Question 1

The nurse is preparing to administer an enteral feeding to a client via an nasogastric feeding tube. The MOST important action of the nurse is?

Accepted Answer

Answer reason: The highest-priority action before administering any enteral feeding is to verify correct NG tube placement. Incorrect placement can lead to catastrophic errors such as aspiration, pneumonitis, or direct infusion of formula into the lungs. Confirming placement prevents these potentially life-threatening complications and is the primary safety check.

Question 2

The home health nurse is visiting a client with Paget's disease. An important part of preventive care for this client is?

Accepted Answer

Answer reason: Paget disease of bone causes bone deformity and fragility, increasing the risk of falls and fractures. Keeping the home free of clutter is a key preventive safety measure to reduce the risk of falls. Other options are not specific primary prevention strategies for this condition.

Question 3

The nurse is preparing a client for surgery. Which item is most important to remove before sending the client to surgery?

Accepted Answer

Answer reason: Contact lenses must be removed preoperatively to prevent corneal drying and abrasion when protective eye reflexes are diminished under anesthesia. Hearing aids and rings may be managed or taped; an artificial eye poses less immediate risk.

Question 4

The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. The best response is: The child needs to use a car seat until the child...?

Accepted Answer

Answer reason: Child passenger safety guidelines recommend a car seat until the child reaches about 40 lb; age, height, or willingness do not ensure proper restraint fit or protection.

Question 5

The mother of a 9-year-old with asthma has brought an electric CD player for her son to listen to while he receives oxygen therapy. The nurse should?

Accepted Answer

Answer reason: Oxygen supports combustion; plug-in electrical devices can spark and increase the risk of fire. A battery-operated player is the safest choice.

Question 6

If the nurse is taking a rectal temperature on an infant, how far should the thermometer be inserted into the rectum?

Accepted Answer

Answer reason: For infants, the rectal thermometer is inserted about 0.5 inches (1.3 cm) to obtain an accurate reading while avoiding rectal injury; deeper insertion is for older children.

Question 7

When preparing a client for admission to the surgical suite, the nurse recognizes which of the following items is most important to remove before sending the client to surgery?

Accepted Answer

Answer reason: Dentures can dislodge during induction and intubation, posing a risk of airway obstruction and aspiration. Contact lenses, hearing aids, and wedding rings are less critical; the ring can be taped, and hearing aids are often left in until anesthesia starts.

Question 8

When admitting an elderly patient, what is an effective nursing action to prevent disorientation?

Accepted Answer

Answer reason: A nightlight reduces sensory deprivation and helps maintain orientation in unfamiliar surroundings, decreasing nighttime confusion and the risk of falls in older adults.

Question 9

Which of the following is a safe game for a child with hemophilia?

Accepted Answer

Answer reason: Children with hemophilia should avoid contact sports that increase trauma and bleeding risk. Swimming is a low-impact, non-contact activity that minimizes joint injury.

Question 10

The nurse is caring for a client with an acoustic neuroma brain tumor. The location of this tumor warrants which of the following nursing diagnosis as the highest priority?

Accepted Answer

Answer reason: Acoustic neuroma involves the vestibulocochlear nerve, leading to vertigo and balance disturbances. Preventing falls and injury is the highest immediate priority.

Question 11

In which of the following clients is a rectal temperature most usually contraindicated?

Accepted Answer

Answer reason: Rectal temperatures can stimulate the vagus nerve and precipitate bradycardia or dysrhythmias, which is especially risky after myocardial infarction. The other conditions are not standard contraindications.
Category reason: This is a nursing safety question about avoiding a harmful assessment technique, fitting Safety and Infection Control under the NCLEX framework.

Question 12

Which comment by the mother of an 18-month-old girl indicates she understands safety concerns?

Accepted Answer

Answer reason: Toddlers are highly curious and at risk for unintentional poisoning; securing medications with cabinet locks is an appropriate safety measure. Constant supervision is unrealistic, toddlers don’t fully understand right/wrong at 18 months, and syrup of ipecac is no longer recommended for poison ingestion.

