Question 1

Which of the following environments are conducive to healing a patient with hypocalcemia? Select one?

Accepted Answer

Answer reason: A well-lit environment reduces environmental hazards and supports safe ambulation and orientation. Using two side rails supports repositioning and safe exiting/entering the bed without creating unnecessary restraint risk. Raising all four side rails is generally considered a restraint and can increase the chance of climbing over the rails and sustaining injury, so it is not the safest default setup.

Question 2

Your patient has an order for 2 mg of morphine IV push. Prior to administration, which action would best promote patient safety?

Accepted Answer

Answer reason: Opioids can rapidly cause sedation, dizziness, and orthostatic hypotension, increasing fall risk and making it unsafe for the patient to ambulate to the bathroom after dosing. Toileting beforehand is a concrete, immediate preventive step that reduces the likelihood of an unsupervised post-medication trip and potential injury. Giving an antiemetic may improve comfort but does not address the most urgent preventable harm tied to immediate opioid effects. Prior exposure to the drug and having family present may help education/support, but neither reliably mitigates the direct physiologic fall risk created by IV push opioid onset.

Question 3

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: The core safety principle is to use at least two approved client identifiers before providing care to prevent wrong-patient errors. In a group therapy setting, asking the client to state their name and date of birth uses two direct identifiers and does not rely on third parties. Visitor identification is unreliable and can breach confidentiality, and staff confirmation after hearing the name still risks mix-ups if clients share similar names. Photos/armbands can support identification, but the most appropriate primary method is active client verification with two identifiers.

Question 4

Which of the following is an example of nursing malpractice?

Accepted Answer

Answer reason: The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia. Malpractice requires a duty owed, breach of the standard of care, foreseeability, and resulting harm (proximate cause). Giving a medication that is clearly contraindicated by a documented allergy is a preventable breach that a reasonably prudent nurse would avoid through allergy verification and medication rights checks. The severe injury described establishes clear causation and damages. By contrast, an error that is promptly recognized and reported may still be negligence, but the question’s most definitive malpractice example is the avoidable contraindicated administration with serious harm.

Question 5

The nurse finds a patient with Alzheimer’s wandering the hallway in an acute state of delirium. After walking the patient back to the room, what action should the nurse take to promote patient safety?

Accepted Answer

Answer reason: Delirium causes acute inattention and disorganized thinking that greatly increases fall and elopement risk, so continuous observation with frequent reorientation is a first-line safety intervention. Having unlicensed assistive personnel stay with the patient provides immediate redirection and rapid help if the patient attempts to wander again. Locking the door or using restraints are restrictive measures with significant safety/legal risks and are not appropriate unless less restrictive measures fail and orders/policies are followed. Checking for an antipsychotic order does not address the immediate need for supervision and does not replace environmental and staffing safety measures.

Question 6

The nurse caring for a client with a history of chronic obstructive pulmonary disease (COPD) is prescribed home oxygen therapy. Which instruction should the nurse include in the client's teaching plan to promote safe oxygen use?

Accepted Answer

Answer reason: Oxygen supports combustion and markedly increases the risk of fire and burns when exposed to an ignition source. Smoking (including cigarettes, cigars, or vaping devices) near oxygen can ignite clothing, tubing, or surrounding materials and is a major preventable cause of home-oxygen injuries. Teaching should emphasize no smoking in the home/room where oxygen is in use and keeping oxygen away from open flames and heat sources. By contrast, petroleum-based products are unsafe with oxygen and tubing under linens can create a trip hazard and impair flow, but the most critical safety instruction is eliminating ignition sources.

Question 7

A patient is becoming increasingly irritated after a provider shared a poor diagnosis. The patient states no one in the hospital is doing anything to help and is becoming vocally loud. You enter the room to assist the primary nurse and am prepared to call security if needed. The patient throws a chocolate pudding at you. Which of the following will best promote safety?

Accepted Answer

Answer reason: This action preserves the ability to retreat, avoids entrapment, and maintains continuous observation of the patient’s hands and body movements. Distraction techniques may be helpful earlier but are unreliable once the patient has become physically aggressive. Touch can escalate agitation and increase risk of injury, and calling additional support for communication does not immediately address the urgent environmental safety threat.

Question 8

The nurse is teaching two unlicensed assistive personnel who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which statement is made?

