Question 1

An enema is prescribed for the 20-month-old who has had severe constipation. The experienced nurse observes the new nurse perform the procedure. Which action by the new nurse requires the experienced nurse to intervene?

Accepted Answer

Answer reason: A 20-month-old should receive a much smaller volume than 500 mL, so proceeding with that amount represents an unsafe medication/therapy dosing error that warrants immediate intervention. Using a small, soft catheter is appropriate to reduce mucosal trauma. Pausing the infusion during cramping is a standard technique to reduce discomfort and risk of forcing solution against resistance.

Question 2

The client with a right femoral arterial line is confused, thrashing about in bed, and picking at the tubing. The HCP prescribes wrist restraints. Based on this information, what should the nurse plan to do?

Accepted Answer

Answer reason: Wrist restraints alone may prevent pulling at tubing but do not prevent leg movement that can kink or dislodge a right femoral line during thrashing. The safest plan is to obtain an additional, properly authorized restraint to limit movement of the extremity associated with the invasive line while continuing least-restrictive measures and close monitoring. Sedation may be used in select cases, but it is not automatically safer and can worsen delirium or respiratory status; the immediate priority is preventing line disruption and hemorrhage. Simply applying only the ordered wrist restraints leaves a major safety risk unaddressed.

Question 3

The nurse asks the NA to apply a mitten restraint for the client seated in the wheelchair next to the bed. Which observation by the nurse indicates that the NA needs further instructions on applying restraints?

Accepted Answer

Answer reason: Restraints must be attached to a nonmoving part of the bed frame or to the wheelchair frame when the client is in a wheelchair to prevent sudden tightening, falls, or strangulation risk as the client moves. Tying the strap to the bed frame while the client is seated in the wheelchair creates hazardous tension and limits safe mobility between the chair and bed. A quick-release (half-bow slip) knot and the two-finger spacing reflect proper safety technique to allow rapid removal and preserve circulation. Proper mitten placement includes keeping the mesh over the palm to allow visualization and reduce pressure injury risk, so placing it on the back of the hand is not the key unsafe finding here compared with incorrect anchoring.

Question 4

The nurse is conducting a support group for clients diagnosed with PD and their significant others. Which information regarding physiological needs should be included in the discussion?

Accepted Answer

Answer reason: Parkinson disease causes bradykinesia, rigidity, postural instability, and a shuffling gait, which significantly increases fall risk and injury potential. Home environmental modification to reduce tripping hazards is a direct, high-yield physiologic safety need because it prevents fractures and head trauma. Loose rugs and unsecured carpet edges commonly trigger falls when clients have freezing episodes or difficulty initiating steps. Advance directives and communication strategies are important but address planning and psychosocial/cognitive support rather than immediate physiologic safety related to mobility.

Question 5

The nurse instructs the client having a left total knee replacement to mark the site where the surgery is to take place. In marking the site, the nurse should?

Accepted Answer

Answer reason: Preventing wrong-site surgery requires active patient involvement and site verification before any sedating preoperative medications that could impair judgment or recall. The operative site should be clearly and unambiguously marked on the correct limb in a way that supports the time-out process and matches the planned procedure. Marking the opposite knee is a serious safety error, and having the patient mark after pre-op meds increases the risk of confusion. Using an “X” is more ambiguous than an affirmative mark and is more prone to misinterpretation in safety protocols.

Question 6

A newborn in a neonatal unit is to receive penicillin G benzathine intramuscularly. The dispensed dose is 10 times the ordered dose. To minimize the number of injections the neonate receives, the nurse should?

Accepted Answer

Answer reason: Medication safety requires verifying and reconciling any dose discrepancy before administration, especially in neonates where dosing errors can rapidly cause harm. A dispensed amount that is 10 times the ordered dose is a red-flag for a dispensing or calculation error and must be clarified rather than “worked around” to reduce injections. Changing route to IV or splitting into multiple IM sites constitutes practicing outside the prescription and can introduce additional risk or toxicity. Collaborating with pharmacy ensures the correct concentration/volume is prepared so the ordered dose can be given safely with the least trauma possible.

