Question 1

The nurse observes a coworker who is inserting a nasogastric tube. Which of the following actions by the staff member would require the nurse to intervene?

Accepted Answer

Answer reason: Flushing immediately “to confirm patency” is unsafe because patency does not confirm correct placement, and fluid could enter the lungs if the tube is in the tracheobronchial tree. The appropriate sequence is to assess for signs of respiratory placement and verify gastric placement per policy (often x-ray for initial placement, then pH/aspirate methods as allowed) before flushing/feeding/medication. The other actions describe standard insertion techniques that facilitate passage into the esophagus and achieve correct measured length.

Question 2

The nurse is teaching the parents of a newborn about newborn safety. What information should the nurse include?

Accepted Answer

Answer reason: " Safe-sleep education aims to reduce suffocation and SIDS risk by keeping the sleep surface clear of loose bedding while maintaining warmth. A wearable blanket provides insulation without introducing blankets that can cover the infant’s face or cause entrapment. Prone sleeping increases SIDS risk and is not recommended for routine sleep in healthy newborns. Bulky coats under a car-seat harness can prevent a snug fit, and newborns should ride rear-facing rather than forward-facing.

Question 3

The nurse’s priority intervention is to?

Accepted Answer

Answer reason: Lowering to the floor reduces the risk of falls and head trauma compared with leaving the client in a chair. Airway suctioning is not a first action unless there is clear evidence of airway obstruction; routine suctioning during active convulsions can be unsafe. Holding the client down increases risk of musculoskeletal injury, and timing the episode is important but only after safety is ensured.

Question 4

The nurse is working with a group of clients during group therapy in the mental health unit. The nurse will likely use which method(s) for client identification?

Accepted Answer

Answer reason: Positive client identification is a core safety practice and should use two client identifiers obtained directly from the client when possible. Having the client verbally provide name and date of birth is the most reliable approach in a group setting because it confirms identity without relying on third parties. An armband can be used to corroborate identity, but in therapy groups it may not be accessible or may be removed, and it does not replace active verification with two identifiers. Relying on staff recognition or visitors introduces avoidable error risk and is not an acceptable primary identification method for safe care.

Question 5

The nurse enters the room of a 5-year-old client and finds the client lying on the floor. The fall was unwitnessed. What is the priority nursing action?

Accepted Answer

Answer reason: After an unwitnessed fall, the priority is immediate assessment for injury using an ABC-focused check and rapid neurologic screening before moving the child. This identifies time-sensitive threats such as head/neck trauma, bleeding, or altered level of consciousness and guides whether spinal precautions and urgent escalation are needed. Moving the child back to bed first could worsen an occult cervical or orthopedic injury. Calling for help is appropriate if the child is unresponsive/unstable, but the nurse’s first action is to assess the child’s condition to determine the urgency and required interventions.

Question 6

The nurse is assisting the unlicensed assistive personnel (UAP) to ambulate their clients. It would be most important for the nurse to review fall precautions with the UAP prior to ambulating the?

Accepted Answer

Answer reason: Orthostatic hypotension causes a sudden drop in blood pressure with position changes, making dizziness and syncope during ambulation a high-probability, high-harm fall risk. Older age further increases vulnerability due to slower compensatory responses and potential comorbidities/medications. This is the client for whom the nurse should most emphasize fall precautions (e.g., dangle before standing, rise slowly, use gait belt, stay close/assist). By contrast, tuberculosis primarily raises transmission-based precaution needs rather than immediate fall risk during walking.

Question 7

A nurse is caring for a client diagnosed with moderate Alzheimer's disease who exhibits wandering behavior. Which of the following interventions should the nurse prioritize?

Accepted Answer

Answer reason: Wandering in moderate Alzheimer’s creates an immediate safety risk for elopement, falls, and exposure, so the priority is to reduce harm while preserving mobility as much as possible. A secured, safe area allows supervised ambulation and decreases the chance of leaving the unit or entering hazardous spaces, directly addressing the highest-risk problem. Identification is helpful if the client gets lost, but it is secondary because it does not prevent the event from occurring. Exercise can support sleep and reduce restlessness, but it is not the most immediate intervention for preventing injury from wandering.

Question 8

The nurse is confirming an ng tube placement by checking the level of pH of the aspirate contents. What level indicates the ng is placed correctly?