Question 13

Nurses must protect themselves and clients from dangerous shocks by keeping their hands dry when manipulating machinery, mopping spilled fluid, ensuring that all plugs are grounded and reporting any equipment damage is called?

Accepted Answer

Answer reason: Keeping hands dry, mopping spills, ensuring grounded plugs, and reporting equipment damage are measures to prevent electrical shock—i.e., electrical safety.

Question 14

The nurse is caring for a client with a history of falls. What safety intervention is essential for preventing falls in this client?

Accepted Answer

Answer reason: Adequate lighting reduces tripping hazards and improves visibility, a key fall-prevention measure. Slip-on shoes are unstable, restraints increase injury risk, and independent ambulation is unsafe for a high fall-risk client.

Question 15

Which of the following is NOT a role of occupational health?

Accepted Answer

Answer reason: Occupational health aims to protect and promote workers’ health, prevent workplace injuries, improve working environments, and support productivity. Option C misidentifies the target group (occupational health staff) rather than all workers, so it is not a stated role.

Question 16

What is the most appropriate nursing diagnosis for a patient requiring anticoagulation therapy who has a history of frequent falls?

Accepted Answer

Answer reason: A patient on anticoagulants with frequent falls is at high risk for serious bleeding and trauma; the priority nursing diagnosis is Risk for Injury.

Question 17

The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?

Accepted Answer

Answer reason: Best practice is to use two acceptable identifiers (e.g., name and medical record number) verified against the armband and MAR. Room number and family identification are not acceptable identifiers, and repeating the same identifier (name) twice is insufficient.

Question 18

A client with a history of falls is admitted to the hospital. What is the priority nursing intervention to prevent falls in this client?

Accepted Answer

Answer reason: Good lighting reduces tripping hazards and improves orientation. Sedatives increase fall risk, slip-on shoes are unsafe, and restraints are not a first-line fall-prevention strategy.

Question 19

The nurse is caring for a client with a seizure disorder. During a seizure, what is the priority nursing intervention?

Accepted Answer

Answer reason: During a seizure, the immediate priority is client safety—protect from injury by removing hazards, padding side rails, and positioning as able. Medications are given after or for status epilepticus, nothing should be placed in the mouth, and limbs should not be restrained.

Question 20

The nurse is discussing accident prevention with parents. Which of the following should the nurse emphasize is at HIGHEST risk for poisoning?

Accepted Answer

Answer reason: Toddlers (around 1–3 years) are at highest poisoning risk due to increased mobility and curiosity, leading to exploration and ingestion of toxic substances. Infants and older children are comparatively less prone.

Question 21

A rectal temperature is not taken when a person?

Accepted Answer

Answer reason: Rectal temperature is contraindicated after rectal surgery because it can cause trauma, bleeding, or vagal stimulation. Rectal temps can be used for unconscious patients and provide core temperature; an NG tube does not preclude rectal measurement.

Question 22

Which child is at greatest risk for accidental poisoning assuming normal cognitive and emotional development?

Accepted Answer

Answer reason: Toddlers and preschoolers are the most at risk for accidental poisoning due to increased mobility, curiosity, and oral exploration; among the choices, the 4-year-old fits this highest-risk group.

Question 23

What is the primary goal during a seizure?

Accepted Answer

Answer reason: Priority during an active seizure is client safety—clear surroundings, pad rails, and prevent injury. Do not insert objects into the mouth or restrain; oxygen may be provided after ensuring safety.

Question 24

The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for?

Accepted Answer

Answer reason: Osteogenesis imperfecta causes fragile bones due to collagen defects, making infants highly susceptible to fractures. Priority teaching is careful handling to prevent injury; extra calcium or sensorimotor stimulation are not primary needs, and routine visual testing is not indicated.

Question 25

The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client?

Accepted Answer

Answer reason: Osteogenesis imperfecta causes fragile bones with high fracture risk; contact sports like football greatly increase injury risk and are contraindicated.

