Question 1

Describe how immediate access to digital X-rays can enhance client safety in nursing practice.?

Accepted Answer

Answer reason: Faster availability of imaging results supports timely clinical decisions and earlier initiation of appropriate interventions. This reduces delays that can worsen patient outcomes and decreases the chance of miscommunication or transcription-related mistakes compared with slower, multi-step processes. Rapid confirmation or exclusion of conditions also helps prevent inappropriate treatments and improves overall patient safety.
Category reason: This item tests how health information technology supports safer care by preventing delays and errors in clinical decision-making, which aligns with preventing accidents and errors in patient care.

Question 2

A client with partial-thickness burns on the arm is in pain. Which intervention is contraindicated?

Accepted Answer

Answer reason: Blisters serve as a natural protective barrier over partial-thickness burns, and rupturing them increases infection risk and delays healing. Appropriate initial care includes cooling the burn with cool (not ice) water to limit tissue damage and covering it with a clean, dry dressing to reduce contamination. Significant burn pain is often managed with opioid analgesia such as IV morphine when clinically indicated and monitored.
Category reason: This question tests safe immediate nursing interventions and infection-prevention measures in burn care, which aligns with Safety and Infection Control.

Question 3

The nurse enters her first client’s room to administer morning medications. What is the first thing she should do??

Accepted Answer

Answer reason: Patient identification using two approved identifiers is the first step before any medication administration to prevent wrong-patient errors. This aligns with medication safety standards and is required prior to confirming allergies, timing with meals, or reviewing side effects at the bedside. Verifying identity first ensures all subsequent checks and actions apply to the correct client, reducing the risk of serious harm.
Category reason: This question tests a nurse’s immediate safety action before administering medications, focusing on preventing errors in patient care, which fits Safety and Infection Control—Accident-Error Prevention.

Question 4

The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client's speech pattern is rapid, and the client's affect is belligerent. Based on these observations, the nurse's immediate priority of care is which?

Accepted Answer

Answer reason: A. Provide safety for the client and other clients on the unit. The presentation suggests escalating agitation with potential for imminent violence, so the first nursing priority is immediate harm prevention. Safety-focused actions include maintaining a safe distance, using de-escalation while summoning assistance per protocol, and removing potential weapons, with escalation to seclusion/restraints only if necessary and per policy. The other options describe helpful strategies, but they are subordinate to ensuring immediate safety for everyone when there is an active risk of assault.
Category reason: This question tests the nurse’s immediate priority action to prevent harm in an acute behavioral emergency, which is a patient and unit safety decision under Safety and Infection Control.

Question 5

A patient with epilepsy suddenly develops tonic-clonic movements. What is the nurse’s first action?

Accepted Answer

Answer reason: Side-lying positioning helps maintain airway patency and promotes drainage of saliva/vomitus, reducing aspiration risk during an active generalized seizure. Nothing should be placed in the mouth during tonic-clonic activity because it can cause oral trauma and obstruct the airway. Restraining the limbs increases risk of musculoskeletal injury. IV antiseizure medication may be indicated if the seizure is prolonged/status epilepticus, but immediate priority is basic safety and airway protection.
Category reason: This item asks for the nurse’s first action during an actively seizing patient, emphasizing immediate safety measures to prevent injury and aspiration, which fits accident/error prevention within Safety and Infection Control.

Question 6

Which instruction is important for a client taking antihypertensive medications?

Accepted Answer

Answer reason: Antihypertensives commonly cause orthostatic hypotension, which increases fall risk when changing positions. Teaching the client to rise slowly from lying or sitting allows time for vascular compensation and reduces lightheadedness and syncope. The other options are unsafe or overly restrictive: antihypertensives should not be stopped just because readings improve, BP monitoring should not be limited to clinic-only, and potassium restriction is not universal (it depends on the specific drug class and renal status).
Category reason: This item tests client safety teaching to prevent a common medication-related complication (orthostatic hypotension and falls), which aligns with accident and injury prevention in nursing care.

Question 7

Q - When Helping A Stroke Patient Nurse Should Assist?

Accepted Answer

Answer reason: Assisting on the stronger side provides the patient with maximal support and control during transfers and ambulation, reducing fall risk. The weaker (hemiparetic) side has impaired strength and coordination, making it less reliable for weight-bearing and balance. Positioning the nurse on the patient’s stronger side also allows safer cueing and guarding while the patient uses the stronger extremity to stabilize and step.
Category reason: This is a nursing safety question about how to physically assist a post-stroke patient during mobility/transfers to prevent falls and injury, which aligns with accident and error prevention.