Accepted Answer

Answer reason: A pH of 5 or less is most consistent with gastric placement and is the commonly taught cutoff for confirming NG/OG tube location before initiating feeds/medications. Higher pH values are more consistent with intestinal or respiratory secretions and increase concern for malposition, especially if the patient is receiving acid-suppressing therapy. This check is a safety verification step aimed at preventing aspiration and other serious harm from incorrect tube placement.

Question 9

The nurse is planning a staff education program about Parkinson disease. Which of the following information should the nurse include about disease progression?

Accepted Answer

Answer reason: Parkinson disease is a progressive neurodegenerative disorder causing bradykinesia, rigidity, postural instability, and a shuffling gait, which directly increases fall risk over time. As the disease advances, impaired balance reactions and freezing episodes make ambulation and transfers increasingly unsafe, so fall-prevention teaching is essential. Weight gain is not the expected progression finding because many clients develop decreased intake, dysphagia, and increased energy expenditure from tremor, leading more often to weight loss. Cognitive changes and mood disorders (depression, anxiety, apathy) can occur in Parkinson disease, so stating they are unaffected or unlikely to change is inaccurate.

Question 10

Which strategy should a nurse teach an adolescent to prevent sportsrelated injuries?

Accepted Answer

Answer reason: A warm-up increases blood flow, improves tissue elasticity, and enhances neuromuscular coordination, which lowers the risk of sprains and strains. It is an immediate, universally applicable strategy that should be done before each practice or game. In contrast, strength building and moderating intensity are beneficial over time but do not replace the immediate protective effect of pre-activity preparation.

Question 11

Which assessment finding would lead the nurse to suspect child abuse?

Accepted Answer

Answer reason: Accidental bruises most commonly occur over bony prominences on the front of the body (e.g., shins, knees, forehead) during normal ambulation and falls. Bruising on protected areas such as the back, buttocks, and trunk is less likely to be accidental and can reflect inflicted injury or impact from an object. In abuse screening, location and pattern of bruising are key red flags that warrant further assessment, documentation, and reporting per policy.

Question 12

Which activity is recommended to prevent foreign body aspiration during meals?

Accepted Answer

Answer reason: Aspiration risk increases when children eat while moving, talking excessively, laughing, or being distracted because coordination of chewing and swallowing is reduced. Keeping a child seated and calm during meals supports safer swallowing mechanics and reduces the chance of choking on poorly chewed food. Supervised, upright, seated eating is a core injury-prevention strategy for toddlers and young children. Distractions such as toys or television can encourage hurried eating or inattentive chewing, increasing choking risk rather than preventing it.

Question 13

The client diagnosed with a CVA has hemiparesis. Which problem would be priority for the client?

Accepted Answer

Answer reason: Hemiparesis after a CVA causes impaired mobility, poor balance, and often sensory/perceptual deficits, creating an immediate fall and trauma hazard. Safety threats are prioritized because they can rapidly lead to serious harm (fractures, head injury) and further neurologic decline. Aspiration risk is a critical concern in stroke, but it is primarily driven by dysphagia or decreased level of consciousness, which are not indicated in the stem. Skin integrity is important but typically evolves over time and is addressed after immediate safety risks are controlled.

Question 14

A nurse is caring for a client following surgery in the postanesthesia care unit. The nurse observes that the client is gagging on his airway and about to vomit. In which position would the nurse place the client?

Accepted Answer

Answer reason: Placing the client in the side-lying recovery position allows oral secretions and vomitus to drain out of the mouth rather than pooling in the pharynx, reducing risk of aspiration and obstruction. This also helps maintain a more patent airway as the tongue and soft tissues are less likely to fall back compared with supine positioning. Trendelenburg can increase risk of regurgitation and does not protect the airway, and prone is not a standard safe positioning choice in PACU for an unstable airway/emesis risk scenario.

Question 15

A child has ingested poisonous hydrocarbons. What is the most important nursing intervention?

Accepted Answer

Answer reason: Hydrocarbon ingestion creates a high risk of aspiration, and any action that increases gagging, coughing, or vomiting can rapidly worsen chemical pneumonitis. Keeping the child calm minimizes crying and agitation that can precipitate emesis and aspiration while urgent guidance/transport and monitoring are arranged. Inducing vomiting is contraindicated because it greatly increases aspiration risk. Activated charcoal is generally not recommended for hydrocarbons due to poor binding and added aspiration risk if the child vomits.

