Question 1

What is important when restraining a violent client?

Accepted Answer

Answer reason: The safest method for restraining a violent client is a coordinated, organized team approach. Other options are unsafe: do not tie to side rails or use quick-release ties to the bed frame, and typically more than three staff are needed.

Question 2

The nurse is caring for a client admitted with a diagnosis of epilepsy. The client begins having a seizure. Which action by the nurse is contraindicated?

Accepted Answer

Answer reason: During an active seizure, nothing should be placed in the client's mouth; inserting a tongue blade or oral airway can cause injury, obstruction, or aspiration. Side-lying, loosening clothing, and raising padded rails promote safety and airway protection.

Question 3

A patient is agitated and continues trying to get out of bed. The nurse tries unsuccessfully to reorient him. What should the nurse do next?

Accepted Answer

Answer reason: Use the least-restrictive intervention before using restraints. Address potential unmet needs and reduce agitation with comfort measures (repositioning, toileting, pain relief, and a soothing environment). Restraints are a last resort and require an order.

Question 4

The nurse is applying a hand mitt restraint for a client with pruritus (see figure). The nurse should first?

Accepted Answer

Answer reason: Before applying any restraint, the nurse must first verify a provider order to ensure legal and safety requirements are met. The other actions occur after the order and proper assessment; tying to the bed frame is unsafe for a mitt.

Question 5

A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an alarm sounds, indicating a decrease in blood pressure. What is the initial nursing action?

Accepted Answer

Answer reason: An alarm indicating hypotension in a client with internal bleeding is a potential emergency. The nurse must immediately assess the client to verify and address the change rather than silencing or adjusting the alarm or continuing report.

Question 6

The intensive care unit is full and the emergency room just called in a report on a ventilator-dependent client who is being admitted to the medical surgical unit. It would be essential that the nurse have which piece of equipment at the client's bedside?

Accepted Answer

Answer reason: A ventilator-dependent client must have a manual resuscitator (Ambu bag) at the bedside to provide immediate ventilation if the ventilator fails or during transport. A monitor, IV controller, or nasal cannula does not secure ventilation in an emergency.

Question 7

Which nursing intervention protects a client regaining consciousness after a craniotomy who becomes restless and attempts to pull out the IV line without increasing intracranial pressure?

Accepted Answer

Answer reason: Soft mitten restraints are the least restrictive option to prevent line pulling and minimize agitation, thereby avoiding increases in intracranial pressure. Wrist restraints or tucking hands can increase agitation/ICP and are unsafe.

Question 8

Which of the following is contraindicated for a client with seizure precautions?

Accepted Answer

Answer reason: Oral glass thermometers can break and injure the mouth or be aspirated if a seizure occurs; safer routes/devices should be used.

Question 9

What is the initial nursing action for a client who is in the clonic phase of a tonic-clonic seizure?

Accepted Answer

Answer reason: During a seizure the priority is to protect the client from injury and maintain airway. Initially, protect the head with padding; do not restrain or insert objects into the mouth. Suction may be prepared but protection of the head is the first action.

Question 10

What important information should the nurse include in the discharge education for a patient diagnosed with G6PD deficiency?

Accepted Answer

Answer reason: G6PD deficiency predisposes to hemolysis with certain drugs and foods. Wearing a medical alert bracelet alerts providers in emergencies to avoid oxidant medications, preventing harm.

Question 11

Which type of restraint does the nurse anticipate for a client who repeatedly attempts to get up from their wheelchair unassisted and has fallen twice?

Accepted Answer

Answer reason: A waist belt/lap belt restraint keeps a client safely seated in a wheelchair to reduce fall risk while allowing arm movement. Wrist or mitten restraints are for preventing pulling lines; seclusion is for violent/unsafe behavior, not fall prevention.

Question 12

Which of the following Nursing diagnosis is INCORRECT?

Accepted Answer

Answer reason: Risk diagnoses should use the label "Risk for," and the etiology should be patient-related risk factors (e.g., confusion, impaired mobility), not an environmental omission like lack of side rails. Therefore option B is an incorrect nursing diagnosis.

Question 13

A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse's action?

Accepted Answer

Answer reason: Seclusion/restraint must be used only when there is an immediate risk of harm and after least-restrictive measures fail. Being loud and boisterous without imminent danger makes seclusion inappropriate and potentially unlawful.