Question 8

PALMER In planning activities and goals for the older adult patient, the nurse’s first priority should be?

Accepted Answer

Answer reason: Older adults have increased risk for injury due to factors like impaired balance, reduced vision/hearing, slower reaction time, and polypharmacy. When setting goals and choosing activities, preventing falls and other harm takes priority over psychosocial or preference-based considerations. Ensuring a safe environment and appropriate activity intensity supports participation while reducing complications. Once safety needs are addressed, the plan can then incorporate interests and self-esteem-building goals.
Category reason: This item tests nursing prioritization when planning care for an older adult, emphasizing prevention of harm and injury during activities, which aligns with Safety and Infection Control—Accident-Error Prevention.

Question 9

If a CNA is exposed to blood through a needle stick, the FIRST action is to?

Accepted Answer

Answer reason: Immediate reporting triggers the facility’s post-exposure protocol (risk assessment, baseline labs, and timely initiation of post-exposure prophylaxis when indicated), which is time-sensitive. It also ensures proper documentation and follow-up testing for bloodborne pathogens. Cleaning the site is important, but delaying notification can compromise rapid evaluation and treatment decisions and increases organizational safety risk.
Category reason: This question centers on a first nursing-assistant action after an occupational needle-stick exposure, emphasizing workplace safety and post-exposure procedures, which fits Safety and Infection Control.

Question 10

Knowing which of the following can best assist a technician in the prevention of data entry errors?

Accepted Answer

Answer reason: A. Names of medications Medication name recognition (including look-alike/sound-alike patterns) is a primary safeguard against selecting the wrong drug during order processing and pharmacy system entry. Data entry errors commonly involve choosing the incorrect medication from drop-down lists or misreading similar names; strong familiarity reduces these selection and transcription mistakes. Insurance co-payments and pharmacokinetics do not directly prevent wrong-drug selection during entry, and physician contact information is mainly used to clarify questionable orders after a potential error is identified rather than preventing entry errors upfront.
Category reason: This item focuses on preventing medication-related errors during the workflow (a safety process issue), which aligns with accident/error prevention under NCLEX Safety and Infection Control.

Question 11

While providing oral care for a client who is unconscious, the practical nurse (PN) positions the client laterally and uses a basin to collect secretions. Which intervention is best for the PN to implement?

Accepted Answer

Answer reason: An unconscious client cannot effectively protect the airway, so pooled secretions during oral care create a significant aspiration risk. Using a Yankauer allows controlled suctioning of oral secretions and helps maintain airway patency while the client is positioned laterally for drainage. Oral swabs or washcloth cleaning alone can mobilize secretions without adequately removing them, increasing the chance of aspiration. A pillow may aid positioning but does not address the primary safety concern of secretion removal.
Category reason: This question tests a nursing safety intervention during routine care of an unconscious patient, with the primary goal of preventing aspiration and airway compromise—an accident-prevention focus within Safety and Infection Control.

Question 12

A nurse is preparing to insert a nasogastric tube for a client who has difficulty swallowing. After inserting the tube, the nurse notices the client coughing and becoming short of breath. What is the nurse’s priority action?

Accepted Answer

Answer reason: Coughing and shortness of breath during insertion strongly suggest the tube may have entered the airway (trachea/bronchus), creating an immediate airway and aspiration risk. The safest priority is to stop the procedure and withdraw the tube to prevent further respiratory compromise or trauma. Continuing to advance or trying to “cough it out” can worsen hypoxia and aspiration. The provider can be notified after the client’s airway and breathing are stabilized and the tube is reattempted with appropriate precautions.
Category reason: This item tests a nurse’s immediate safety-focused intervention during a bedside procedure to prevent harm from accidental airway placement, which aligns with Safety and Infection Control—Accident-Error Prevention.

Question 13

Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client?

Accepted Answer

Answer reason: Unexpected thermal exposure (water that is too hot or too cold) is a common environmental stimulus that can provoke discomfort, especially in clients with altered sensation, impaired circulation, or acute illness. Verifying bath water temperature is a simple safety measure that prevents burns or chilling and reduces avoidable sensory stress during care. The other options address wound management, repositioning mechanics, or positioning that do not primarily target controlling external sensory input in the immediate environment.
Category reason: This item tests a nursing safety intervention to prevent discomfort and harm from an external environmental factor (temperature exposure) during routine care, which aligns with accident and error prevention.

