NCLEX-RN Nursing — All Questions

A client with a living will refusing mechanical ventilation is alert, oriented, and able to state their wishes. The client now tells the nurse, “If it would only be for a few days, I would want the breathing machine.” Which action should the nurse take?

• a.Tell the client the directive can be changed only by an attorney at a later date
• b.Document the client’s current wishes and notify the provider of the change✓
• c.Ask the client’s health care proxy to decide whether ventilation should be used
• d.Follow the living will, because a signed directive overrides later spoken wishes

An advance directive guides care only when the client can no longer make or communicate decisions, so an alert client with capacity speaks for themselves and may revise their wishes at any time. The proxy’s authority begins when capacity is lost, so turning to the proxy now would displace the client’s own voice.

A nurse is admitting an adult client to a hospital that participates in Medicare. Which action meets the facility’s federal obligation regarding advance directives?

• a.Provide directive information only to clients admitted for terminal conditions
• b.Ask whether the client has an advance directive and document the answer in the record✓
• c.Have the client’s family complete a directive if the client has not done so
• d.Require the client to complete an advance directive before care is provided

Federal rules require providers to give each adult written information about advance directives and to document in a prominent part of the record whether the individual has executed one. Care may not be conditioned on whether a directive exists, so requiring one before treatment would violate the rule.

A client with metastatic cancer has a do-not-resuscitate order written by the provider. The client develops a temperature of 102.6 F (39.2 C) and reports pain rated 8 of 10. Which action should the nurse take?

• a.Give the prescribed antipyretic and analgesic and continue routine monitoring✓
• b.Limit care to hygiene and repositioning until the family can be contacted
• c.Ask the provider to rescind the order before treating the fever and pain
• d.Withhold the analgesic because comfort measures conflict with the written order

A do-not-resuscitate order directs staff not to perform cardiopulmonary resuscitation; every other prescribed treatment, including antipyretics, analgesia, and monitoring, continues unchanged. Treating fever and pain does not conflict with the order, so there is nothing to rescind.

A nurse posts on a personal social media account: “Long shift with my 32-year-old motorcycle crash guy in room 12 — three surgeries and he is still smiling.” No name appears in the post. How should this post be evaluated?

• a.It is acceptable, because the account is set to be seen by friends
• b.It is acceptable, because no name or medical record number appears
• c.It breaches confidentiality only if the client’s family reads the post
• d.It breaches confidentiality, because the details identify the client✓

Describing a client by room number, age, and circumstance still allows identification, so the post is a breach of confidentiality even though no name is used. Privacy settings and later deletion give no protection, because posted content can be copied and remains retrievable.

An alert, oriented client is in bed when an adult son arrives and asks the nurse for the results of the morning laboratory tests. Which action should the nurse take?

• a.Tell the son that laboratory results are released only by the provider
• b.Ask the client, in the son’s presence, whether the results may be shared✓
• c.Direct the son to submit a written request to the medical records department
• d.Give the results, because a son is a member of the immediate family

When the client is present and has capacity, information may be shared with a family member if the client agrees or is given a chance to object, so the client controls the disclosure. Being a close relative does not by itself authorize release of results.

A charge nurse is reviewing electronic health record access logs for the unit. Which finding requires the charge nurse to intervene?

• a.A nurse opened the chart of a neighbor on another unit✓
• b.A nurse reviewed the chart of a client assigned to her tonight
• c.A nurse read the surgical history of a client she is admitting
• d.A nurse opened a chart to check an order for a client she covers

Client information may be accessed only by team members actively involved in that client’s care, so opening a neighbor’s chart out of concern or curiosity is a privacy violation even if nothing is repeated to anyone. Reviewing charts of assigned or covered clients is a permitted use for treatment.

A charge nurse asks an RN who has not completed the facility’s chemotherapy certification to hang a vesicant chemotherapy infusion because the unit is short-staffed. Which response by the RN is appropriate?

• a.“I will hang it and document that I was directed to give it while short-staffed.”
• b.“I will hang it because the order is written and the pharmacy prepared it.”
• c.“I have not completed the chemotherapy competency, so I cannot hang that infusion.”✓
• d.“I will hang it if you stay in the room and observe me for the first hour.”

A nurse is personally accountable for practicing within their scope and demonstrated competence, and a staffing shortage, a valid order, or a note about who gave the direction does not transfer that accountability. Being watched by another nurse is not a substitute for the required competency.

A hospital policy permits RNs to perform a procedure that the state’s nurse practice act does not include within the RN scope of practice. Which understanding should guide the nurse?