Accepted Answer

Answer reason: "Suicide precautions require observation that is frequent but also intentionally irregular to prevent the patient from anticipating checks and timing self-harm attempts between them. Stating that checks must occur precisely every 15 minutes reflects a common safety misconception and indicates the UAP needs further education on observation practice and unit policy. The other statements align with core safety principles: accurate documentation is essential for continuity and legal protection, 1:1 means continuous visual observation, and sharp items like razors require supervision/controlled access. The priority is preventing self-harm by reducing predictability and access to means while maintaining continuous monitoring when ordered.

Question 9

A nurse caring for a patient with severe bipolar disorder who is experiencing a manic episode. Which of the following behaviors exhibited by the patient should the nurse address first? Select one?

Accepted Answer

Answer reason: Risky sexual behavior can lead to urgent, potentially irreversible consequences such as sexual assault vulnerability, unintended pregnancy, and exposure to sexually transmitted infections, making it a higher priority than financial or speech/thought abnormalities. The nurse should implement protective supervision, set clear limits, and reduce opportunities for impulsive sexual behavior while coordinating evaluation and treatment. Grandiosity and flight of ideas are expected manic manifestations but are less likely to cause immediate physical harm compared with unsafe sexual activity.

Question 10

A nurse is managing a client with Alzheimer’s dementia. What should the nurse prioritize to ensure the client’s safety and well-being?

Accepted Answer

Answer reason: In Alzheimer’s dementia, impaired judgment, visuospatial deficits, and wandering increase fall risk, so the highest priority is environmental safety and injury prevention. Removing throw rugs reduces tripping hazards and is a direct, high-impact intervention that prevents a potentially catastrophic complication. Nutrition/hydration and social interaction support overall health but are secondary to immediate safety threats. Memory lists are often ineffective as cognitive decline progresses and do not address acute risk of harm.

Question 11

The nurse has just finished inserting a client’s nasogastric tube when the healthcare provider enters an electronic order to administer the client’s daily amlodipine through the tube. Which potential action is best for the nurse to take at this time?

Accepted Answer

Answer reason: Radiographic confirmation is the most reliable method for initial placement verification and is the standard safety step before first use. pH testing can support ongoing checks but is less definitive and can be affected by factors like continuous feeds or acid-suppressing therapy. The air-bolus auscultation method is unreliable and can falsely suggest gastric placement even when the tube is malpositioned.

Question 12

The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?

Accepted Answer

Answer reason: Securement should prevent traction and kinking while keeping tubing aligned with the insertion site to reduce discomfort, dislodgement, and tissue trauma. A suprapubic catheter exits the lower abdomen, so anchoring the tubing to the inner thigh can create pulling and angulation as the leg moves, increasing risk for leakage, skin breakdown, and accidental removal. Proper practice is to secure the catheter/tubing to the abdomen (or an appropriate stabilization device) to minimize movement at the abdominal stoma. The other actions reflect acceptable care such as using airborne/contact precautions for varicella-zoster and limiting suction duration to reduce hypoxemia and mucosal trauma.

Question 13

The intensive care nurse (ICU) cares for a group of assigned clients. The nurse should initially follow-up with the client who is?

Accepted Answer

Answer reason: Vasoactive infusions given through a peripheral IV can cause rapid, severe tissue injury if infiltration or extravasation occurs, so new pain at the site is an urgent safety finding requiring immediate assessment and intervention. Dopamine is a potent vasoconstrictor; extravasation can lead to local ischemia and necrosis and may require prompt antidote administration and catheter management. In contrast, gentle bubbling in the water-seal chamber with coughing is expected tidaling behavior, and pleuritic pain with flail chest still requires treatment but is typically less immediately limb-threatening than suspected extravasation. Lack of spontaneous breaths in assist-control can be acceptable if the patient is adequately ventilated and sedated; it warrants monitoring but is not as emergent as a potentially damaging infusion complication.

Question 14

The nurse is beginning an assessment and needs to verify they have the correct patient. Which of the following is NOT a valid patient identifier?

Accepted Answer

Answer reason: Acceptable identifiers include name, date of birth, and a unique medical record number because they are linked directly to the individual across encounters and locations. A room number is location-based and can change with transfers, bed swaps, or shared rooms, making it unsafe as an identifier. Using it risks misidentification and downstream errors in assessment, medication administration, and procedures.