Question 14

A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder. The nurse should teach the parents to take which of the following actions during a seizure?

Accepted Answer

Answer reason: The priority during an active seizure is injury prevention by protecting the client from environmental hazards. Removing nearby hard or sharp objects reduces the risk of head trauma and extremity injury from uncontrolled movements. Restraining the limbs can cause musculoskeletal injury, and inserting anything into the mouth risks dental trauma and aspiration. Positioning should focus on airway protection (typically side-lying when possible), not prone.
Category reason: This question tests safe nursing actions to prevent injury during a seizure, which is a patient safety intervention under Safety and Infection Control.

Question 15

You are observing one of the RNs on the unit administer medication. What action by the nurse would lead you to conclude there is a risk for a medication error?

Accepted Answer

Answer reason: Interruptions and distractions during medication administration increase the likelihood of wrong patient, drug, dose, route, or timing errors. Safe practice is to avoid non-urgent interruptions during the med pass and to complete one medication task at a time. The other actions listed are safety-promoting behaviors: using standardized time notation, seeking help with calculations, and pausing administration when a patient raises a concern support error prevention.
Category reason: This question tests nursing safety judgment about behaviors that increase medication-administration error risk, which aligns with preventing accidents and errors in patient care.

Question 16

Which condition is an indication to stop or withhold resuscitative efforts?

Accepted Answer

Answer reason: Resuscitation should not be initiated or should be stopped if the scene is unsafe because provider safety is the first priority in any emergency response. Continuing CPR in a hazardous environment risks additional victims and compromises overall emergency management. The other options are not absolute indications to withhold CPR by themselves; decisions about termination depend on broader clinical context and local protocols rather than age alone or an arbitrary time threshold.
Category reason: This question tests nursing/emergency response judgment about when to withhold or stop CPR based on scene safety, which falls under patient and provider safety responsibilities.

Question 17

A client with schizophrenia reports command hallucinations. Which action should the nurse take first?

Accepted Answer

Answer reason: Command hallucinations can include directives to harm self or others, so immediate assessment of what is being heard determines the level of risk. The nurse’s first priority is to protect the client and others by implementing safety measures (e.g., close observation, removing hazards, obtaining assistance) based on the content and intent. Medication may be needed, but it does not provide immediate risk mitigation and should follow rapid safety assessment. Ignoring or encouraging the hallucinations increases danger and is not therapeutic.
Category reason: This question tests immediate nursing action to prevent harm in a psychiatric situation, emphasizing safety-first assessment and intervention rather than disease mechanisms.

Question 18

A nurse is caring for a patient with a chest tube connected to water-seal drainage. Which observation requires immediate nursing action?

Accepted Answer

Answer reason: This finding strongly suggests an air leak in the chest tube system (e.g., loose connections, tubing leak, or leak at the insertion site), which can prevent adequate pleural drainage and impede lung re-expansion. Unlike expected tidaling, persistent bubbling is abnormal and requires prompt troubleshooting of the system starting from the patient and moving outward through connections. Gentle bubbling in the suction control chamber can be normal when suction is applied, and tidaling reflects pressure changes with breathing. Drainage of 70 mL/hr may be acceptable depending on timing and trend, but it is less immediately indicative of system failure than a suspected air leak.
Category reason: This item tests immediate nursing recognition of an unsafe/abnormal chest tube drainage system finding (air leak) and the need for urgent corrective action, which is a patient-safety intervention rather than foundational science.

Question 19

1142: ETT cuff is underinflated. What’s the danger?

Accepted Answer

Answer reason: An underinflated endotracheal tube cuff creates an inadequate seal between the tube and tracheal wall, allowing oral/pharyngeal secretions and gastric contents to leak past the cuff into the lower airway. This significantly increases the risk of aspiration and subsequent ventilator-associated pneumonia. While hypoxia can occur secondarily from air leak and poor ventilation, the primary direct danger of cuff underinflation is aspiration.
Category reason: This question tests nursing safety related to airway management and prevention of complications from endotracheal tube care, which fits patient-safety error prevention within Safety and Infection Control.

Question 20

A patient has a chest tube and you notice continuous bubbling in the water seal chamber. What do you do next?