Question 7

The nurse is reviewing the HCP orders for the child weighing 40 lb who has infectious diarrhea caused by Salmonella. Which order should the nurse question?

Accepted Answer

Answer reason: This risk is especially important in children, where infectious diarrhea can deteriorate quickly and requires supportive care rather than bowel “shut down.” Additionally, the ordered dose is not weight-based and appears excessive for a 40‑lb child, raising safety concerns. In contrast, oral rehydration is first-line therapy, antipyretic dosing is reasonable, and stool testing can help assess severity/complications.

Question 8

During a home health visit, a nurse assesses a client’s medication and notes the client has two prescriptions for fluid retention. One prescription reads, “Lasix, 40 mg, one tablet daily.” The next prescription reads, “Furosemide, 40 mg, one tablet daily.” Which instruction is given to the client?

Accepted Answer

Answer reason: The core safety principle is medication reconciliation to prevent therapeutic duplication and adverse effects. These two prescriptions represent the brand name and the generic name of the same loop diuretic, so taking both would double the dose and increase risk of dehydration, hypotension, electrolyte loss (especially hypokalemia), and kidney injury. Alternating days would create inconsistent dosing and does not resolve the underlying duplication. Discarding a medication independently is unsafe; the nurse should clarify with the prescriber/pharmacy while teaching the client about brand–generic equivalence.

Question 9

The NA is assigned to provide care for a severely disoriented older adult client who has been restrained for client safety after least-restrictive methods have been tried. Which statement made by the NA indicates the most immediate need for education regarding safe client care?

Accepted Answer

Answer reason:  Any sign of skin breakdown, bruising, swelling, numbness, or impaired circulation from restraints is a potential injury that requires prompt assessment and intervention to prevent neurovascular compromise. Minimizing bruising as “not really hurt” shows a dangerous misunderstanding of restraint risks and the need to report and address complications immediately (padding, fit, repositioning, and RN notification). While frequent checks are appropriate, the highest immediate safety concern is failure to recognize and respond to restraint-related injury. This statement signals the greatest knowledge gap because it could allow worsening injury to go untreated.

Question 10

Upon arrival to an OR holding area, the client who is scheduled for abdominal surgery is noted to have replaced a tongue ring that was removed when the operative checklist was completed. Which is the most appropriate initial action by the nurse?

Accepted Answer

Answer reason: Airway safety is the priority in the perioperative period because oral jewelry can dislodge during intubation, cause mucosal trauma, or become an aspirated/obstructing foreign body. The most appropriate initial nursing action is to eliminate the immediate hazard by having the client remove the tongue ring before anesthesia care proceeds. Simply documenting does not mitigate the risk, and an incident/variance report is not the first step for a correctable safety issue. While the surgical and anesthesia teams should be informed if the item cannot be removed or if surgery must be delayed, the nurse should first attempt prompt removal to prevent harm.

Question 11

The nurse is evaluating the performance of the UAP. The nurse should provide feedback to the UAP about which unsafe action?

Accepted Answer

Answer reason: Electrical safety requires unplugging equipment by grasping the plug rather than pulling on the cord to prevent cord damage, exposed wiring, and shock or fire risk. Pulling on the cord can also loosen internal connections, creating intermittent malfunction that may not be immediately obvious. The other actions described reflect appropriate safety practices (cleaning shared equipment, using a quick-release knot with restraints, and using a bed-exit alarm for a confused client). Therefore, this cord-pulling behavior is the unsafe action needing feedback.

Question 12

The mother calls the nurse to ask when her newborn will be brought back to her room to finish feeding. The mother states that a doctor came about 30 minutes ago to take the baby for an examination and has not returned with her baby- Which action should be taken by the nurse first?

Accepted Answer

Answer reason: Confirming whether the newborn is still with the provider promptly resolves the most likely cause (routine exam delay) and initiates immediate follow-up if the infant is not there. Initiating an abduction protocol is appropriate only after initial verification steps fail, because it triggers high-alert actions and system-wide disruption. Indirect steps like asking other staff or searching the unit are slower and less definitive than checking the exam location/provider first.

Question 13

The experienced nurse is instructing the new nurse on client safety. Which statement made by the new nurse should the experienced nurse correct?