Question 16

A client needs to void 3 hours after a vaginal delivery. Which risk factor necessitates assisting her out of bed?

Accepted Answer

Answer reason: Assisting the client out of bed directly mitigates injury risk while she mobilizes to void. This aligns with safety-focused nursing care during early postpartum ambulation and toileting. Breast engorgement and episiotomy issues may affect comfort, but they do not create the immediate hemodynamic instability that makes ambulation unsafe without assistance.

Question 17

A client is diagnosed with Ménière’s disease. Which nursing diagnosis would take priority for this client?

Accepted Answer

Answer reason: Priority nursing diagnoses focus first on preventing harm, especially during acute vertigo attacks when gait is unstable and the client may be unable to ambulate safely. The other options are not the most immediate threats to life or safety; impaired social interaction and nutrition concerns are secondary, longer-term issues. Cerebral tissue perfusion is not the primary expected risk from Ménière’s and would not outrank preventing falls and related trauma in this scenario.

Question 18

A child is being admitted through the emergency department with a diagnosis of suspected accidental poisoning by medication. The nurse is aware that the most common cause of accidental poisoning in children is which of the following?

Accepted Answer

Answer reason: Analgesics—especially acetaminophen and opioids—are frequently accessible and are well-known leading contributors to accidental ingestions in children. This makes them a more likely primary cause than antibiotics, which may be prescribed but are typically less lethal per dose in many accidental ingestions. Vitamins and laxatives can cause harm, but they are less commonly the leading source of accidental medication poisoning overall.

Question 19

At the scene of a trauma, which nursing intervention is appropriate for a child with a suspected fracture?

Accepted Answer

Answer reason: At a trauma scene, the priority is to prevent further injury while ensuring the child is not left in danger. Suspected fractures should be stabilized/splinted in the position found to limit movement, pain, bleeding, and risk of neurovascular compromise. After immobilization, relocating the child is appropriate when the environment is unsafe, balancing spinal/limb protection with scene safety. “Never move the child” is unsafe if there is ongoing threat, and moving immediately without immobilization increases the risk of worsening tissue damage.

Question 20

An order is written to give MSO4 100 mg intramuscularly now. The nurse should?

Accepted Answer

Answer reason: MSO4 is a high-alert medication abbreviation because it can be confused with MgSO4, creating a significant risk of a wrong-drug error. A 100 mg IM dose of morphine is also unusually high for most patients and requires verification before administration. The safest nursing action is to clarify the intended medication, dose, and route directly with the prescriber to prevent a potentially fatal error. Proceeding to pharmacy processing or gathering supplies without clarification increases the chance the error reaches the patient.

Question 21

An incorrect needle count is found during the closing of a surgical wound. Which action should the nurse take first?

Accepted Answer

Answer reason: The priority principle is immediate patient safety by preventing a retained surgical item, which can cause serious injury and requires urgent intraoperative correction. When a count is incorrect during closure, the nurse should initiate the facility’s count discrepancy protocol immediately (stop/hold closure, re-count, search the sterile field and room, and escalate for imaging if not found) to resolve the hazard before the patient leaves the OR. Notifying leadership and completing an incident report are important but are secondary actions after the immediate risk is addressed. Informing the family is not the nurse’s first step and is typically handled by the surgeon per disclosure policies after the situation is clarified.

Question 22

A client with alcohol withdrawal syndrome is pulling at his central venous catheter, saying he’s swatting the spiders crawling over him. What is the priority action by the nurse?

Accepted Answer

Answer reason: Alcohol withdrawal with visual/tactile hallucinations and agitation creates an immediate safety risk, including accidental removal of a central line with bleeding, air embolism risk, and infection. The nurse’s first priority is to prevent injury by ensuring close observation and implementing safety measures (e.g., maintain line security, call for assistance, use least-restrictive measures per policy). Attempts to correct the hallucination or provide orientation may be appropriate later, but they do not address the immediate danger. Encouraging rest is also non-urgent compared with preventing harm in an acutely delirious, impulsive patient.

Question 23

A nurse wants to use a waist restraint for a client who wanders at night. Which factor should be considered before applying the restraint?