Question 14

A nurse is teaching a parent about home safety for a toddler who has just started walking. Which safety device is most appropriate to prevent accidental poisoning?

Accepted Answer

Answer reason: Toddlers are at high risk for accidental poisoning due to curiosity, oral exploration, and limited danger awareness. Medications are a leading cause of pediatric poisoning. The most effective preventive intervention is secure storage in a locked cabinet placed out of reach and sight. This intervention directly targets the hazard source and provides an environmental barrier, which is the primary principle of injury prevention in this age group.

Outlet covers prevent electrical injury, not poisoning. Night-lights reduce fall risk in low visibility conditions but do not address toxic exposure. Securing heavy furniture prevents crush injuries from tip-over incidents. While all are important safety measures, they do not directly prevent accidental poisoning.

Question 15

When caring for a client with a Sengstaken-Blakemore tube, which priority item should the nurse ensure is readily available at the bedside?

Accepted Answer

Answer reason: A Sengstaken-Blakemore tube can migrate and obstruct the airway. Keeping scissors at the bedside allows the nurse to immediately cut the tube/balloon ports to deflate and relieve airway compromise.

Question 16

The nurse is caring for a cognitively impaired client who begins to pull at the tape securing his IV site. To prevent the client from removing the IV, the nurse should?

Accepted Answer

Answer reason: When a cognitively impaired client is at risk of self-harm by removing essential medical devices such as an IV line, the least-restrictive but effective protective device is a soft restraint (e.g., clove hitch). Physical punishment and threatening statements are unethical and unsafe, and taping around the extremity is dangerous.

Question 17

Infants should be restrained in a car seat in a semi-reclined position facing the rear of the car until they weigh?

Accepted Answer

Answer reason: Rear-facing car seats provide optimal head and neck protection for infants. Standard pediatric safety guidance recommends that infants remain rear-facing until at least 20 pounds (and typically at least 1 year old), because their cervical spine cannot yet tolerate forward-facing forces.

Question 18

A 25-year-old male is brought to the emergency room with a piece of metal in his eye. The first action the nurse should take is?

Accepted Answer

Answer reason: With a suspected embedded foreign body, do not irrigate or attempt removal. Protect the eye and prevent ocular movement by shielding both eyes (e.g., paper cups) until specialist evaluation.

Question 19

The nurse is caring for a 2 month-old child who has had a cleft lip repair. The BEST restraint to use for this child is the?

Accepted Answer

Answer reason: Elbow restraints prevent the infant from flexing the elbows to touch or disrupt the cleft lip repair while allowing movement of other body parts.

Question 20

For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?

Accepted Answer

Answer reason: AGN with hypertension puts the child at risk for hypertensive encephalopathy and seizures; seizure precautions protect from injury. Daily weights are sufficient (not twice per shift), protein may be restricted in renal disease, and activity is limited during the acute phase.

Question 21

Which of the following nursing interventions is MOST important when caring for a client who has just been placed in physical restraints?

Accepted Answer

Answer reason: Immediate priority after restraint application is patient safety—verify correct application and circulation to prevent injury. Medication, policy review, and hydration are important but not as urgent.

Question 22

During the development of a nursing care plan, the nurse should consider which of the following clients for the use of a restraint?

Accepted Answer

Answer reason: After cleft lip repair, elbow restraints are used to prevent the infant from touching or disrupting the suture line. Restraints are not routinely indicated for septicemia, post-tonsillectomy, or meningitis.

Question 23

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

Accepted Answer

Answer reason: For a child with febrile seizures, the priority is preventing injury during possible seizure activity. Padding side rails is a key seizure precaution and takes precedence over labs, urine collection, or temperature control measures.

Question 24

A nurse is planning care for a newly admitted school-age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include?

Accepted Answer

Answer reason: Seizure precautions prioritize airway and safety. Oxygen and suction should be readily available; tongue blades are contraindicated, video games may trigger seizures, and independent tub bathing is unsafe.

Question 25

A nurse is caring for an older adult patient who is at high risk for falls. Which intervention should the nurse implement to promote patient safety?

Accepted Answer

Answer reason: Keeping the bed low and wheels locked reduces the chance of injury if the patient attempts to get out of bed. It is one of the most effective evidence-based fall-prevention measures.

Question 26

A nurse is preparing to use a blood pressure monitor that has not been used in several weeks. Which action is most important before use?