Accepted Answer

Answer reason:  Population-level injury prevention teaching is based on epidemiologic leading causes of morbidity and mortality, and for young adults the dominant causes of death are unintentional injuries (especially motor-vehicle related) along with homicide and suicide, not substance abuse as a leading category. Substance use is a major risk factor that contributes to accidental death and mental health crises, but it is not typically listed as a primary “leading cause of death” category in standard injury-prevention frameworks. The other statements align with common safety priorities: sports injury prevention for school-age children, fall-history screening in older adults, and close supervision of preschoolers because falls are a frequent source of nonfatal injury. Therefore, the young-adult mortality statement is the one requiring correction.

Question 14

The expectant mother asks the nurse, “With all the babies in the nursery, how will I know that the nurse is bringing rue my baby?” What is the nurse’s best response?

Accepted Answer

Answer reason:  Safe newborn identification relies on matching unique identifiers on the parent/infant ID bands at every transfer or handoff to prevent misidentification. This response directly explains how the mother can verify the infant’s identity using printed identifiers that can be checked immediately before the baby is returned. Alarm bands and locked exits are anti-abduction measures, but they do not confirm that a specific infant belongs to a specific parent at the bedside. Footprints are commonly collected for records, yet they are not the primary real-time method used to verify identity during routine returns from the nursery.

Question 15

The nurse cares for a client who undergoes a left total knee replacement. Before surgery begins, the “time-out” takes place. “Time-out” is a process?

Accepted Answer

Answer reason: The core safety principle is preventing wrong-patient, wrong-procedure, and wrong-site surgery through a standardized, team-based verification immediately before incision. A surgical time-out requires all team members to stop and verbally confirm the patient identity, planned procedure, correct side/site marking, and any critical items such as implants. Sponge/instrument counts are separate perioperative safety checks performed at designated times (e.g., before closure), not the definition of the time-out itself. Opening correct instrumentation and the surgeon’s scrub are preparatory steps but do not replace the mandated final, active verification process.

Question 16

The nurse takes a telephone order from a physician. Which statement most appropriately applies to the implementation of the telephone order?

Accepted Answer

Answer reason: Read-back is a core error-prevention strategy for verbal/telephone orders to verify accuracy and prevent miscommunication before any downstream steps. Confirming the order first allows immediate correction of drug name, dose, route, frequency, or patient-specific parameters before the order becomes part of the medical record and is acted upon. Transcribing before read-back increases the chance that an incorrect order is documented and carried out, especially with look-alike/sound-alike medications and similar dosing units. Delaying documentation until end of shift is unsafe because it increases risk of omission, memory error, and delays in care.

Question 17

The nurse is advising parents about the prevention of burns to their child from tap water. What is the most important instruction for the nurse to include?

Accepted Answer

Answer reason: Set the water heater temperature at 130° F (54.4° C) or less. The key prevention principle is engineering/environmental control: lowering the maximum hot-water temperature reduces scald risk at the source and protects the child even if supervision lapses. Setting a safe heater limit prevents sudden exposure to dangerously hot tap water throughout the home, including sinks and tubs. Testing bath water by hand is subjective and can miss hot spots or sudden temperature changes, making it less reliable than controlling the heater setting. Running hot water first increases exposure risk and can rapidly raise the basin temperature before it is corrected, making it a poor safety instruction compared with limiting heater temperature.

Question 18

A 49-year-old client is admitted to the emergency department frightened and reporting that he's hearing voices telling him to do bad things. Which intervention should be the nurse's priority?

Accepted Answer

Answer reason: Command hallucinations raise immediate safety concerns because they can direct self-harm or harm to others, so the nurse must first determine the content, intensity, and whether the client feels compelled to act. Direct assessment informs the level of risk and the urgency of protective measures (e.g., observation level, removal of hazards, notifying the provider/security). Attempts to reassure or argue about the reality of hallucinations can be ineffective and may worsen mistrust without addressing imminent danger. Medication may be appropriate but is not the first step until the immediate risk is clarified and safety planning is initiated.

