Question 1

A 3-year-old is admitted to the pediatric unit with febrile seizures. No seizures have been witnessed in the Emergency Department, but parents state one occurred at home. The patient's current temperature is 39.8 degrees Celsius and acetaminophen was administered moments prior to admission. What is the nurses’ priority?

Accepted Answer

Answer reason: With a recent febrile seizure and persistent high fever, the child remains at risk for recurrent seizure activity, so implementing safety measures to prevent trauma is the most time-sensitive action. Padding side rails and ensuring a safe environment protects the child from head injury or limb entrapment if a seizure occurs. Giving another antipyretic is not immediate because acetaminophen was just administered and fever reduction takes time; also, antipyretics do not reliably prevent febrile seizures. Lab/IV checks and history collection are important but are secondary to preventing imminent harm.

Question 2

The nurse has placed a client in soft wrist restraints due to continued attempts to pull out IV lines and a nasogastric tube. The client is delirious and does not understand instructions. The nurse understands assessing the client in restraints every two hours is important for what primary reason?

Accepted Answer

Answer reason: Two-hourly checks focus on circulation, sensation, movement, skin integrity, and capillary refill distal to the restraint to detect ischemia early and avoid permanent injury. This option directly targets the most common and serious restraint-related complication for soft wrist restraints. While pain assessment is important, it is secondary to ensuring the restrained extremity remains perfused and neurologically intact. Breathing and strangulation risk are higher priorities with vest/waist or neck-adjacent restraints rather than properly applied soft wrist restraints.

Question 3

A 14-year-old is admitted for suicidal ideations and expresses a history of physical abuse from her mother’s boyfriend. When preparing the room for her admission, what action will best support this patient’s safety?

Accepted Answer

Answer reason: Removing cords/wires and using plastic utensils directly mitigates immediate means for strangulation or cutting during the high-risk admission period. Having the mother stay is unsafe because the patient reports abuse linked to the mother’s boyfriend and family presence can increase distress and does not replace appropriate observation protocols. Activities and documentation are important components of care but do not address the most urgent, preventable safety hazards in the room.

Question 4

The nurse has become aware of the following client situations. For which client should the nurse recommend utilizing a restraint?

Accepted Answer

Answer reason: Attempting to remove an indwelling urinary catheter can cause urethral trauma, bleeding, and infection, and also compromises ordered monitoring needed for clinical management. Disorientation increases the likelihood that redirection alone will be ineffective and that device removal will recur. By contrast, agitation or anxiety without imminent harm and fall risk are typically managed first with de-escalation, close observation, environmental modifications, and toileting/bed alarms rather than restraints.

Question 5

A child is admitted to the pediatric unit with an unknown mass in her lower left abdomen. Which action should be the nurse’s priority?

Accepted Answer

Answer reason: An unexplained abdominal mass in a child raises concern for conditions such as Wilms tumor, where palpation can cause tumor rupture and dissemination. Preventing abdominal palpation is an immediate safety priority to avoid harm. While assessment and diagnostics are important, protecting the child from a potentially dangerous intervention takes precedence.

Question 6

The nurse has determined that a confused older adult client who keeps pulling out the intravenous line and indwelling catheter is in need of soft wrist restraints. Which of the following should the nurse include in this client’s plan of care?

Accepted Answer

Answer reason: Hourly checks with documentation are a core safety standard because changes can occur quickly in older adults with fragile skin and vascular disease. This action directly addresses ongoing monitoring and timely intervention, which is essential once restraints are applied. A common error is securing restraints to side rails, which can tighten during rail movement and increase injury risk, making that option unsafe.

Question 7

A nurse is caring for a client at 34 weeks gestation who presents with blood pressure of 160/110 mm Hg, proteinuria, and complaints of headache and visual disturbances. Which of the following is the priority nursing action?

Accepted Answer

Answer reason: Implementing seizure precautions (airway/suction/oxygen readiness, padded side rails, minimal stimulation) directly addresses the most imminent life-threatening complication. Assessing deep tendon reflexes helps identify increasing CNS irritability and guides urgency of escalation and monitoring, especially if magnesium sulfate therapy is anticipated. Antihypertensives, positioning, and fluid status monitoring are important but are secondary to immediate protection from an impending seizure in a symptomatic client.

Question 8

A nurse is caring for a 9-year-old client having a convulsion. Which of the following should be the nurse’s priority action?