Question 15

To prevent development of a pressure injury, the nurse should reposition a patient’s ET tube how frequently?

Accepted Answer

Answer reason: Scheduled repositioning of an endotracheal tube helps redistribute pressure points and allows frequent skin/mucosa assessment for early erythema or breakdown. A 12-hour interval aligns with common ventilator care bundles that include routine retaping/repositioning and oral assessment to reduce device-related injury risk. Longer intervals (24 hours or 2 days) increase sustained pressure time and raise the likelihood of mucosal ulceration, while 8 hours is more frequent than typically required for standard preventive practice in stable patients.

Question 16

Nurse Evans is suctioning secretions from Mr. Lang, a 45-year-old male client with a tracheostomy tube, to maintain a clear airway. To ensure safety during the procedure, what is the maximum time Nurse Evans should apply suction?

Accepted Answer

Answer reason: Limiting suction application to about 10 seconds reduces oxygen depletion while still allowing secretion removal. Longer durations (e.g., 30 seconds or 1 minute) significantly increase the risk of hypoxia and mucosal trauma. Although 5 seconds is safer, it may be insufficient to clear thick secretions in many adults, making 10 seconds the standard maximum per pass.

Question 17

A client who sustained a right finger laceration from a fish hook while fishing was assessed by the nurse in the emergency department. Which priority question should the nurse ask the client?

Accepted Answer

Answer reason: A puncture wound from a fish hook poses a risk for tetanus infection. Determining tetanus immunization status is the immediate priority to guide prophylaxis. Other questions are not urgent in this context.

Question 18

The charge nurse is supervising the nursing care administered on a busy medical/surgical unit. Which of the following situations, if noticed, would require immediate intervention?

Accepted Answer

Answer reason: Changing bed linens while the patient is walking to the bathroom creates an unsafe environment because the UAP is not positioned to assist/guard the patient and the task diverts attention from fall prevention. Immediate intervention is needed to stop the unsafe practice and ensure the patient is assisted with ambulation (e.g., stay with the patient, use gait belt, ensure clear path/call light within reach). In contrast, communicating with family with the patient’s permission is appropriate, and gown/gloves for localized zoster reflects basic contact precautions consistent with preventing transmission.

Question 19

Which of the following criteria should the nurse give first priority to when planning the care of a client with dementia?

Accepted Answer

Answer reason: Planning should therefore first focus on environmental modification, supervision strategies, and routines that reduce hazards and maintain a secure setting. Slowing cognitive decline is often limited and not immediately achievable, so it cannot supersede immediate physical safety needs. Placement decisions and caregiver support are important but are secondary to ensuring the client is protected from acute injury risks during daily care.

Question 20

Six hours after a cesarean delivery, the patient is requesting to get out of bed. What does the nurse need to verify prior to ambulation?

Accepted Answer

Answer reason: Residual effects of neuraxial anesthesia/analgesia can cause lower-extremity weakness or numbness, making standing and walking unsafe. Verifying intact sensation and the ability to actively move the legs confirms the patient can bear weight and follow motor commands. Pain medication, Foley removal, and complete cessation of lochia are not required prerequisites for the first assisted ambulation and do not address the immediate fall-risk concern.

Question 21

A 2-year-old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action?

Accepted Answer

Answer reason: Padding side rails helps prevent head and limb trauma if a seizure occurs during hospitalization, which is a high-likelihood, high-harm event. Ordering diagnostic tests is a provider role and does not address the immediate safety risk on admission. Fever-reduction strategies can be helpful but are secondary to protecting the child from trauma during a possible seizure episode.

Question 22

The nurse is caring for an older adult client who is confused and repeatedly tries to climb out of bed despite safety reminders. Which intervention is the priority to reduce the client’s risk of injury?

Accepted Answer

Answer reason: Lowering and locking the bed reduces the height of a potential fall and stabilizes the bed, while a bed alarm provides immediate notification so staff can intervene quickly when the client attempts to get up. Restraints and sedatives increase risk for injury (entrapment, agitation, respiratory depression, worsening delirium) and require strict indications and monitoring, so they are not first-line for this situation. Moving the client closer to the nurse’s station can help observation but does not directly reduce fall impact risk as effectively as bed positioning plus an alarm.