Question 19

The client, who is to receive general anesthesia, reports having a dry mouth because food and fluids have been withheld for 8 hours. Which action by the nurse is most appropriate?

Accepted Answer

Answer reason: The nurse’s safest, most appropriate action is to provide accurate teaching that supports adherence to this safety measure. Offering water based on an incorrect “4 hours” claim undermines anesthesia safety and could increase aspiration risk. Explaining diaphragm pressure is not the primary perioperative danger, and dismissing the symptom with reassurance ignores patient education and safety concerns.

Question 20

The client makes the following statements to the home health nurse. Which statement requires the nurse to intervene immediately?

Accepted Answer

Answer reason:  Using a gas oven for space heating is an immediate life-safety hazard because it can produce carbon monoxide and deplete oxygen, especially with inadequate ventilation. It also increases fire and burn risk and is not designed with the safety controls required for continuous room heating. This statement indicates an ongoing exposure that can rapidly lead to poisoning, loss of consciousness, or death, so it warrants urgent teaching and corrective action. By comparison, the nonskid slippers represent a risk-reduction behavior rather than an active, high-lethality hazard.

Question 21

The nurse manager overhears multiple conversations on a hospital unit. Based on the statement made, the nurse manager should initiate the process for reporting incivility with which person?

Accepted Answer

Answer reason:  Incivility includes disrespectful, demeaning, blaming, or shaming communication that undermines a culture of safety and therapeutic care. This statement is contemptuous toward the client and communicates abandonment/blame rather than support and problem-solving, making it a clear professionalism and safety concern requiring reporting/escalation. By contrast, discussing a medication error or clarifying clinical details can be appropriate when done respectfully, and reminding a coworker about missed documentation is a task-focused prompt rather than inherently hostile. Addressing such behavior protects the client’s psychological safety and helps prevent breakdowns in communication that contribute to adverse events.

Question 22

The experienced nurse is observing the new nurse providing care to the hospitalized client. Which action requires the experienced nurse to intervene to ensure client safety?

Accepted Answer

Answer reason: Using room number as part of identification increases the risk of giving medications to the wrong patient, a high-harm preventable error. The appropriate approach is to use two identifiers such as the client’s name and a second unique identifier (e.g., date of birth or medical record number) compared to the medication record. The other actions described are safety-promoting measures (fall prevention lighting, dysphagia aspiration prevention, and procedural time-out), so they do not warrant intervention.

Question 23

Prior to checking a fingerstick blood glucose level, the nurse checks the identification band of the newly admitted client transferred from another facility. The nurse notes that the name and birth date are correct but that the band has the logo from another facility. Which is the best action by the nurse?

Accepted Answer

Answer reason: Patient identification is a core safety step before any procedure, including point-of-care testing, and the identification process must align with the current facility’s policy and approved identifiers. A band from another institution introduces risk of mismatch, duplication, or undocumented changes during transfer, so the safest action is to correct the identifier source before proceeding. Having the client state name and DOB is an important verification step, but it does not address the system-level error of an incorrect/foreign facility armband remaining in place. Proceeding while delegating band replacement or leaving the outside band in place increases the chance of wrong-patient testing or downstream errors.

Question 24

The nurse manager is reviewing a list of serious reportable events that occurred in a hospital setting before submitting the list to an external agency. Which event should the nurse manager remove from the list before it is submitted?

Accepted Answer

Answer reason: Serious reportable events (often termed sentinel/never events) are unexpected occurrences involving death or serious physical/psychological injury, or significant risk thereof, typically requiring immediate investigation and external reporting. A minor transfer-related injury such as a skin tear/abrasion does not meet the threshold of “serious” harm and is generally handled through internal incident reporting and quality improvement rather than external serious-event reporting. By contrast, a hip fracture from an elopement/fall and a cardiac arrest linked to failure to communicate a critical lab value represent severe outcomes and system/process failures. Staff serious injury related to an electrical procedure is also a significant safety event that warrants inclusion for external reporting and corrective action.

Question 25

The transporter is on the floor to take a client to the radiology department for a left lung tissue biopsy. The nurse is performing a final check before the client is transported to the radiology department. The nurse should ensure that?