Accepted Answer

Answer reason: Raising (and padding, if available) the bed rails protects the child from falling or striking the environment during uncontrolled motor activity. Restraining is contraindicated because it can cause musculoskeletal injury and does not stop the seizure. Side-lying positioning and oxygen may be appropriate supportive measures, but safety from traumatic injury is the most immediate action that can be implemented instantly at the bedside.

Question 9

The nurse is caring for a client with a suspected cervical spine fracture who is wearing a cervical collar while CT scan results are pending. The nurse enters the room and finds the client laying in bed without the cervical collar on. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: The immediate priority is preventing further injury by manually maintaining the head/neck in neutral alignment and obtaining assistance to reapply immobilization safely. Assessment questions (eg, incontinence) and provider notification are important but come after the spine is stabilized because they do not reduce the immediate risk. Client education is appropriate later, once safety is restored and the patient is re-immobilized.

Question 10

You have admitted a patient with a history of frequent seizures to your unit. What precautions will you implement to prevent the patient from harm should a seizure occur?

Accepted Answer

Answer reason: Having functioning suction and oxygen at the bedside supports immediate postictal airway clearance and supplemental oxygenation, reducing risk of respiratory compromise. Keeping the bed in the highest position increases fall risk and is unsafe; standard practice is to keep the bed low with padded side rails as indicated. Room placement far from staff delays response, and removing side rails increases risk of falling from bed during convulsions.

Question 11

What is the priority nursing intervention for a client receiving antiemetic?

Accepted Answer

Answer reason: Keeping the bed low and using side rails reduces the chance of injury during drowsiness, sudden position changes, or attempts to get up quickly. Monitoring intake and output can be important in ongoing vomiting/dehydration, but it does not address the highest, immediate harm related to the medication’s CNS effects. Encouraging walking or placing items far away increases exertion and unassisted ambulation, which can worsen fall risk.

Question 12

A comatose client needs a nasopharyngeal airway for suctioning. After the airway is inserted, he gags and coughs. Which action should the nurse take?

Accepted Answer

Answer reason: Gagging and coughing after placement indicates the airway is too long or improperly sized and is stimulating the posterior pharynx, increasing aspiration risk and worsening airway obstruction. The immediate safety priority is to remove the offending device and replace it with an appropriately sized adjunct that maintains patency without triggering protective airway reflexes. Simply repositioning is less reliable when the symptom suggests excessive length rather than minor malposition. Leaving it in place is unsafe because ongoing gagging can provoke vomiting/aspiration, and suctioning without an airway may be less effective and can cause additional mucosal trauma or inadequate clearance.

Question 13

The following are teaching guidelines regarding radiation therapy except?

Accepted Answer

Answer reason: Patients are positioned and instructed before treatment starts, then observed via camera/intercom while irradiation occurs. Teaching should emphasize that the treatment itself is painless and that patients can communicate with staff during the procedure if needed. A common misconception is that staff remain physically present during beam delivery, which would unnecessarily increase occupational exposure.

Question 14

The client with delirium is restrained to prevent the removal of a urinary catheter and an IV line. Which response should the nurse expect after the client is restrained?

Accepted Answer

Answer reason: Restraints are a safety intervention that can worsen confusion and distress in clients with delirium because they limit autonomy and increase sensory and psychological stress. A delirious client commonly misinterprets the situation, struggles against restraints, and escalates to agitation and combative behavior. Rather than improving sleep or comfort, restraints often increase stimulation and can precipitate further disorientation. Blood pressure is more likely to rise with agitation and stress than decrease, making that distractor inconsistent with expected physiologic response.

Question 15

The nurse is changing the ties of the client with a tracheostomy. The safest method of changing the tracheostomy ties is to?

Accepted Answer

Answer reason: The key safety principle is preventing accidental decannulation, because a fresh or unsecured tracheostomy can be rapidly life-threatening if the tube dislodges. Having a second person stabilize the tracheostomy tube/faceplate while ties are changed reduces the chance of tube movement and provides immediate assistance if respiratory distress or tube displacement occurs. This approach also supports rapid intervention (e.g., maintaining airway patency, calling for help, preparing a replacement trach) during the brief period when the tube is most vulnerable. While preparing the new ties is important, relying on that alone does not provide the same level of safety as an assistant actively stabilizing the airway device. Suturing is not a routine nursing solution and does not address the immediate procedural safety need during tie change.