Question 23

You are the nurse caring for a 68-year-old client hospitalized with pneumonia. The client has a peripheral IV, urinary catheter, and is receiving IV antibiotics. During morning rounds, the unlicensed assistive personnel (UAP) reports: • The client’s IV pump is beeping with an occlusion alarm. • The urinary catheter drainage bag is lying on the floor. • The client is coughing and requesting tissues. • Another client down the hall is wandering toward the medication cart unattended. Which action should the nurse take first?

Accepted Answer

Answer reason: An unattended medication cart creates a high-risk safety situation (access to medications, potential overdose, poisoning, diversion, or injury) requiring prompt nurse intervention to stop the hazard. The IV occlusion alarm suggests interruption of therapy but is typically not an immediate life-threatening event in the moment and can be addressed next. The catheter bag on the floor and the need for tissues are important but represent lower-acuity infection-control/comfort needs compared with a wandering client approaching medications.

Question 24

The nurse is volunteering at a St. Patrick's Day parade when a 23-year-old male client suffers an unwitnessed fall from a parade float and lands on his left leg. The nurse verifies that the scene is safe. The client smells strongly of alcohol and has exposed bone above the left knee without any active bleeding. Which action should the nurse take first?

Accepted Answer

Answer reason: Immobilizing the cervical spine is an immediate safety intervention that should occur before moving the client or focusing on the isolated extremity injury. Covering the exposed bone is important to reduce contamination, but it is secondary once life- and function-threatening risks from occult head/neck trauma are addressed. Obtaining an ethanol level and starting an IV are not first-aid priorities and do not change the immediate stabilization needs at the scene.

Question 25

Peripheral Intravenous Sites to Avoid?

Accepted Answer

Answer reason: Edema makes veins harder to palpate/visualize and increases the chance that infused fluid will leak into surrounding tissue without early detection. Many other listed sites are also contraindicated (e.g., arm with AV fistula or post-mastectomy due to lymphatic compromise), so the content functions as a “do not use” checklist rather than a single-best-answer MCQ. Because multiple options are simultaneously correct, forcing one best option would be unsafe and not exam-faithful.

Question 26

SITUATION: A nurse is preparing to draw blood from a child with hemophilia. The child has a history of prolonged bleeding times due to a clotting factor deficiency. Which of the following actions should the nurse prioritize?

Accepted Answer

Answer reason: Minimizing invasive punctures is the key safety principle for patients with hemophilia because impaired coagulation increases the risk of persistent oozing and hematoma formation after any needle stick. Consolidating ordered tests into a single phlebotomy event reduces repeated venipunctures and therefore reduces cumulative bleeding risk. Using finger punctures is not preferred because capillary sticks can also bleed longer and are harder to compress effectively than a single controlled venipuncture site. Applying heat promotes vasodilation but does not address the primary risk of post-procedure bleeding; the priority is reducing the number of punctures and ensuring effective hemostasis after the draw.

Question 27

A young toddler is being discharged after an emergency admission for foreign body aspiration. The parents ask what they can do to prevent another accident. What advice is appropriate for the nurse to give the parents?

Accepted Answer

Answer reason: The key prevention principle for toddlers is hazard elimination because this age group explores by mouthing objects and cannot reliably follow safety instructions. Removing or securing small items directly reduces the chance of choking/aspiration events in the home environment. “Watch carefully” or “continuous observation” are nonspecific, unrealistic to maintain at all times, and do not address the source of risk. Teaching avoidance of nonfood items is developmentally limited and less effective than modifying the environment.

Question 28

A client calls the emergency department and tells the nurse that he came directly into contact with poison ivy shrubs. The client tells the nurse that he cannot see anything on the skin and asks the nurse what to do. The nurse should make which response?

Accepted Answer

Answer reason: Poison ivy dermatitis is caused by urushiol oil on the skin, and early decontamination can prevent or reduce the delayed allergic reaction. Immediate showering with soap and repeated lathering/rinsing physically removes the resin before it binds to skin and spreads via contaminated hands/clothing. Calamine is a symptomatic treatment used after a rash develops, not the first action right after exposure. Advising no action is unsafe because the rash can appear hours to days later even when nothing is visible initially.

Question 29

The nurse is using progressive relaxation on a client who is experiencing a great deal of stress. What nursing action is necessary in order to protect the client's safety prior to the start of the session?