Accepted Answer

Answer reason: Pre-procedure safety centers on preventing wrong patient/procedure/site events and avoiding predictable complications. A complete final check includes verifying informed consent, confirming required labs (e.g., coagulation/platelet status for biopsy-related bleeding risk), administering ordered premedication at the appropriate time, and ensuring correct site marking per universal protocol. Omitting lab verification leaves a major risk unaddressed for an invasive biopsy. Shaving with a razor is not part of the essential final transport check and increases skin microabrasions and infection risk.

Question 26

A home health nurse is caring for a client whose spouse smokes cigarettes. Knowing that smoking is the leading cause of fire-related deaths, the nurse includes which instructions when teaching the client and spouse how to prevent fires?

Accepted Answer

Answer reason: Fire prevention teaching prioritizes eliminating common ignition sources and preventing unintentional access, especially by children who may experiment and start household fires. Securing matches and lighters in a locked location is a clear, actionable harm-reduction intervention appropriate for home safety education. In contrast, the other options either promote unsafe practices related to smoking (bed smoking or leaving lit cigarettes unattended) or give an incorrect/insufficient safety recommendation (smoke alarms should be checked more frequently than every 6 months). This instruction directly reduces risk in a household where smoking materials are present.

Question 27

The nurse provides a group of adolescent clients with information to promote injury prevention. Which client statement indicates a correct understanding of the information presented?

Accepted Answer

Answer reason: Alcohol impairs judgment, reaction time, coordination, and risk perception even at low blood alcohol levels, and adolescents are at particularly high risk for motor vehicle crashes. A clear injury-prevention teaching point is to avoid driving after any alcohol intake and to use alternative transportation. In contrast, using a hands-free device does not eliminate cognitive distraction and still increases crash risk. Statements claiming vaping or edible cannabis is “safer” can normalize use and ignore associated impairment/health risks, so they do not reflect appropriate injury-prevention understanding.

Question 28

The nurse is providing discharge education for an elderly client newly diagnosed with macular degeneration. Which safety topic is most important for the nurse to include in the teaching?

Accepted Answer

Answer reason: Teaching purposeful scanning reduces risk of trips, falls, and collisions in the home and community, which is the most immediate safety priority for discharge. The other options are either not core safety teaching for macular degeneration or relate to different conditions (e.g., tonometry monitoring is primarily emphasized for glaucoma). Prioritizing fall-prevention strategies aligns with protecting an elderly client from injury during activities of daily living.

Question 29

The nurse on an orthopedic unit is caring for a client after a knee arthroplasty. All of the following interventions are appropriate except?

Accepted Answer

Answer reason: Heat causes local vasodilation, which can increase swelling and may worsen postoperative bleeding in the early period; cold therapy is typically preferred to decrease pain and edema. Early ambulation with PT/UAP support is appropriate to promote mobility and reduce thromboembolic risk when done safely. Teaching to use the call light and administering prescribed analgesics support fall prevention and adequate pain control to enable participation in rehabilitation.

Question 30

A nurse draws up a medication to administer an IM injection to a client. The nurse notes a few small air bubbles in the syringe. Which is affected when the nurse fails to remove air bubbles prior to administration?

Accepted Answer

Answer reason: This is primarily a medication administration accuracy issue: the measured volume in the barrel is not fully drug solution. For small intramuscular air bubbles, the main consequence is underdosing rather than altered pharmacokinetics. Onset and duration are determined mainly by the drug’s formulation and tissue perfusion, and a tiny bubble does not meaningfully change them compared with giving the wrong amount of drug.

Question 31

A busy, harried-looking physician comes onto the floor and writes out four orders in less than one minute. He leaves, shoving over a stack of the nurse’s charting on the way out the door. Of the following four orders, which one should the nurse ask?

Accepted Answer

Answer reason: Heat therapy is contraindicated on areas with impaired circulation and/or decreased sensation because it can cause unrecognized thermal injury and worsen tissue damage. A diabetic foot ulcer often occurs in the setting of neuropathy and peripheral vascular disease, so applying a heating pad can lead to burns, increased inflammation, and delayed wound healing. The other orders represent commonly accepted comfort measures when used appropriately (e.g., cold/elevation after infiltration; heat for chronic inflammatory joint pain; sitz baths post-episiotomy). Therefore, this order raises an immediate patient-safety concern and requires clarification before implementation.