Question 16

A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?

Accepted Answer

Answer reason: The priority with restraints is preventing injury from impaired circulation, nerve compression, and skin breakdown caused by prolonged pressure and restricted movement. Neurovascular assessment of restrained extremities (color, temperature, capillary refill, pulses, sensation, movement) and checking skin integrity directly addresses the most serious and common restraint-related complications. Offering fluids only on request is inadequate because restrained clients may be unable or afraid to ask and dehydration is a known risk. Vital signs every 4 hours is too infrequent for a restrained, potentially unstable client, and “exercise every 2 hours” is not the key safety intervention compared with focused circulation/skin monitoring.

Question 17

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action?

Accepted Answer

Answer reason: Covering the IV site with gauze and elastic stockinette helps camouflage and secure the catheter, reducing visual/tactile cues that prompt pulling while still allowing circulation checks and site monitoring. Escalating to restraints (mitt or wrist restraint) is more restrictive and typically requires a specific order and ongoing restraint monitoring, and should be reserved for when less restrictive measures fail. An arm board mainly prevents joint flexion/occlusion but does not reliably stop a patient from grabbing and pulling the catheter and can add discomfort or pressure risk.

Question 18

A nurse is reinforcing teaching to a group of assistive personnel (AP) about caring for clients with restraints. Which of the following statements by one of the APs indicates an understanding of the teaching?

Accepted Answer

Answer reason:  Restraints must be applied in a way that maintains safety while minimizing risk of injury and allowing rapid release in an emergency. This statement best reflects appropriate secure application compared with the unsafe alternatives: tying to the moving part of the bed can cause tightening and injury as the bed is repositioned, restraints should allow room for circulation (not be tight against the client), and raising all four side rails for a confused client is considered a restraint and increases fall/entrapment risk. The other options describe common restraint-related safety errors that can directly lead to impaired circulation, skin injury, or entrapment. Therefore this option most closely indicates correct restraint safety understanding among the choices provided.

Question 19

The registered nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction?

Accepted Answer

Answer reason: " Safe sleep guidance prioritizes reducing suffocation, strangulation, and entrapment risks in the sleep environment. Crib bumper pads are not recommended because they can obstruct an infant’s airway and create a rebreathing/suffocation hazard, and ties can pose strangulation risk. A firm mattress and offering a pacifier at sleep are consistent with SIDS risk-reduction recommendations. Wearable blankets (sleep sacks) are preferred over loose bedding; if a blanket is used, it should be thin and tucked to minimize loose fabric near the face.

Question 20

The charge nurse is rounding on clients in restraints. Which of the following situations would require immediate intervention by the nurse?

Accepted Answer

Answer reason: A vest restraint in a high-Fowler position increases the risk that the client will slide down in bed and the restraint will ride up, compressing the chest/neck and impairing ventilation. This creates an immediate threat to breathing and requires prompt repositioning and reassessment of restraint type and fit. By comparison, semi-Fowler with a belt restraint or side-lying with mittens is generally safer when properly applied and monitored, as it is less likely to restrict chest expansion.

Question 21

The nurse prepares to administer an enteral feeding to a client through a nasogastric tube (NGT). Which is the priority intervention for the nurse to complete before administering the feeding?

Accepted Answer

Answer reason: Verifying correct tube placement ensures the distal tip is in the gastrointestinal tract rather than the respiratory tract, which would place the client at immediate risk for aspiration pneumonia or fatal airway instillation. Bowel sounds may be present even when the tube is malpositioned and are not a reliable pre-feeding safety check. Intake/output and baseline weight are important for ongoing nutrition and fluid monitoring but do not address the immediate, highest-risk complication at the moment of feeding.

Question 22

The nurse is caring for clients who are receiving prescribed oxygen therapy. It may indicate equipment malfunction and would require immediate intervention if the client who is receiving oxygen via a?

Accepted Answer

Answer reason: If the bag fully collapses with each breath, the flow rate is insufficient or there is a leak/obstruction, which can rapidly reduce delivered FiO2 and worsen hypoxemia. This finding suggests equipment setup malfunction or incorrect flow and requires immediate correction (increase flow, check connections/valves, replace device as needed). In contrast, humidifier water at a halfway level is expected, and a simple face mask at 6 L/min meets the minimum flow needed to avoid CO2 rebreathing.

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