• a.The hospital policy governs, because the employer accepts the legal liability
• b.The nurse practice act sets the limit, so the nurse should not perform it✓
• c.The procedure is allowed once the nurse is checked off by a unit educator
• d.The procedure is allowed if a provider writes an order authorizing it

The state’s nurse practice act and board of nursing define what a licensed nurse may legally do; employer policy, a provider’s order, and an in-house competency check cannot widen that legal scope. A nurse who practices beyond the act risks licensure discipline no matter who directed the act.

A nurse tells a client, “I will be back at 2 p.m. to walk with you in the hallway.” Despite a heavy assignment, the nurse returns at 2 p.m. as promised. Which ethical principle does this action demonstrate?

• a.Justice, which is the fair distribution of nursing care
• b.Fidelity, which is keeping promises made to the client✓
• c.Nonmaleficence, which is the duty to avoid causing harm
• d.Veracity, which is telling the client the truth

Fidelity is faithfulness to the commitments and promises a nurse makes to a client, which is exactly what returning at the promised time demonstrates. Veracity concerns truthfulness in what the nurse tells the client rather than following through on an agreement.

A nurse believes a dying client’s pain is undertreated but is directed by unit leadership to follow the current order and not contact the provider. The nurse continues to feel troubled about the client’s suffering. Which term best describes what the nurse is experiencing?

• a.Moral courage, acting on ethical values despite the personal risk involved
• b.Moral distress, knowing the right action but being blocked from taking it✓
• c.Ethical uncertainty, being unsure which ethical principles apply in the case
• d.Ethical dilemma, choosing between two options of equal ethical weight

Moral distress arises when the nurse has identified the ethically correct action but is blocked from carrying it out by organizational or other constraints. An ethical dilemma is different: there the nurse must choose between competing options rather than being prevented from acting on one already judged right.

A nurse caring for a 4-year-old notes bruises in several stages of healing across the child’s back, and the parent’s explanation does not match the pattern of injury. Which action should the nurse take?

• a.Ask the parent for written permission to report the injuries to the state
• b.Gather proof of abuse before making a report to an outside agency
• c.Report the suspicion to child protective services as a mandated reporter✓
• d.Wait for the provider to decide whether the injuries should be reported

Nurses are mandated reporters and must report a reasonable suspicion of abuse; proof, parental permission, and a provider’s agreement are not prerequisites, and federal privacy rules permit the disclosure to the authority receiving such reports. Waiting to build a case leaves the child in the setting where the injuries occurred.

A client is newly diagnosed with active pulmonary tuberculosis and tells the nurse, “I do not want anyone outside this hospital to know about this.” Which action should the nurse take?

• a.Agree to keep the diagnosis inside the hospital as the client requests
• b.Obtain the client’s written authorization before the case is reported
• c.Explain that the case is reported to the public health department as the law requires✓
• d.Report the case directly to the federal agency that tracks the disease

Tuberculosis is a reportable condition, and privacy rules permit disclosure of protected health information to a public health authority without the client’s authorization. Case reports go to state or local public health officials, who then notify federal surveillance, so the nurse does not report federally.

During a resuscitation, a provider gives the nurse a verbal medication order. Which action by the nurse meets the standard for receiving a verbal order?

• a.Ask a second nurse to listen to the order and confirm what was said
• b.Enter the order into the record afterward and ask the provider to sign it
• c.Repeat the order aloud from memory and then carry it out immediately
• d.Write the order down and read it back to the provider for confirmation✓

The nurse receiving a verbal order writes it down and reads back what was written, which verifies both what was heard and what was transcribed; the prescriber then dates, times, and authenticates the order. Repeating from memory confirms only hearing, leaving a transcription error undetected.

A nurse reviews a newly written order that reads “digoxin .125 mg PO daily.” Which action should the nurse take?

• a.Have the prescriber rewrite the order with a leading zero✓
• b.Transcribe the order as 0.125 mg and give the dose without a call
• c.Ask another nurse to confirm the intended dose before giving it
• d.Give the dose as written, since the intent of the order is clear

A dose written without a leading zero reads as a whole number if the decimal point is missed, so “.125 mg” can be given as 125 mg; only the prescriber may correct their own order. A nurse rewriting the dose or getting a colleague’s opinion leaves the ambiguous original order in place.

A client is found on the floor beside the bed and is assessed as uninjured. After completing the facility’s occurrence report, what should the nurse document in the client’s medical record?