Question 32

Which is the priority nursing action when preparing to administer two continuous intravenous (IV) medications through a patient's peripheral IV?

Accepted Answer

Answer reason: Administering two continuous IV infusions through the same peripheral line creates a high-risk situation for physical or chemical incompatibility, which can cause precipitation, catheter occlusion, loss of drug efficacy, or embolic complications. Verifying compatibility (and Y-site compatibility specifically) is the key safety step that prevents an avoidable medication administration error before the drugs ever reach the bloodstream. Although verifying IV patency and using two identifiers are essential safety checks, they do not address the unique hazard of mixing two infusions in the same tubing. Flushing with saline is not the priority for continuous concurrent infusions and can be inappropriate depending on the setup and ordered rates.

Question 33

The nurse is caring for a client receiving continuous enteral tube feedings who begins vomiting. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: The immediate priority with active vomiting is airway protection and aspiration prevention. Turning the client to a side-lying position promotes drainage of emesis out of the mouth and reduces the chance of aspiration into the trachea, addressing the most time-critical safety risk first. Stopping the tube feeding is important but follows stabilization of the airway because aspiration can occur during the vomiting episode regardless of whether the feeding is still running. Suctioning and notifying the provider are appropriate next steps depending on the client’s status, but positioning is the fastest initial intervention to reduce harm.

Question 34

The preoperative nurse is caring for a client who is scheduled for a bilateral adrenalectomy for primary hyperaldosteronism. Which of the following interventions should the nurse include in the client’s preoperative plan of care?

Accepted Answer

Answer reason: Primary hyperaldosteronism commonly causes hypokalemia, which increases risk for muscle weakness, cramps, and dysrhythmias that can contribute to dizziness and falls. Preoperative nursing care prioritizes patient safety and prevention of injury while electrolyte abnormalities are being corrected and monitoring is ongoing. A loop diuretic would further waste potassium and can worsen hypokalemia, making it an unsafe routine intervention here. A high-iodine diet is unrelated to aldosterone excess (more relevant to thyroid disorders). Lifelong prednisone is not the expected education point for this procedure; adrenal steroid replacement is primarily a postoperative management issue and is not universally lifelong for all adrenal surgeries.

Question 35

A nurse prepares to administer medication for a client in a correctional facility. Which identifier does the nurse verify?

Accepted Answer

Answer reason: Full legal name and date of birth are standard, reliable identifiers that can be directly verified with the client and matched to the MAR/wristband. Identifiers such as room/cell number, initials, or a non-unique first name are unsafe because they can be shared by multiple clients. In correctional settings, an inmate number may be used by facility policy, but it should not replace using two patient-specific identifiers; initials are not an acceptable second identifier.

Question 36

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: Accurate patient identification relies on using reliable identifiers that are not easily mistaken, especially in group settings where names can be similar and patients may give incorrect information. An armband provides a standardized, facility-approved identifier that can be verified consistently before any intervention. Relying on self-report alone can be unsafe due to confusion, cognitive symptoms, or intentional misidentification. Staff confirmation after the patient states a name is less robust than using an objective identifier and can still perpetuate an initial error. Photo matching can help in some workflows but is less universally available and may be outdated or bypass standard policy compared with armband verification.

Question 37

The charge nurse is observing a staff nurse perform tracheostomy suctioning. Which of the following actions by the staff nurse would require the charge nurse to intervene?

Accepted Answer

Answer reason: Applying suction while advancing increases the risk of tracheal mucosal damage, bleeding, and vagal stimulation (bradycardia) because negative pressure is applied directly to sensitive airway tissue. Proper technique is to advance the catheter without suction to the premeasured depth, then suction intermittently while withdrawing over a limited time. Semi-Fowler’s positioning and hyperoxygenation between passes are appropriate measures to promote ventilation and reduce desaturation during the procedure.