Question 26

A client with AIDS is admitted with a diagnosis of Pneumocystis jirovecii pneumonia. Shortly after his admission, he becomes confused and disoriented. He attempts to pull out his IV and refuses to wear an O2 mask. Based upon his mental status, the priority nursing diagnosis is?

Accepted Answer

Answer reason: Confusion and disorientation with attempts to remove lines and refusal of O2 create immediate safety hazards; preventing self-injury is the highest priority.

Question 27

A client has ataxia following a cerebral vascular accident. The nurse should?

Accepted Answer

Answer reason: Ataxia causes poor coordination and balance after stroke, creating a high fall risk. The priority is to supervise ambulation. The other options address issues like fluid balance or communication deficits, not ataxia.

Question 28

The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should tell the parents?

Accepted Answer

Answer reason: Osteogenesis imperfecta causes extreme bone fragility; during diapering the infant should not be lifted by the ankles. Lifting by the buttocks reduces fracture risk. Calcium supplements don’t correct the collagen defect, the condition is lifelong, and extra-skeletal features (e.g., blue sclera, hearing/dental issues) occur.

Question 29

The home health nurse is visiting an elderly client following a hip replacement. Which finding requires further teaching?

Accepted Answer

Answer reason: A soft, low sofa promotes hip flexion beyond 90 degrees and makes rising difficult, increasing risk of dislocation and falls after hip replacement. Grab bars and nonskid shoes are appropriate; having a pet is not inherently unsafe with precautions.

Question 30

What position should the nurse place the patient in when they are experiencing a seizure?

Accepted Answer

Answer reason: Place the patient in a side-lying position during a seizure to keep the airway open and allow secretions to drain, reducing aspiration risk. Supine, prone, or dorsal recumbent do not protect the airway.

Question 31

Nurse Renor is about to perform Romberg’s test to zakir. To ensure the latter’s safety, which intervention should nurse Renor implement?

Accepted Answer

Answer reason: During the Romberg test the client stands with feet together and eyes closed, increasing fall risk. The nurse should stand close to guard and prevent a fall.

Question 32

The nurse enters the room as a three year-old is having a generalized seizure. Which of the following should the nurse do FIRST?

Accepted Answer

Answer reason: During an active seizure the priority is airway protection. Side-lying positioning helps maintain a patent airway and reduces aspiration risk. Do not restrain; medications and clearing hazards follow after ensuring airway and safety.

Question 33

When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to?

Accepted Answer

Answer reason: Oxygen supports combustion; smoking near oxygen equipment poses a fire hazard. The family should not adjust flow rates, oxygen should not be turned off for meals, and keeping the mouth closed is irrelevant.

Question 34

A four year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do FIRST?

Accepted Answer

Answer reason: During an active seizure, the first priority is safety—remove nearby hard objects to prevent injury. Do not place items in the mouth or move the child unnecessarily; medications may follow once safety is ensured.

Question 35

While assessing the quality of home care for a client with Alzheimer's disease, the PRIORITY for the nurse is to emphasize?

Accepted Answer

Answer reason: Clients with Alzheimer's are at high risk for injury and wandering; safety is the highest priority over nutrition, counseling, or medication adherence.

Question 36

Which of the following is MOST hazardous to an 8 month-old child?

Accepted Answer

Answer reason: Peanuts pose a high choking/aspiration risk for infants; airway obstruction is a leading cause of injury death in young children.

Question 37

Nurse Jane is visiting a client at home and is assessing him for risk of a fall. The most important factor to consider in this assessment is?

Accepted Answer

Answer reason: Home fall risk is primarily related to environmental hazards; adequate lighting is a key determinant to prevent trips and missteps. The other options are less directly related to immediate fall risk.

Question 38

Mrs. Parker, a 70-year-old woman with severe macular degeneration, is admitted to the hospital the day before scheduled surgery. The nurse's preoperative goals for Mrs. M. would include?