Accepted Answer

Answer reason: B) Locate the leak and tighten the loose connection Continuous bubbling in the water-seal chamber indicates an air leak in the system (not expected; intermittent bubbling may occur early with an air leak from the patient). The priority is to assess the drainage system and tubing connections for loose connections or cracks and correct them to restore an intact closed system. Leaving it alone risks loss of negative intrapleural pressure and ineffective lung re-expansion. Disconnecting the tube is unsafe and can precipitate an open pneumothorax and contamination.
Category reason: This item tests nursing recognition of an abnormal chest tube finding and the immediate safety-focused intervention to correct it, which is a patient-care decision under safety/accident prevention.

Question 21

A postoperative client is receiving patient-controlled analgesia (PCA) for pain management. The nurse educates the client on the importance of not allowing anyone else to push the PCA button. What is the rationale behind this instruction?

Accepted Answer

Answer reason: PCA is designed so only the patient self-administers doses when awake enough to feel pain and press the button; this provides an inherent safety check. If someone else pushes the button, medication can be delivered while the patient is sleepy or already adequately sedated, increasing risk of opioid-induced respiratory depression. Although the pump has lockout intervals, repeated unauthorized dosing can still lead to excessive cumulative opioid effect and missed early signs of oversedation.
Category reason: This question tests a nursing safety teaching intervention for a client using PCA and focuses on preventing medication-related harm, fitting Safety and Infection Control—Accident-Error Prevention.

Question 22

How do you know NG tube is in place?

Accepted Answer

Answer reason: An x-ray is the most reliable method to confirm initial NG tube placement and helps prevent serious complications such as pulmonary placement and aspiration. Bedside methods like auscultation after injecting air are unreliable and can falsely suggest correct placement. pH testing of aspirate can be supportive in some settings but may be inaccurate with acid-suppressing therapy or inability to aspirate, so radiographic confirmation remains the standard for initial verification. CT is not routinely used for this purpose due to unnecessary radiation, cost, and limited practicality compared with standard radiography.
Category reason: This question tests safe verification of enteral tube placement to prevent misplacement-related harm (e.g., aspiration), which is a patient safety/accident-prevention nursing decision rather than foundational biomedical science.

Question 23

Which action ensures safety? A nurse is assisting a client with ambulation after surgery.?

Accepted Answer

Answer reason: A gait belt provides the nurse a secure handhold to support balance and control during ambulation, reducing the risk of falls, especially after surgery when weakness, dizziness, or effects of anesthesia/analgesics may be present. It allows safer assistance with transfers and walking and helps protect both client and nurse from injury. Allowing independent walking, encouraging rapid movement, or ignoring fatigue increases fall risk and can worsen postoperative complications.
Category reason: This question tests a nursing safety intervention to prevent falls during postoperative ambulation, which fits accident and error prevention in the Safety and Infection Control category.

Question 24

A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse's station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first?

Accepted Answer

Answer reason: The priority is to immediately assess the client to determine whether this is true asystole/pulseless arrest or a monitoring artifact. Loss of complexes on the monitor is commonly caused by disconnected or poorly adherent leads, depleted battery, or loose cables, and addressing these can rapidly restore accurate monitoring. If the client is unresponsive and pulseless, emergency response is activated after rapid assessment; if stable, then troubleshoot equipment and notify the provider as indicated.
Category reason: This item tests immediate nursing action in response to a monitor alarm, emphasizing rapid patient assessment and prevention of harm from misinterpreting equipment malfunction.

Question 25

A nurse is preparing to administer an IV push medication. What is the first step?

Accepted Answer

Answer reason: Medication administration begins with confirming the provider’s order is complete and appropriate (right medication, dose, route, time, and any required parameters). This prevents wrong-drug or wrong-dose errors before any further steps are taken. Allergy assessment is essential but is part of the broader verification process after confirming what is ordered. Flushing and administration technique occur only after the order is validated and the medication is prepared correctly.
Category reason: This is a nursing safety question focused on preventing medication errors by prioritizing the correct first action before IV push administration, which aligns with Accident-Error Prevention.

Question 26

With a suspected fracture, the client is not moved unless it is safe and dangerous to remain in that spot. The nurse should remain with the client and have someone else call for emergency help. If client is not reduced to the scene. Before moving the client, the site of the fracture is immobilized to prevent further injury.) The nurse witnesses a client sustain a fall and suspects that the client's leg may be fractured. Which action is the "priority"?