Accepted Answer

Answer reason: Damaged electrical cords pose a fire and electrical hazard. Inspection must occur before plugging in or using the device to ensure safety.

Question 27

Adult suction pressure?

Accepted Answer

Answer reason: Recommended negative pressure for adult airway suctioning is typically around 100–150 mmHg to effectively remove secretions while minimizing mucosal trauma and hypoxemia. Lower settings such as 60–80 mmHg are more consistent with pediatric/infant ranges and may be insufficient for adults. Very high suction (e.g., 200–250 mmHg) increases the risk of airway damage, bleeding, and atelectasis. Therefore, 100–150 mmHg is the safest effective range among the options.

Question 28

During phototherapy, the baby should be kept?

Accepted Answer

Answer reason: During neonatal phototherapy for hyperbilirubinemia, the infant should be minimally clothed to maximize skin exposure to the therapeutic light while maintaining thermal stability. The eyes must be protected with an eye shield to prevent retinal damage from the bright light. A diaper is typically left on to cover the genital area and reduce risk of gonadal exposure and skin irritation while still allowing adequate treatment area.

Question 29

First step suction?

Accepted Answer

Answer reason: Before performing suctioning, the nurse should first verify that the suction equipment is functioning properly (correct setup, tubing connections, and appropriate negative pressure). Checking the suction bottle/device prevents delays and reduces the risk of hypoxia if suction fails during the procedure. Preoxygenation is an important step just before catheter insertion, but it assumes the suction apparatus is ready and working. Saline instillation/wash is not a routine first step and is generally avoided unless specifically indicated.

Question 30

A nurse is caring for a client who is transferred to the surgical unit by stretcher after surgery. Which of the following is the most important nursing action to be taken after the transfer? Choose one of the following?

Accepted Answer

Answer reason: Immediately after transfer from a stretcher, the postoperative client is at high risk for falls due to residual anesthesia, opioids, dizziness, and weakness. Raising the bed side rails is an immediate safety intervention that helps prevent injury while the nurse completes the initial assessment and ensures the client is stable. Monitoring outputs and providing ice chips are important postoperative actions but are not as immediately protective as preventing a fall. Call-light teaching is appropriate but does not provide the same immediate physical safeguard as the side rails.

Question 31

A nurse is caring for a client on mechanical ventilation. The high-pressure alarm sounds. What should the nurse do first?

Accepted Answer

Answer reason: A high-pressure ventilator alarm most commonly indicates increased resistance to airflow, such as a kinked/occluded circuit or the client biting the tube. The first action is to quickly assess the ventilator circuit for an easily reversible cause (e.g., kinks, water in tubing, secretions in the circuit) to restore ventilation. Silencing the alarm does not correct the cause and delays intervention, and suctioning is appropriate after checking for simple mechanical obstruction or if assessment suggests mucus plugging.

Question 32

The RN is assessing a patient who is oriented x1 and is impulsive at times. During the initial assessment, the RN notes that the patient continually tries to swing his legs out of the bed. Which is not an appropriate action by the RN?

Accepted Answer

Answer reason: Applying restraints is not an appropriate initial intervention for an impulsive, confused patient because restraints are a last-resort safety measure and require a specific order and ongoing monitoring due to risks (injury, strangulation, increased agitation, impaired circulation). First-line actions focus on the least restrictive methods: frequent reorientation, environmental modification, and supervision such as a sitter to prevent falls. Providing a simple, safe distracting activity can also reduce restlessness and unsafe bed-exiting behavior. Therefore, restraining the patient to the bed is the inappropriate action at this stage.

Question 33

The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse would be contraindicated?

Accepted Answer

Answer reason: Restrain the client's limbs. During an active seizure, restraining the client can cause musculoskeletal injury (e.g., fractures, dislocations) and does not stop seizure activity. Priority seizure care is to protect the airway and prevent injury by removing hazards, padding/raising side rails, and positioning on the side if possible to promote drainage of secretions. Loosening restrictive clothing also helps support breathing and circulation.

Question 34

The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP to check the skin integrity of the restrained hands how frequently?

Accepted Answer

Answer reason: Every 30 minutes. Clients in restraints are at high risk for impaired circulation, pressure injury, and nerve damage, so frequent assessment of the restrained extremity is a key safety requirement. Checking skin integrity (and circulation, motion, sensation) at least every 30 minutes helps identify early signs of compromise such as discoloration, swelling, numbness, or breakdown. Longer intervals (2–4 hours) are too infrequent and increase the risk of preventable injury while restraints are in use.