Accepted Answer

Answer reason: Progressive muscle relaxation can produce generalized muscle loosening, reduced postural tone, and drowsiness, which increases risk for slipping, falling, or airway/neck strain if the client is not well positioned. A fully supported posture (e.g., seated with head/neck/limbs supported or lying down) is the most direct, immediate safety action before beginning the technique. Checking for sedative use may be relevant to assess level of alertness, but it does not by itself prevent an injury during the session. Allergies and baseline muscle strength are not primary safety determinants for this noninvasive relaxation intervention.

Question 30

To ensure the safety of a patient who is hospitalized for the first time, which of the following actions should be taken?

Accepted Answer

Answer reason: A dry, clutter-free floor directly reduces slips and trips, which are among the most frequent causes of inpatient injury, especially when patients are disoriented or attached to lines/tubing. This intervention is universally appropriate on admission and does not require additional patient-specific criteria to be safe. By contrast, raising side rails can be appropriate in select cases but may function as a restraint and can increase injury risk if the patient attempts to climb over them.

Question 31

A client is in the intensive care unit, admitted with a subdural hematoma. Just before shift change, as the nurse prepares to provide a bedside clinical hand-off and report, an alarm goes off, indicating a drop in the client's blood pressure. The initial action of the nurse would be?

Accepted Answer

Answer reason: A monitor alarm indicating hypotension signals potential immediate physiologic instability, so the nurse must prioritize patient assessment and rapid response over communication tasks. In a client with a subdural hematoma, hypotension can reduce cerebral perfusion pressure and worsen secondary brain injury, making prompt evaluation and intervention time-critical. Actions like silencing the alarm, changing alarm parameters, or proceeding with handoff delay recognition and management of a potentially life-threatening change. After assessing (e.g., verifying BP, evaluating neuro status, checking bleeding/IVs, and initiating appropriate interventions and notification), a safe handoff can then occur with accurate, updated information.

Question 32

Nurse Laura is about to administer Augmentin to Mr. Stevens, who is being treated for a sinus infection. To ensure she gives the medication to the correct patient, what is the best practice for Nurse Laura to follow?

Accepted Answer

Answer reason: Safe medication administration requires using reliable patient identifiers at the point of care to prevent wrong-patient errors. The wristband provides an institution-issued identifier that can be matched to the medication administration record and typically contains required identifiers (e.g., name and medical record number or date of birth). Calling the patient by name is less reliable because patients may not respond accurately, may be confused, or another patient may answer. Door names and room/census lists are not patient identifiers and can change, so they are unsafe as primary verification methods.

Question 33

A second-year nursing student has just suffered a needlestick while working with a patient who is HIV-positive. Which of the following is the most important action that the nursing student should take?

Accepted Answer

Answer reason: Starting PEP as soon as possible (ideally within hours, and no later than 72 hours) significantly lowers the probability of seroconversion after a percutaneous exposure. Social work referral and counseling may be appropriate supports but do not reduce viral transmission risk in the acute window. Pentamidine is used for Pneumocystis jirovecii prophylaxis/treatment in immunocompromised patients and has no role in preventing HIV acquisition after needlestick injury.

Question 34

Janae has a seizure disorder; which of the following would be the lowest priority when caring for her?

Accepted Answer

Answer reason: Protecting the patient from trauma during a seizure is time-critical, and documenting seizure characteristics guides diagnosis and treatment adjustments. Monitoring for increased ICP is also higher priority because it signals a potentially life-threatening etiology or complication requiring urgent intervention. Teaching about anticonvulsants is important for long-term management but is not as urgent as immediate safety and complication surveillance.

Question 35

A 50-year-old blind and deaf patient has been admitted to your floor. As the charge nurse, your primary responsibility for this patient is to?

Accepted Answer

Answer reason: Safety is the priority nursing responsibility, especially when sensory impairments significantly increase risk for injury, falls, and inability to perceive hazards. A secure, predictable environment (clear pathways, consistent room layout, accessible call system adaptations, frequent rounding) directly reduces preventable harm and supports orientation. Sharing deficits broadly is not the primary action and risks unnecessary disclosure beyond the care team. Updating on the social environment can help communication and reduce anxiety, but it is secondary to ensuring physical safety.

Question 36

The nurse just administered IM toradol to a 15 year old female. What is the correct way for her to dispose of the needle?