Accepted Answer

Answer reason: Suspected fractures should be stabilized immediately to prevent displacement, neurovascular injury, bleeding, and additional soft-tissue damage. Immobilizing the extremity before any movement reduces pain and limits complications during transport or repositioning. Vital signs and reassurance are appropriate supportive measures but do not address the immediate risk of worsening injury. Radiology is not contacted until the client is stabilized and safe transport is arranged per facility protocol.
Category reason: This item tests nursing priority actions for injury management and preventing further harm after a fall, which aligns with safety-focused nursing interventions.

Question 27

A patient is at risk for a fall at 1:00 PM today. Which intervention should the nurse prioritize?

Accepted Answer

Answer reason: This directly reduces fall risk by enabling the patient to summon assistance before attempting to ambulate unassisted. In contrast, raising the bed increases fall and injury risk, and administering a sedative can worsen dizziness, confusion, and gait instability. Removing side rails is not a primary fall-prevention strategy and may increase the likelihood of the patient rolling out of bed or attempting unsafe exits without support.
Category reason: This is a nursing safety-priority question about preventing inpatient falls through immediate environmental and behavioral interventions, aligning with Accident-Error Prevention.

Question 28

When helping a stroke patient, the Nurse should assist?

Accepted Answer

Answer reason: Assisting from the patient’s stronger side maximizes their available motor control and balance, reducing fall risk during transfers or ambulation. The stronger arm/leg can better bear weight, grasp assistive devices, and respond to loss of balance. Supporting the weaker side as needed while positioning yourself on the strong side improves stability and safety. Approaching from behind/back can startle the patient and limits your ability to monitor facial cues and gait changes.
Category reason: This asks about safe patient handling and positioning during mobility assistance for a stroke patient, emphasizing fall prevention and injury avoidance—an NCLEX safety/intervention focus.

Question 29

In managing a patient with Delirium Tremens, which of the following is the priority nursing intervention?

Accepted Answer

Answer reason: B. Ensuring a safe environment Delirium tremens can cause severe agitation, confusion, hallucinations, and autonomic instability, placing the patient at high immediate risk for injury (falls, pulling lines) and harm to others. Nursing priority follows ABCs and safety: reduce stimuli, maintain close observation, implement seizure/fall precautions, and ensure rapid access to emergency support. Medications and supportive care are important, but they are implemented within the context of protecting the patient from imminent harm. Nutritional support and liver monitoring are secondary priorities once immediate safety and stabilization are addressed.
Category reason: This question asks for the priority nursing intervention in an acute, high-risk clinical situation, emphasizing immediate patient safety and prevention of injury, which aligns with Safety and Infection Control.

Question 30

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic activity on the screen. Which is the priority nursing action?

Accepted Answer

Answer reason: A flatline on a monitor can be true asystole or an artifact from disconnected leads or equipment malfunction. The nurse should immediately assess the patient for responsiveness, breathing, and a pulse while simultaneously ensuring electrodes/leads are attached and the monitor is functioning. Activating emergency response or calling the provider comes after confirming the client’s actual condition to avoid delays or unnecessary interventions. Recording the strip does not address immediate patient safety.
Category reason: This item tests immediate nursing action and safety decision-making in response to a monitor alarm, which aligns with preventing errors and ensuring accurate assessment before escalating care.

Question 31

Before administering medication, what should the nurse check?

Accepted Answer

Answer reason: Verifying the client’s identity using appropriate identifiers is a core medication-safety step and prevents wrong-patient medication errors. This aligns with the “rights” of medication administration and standard safety practices prior to giving any drug. Other choices do not directly prevent a serious medication error at the point of administration.
Category reason: This item tests a nursing safety action required immediately before medication administration to prevent harm, which fits NCLEX safety/medication error prevention.

Question 32

An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client’s nursing care?

Accepted Answer

Answer reason: Friction and shear during repositioning increase the risk of pressure injuries, especially in older adults on strict bedrest. Using a lift/turning technique rather than dragging helps protect fragile skin and promotes tissue perfusion. Massaging reddened areas can worsen tissue damage over bony prominences, and prone positioning is typically inappropriate and unsafe for many elderly hip-fracture clients. Active ROM may be beneficial but is not as universally essential for immediate safety and skin protection as minimizing shear during repositioning.
Category reason: This item tests a nursing intervention to prevent complications of immobility (skin breakdown) and safe repositioning technique, which falls under patient safety measures rather than biomedical recall.