Accepted Answer

Answer reason: Severe macular degeneration limits vision, so the key preoperative safety goal is orienting the patient to the room and ensuring safe maneuvering. Independent unit ambulation is unsafe, reading materials may be ineffective, and a bedpan is unnecessary without mobility limitations.

Question 39

When a client is having a general tonic clonic seizure, the nurse should?

Accepted Answer

Answer reason: Side-lying maintains airway patency and allows secretions to drain, reducing aspiration risk during a seizure. Do not restrain limbs or place objects in the mouth; elevating the head alone is insufficient.

Question 40

Which type of accidental poisoning would the nurse expect to occur in children under age six?

Accepted Answer

Answer reason: Young children most commonly ingest toxic substances orally; other exposure routes are less frequent.

Question 41

Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis BEST applies?

Accepted Answer

Answer reason: Substance intoxication impairs judgment and increases risk-taking, making safety the priority; the most appropriate diagnosis is Risk for injury.

Question 42

The nurse is teaching parents how to reduce risks in the home, the most important consideration is?

Accepted Answer

Answer reason: Safety teaching must be developmentally appropriate. The risks and necessary precautions differ dramatically between infants, toddlers, school-aged children, and adolescents, so the age of the children dictates what hazards and prevention strategies are most critical.

Question 43

When collecting a specimen, there is a correct order to draw in order to not contaminate the next tube. What is the order of draw?

Accepted Answer

Answer reason: CLSI order of draw to prevent additive carryover: blood cultures (yellow), coagulation (light blue), serum tubes (red/orange), heparin (green), EDTA tubes (pink/white), then glycolytic inhibitor (gray). Option D matches this sequence.

Question 44

The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness. Which of the following interventions would be MOST effective in preventing falls?

Accepted Answer

Answer reason: Improving lighting in the bedroom reduces nighttime trips and is the most immediate, high-impact environmental change to prevent falls in older adults. Glasses, grab bars, and exercise can help but are less universally effective or not as immediate.

Question 45

An 8 year-old client is admitted to the hospital for surgery. The child's parent reports several allergies. Which of the following should all health care personnel be aware of?

Accepted Answer

Answer reason: Allergy to balloons suggests latex allergy; all staff must avoid latex products and use non-latex gloves to prevent a reaction.

Question 46

An older adult client is identified as being at high risk for falls. Which nursing intervention is MOST appropriate to help prevent falls?

Accepted Answer

Answer reason: A low, locked bed significantly reduces injury if the patient attempts to get out unassisted. Encouraging unsupervised ambulation increases fall risk, poor lighting promotes accidents, and raising all side rails is considered a restraint and is unsafe.

Question 47

A nurse is caring for an elderly patient who is at high risk for falls. Which intervention should be implemented?

Accepted Answer

Answer reason: Non-slip footwear directly decreases the risk of slipping and improves stability during ambulation, making it an evidence-based fall-prevention intervention. Keeping the bed high, dim lighting, placing items out of reach, and using side rails as restraints all increase the risk of injury.

Question 48

A nurse is preparing to administer a medication but notices that two clients on the unit have the same last name. What is the nurse’s **priority action** to prevent an error?

Accepted Answer

Answer reason: Using two patient identifiers (name + DOB) is the foundational error-prevention step endorsed by safety guidelines. Room numbers and diagnoses are unreliable and prohibited as identifiers.

Question 49

A nurse enters a client’s room and finds the bed in a high position, side rails down, and the call light out of reach. The client is confused and attempting to get up. What is the **best action** to prevent an accident?

Accepted Answer

Answer reason: The safest immediate action is reducing fall risk by lowering the bed and making the call light accessible. Four side rails constitute a restraint, and restraints/lap belts are not first-line fall-prevention strategies.

Question 50

A nurse enters the medication room and finds an unlabeled syringe filled with a clear liquid left on the counter. No staff members are present. What is the nurse’s best action to prevent a medication error?

Accepted Answer

Answer reason: Any unlabeled medication must be considered unsafe and discarded. Identifying or assuming its contents is dangerous and violates medication safety standards. Nurses must never administer or “guess” the medication.

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