Accepted Answer

Answer reason: Immediately disposing of the needle directly into an approved sharps container minimizes handling and eliminates the high-risk step of recapping. Recapping is discouraged because it is a common cause of accidental punctures, even when attempting “safe” techniques. A biohazard bag is not puncture-resistant and increases risk of exposure during transport or disposal. Placing any needle in regular trash is unsafe and violates standard sharps-disposal practices.

Question 37

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?

Accepted Answer

Answer reason: Even if the client is alert and oriented, neck movement during assessment or positioning can convert a stable injury into a catastrophic neurologic deficit. Airway interventions should be performed with spinal precautions; using a head-tilt–chin-lift risks cervical extension, so a jaw-thrust would be preferred if airway support were needed. Full ROM testing and diagnostic imaging are deferred until the spine is stabilized because they can provoke movement and worsen injury.

Question 38

A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority for this client’s plan of care?

Accepted Answer

Answer reason: After a concussion, confusion and agitation increase the likelihood of falls, pulling at lines, or other unintentional harm, so preventing injury is the most urgent nursing focus. This diagnosis drives rapid implementation of protective interventions (close observation, safe environment, fall precautions) while ongoing neurologic assessment continues. Communication or self-care problems are important but are lower priority because they do not pose the same immediate threat to life and physical safety.

Question 39

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 involves impaired awareness and judgment during sleep, creating a high, unpredictable risk for wandering and falls. A bed-exit alarm provides immediate notification so staff can intervene before the child attempts to ambulate with a fractured leg, directly reducing injury risk. Teaching to use the call light assumes the client will be awake, oriented, and able to follow instructions during an episode, which is unreliable in sleepwalking. The other options do not address the primary safety threat of unobserved bed exit and fall risk.

Question 40

A patient was accidently medicated at the wrong time. In this situation, what is the first priority of the nurse?

Accepted Answer

Answer reason: Immediate assessment (vital signs, level of consciousness, symptoms, and any drug-specific effects) identifies urgent complications and guides rapid interventions if needed. Only after stabilizing and assessing the patient should the nurse notify the provider and appropriate leadership to obtain further orders and ensure continuity of care. Completing an occurrence report is important for quality improvement and risk management but is never the first step when a patient could be at risk.

Question 41

The nurse inserts an indwelling urinary catheter into a client. As the catheter moves into the bladder, urine begins to flow into the tubing. Which action should the nurse implement next?

Accepted Answer

Answer reason: Advance the catheter 2.5 to 5 cm. Urine flow indicates the catheter tip has entered the bladder, but the balloon must only be inflated once the catheter is fully seated so the balloon is not inflated in the urethra. Advancing a bit further ensures the balloon is past the bladder neck and reduces the risk of urethral trauma, pain, and bleeding. Inflating immediately is a common error that can cause significant injury if the catheter is not far enough in. Securing and measuring output are appropriate later steps, after correct placement is ensured and the balloon is safely inflated.

Question 42

The nurse is taking a sample of the fluid pulled from a nasogastric tube to ensure proper placement. The nurse will confirm appropriate placement of the NG tube if the stomach contents have a pH of?

Accepted Answer

Answer reason: Gastric aspirate is typically acidic due to hydrochloric acid, and an acidic pH supports that the tube is in the stomach rather than the respiratory tract. A pH in the low range (commonly ≤5 to 5.5 in many nursing references) is used at the bedside as supportive evidence of gastric placement. A neutral or alkaline pH (around 7–8) is more consistent with intestinal or respiratory/bronchial secretions or with altered gastric acidity from continuous feedings/acid-suppressing therapy, so it is less reassuring for stomach placement. Therefore, the distinctly acidic value provided best confirms stomach contents.

Question 43

A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene?

Accepted Answer

Answer reason: " Clients with epilepsy should be taught to avoid medications or substances that can lower the seizure threshold or interact with antiepileptic drugs unless approved by the prescriber/pharmacist. Over-the-counter products (e.g., antihistamines, decongestants, certain herbal supplements) can provoke seizures, cause sedation, or alter antiepileptic drug levels, increasing risk for breakthrough seizures or toxicity. The other statements reflect standard safety teaching: alcohol can precipitate seizures and worsen medication effects, medical alert identification improves emergency response, and maintaining airway safety during seizures helps reduce hypoxia and aspiration risk. Therefore the blanket reassurance about OTC use is unsafe and requires correction.