Question 33

Which of the following actions by the nurse would be considered negligence?

Accepted Answer

Answer reason: Abdominal palpation or massage is contraindicated with suspected/known Wilms tumor because it can rupture the tumor and potentially disseminate malignant cells, increasing risk of hemorrhage and metastasis. This is a preventable harm that violates standard pediatric oncology safety precautions and would be viewed as a breach of the duty to protect the child from injury. The other options describe appropriate screening, respiratory play therapy for asthma, or activity that can be safely modified for juvenile arthritis.
Category reason: This question tests nursing safety judgment—identifying an unsafe nursing action that could cause preventable harm in a pediatric patient—so it fits Safety and Infection Control, specifically accident/error prevention.

Question 34

The nurse has the role of protecting the patient from the clinical environment, which of the following actions won't necessarily protect the patient?

Accepted Answer

Answer reason: Protecting patients from the clinical environment focuses on preventing hazards such as medication errors, faulty equipment, and falls. Proper medication organization helps reduce administration errors; maintaining equipment reduces injury/malfunction risk; and keeping floors dry reduces fall risk. Air-conditioning may improve comfort, but it is not a direct or necessary safety intervention for environmental protection in routine patient care.
Category reason: This item asks which nursing action best supports environmental safety and prevention of patient harm in a clinical setting, aligning with Safety and Infection Control—Accident-Error Prevention.

Question 35

A nurse is instructing a client how to safely use crutches for ambulating at home. Which measure would the nurse recommend to minimize the risk of falls while ambulating with the crutches?

Accepted Answer

Answer reason: Loose rugs are a common household tripping hazard and can easily catch a crutch tip, causing loss of balance. Removing them directly reduces environmental fall risk during gait training at home. Grab bars help in the bathroom but do not address the primary hazard during crutch ambulation throughout the home. Soft-soled slippers can be unstable and increase slipping risk, and eliminating all pets is unnecessary and unrealistic compared with modifying obvious hazards.
Category reason: This item tests nursing safety teaching and home-environment modification to prevent falls during assistive-device ambulation, which is an Accident-Error Prevention focus under Safety and Infection Control.

Question 36

A nurse is teaching a client about fall prevention. Which action should the nurse prioritize?

Accepted Answer

Answer reason: This directly reduces modifiable fall risks by promoting safe ambulation with appropriate assistive devices and by eliminating environmental hazards. It supports both intrinsic (balance/strength) and extrinsic (clutter/obstacles) prevention strategies, which are core to fall-risk reduction. The other options increase risk by encouraging unsupervised mobility, promoting overreliance on others, or omitting safety measures.
Category reason: This is a patient-safety teaching scenario focused on preventing accidental injury (falls) through safe mobility and environmental risk reduction, which aligns with Accident-Error Prevention.

Question 37

Exercise precaution must be taken to protect health worker dealing with the AIDS patient: which among these must be done as priority?

Accepted Answer

Answer reason: D. Avoid accidental needle pricking Needlestick injuries are a high-risk route for occupational exposure to bloodborne pathogens, so preventing sharps injuries is the most immediate and critical safety priority. Standard precautions emphasize safe handling and disposal of needles, avoiding recapping, and using safety-engineered devices to reduce percutaneous exposures. Boiling syringes is not an appropriate infection-control method in clinical practice, and while gloves reduce contamination, they do not reliably prevent percutaneous inoculation from sharps. Labeling personal belongings does not address the primary transmission risk in this setting.
Category reason: This question focuses on protecting a healthcare worker from occupational exposure during patient care, emphasizing sharps injury prevention and standard precautions, which fits Safety and Infection Control.

Question 38

Which of the following treatment should NOT be considered if the child has severe dengue hemorrhagic fever?

Accepted Answer

Answer reason: In severe dengue hemorrhagic fever, platelet dysfunction and capillary fragility increase bleeding risk, so medications that inhibit platelet function can worsen hemorrhage. Aspirin irreversibly inhibits platelet aggregation and is therefore contraindicated. Supportive care focuses on careful fluid management, treating shock, and preventing complications such as hypoglycemia rather than using antiplatelet agents.
Category reason: This question tests a safety-focused nursing decision about avoiding a contraindicated medication in a bleeding-risk condition, aligning with preventing iatrogenic harm.