Question 38

A 45-year-old woman is being discharged after having a hysterectomy. Which of the following demonstrates proper understanding of the instructions?

Accepted Answer

Answer reason: Postoperative discharge teaching emphasizes medication safety to prevent injury and adverse events at home. Opioid and other sedating analgesics can impair alertness, coordination, and reaction time, so avoiding driving while using them reduces risk of accidents. Taking the medication exactly as prescribed also prevents under-treatment of pain and reduces the chance of over-sedation, respiratory depression, or other dose-related harms. In contrast, heavy bleeding for weeks is abnormal after hysterectomy and should be reported, and extended bedrest increases venous thromboembolism risk and delays recovery.

Question 39

A client delivered 90 minutes ago. She is alert and physically active in bed. She states that she needs to go to the bathroom. The nurse's most appropriate response is?

Accepted Answer

Answer reason: " Postpartum clients are at increased risk for orthostatic hypotension and syncope in the first hours after delivery due to blood loss, fluid shifts, and residual effects of analgesia/anesthesia. Assisting to the bathroom with continuous supervision prioritizes fall prevention while also supporting early ambulation and spontaneous voiding. Offering a bedpan is less appropriate when the client is able to ambulate and may increase discomfort and urinary retention. Teaching perineal hygiene is important, but it does not address the immediate safety need when first getting out of bed.

Question 40

The nurse is caring for a client with a platelet count of 18,000 mm3 [150,000-400,000 mm3]. What is the priority action the nurse should take?

Accepted Answer

Answer reason: A platelet count of 18,000 indicates severe thrombocytopenia with high risk for spontaneous bleeding and catastrophic hemorrhage after even minor trauma. The most immediate nursing priority is injury prevention, especially fall prevention, because a fall could cause intracranial or internal bleeding. Having the client call for assistance before ambulating reduces the likelihood of unassisted transfers and falls and allows the nurse to implement bleeding precautions during mobility. Monitoring temperature addresses infection risk, but bleeding from trauma is the more immediate safety threat at this platelet level. Encouraging coughing can increase intrathoracic pressure and mucosal irritation and is not the priority compared with preventing injury.

Question 41

A nurse is conducting a dysphagia screening on a client who was recently extubated. Which assessment finding requires intervention?

Accepted Answer

Answer reason:  A “wet/gurgly” vocal or cough quality after swallowing is a classic sign of poor airway protection with possible aspiration of thin liquids, which is a high-priority safety concern after extubation. This finding indicates secretions or fluid are sitting near the vocal cords and may enter the trachea, increasing risk for aspiration pneumonia and respiratory compromise. The nurse should stop oral intake, maintain aspiration precautions (upright positioning, suction available), and notify the provider/speech-language pathologist for formal swallow evaluation. Mild throat discomfort and hoarseness can be expected transient effects of recent intubation and are less specific for aspiration. A slight cough can occur with irritation, but the “wet/gurgling” quality is more concerning for aspiration and requires immediate intervention.

Question 42

A nurse is preparing to administer medications through a newly inserted nasogastric (NG) tube. Which action should the nurse take first?

Accepted Answer

Answer reason: g., respiratory tract) can cause aspiration and severe injury. With a newly inserted NG tube, placement must be verified before any flush or medication administration. Flushing is appropriate only after correct placement is confirmed, and giving meds one at a time is a later step to reduce incompatibilities and clogging. Mixing crushed medications together is unsafe because it increases the risk of drug interactions, altered absorption, and tube occlusion.

Question 43

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

Accepted Answer

Answer reason: Romberg testing intentionally challenges balance by removing visual input, so the primary nursing priority is fall prevention during the maneuver. Remaining close (ready to steady the patient without interfering) minimizes injury risk if swaying or loss of balance occurs. Allowing eyes to stay open defeats the purpose of the test, while holding furniture provides external stabilization that can mask instability. Spreading the feet apart increases the base of support and can also reduce the sensitivity of the assessment rather than ensuring safe, valid testing.

Question 44

A client is taking morphine sulfate for acute pain. The client stands, is immediately "lightheaded," and calls for the nurse. What is the nurse's priority action?