Accepted Answer

Answer reason: Nighttime wandering may be driven by toileting needs, pain, confusion, insomnia, hypoxia, or medication effects, and addressing the underlying trigger can reduce risk without restraint. Considering staffing shortages or convenience is not a clinically or ethically acceptable justification for restraining a client. Using PRN sedatives to manage wandering can increase falls and delirium risk and is not a substitute for identifying the cause of the behavior.

Question 24

A nurse is at highest risk for blood-borne exposure during which situation?

Accepted Answer

Answer reason: Blood-borne pathogen risk depends on whether infectious blood has a direct route into the clinician’s bloodstream, most importantly via percutaneous injury. If gloves are visibly contaminated with blood, a needlestick can carry that blood into the puncture tract even if the needle itself started “clean,” creating a true exposure to the client’s blood. In contrast, a needlestick that occurs before venipuncture is less likely to involve patient blood (though still an injury requiring reporting and follow-up). The highest-risk scenario is the one that clearly combines a skin-penetrating injury with exposure to blood.

Question 25

A client comes to the emergency department after hitting his head in a motor vehicle collision. He’s alert and oriented. Which nursing intervention should be done first?

Accepted Answer

Answer reason: In blunt trauma with possible head impact, the priority is preventing secondary spinal cord injury by assuming a cervical spine injury until proven otherwise. Immediate manual stabilization and cervical immobilization protects the spinal cord during assessment and any movements or transfers. Even though the client is alert and oriented, neurologic status does not rule out an unstable cervical fracture. Head-tilt/chin-lift can worsen an unrecognized C-spine injury; if airway support were needed, a jaw-thrust with inline stabilization would be safer, and ROM assessment is delayed until spine injury is excluded.

Question 26

What is the most important intervention for an occupational nurse to implement when treating a client with a foreign body protruding from the eye?

Accepted Answer

Answer reason: A protruding ocular foreign body should be stabilized and left in place because manipulation or irrigation can worsen penetration, increase bleeding, and cause permanent vision loss. The key nursing priority is to prevent any eye movement and additional trauma; covering both eyes reduces consensual eye movements that occur when only one eye is patched. Attempting removal with forceps or irrigating is contraindicated when an object is embedded/protruding due to high risk of globe rupture. Visual acuity is important to document, but immediate protection/immobilization of the injured eye is the most safety-critical intervention while awaiting specialist care.

Question 27

The nurse has just completed discharge teaching for the family of a school-age child with idiopathic thrombocytopenia. The nurse determines that teaching was effective when the family identifies that which activity should be restricted?

Accepted Answer

Answer reason: Teaching should emphasize restricting activities with a high likelihood of falls or collisions. Riding a bicycle commonly involves falls and head injury risk, so it is an unsafe activity unless specifically cleared with strict protective measures. In contrast, sedentary activities such as computer games do not increase bleeding risk through trauma, and exposure to crowds relates more to infection risk than bleeding prevention in this condition.

Question 28

A 4-year-old child has a tick embedded in the scalp. Which method should the nurse use to remove the tick?

Accepted Answer

Answer reason: Using fine-tipped tweezers with steady, slow outward traction helps disengage the mouthparts from the skin and reduces the risk of leaving parts behind. Burning or other irritant methods can prompt the tick to regurgitate contents into the bite site and should be avoided. A rapid yank is more likely to break off mouthparts and complicate wound care and infection risk assessment.

Question 29

A school-age child tells a nurse that he’s experiencing intense itching from under his cast. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason:  The key safety principle with cast itching is to avoid inserting any objects or substances under the cast because this can abrade the skin, introduce bacteria, and lead to infection or pressure injury. Cool, dry air can reduce itching by decreasing moisture and mild local irritation without traumatizing the skin. Using a pencil (or any object) is a common but unsafe practice and can create wounds that are hidden until serious complications develop. Elevation helps swelling and pain, but it does not directly address pruritus and is not the most appropriate response to itching.

Question 30

When entering the client’s room, the nurse sees that the client is standing on the far side of the room with clothing on fire. Which action should be taken by the nurse immediately?

Accepted Answer

Answer reason: Having the client drop to the floor and roll quickly smothers flames on clothing and reduces spread toward the face and airway, which is the most time-critical threat. This action can be initiated instantly without leaving the client or searching for equipment, minimizing burn depth and extent. Activating the alarm or retrieving items delays extinguishing the flames and increases risk of severe burns and inhalation injury. Water can help, but obtaining it takes time and is less reliable than immediate smothering when clothing is actively burning.