Question 39

Scenario: A patient uses a walker and urgently needs to go to the bathroom. What is the nurse's priority?

Accepted Answer

Answer reason: This is a fall-risk situation because the patient uses a walker and is urgently trying to ambulate to the bathroom. Prompt assistance addresses immediate safety needs and helps prevent injury while also meeting an urgent elimination need. Encouraging the patient to go alone or leaving them with lowered side rails increases the likelihood of a fall, and delaying care with a bedpan is not the safest priority if the patient is trying to get up now.
Category reason: The question tests nursing prioritization to prevent falls during urgent toileting in a mobility-impaired patient, which is a patient safety intervention under Accident-Error Prevention.

Question 40

Scenario: A confused elderly patient keeps pulling at their IV line. What is the nurse’s first action?

Accepted Answer

Answer reason: Least-restrictive interventions should be tried first to prevent injury and preserve patient rights while maintaining treatment. Redirection, distraction, covering/securement of tubing, closer observation, and addressing contributing causes (pain, anxiety, delirium, toileting needs) can often stop line-pulling without restraints. Restraints are a last resort due to risks such as injury, increased agitation, and reduced circulation, and typically require an order and ongoing monitoring. Security is not indicated unless there is imminent danger, and family presence is supportive but not the immediate first-line nursing intervention.
Category reason: This is a patient-safety nursing judgment question about preventing harm and using the least-restrictive measures before restraints, aligning with safety-focused nursing interventions.

Question 41

Position to reduce risk of aspiration during seizures:

Accepted Answer

Answer reason: This position promotes drainage of saliva or vomitus from the mouth and helps keep the airway more patent, lowering aspiration risk. Supine positioning increases the chance of secretions pooling in the oropharynx and being aspirated. Prone is not recommended because it can compromise ventilation and makes airway access and assessment more difficult. High Fowler’s is helpful when awake and able to protect the airway, but during an active seizure the safest general approach is lateral recovery positioning to facilitate drainage.
Category reason: This question tests a nursing safety intervention to protect the airway during a seizure, which is primarily about preventing injury/complications during an acute event rather than underlying biomedical mechanisms.

Question 42

Scenario: An elderly patient with poor vision walks without assistive devices. What action reduces fall risk the most?

Accepted Answer

Answer reason: Improving traction is a direct, evidence-based fall-prevention intervention that reduces slipping during ambulation, especially when vision is impaired. Turning off lights worsens environmental visibility and increases fall risk. “Encourage independence” is not a specific safety intervention and can be unsafe without supportive measures. Restraints are associated with higher risk of injury, agitation, and falls and should not be used for routine fall prevention.
Category reason: This question asks for a nursing safety intervention to prevent patient falls, which fits patient safety and accident prevention in the NCLEX Safety and Infection Control domain.

Question 43

A client is in the postictal phase after a tonic-clonic seizure. Which position is safest?

Accepted Answer

Answer reason: This position helps maintain a patent airway and reduces aspiration risk by allowing saliva or emesis to drain from the mouth. During the postictal phase, decreased level of consciousness and loss of protective reflexes increase the chance of airway obstruction if the client is supine. It also supports safer breathing while the client recovers and allows easier observation of respiratory status without compressing the chest.
Category reason: This question asks for the safest nursing positioning intervention after a seizure to prevent airway obstruction and aspiration, which is a patient safety action.

Question 44

A 72-year-old patient with Alzheimer’s disease repeatedly tries to get out of bed without assistance and has a history of falls. What is the best nursing action?

Accepted Answer

Answer reason: This intervention reduces fall risk through closer observation and faster staff response while preserving the patient’s mobility and dignity. Restraints and raised side rails can increase agitation, lead to injury from climbing over rails, and are not first-line measures unless all less restrictive options fail and policy criteria are met. Encouraging bed rest does not address unsafe attempts to mobilize and can worsen deconditioning and delirium risk. Enhanced monitoring and environmental placement are appropriate least-restrictive safety measures for a cognitively impaired, high-fall-risk patient.
Category reason: This question asks for the safest nursing intervention to prevent falls in a hospitalized patient, which is primarily about patient safety and accident prevention rather than biomedical mechanisms.

Question 45

Scenario: A patient with schizophrenia states, "I hear voices telling me to hurt myself". Q. What is the priority nursing intervention?