Question 44

The physician orders tobramycin sulfate 3 mg/kg IV every 8 hours for a 3-year-old boy. The nurse enters the client's room to administer the medication and discovers that the boy does not have an identification bracelet. Which of the following should the nurse do?

Accepted Answer

Answer reason: Medication administration requires reliable patient identification using institution-approved identifiers; without an ID band, the risk of wrong-patient medication error is unacceptably high. Stopping the process until proper identification is established is the safest action and aligns with the “rights” of medication administration and safety standards. Family members or verbal confirmation from a young child are not sufficiently reliable identifiers and can be inaccurate. A coworker’s recognition is also not an approved substitute for formal identification and can still lead to error in pediatrics.

Question 45

A nurse is reinforcing teaching with the parents of a 10-month-old infant about home safety. Which of the following statements by a parent indicates an understanding of the teaching?

Accepted Answer

Answer reason: ” Burn prevention and suffocation/fall prevention are key home-safety priorities for infants. Cool-mist humidifiers are preferred over warm/steam vaporizers because they avoid scald burns if the device is touched or tipped. Setting the water heater to 160°F greatly increases scald risk (recommended is much lower, commonly around 120°F). Placing plastic over a mattress can create an unsafe sleep environment with suffocation risk, and positioning a crib under a window increases risks from cords, blinds, drafts, or falling objects.

Question 46

The physician ordered pain medication STAT. Which medication order should the nurse question?

Accepted Answer

Answer reason: This drug (propoxyphene; misspelled in the option) has been withdrawn in many settings because of potentially fatal cardiac arrhythmias and overdose toxicity with limited analgesic benefit. A STAT pain order should prioritize effective, currently accepted analgesics; an order for a withdrawn/high-risk agent signals a likely prescribing or transcription error. While other opioids can also cause respiratory depression and require monitoring, they remain clinically used when appropriately dosed and indicated.

Question 47

A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the safest method of transfer, which of the following is most important for the nurse to determine?

Accepted Answer

Answer reason: Safe transfer technique is primarily determined by how much the client can physiologically support their own body weight during movement. Weight-bearing status dictates whether a stand-pivot transfer is appropriate versus requiring a mechanical lift or additional staff to prevent falls and musculoskeletal injury. It is the key safety criterion because it directly affects stability, balance, and the risk of collapse during the transfer. Communication ability and prior equipment may influence teaching and comfort but do not define the client’s physical capacity to safely bear weight in the moment.

Question 48

A nurse is caring for a postpartum client who is being discharged with her newborn. Which discharge instruction should the nurse teach the client regarding newborn safety?

Accepted Answer

Answer reason: A wearable sleep sack provides warmth without blankets that can cover the infant’s face or lead to entrapment. Prone sleeping increases SIDS risk and is not recommended for routine sleep. Car seats for newborns should be rear-facing in the back seat, making the forward-facing instruction unsafe.

Question 49

The nurse is preparing to give Morphine to a client with renal calculi and severe pain rated 9/10. Vitals are stable. What is the next step the nurse need to take?

Accepted Answer

Answer reason: Medication safety requires correct patient identification using an approved identifier process immediately before administration to prevent wrong-patient errors. Severe pain and stable vital signs support timely analgesia, but urgency does not override the basic rights of medication administration. Verifying the IV site and administering slowly are important technique steps, yet they assume the medication is being given to the correct person. Clamping the IV tubing is not a universal “next step” and can introduce flow and safety issues depending on the setup.

Question 50

A nurse witnesses an adult male collapse at the airport, and an automated external defibrillator (AED) is brought to the scene. The nurse should perform which action in using the device?

Accepted Answer

Answer reason: Electrical defibrillation requires a dry environment to reduce the risk of arcing and unintended current pathways that could injure rescuers or decrease effective energy delivery to the myocardium. Clearing liquid from the chest area helps ensure good pad contact and safer shock delivery. With excessive chest hair, the priority action is usually to shave or use a spare set of pads to “wax” hair off if adhesion is poor rather than relying on pressure alone. CPR should be resumed immediately after shocks or when advised by the AED, not delayed for minutes, and everyone must be completely clear during shock delivery rather than assigning someone to manage the airway at that moment.

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