Question 31

The hospitalized client tells the nurse about feeling a strong shock when turning on an electric hair dryer. What should the nurse do first?

Accepted Answer

Answer reason: Unplugging the device stops ongoing exposure and reduces risk of repeated shock or escalation to a more serious electrical event. After the source is made safe, the nurse should then assess the client for complications such as dysrhythmias or burns. Tagging/sending the device is a follow-up safety step but does not address the urgent, active risk.

Question 32

The parent of a 5-year-old asks the nurse if the child is old enough to ride in the front passenger seat of the car. The nurse tells the parent that the recommended age for riding in the front seat of a vehicle is?

Accepted Answer

Answer reason: Child passenger safety guidance prioritizes minimizing airbag-related injury risk, which is highest for smaller children seated in front. Keeping children in the back seat until about age 12 provides a safer distance from airbags and allows proper fit of restraints/seat belts. A 5-year-old should remain in an age-appropriate car seat or booster in the rear seat rather than riding in front. Options suggesting younger ages do not align with standard safety recommendations, while 18 years is unnecessarily restrictive and not the usual guideline.

Question 33

Which intervention should the nurse implement first when defibrillating a client who is in ventricular fibrillation?

Accepted Answer

Answer reason: Defibrillation requires strict electrical safety to prevent accidental shock to staff or bystanders, so ensuring everyone is clear is the immediate priority before delivering energy. This step is performed immediately before the shock and is the nurse’s key safety action in the sequence. While removing oxygen can reduce fire risk and selecting an energy dose is important, neither is as universally time-critical as preventing inadvertent electrocution at the moment of discharge. Energizing/charging the device is a procedural step, but it does not replace the required safety check to confirm no one is in contact with the client or bed.

Question 34

The nurse is developing an educational program about bum prevention for parents of toddlers. Which most common cause of burns in toddlers should the nurse be sure to address?

Accepted Answer

Answer reason: The most common serious burn mechanism in this age group is hot liquid/food being pulled down from a table/counter or stove when a child grabs a dangling cord or reachable pot/pan handle. Prevention teaching prioritizes environmental control such as turning pot handles inward, keeping hot beverages away from edges, and securing/shortening appliance cords. While irons, candles, and matches can cause burns, they are generally less frequent causes than kitchen-related pull-down scald injuries in toddlers.

Question 35

While receiving teaching about giving insulin injections, an adolescent questions the nurse about the reuse of disposable needles and syringes. What is the best response by the nurse?

Accepted Answer

Answer reason: Infection prevention and injection safety require using a new sterile needle and syringe for each injection to avoid contamination. Reuse increases the risk of introducing bacteria, causing local infection, and dulling the needle, which increases tissue trauma and pain. It also raises safety risks if disposal practices lapse, including needlestick injury to household members. Time-based or resource-based exceptions are not appropriate teaching because they normalize an unsafe practice rather than addressing access issues through safer alternatives (e.g., assistance programs, proper supplies).

Question 36

The nurse is preparing to administer medications to a client. To properly identify the client, the nurse must use two client identifiers. Which statement is an example of two client identifiers?

Accepted Answer

Answer reason: Patient identification before medication administration is a core medication-safety practice to prevent wrong-patient errors. Acceptable identifiers include data unique to the patient (e.g., name and date of birth) verified against the medical record/ID band. Room number is not a reliable identifier because patients can be moved and beds reassigned, and visitors are never valid identifiers. Therefore, pairing date of birth with the identification band meets the two-identifier requirement and directly reduces administration errors.

Question 37

A public health nurse visiting a new postpartum client notices that the client has two children under age 4. The nurse notices one infant playing in the cabinet under the sink. Which instruction should the public health nurse give the client?

Accepted Answer

Answer reason: Young children are at high risk for accidental poisoning, so the safest primary prevention is eliminating access to toxic substances. Removing or relocating cleaners to a locked, out-of-reach location prevents ingestion more reliably than relying on caps or labeling. Labeling does not reduce a toddler’s exposure risk and may not prevent ingestion during brief lapses in supervision. Keeping ipecac is outdated and not recommended because induced emesis can increase aspiration risk and delays appropriate poison control guidance.