Question 35

A nursing student is planning care for a client with paraplegia who is at risk for injury because of spasticity of his leg muscles. The nurse intervenes if the student plans to include which intervention to minimize the risk of injury to the client?

Accepted Answer

Answer reason: Use of padded restraints to immobilize the limb. Routine use of restraints is not an appropriate intervention to manage spasticity-related injury risk and can increase harm (skin breakdown, impaired circulation, reduced mobility, and ethical/legal concerns). Safer interventions include maintaining a hazard-free environment, providing range-of-motion/positioning to reduce contractures, and using prescribed antispasmodics when indicated. Therefore, the nurse should intervene when the student plans restraint immobilization.

Question 36

Temperature in an ILR at PHC is recorded using?

Accepted Answer

Answer reason: An ILR (ice-lined refrigerator) used for vaccine cold-chain monitoring requires routine documentation of internal temperature to ensure vaccines remain within the recommended range. A dial thermometer is a standard, simple device used inside ILRs to continuously display temperature for recording on temperature logs. A sling psychrometer measures humidity, anemometer measures air velocity, and kata thermometer is used for measuring low air movement/cooling power rather than refrigerator temperature.

Question 37

A nurse is caring for a patient with a chest tube connected to a water-seal drainage system. Which of the following findings should the nurse report to the healthcare provider immediately?

Accepted Answer

Answer reason: This indicates an air leak in the system (e.g., loose connection, tubing leak, or dislodgement) that can prevent effective lung re-expansion and may worsen or sustain a pneumothorax. It requires prompt assessment of the entire drainage setup and the patient’s respiratory status, and provider notification if not quickly correctable. In contrast, gentle bubbling in the suction control chamber reflects expected suction operation, tidaling with respirations is expected in a patent system, and 80 mL serosanguinous drainage over 4 hours is typically within expected postoperative drainage ranges.

Question 38

A 75-year-old patient with dementia wanders at night. What is the best safety measure?

Accepted Answer

Answer reason: This provides a least-restrictive, noninvasive way to alert staff/caregivers when the patient attempts to get up, allowing timely assistance and reducing fall risk. Physical restraints and sedatives increase risk of injury, delirium, aspiration, and decreased mobility and are not first-line for wandering. Locking the patient in a room is unsafe and violates patient rights while increasing risk of harm during emergencies. Safety devices and supervision strategies are preferred to maintain dignity and safety.

Question 39

A nurse is orienting a new client and family to the inpatient unit. What information does the nurse provide to help the client promote his or her own safety?

Accepted Answer

Answer reason: Patient identification is a primary safety intervention to prevent wrong-patient medications, procedures, and specimen errors. Consistent use of an ID band supports the two-identifier standard and helps staff verify identity before any intervention. While hand hygiene awareness and family presence can be helpful, they are not as universally reliable or foundational to immediate inpatient safety as correct identification.

Question 40

Which device is used for suctioning airway?

Accepted Answer

Answer reason: These devices are specifically designed to remove secretions from the oropharynx or airway while minimizing mucosal trauma. An NG tube is for gastric decompression/feeding, a Foley catheter is for urinary drainage, and an endotracheal tube is an airway conduit but not the suctioning device itself (suctioning is performed through it using a suction catheter). Using the correct suction equipment supports airway patency and reduces risk of aspiration and hypoxia during care.

Question 41

A patient is to get an MRI of the abdomen. Which of the following instructions should the nurse give the patient?

Accepted Answer

Answer reason: MRI uses a powerful magnetic field that can attract ferromagnetic items, creating a serious projectile hazard and risking burns from induced currents. Removing jewelry and other metal objects is a key safety step to prevent patient injury and equipment damage. The other choices are not routine MRI instructions; MRI generally does not require avoiding urination, holding medications for 12 hours afterward, or universal 12-hour solid-food fasting unless sedation/contrast-specific policies apply.

Question 42

Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker. Which of the following statements by the nurse is BEST?

Accepted Answer

Answer reason: This is the key immediate safety check to prevent slipping and falls when initiating ambulation with an assistive device. Ensuring intact rubber tips improves traction and walker stability, reducing risk of injury in a postoperative older adult. The low chair advice increases hip flexion and makes standing harder, which can violate hip precautions. The weight-bearing statement depends on the surgeon’s specific orders, and tying shoes requires bending at the hip, which is generally restricted after hip replacement.