Accepted Answer

Answer reason: This statement indicates command auditory hallucinations with potential imminent self-harm, making immediate safety the highest priority. Remaining with the client and creating a safe environment enables close observation, rapid intervention, and removal of potential means for self-injury. Assessing the content of the voices is important but should occur after the client is secured and not left alone. Challenging the hallucination or offering rest does not adequately address the immediate risk of suicide/violence.
Category reason: This item asks for the nurse’s priority action to prevent self-harm in response to a psychiatric safety threat, which is a patient-safety intervention within Safety and Infection Control.

Question 46

During a home visit, the nurse finds a diabetic client storing insulin in a warm cabinet. What should the nurse do?

Accepted Answer

Answer reason: Insulin potency can be reduced by exposure to inappropriate temperatures, increasing the risk of poor glycemic control and complications. The nurse’s priority is to prevent medication error and promote safe self-management by teaching correct storage (generally refrigerated before opening; after opening, per product instructions, kept at recommended room temperature and protected from heat/light). Discarding may be needed only if storage conditions likely compromised the medication or if appearance is abnormal, but education and assessment of the insulin’s condition and duration of heat exposure come first. Giving extra doses or ignoring the issue is unsafe and increases risk for hypo- or hyperglycemia.
Category reason: This is a patient-care safety question focused on preventing medication errors and teaching safe home management, which aligns with NCLEX Safety and Infection Control—Accident-Error Prevention.

Question 47

Scenario: A post-stroke patient has left-sided weakness and confusion. Q. What is the nurse's first priority?

Accepted Answer

Answer reason: Left-sided weakness and confusion place the client at immediate high risk for injury from falls, so implementing safety measures is the most urgent action. Priority nursing care follows ABCs and safety; preventing a foreseeable harm takes precedence over mobility aids, teaching, or referrals. Fall precautions (e.g., bed in low position, call light within reach, close observation, assist with transfers) reduce risk while further assessment and rehabilitation planning proceed.
Category reason: This item asks for the nurse’s first priority intervention to prevent injury in a confused, weak post-stroke patient, which is a patient-safety and accident-prevention decision within NCLEX Safety and Infection Control.

Question 48

Scenario: A nurse is administering enteral feeding via NG tube when the patient begins to cough and gag. Q. What is the priority action?

Accepted Answer

Answer reason: Coughing and gagging during NG feeding raises concern for tube displacement or aspiration into the airway. The nurse should immediately verify correct tube placement before continuing any feeding to prevent aspiration and respiratory compromise. Slowing the rate or flushing could worsen aspiration if the tube is malpositioned, and documenting as normal ignores a potentially dangerous complication. After confirming placement, reassess respiratory status and follow facility protocol for aspiration risk management.
Category reason: This question tests a nurse’s immediate safety-focused intervention during enteral feeding to prevent aspiration, which is a patient-care judgment under Safety and Infection Control.

Question 49

Scenario: A nurse is preparing to give IV potassium chloride (KCl) for a patient with hypokalemia. Q. What is the most important safety step?

Accepted Answer

Answer reason: Potassium chloride is a high-alert medication because dosing or administration errors can rapidly cause life-threatening dysrhythmias and cardiac arrest. The first safety step is to confirm the patient actually needs replacement and assess severity by checking the most recent serum potassium value (and trend) before preparation/administration. IV push KCl and undiluted administration are unsafe and contraindicated due to the high risk of fatal arrhythmias and tissue injury. While dilution/infusion rate matters, verifying the lab value is the primary step to prevent an inappropriate or excessive dose.
Category reason: This question tests safe medication administration judgment for a high-alert electrolyte infusion, emphasizing prevention of serious harm from errors, which aligns with Accident-Error Prevention.

Question 50

Scenario: An elderly patient with a history of falls is admitted. Q. What intervention is most appropriate?

Accepted Answer

Answer reason: This strategy reduces fall risk while preserving the patient’s mobility and autonomy, using standardized identification and early warning to prompt staff assistance. Raising all four side rails is considered a restraint and can increase injury risk if the patient attempts to climb over. Wrist restraints are not indicated for routine fall prevention and increase risks such as agitation, injury, and impaired circulation. Keeping the bed in a high position increases the chance of falls and should be avoided; the bed should be kept low with safety measures in place.
Category reason: This question asks for the safest nursing intervention to prevent inpatient falls, which is a patient-safety and accident-prevention decision within Safety and Infection Control.

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