Question 38

Which expected outcome or goal should a nurse identify for a client with the nursing diagnosis of risk for injury related to lack of awareness of environmental hazards?

Accepted Answer

Answer reason: A safe, measurable expected outcome for a risk diagnosis should reflect the client’s ability to reduce or remove the identified risk factor. Removing environmental hazards directly addresses the lack of awareness by translating education into a concrete behavior that prevents injury. The other options describe nursing interventions (teaching, encouraging, referrals) rather than a client-centered outcome that demonstrates risk reduction. A strong goal focuses on the client’s observable change in the environment that decreases the probability of harm.

Question 39

A nurse is preparing a client with a tracheostomy for discharge. Which of the following statements by the client indicates that he understands the teaching regarding his tracheostomy care?

Accepted Answer

Answer reason:  A tracheostomy creates a direct airway opening, so preventing water entry is a critical safety measure to avoid aspiration and respiratory distress. Covering the stoma during showering reduces the risk of water being forced into the trachea and lungs. Swimming is unsafe because even brief submersion or splashing can allow water into the airway. Routine prophylactic antibiotics are not indicated; infection prevention relies on aseptic technique, proper cleaning, and monitoring for signs of infection.

Question 40

The nurse is caring for the 10-year-old with peritonitis secondary to a ruptured appendix. Which intervention prescribed by the HCP should the nurse question?

Accepted Answer

Answer reason: A setting of 180 mm Hg is unusually high for routine gastric decompression in a child and therefore represents a potential safety hazard that warrants clarification with the prescriber. The other orders are consistent with typical postoperative/peritonitis management: monitor JP output, maintain NPO with IV fluids to support bowel rest, and perform ordered wound care to manage contamination/infection risk. High NG output is clinically important, but the problem here is the unsafe suction level rather than the monitoring instruction.

Question 41

The nurse reads in the 12-year-old client’s medical record, “Fractured left leg from a fall during an episode of somnambulism.” Which nursing intervention is most important to add to the client’s plan of care?

Accepted Answer

Answer reason: Somnambulism increases risk for unintentional ambulation and injury because the client can get out of bed without full awareness or judgment. A bed-exit alarm provides immediate staff notification so the client can be assisted before weight-bearing or walking, which is critical given the history of a serious fall and current leg fracture risk. Teaching the client to use the call light is less reliable because sleepwalking episodes are not consciously controlled. Visitor restriction and hallucination-focused interventions do not address the primary, immediate safety hazard of nocturnal wandering and falls.

Question 42

The home health nurse is using the home Safety Assessment Scale to evaluate the dangers that may exist in the home of the client who is mildly cognitively impaired. Which finding on the scale should be most concerning to the nurse?

Accepted Answer

Answer reason: Active ignition sources in the home are prioritized because they can cause sudden, catastrophic outcomes before help arrives. In contrast, poor vision or lack of social supports increases risk but is typically less immediately life-threatening than a behavior that can start a fire. Spoiled-food recognition mainly raises risk for foodborne illness, which is generally less acute than a house fire.

Question 43

The nurse is teaching parents measures to prevent scald and burn injuries to toddlers in the home. Due to toddlers’ inquisitiveness, which recommendation by the nurse is most important?

Accepted Answer

Answer reason: Toddlers explore by reaching and pulling, making countertop and stovetop edges high-risk areas for immediate scald injury. Turning handles inward/back reduces access and prevents a child from pulling a pot of hot liquid down onto themselves, a common mechanism of severe burns. Smoke detectors are critical for fire safety but do not directly prevent the frequent, sudden contact/pull scalds typical in toddlers. Bathwater and microwave precautions matter, but the stovetop pot-pull hazard is a highly preventable, high-severity risk linked directly to inquisitive behavior.

Question 44

The nurse walks into the room and notes the male client is lying supine, and the entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?

Accepted Answer

Answer reason: During an active generalized tonic-clonic seizure, the immediate priority is airway protection and prevention of aspiration. Side-lying positioning promotes drainage of saliva/emesis and helps keep the tongue from occluding the airway while the patient is unresponsive and making guttural sounds. Padding side rails and loosening clothing are appropriate safety measures, but they are secondary to establishing the safest position for breathing. Vital signs assessment can be delayed until the seizure stops and the patient can be safely evaluated without compromising airway protection.