Accepted Answer

Answer reason: The priority is to prevent injury by promptly lowering the client’s center of gravity and supporting them in a safe position. Sitting is an immediate, practical action that can be done while simultaneously assessing symptoms and vital signs. Measuring orthostatic blood pressure is appropriate after the client is safe, but it does not address the imminent fall risk. Ambulating the client increases the likelihood of collapse, and ordering bed rest is unnecessary and overly restrictive compared with immediate assisted positioning and reassessment.

Question 45

The nurse provides care for a patient who is prescribed the following medications: torsemide 10 mg PO daily, atenolol 50 mg PO daily, cyclobenzaprine XL 5 mg PO daily, and oxycodone 40 mg PO every 6 hours PRN pain. Based on the patient's medications, which is the priority nursing diagnosis to include in the plan of care?

Accepted Answer

Answer reason: Oxycodone and cyclobenzaprine both cause CNS depression, sedation, and dizziness, and when combined they increase fall risk. Atenolol can contribute to hypotension/bradycardia and torsemide can cause volume depletion/orthostatic hypotension, further elevating risk for syncope and injury. While pain may be present, it is not as immediately life/safety threatening as a high likelihood of falls in a patient on multiple sedating and blood-pressure-lowering agents.

Question 46

The nurse is planning care for a client who underwent a hip arthroplasty and requires one-person assist when ambulating. The client is alert and fully-oriented. Which of the following interventions is most important to promote client safety?

Accepted Answer

Answer reason: After hip arthroplasty, impaired mobility and pain increase fall risk, so timely access to assistance is the highest-impact safety measure. Keeping the call light within reach directly enables the client to summon staff for the required one-person assist. Non-skid socks and a gait belt are helpful adjuncts, but they do not prevent the client from attempting to ambulate alone. A yellow wristband improves staff awareness but is less immediately protective than ensuring the client can call for help.

Question 47

In group therapy, the client is interrupted while speaking. She becomes visibly agitated, pulling another client’s hair. The priority action for the nurse to take is?

Accepted Answer

Answer reason: Immediate safety is the priority when a client becomes physically aggressive toward others. Separating the client from the group stops ongoing harm and allows the nurse to set firm limits and assess triggers, impulse control, and need for further interventions. A behavioral contract is not an acute de-escalation or safety measure and is inappropriate while the client is actively assaultive. Praising or redirecting to exercise may be useful later, but it does not first protect the victim or restore a safe therapeutic milieu.

Question 48

The charge nurse is observing as a new nursing graduate performs an ear irrigation to remove impacted cerumen from the client’s ear. The charge nurse would intervene during the procedure if the new nursing graduate performs which action?

Accepted Answer

Answer reason: Keeping the affected side up can trap fluid in the canal, increasing discomfort and the risk of otitis externa. Using solution near body temperature helps prevent vertigo and nausea from vestibular stimulation, and directing the stream toward the canal wall (not the tympanic membrane) reduces risk of trauma. Hand hygiene is an appropriate standard precaution and does not warrant intervention.

Question 49

A nurse enters a client's room and finds the client lying down on the floor. What should the nurse do first?

Accepted Answer

Answer reason: Initial nursing priority follows ABCs and rapid assessment after a potential fall to identify immediate life threats and need for emergency response. Assessing responsiveness (level of consciousness, ability to answer, obvious distress) quickly determines whether the client needs urgent interventions such as activating emergency protocols, airway support, or spine precautions. Calling for help may be necessary, but the nurse must first determine if the client is unresponsive or unstable to guide the urgency and type of assistance required. Moving the client back to bed risks worsening an unrecognized injury, and documentation is performed after assessment and immediate safety actions.

Question 50

A patient is having a tonic-clonic seizure. A nurse should take which of the following steps?

Accepted Answer

Answer reason: Protecting the head with soft padding reduces risk of blunt trauma from repetitive jerking movements against the bed or floor. In contrast, inserting objects into the mouth can fracture teeth and obstruct the airway, and restraining the patient increases risk of musculoskeletal injury. Supine positioning can worsen secretion pooling/airway obstruction; lateral positioning is preferred when feasible, but among these choices head protection is the safest appropriate action.

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