the immediate priority is personal safety and de-escalation by increasing distance. Leaving removes the nurse from a potentially escalating threat and prevents provoking further agitation or violence in an uncontrolled home environment. Verbal calming techniques are appropriate only if safety can be maintained, but the client’s behavior indicates poor reality testing and potential danger. Calling police may be necessary later if there is imminent risk, but first the nurse should exit to a safe location before initiating further actions.

Question 32

A client is admitted with suspected active internal bleeding. The nurse reviews the provider’s orders. Which order should the nurse question or seek clarification for FIRST?

Accepted Answer

Answer reason: Anticoagulation can exacerbate ongoing hemorrhage and rapidly destabilize the patient, so this order is potentially unsafe and requires immediate clarification before implementation. By contrast, obtaining labs and a type/crossmatch support rapid assessment and readiness for transfusion, and imaging may help localize the bleeding source once stabilized. The nurse should verify the indication and rule out bleeding as the primary process before initiating anticoagulants.

Question 33

The nurse is inserting an indwelling (Foley) urinary catheter into a male client. After inserting the catheter about 6 in (15.2 cm), the nurse notes drops of urine in the tubing. What action should the nurse take next?

Accepted Answer

Answer reason: Further insert the catheter 1-2 in (2.5-5.1 cm) Urine return indicates the catheter tip has reached the bladder neck/urethra-bladder junction, but the balloon may still be in the prostatic urethra. Advancing a bit further ensures the balloon is fully within the bladder before inflation, preventing urethral trauma, pain, bleeding, and false passage. Inflating the balloon immediately after initial urine return is a common error and can injure the urethra. Securing the catheter is done after correct placement and balloon inflation, not before confirming bladder positioning.

Question 34

A nurse is collecting data on a client’s circulatory system. Which of the following pulse sites should the nurse avoid checking bilaterally at the same time?

Accepted Answer

Answer reason: This vagal response may cause bradycardia, hypotension, dizziness, or syncope, creating an avoidable safety risk during assessment. Therefore, carotid pulses should be assessed one side at a time. Other listed peripheral pulses do not carry the same risk of compromising cerebral circulation when palpated bilaterally.

Question 35

A client receives a wrong medication. The nurse who made the medication error should do which of the following first?

Accepted Answer

Answer reason: Client safety and physiologic stability take priority after any medication error. The immediate first action is to assess for actual or potential adverse effects (vital signs, level of consciousness, symptoms, and relevant focused assessment) so harm can be identified early. Once the client is assessed, the provider can be notified with meaningful clinical data to obtain appropriate treatment orders if needed. Reporting to the nurse manager and completing an incident report are important but follow immediate patient assessment and stabilization.

Question 36

After a power outage, a confused client with an unsteady gait arrives at a portable emergency response station. Which action does the nurse take first?

Accepted Answer

Answer reason: Providing a chair promptly reduces risk of collapse and stabilizes the client so further assessment can be performed safely. After the client is seated and safe, the nurse can assess level of consciousness and complete triage. Asking where the client lives is not time-critical and does not address the immediate hazard.

Question 37

The client received hydromorphone 1.5 mg IV 2 hours ago for pain. The client tells the nurse of needing to go to the bathroom. The health care provider ordered bathroom privileges. The nurse takes which action?

Accepted Answer

Answer reason: Opioids like hydromorphone can cause sedation and orthostatic hypotension, increasing fall risk when changing positions. Dangling at the bedside allows the nurse to assess dizziness, steadiness, and vital tolerance before ambulation and provides a safer transition from lying to standing. This action aligns with bathroom privileges while implementing fall-prevention technique without unnecessarily restricting mobility. A bedpan or bedside commode may be indicated if the client is unstable, but the stem does not indicate current instability—only recent IV opioid use requiring safety screening.

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