Question 45

A physician orders intravenous lipids to be administered to a critical care client. The client has a triple lumen subclavian central line, an epidural line, and an arterial line. Which line should the nurse choose to administer the intravenous lipids?

Accepted Answer

Answer reason: IV lipids are administered via an IV access device intended for infusion, and selecting an unused lumen reduces the risk of incompatibility, occlusion, and interruption of other critical infusions. An arterial line is reserved for monitoring and blood sampling, not medication or nutrition infusion, and an epidural catheter is only for neuraxial medications, so neither is appropriate. A multi-lumen central venous catheter is appropriate for lipid infusion; choosing a dedicated/unused lumen minimizes mixing with other drugs and helps preserve patency. Simply using the “labeled” line is unsafe because labeling does not ensure the lumen is designated for lipid/TPN use or free of incompatible infusions.

Question 46

The nurse working in a high school educates the students about car accident prevention. The nurse tells the students that teenagers at highest risk for a motor vehicle crash are?

Accepted Answer

Answer reason: Crash risk in adolescents is driven most by inexperience and poor hazard recognition during the first months of independent driving. Newly licensed teens have not yet developed consistent scanning, speed control, and decision-making skills under real-world conditions, especially in complex traffic or at night. This early driving period is associated with higher rates of risk-taking and distraction, which further increases collision likelihood. Age alone (e.g., turning 19) is a weaker predictor than time since licensure, and specific events like prom or football games are situational rather than the broad, highest-risk determinant.

Question 47

Which statement most accurately describes the use of restraints?

Accepted Answer

Answer reason: Restraints are a last-resort safety measure and should be used for the shortest duration possible with ongoing reassessment for continued need. Regularly evaluating whether restraint use can be reduced or discontinued supports least-restrictive care and helps prevent restraint-related harms (e.g., impaired circulation, skin injury, agitation). Monitoring only “every shift” is too infrequent for safety surveillance and reassessment, which should occur more often than shift-to-shift. A fixed 36-hour renewal interval is inconsistent with common standards that require more frequent time-limited orders and reassessment, and restraints should not be a default step before less restrictive approaches or appropriate pharmacologic treatment when clinically indicated.

Question 48

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 proclaims "Away from me, Demon!" What is the most important intervention for the nurse to implement?

Accepted Answer

Answer reason: Safety is the priority when a client is highly paranoid, shouting, and perceiving the nurse as a threatening figure, because agitation can rapidly escalate to violence. Leaving immediately reduces risk to the nurse and prevents further stimulation that may worsen the client’s fear-driven behavior. Calling police is not the first action unless there is an imminent threat requiring emergency response; the nurse should first remove herself from danger. Calming communication or reorientation is appropriate only when the environment is safe enough to attempt de-escalation.

Question 49

Which step, if taken by a nurse after insertion of a nasogastric (NG) tube, could harm the client?

Accepted Answer

Answer reason: NG tube placement must be verified using safe, evidence-based methods before introducing any significant fluid or feeding because a malpositioned tube can enter the airway. Instilling a large volume can be aspirated into the lungs, causing aspiration pneumonitis, respiratory compromise, or worsening hypoxia, especially if the tube is inadvertently in the tracheobronchial tree. Safer bedside checks include aspirating gastric contents and testing pH, and the gold standard for initial placement confirmation is radiography when required by policy. Securing the tube and documenting the procedure support safety and continuity of care and do not inherently create the same immediate harm risk.

Question 50

The pediatric client receives treatment to convert an SVT rhythm to a sinus rhythm. The nurse instructs the child's parents on interventions to terminate the SVT rhythm should the rhythm recur. Which information stated by a parent indicates further teaching is needed?

Accepted Answer

Answer reason: Vagal maneuvers can help terminate SVT by increasing parasympathetic tone and slowing AV nodal conduction, but they must be used in age-appropriate, safe ways. Bilateral carotid sinus massage is contraindicated because it can markedly reduce cerebral perfusion and may precipitate severe bradycardia or neurologic compromise, especially if done improperly. Home teaching for children typically emphasizes safer options such as Valsalva-type techniques (when developmentally able) and facial cold stimulation. This statement reflects an unsafe intervention and indicates the need for further teaching.

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