Question 43

For an unconscious trauma patient with a suspected spinal injury, the best initial position is?

Accepted Answer

Answer reason: Suspected spinal injury requires immediate spinal motion restriction to prevent secondary spinal cord damage. Keeping the patient supine on a firm surface with the cervical spine immobilized maintains neutral alignment while allowing airway and breathing management. Fowler’s positions can increase spinal movement and are not appropriate initially in trauma with possible cervical injury. Left lateral positioning may be used for airway protection only after spinal precautions are maintained (e.g., log-roll with stabilization), not as the default initial position.

Question 44

This quality is being demonstrated by Nurse Ron who raises the side rails of a confused and disoriented patient?

Accepted Answer

Answer reason: Prudence is the practical judgment to anticipate likely harm and take reasonable preventive measures to protect the patient. A confused, disoriented patient is at high risk for falls and injury during transfers or attempts to get out of bed unassisted. Raising side rails is a safety-device intervention aimed at minimizing foreseeable injury risk in this context. In contrast, autonomy focuses on independent decision-making, not immediate hazard prevention, and responsibility is broader accountability rather than the specific foresight demonstrated here.

Question 45

Which action is appropriate when using physical restraints on a confused patient?

Accepted Answer

Answer reason: Choosing the least restrictive option reduces risks such as skin injury, impaired circulation, agitation, and decreased mobility. Tying restraints to side rails is unsafe because rail movement can tighten restraints and increase risk of injury or entrapment. Documentation and frequent reassessment/release are required by policy and regulation, so omitting charting or using overly long release intervals is inappropriate.

Question 46

The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

Accepted Answer

Answer reason: On admission, the nurse’s first responsibility is rapid risk assessment and implementation of protective measures (e.g., observation level, removing hazards, ensuring a safe milieu) before addressing longer-term needs. Physiologic concerns like nutrition, elimination, and activity may be affected, but they are typically secondary unless there is evidence of acute compromise. Prioritization follows ABCs/safety frameworks, placing protection from self-directed violence at the top.

Question 47

A 2 month-old child has had a cleft lip repair. The selection of which restraint would require no further action by the charge nurse?

Accepted Answer

Answer reason: Elbow restraints are commonly used postoperatively because they limit elbow flexion while still allowing some movement and circulation checks, making them an appropriate, standard safety device in this situation. A clove hitch is a knot/tying method rather than a pediatric postoperative restraint choice and can raise safety concerns if used improperly. More restrictive options (e.g., mummy or jacket) are not the typical first-line choice when targeted prevention of hand-to-mouth contact is the goal.

Question 48

When taking the client’s blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. Which action should the nurse take first?

Accepted Answer

Answer reason: If no Korotkoff sounds are audible, the most likely immediate cause is a malfunction or improper setup (e.g., disconnected/plugged earpieces, incorrect placement, or valve issues). Verifying the stethoscope is functioning can correct the problem quickly and allows a proper manual BP to be obtained. Repeating the measurement (immediately or after waiting) or switching arms/devices skips the basic safety check and may still fail if the listening equipment is the actual problem.

Question 49

Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working?

Accepted Answer

Answer reason: From 8 AM to noon is 4 hours, so the expected volume infused is 40 mL; the bag should drop from 100 mL to about 60 mL (not accounting for any additional PRN boluses). A decrease to only 80 mL implies only 20 mL infused (5 mL/hr), indicating under-infusion consistent with pump malfunction/occlusion or programming error. Pain reports can occur despite correct infusion (opioid tolerance, inadequate dose), and IV site discomfort suggests local complication rather than definitive pump failure; a drop to 50 mL would indicate more than the basal rate and does not support “not working.”.

Question 50

During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member?

Accepted Answer

Answer reason: In Alzheimer’s disease, impaired judgment, wandering, and high fall risk make safety the highest-priority home-care goal. Environmental modifications that prevent falls and elopement reduce immediate risk of injury and death more directly than nutrition, social support, or medication convenience. Bathroom grab bars address a common site of falls, while door alarms help detect wandering promptly and support rapid caregiver response. Adequate meals and support groups are beneficial but are secondary when compared with preventing foreseeable, high-harm safety events in the home.

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