• a.A statement that an occurrence report was completed for this fall
• b.The nurse’s conclusion that the bed alarm had not been switched on
• c.The objective findings of the assessment and how the client was found✓
• d.A copy of the occurrence report filed behind the nursing progress notes

The chart carries the objective facts — how the client was found, the assessment, and what was done — while the occurrence report is a separate quality and risk-management document that is not included in the medical record and is not referenced in it. Charting a cause records an opinion rather than an observation.

A hospital convenes a root cause analysis after a client received a fatal dose of the wrong medication. Which statement describes the purpose of this process?

• a.To decide whether the event must be disclosed to the client’s family
• b.To find the system factors that allowed the error and change them✓
• c.To calculate the financial exposure the hospital faces from the event
• d.To identify the staff member at fault and apply corrective discipline

Root cause analysis repeatedly asks why an error reached the client in order to expose the process and system vulnerabilities behind it, then produces an action plan to correct them. It deliberately looks past the individuals involved, because disciplining one nurse leaves the same failure available to the next one.

A nurse is handwriting an entry on a paper medication administration record after giving a scheduled dose of insulin. Which entry uses approved terminology and abbreviations for the medical record?

• a.Regular insulin 6 units subcutaneously at 0730✓
• b.Regular insulin 6.0 units subcutaneously at 0730
• c.Regular insulin 6 U subcutaneously at 0730
• d.Regular insulin 6 IU subcutaneously at 0730

The Joint Commission's official 'Do Not Use' list governs every handwritten medication entry. Write 'unit' in full, because a handwritten 'U' is read as a zero, as a four, or as 'cc'. Write 'International Unit' in full, because 'IU' is read as 'IV' or as the number 10. And do not write a trailing zero after a decimal point, because 6.0 units is read as 60 units — a tenfold insulin overdose. Spelling out 'units' with no trailing zero is the entry that satisfies all three rules.

A client whose record lists the name “Robert” tells the nurse, “I go by Robin, and I use she and her.” Which action by the nurse is appropriate?

• a.Use the legal name on the record when other staff are present
• b.Ask the provider whether the client’s stated name may be used
• c.Use Robin and she and her, and record this in the client’s chart✓
• d.Use Robin with the client but Robert in the change of shift report

Nursing practice requires compassion and respect for the dignity and unique attributes of every person, so the nurse uses the name and pronouns the client states and passes them to the team through the record. Switching back to the legal name in front of staff tells the client that respect depends on who is listening.

Two nurses on a unit have argued repeatedly about who restocks the medication room, and the dispute is now disrupting handoff. Which approach by the nurse manager is most likely to resolve the conflict durably?

• a.Assign the restocking task to one nurse and end the discussion there
• b.Wait to see whether the two nurses settle the matter between themselves
• c.Ask each nurse to give up part of the task so both share the burden
• d.Bring both nurses together to build a plan that meets both their needs✓

Collaboration — surfacing what each party actually needs and building a shared solution — takes the most effort but produces the most durable resolution. Imposing a decision, splitting the difference, and waiting all leave the underlying interests unaddressed, so the conflict resurfaces.

At discharge a client tells the nurse, “That inhaler costs more than my share of the rent, so I will use it only when I feel really bad.” Which action should the nurse take first?

• a.Teach the client that skipping doses will worsen the breathing problem
• b.Document the client’s plan and reinforce the prescribed dosing schedule
• c.Give the client a list of pharmacies that may sell the inhaler for less
• d.Tell the provider that cost is blocking the client from taking it✓

Advocacy here means telling the prescriber that affordability is what is blocking adherence, so a therapeutically equivalent lower-cost drug or an assistance program can be considered before the client leaves. Repeating the teaching or listing pharmacies leaves the client holding a prescription they have already said they cannot afford.

A 6-year-old is admitted with a widespread vesicular rash and is diagnosed with varicella (chickenpox). Which precautions should the nurse implement in addition to standard precautions?

• a.Airborne and contact precautions until the lesions are dry and crusted✓
• b.Contact precautions until 24 hours after antiviral therapy begins
• c.Airborne precautions until 4 days after the rash first appeared
• d.Droplet and contact precautions until the lesions are dry and crusted

CDC lists varicella as requiring airborne plus contact precautions, continued until all lesions are dry and crusted, because the virus spreads both through the air and by contact with vesicle fluid. Dropping the airborne component leaves other clients and non-immune staff exposed, and the 4-days-after-rash endpoint belongs to measles, not varicella.

A client is admitted with suspected pertussis. Which personal protective equipment should the nurse put on before entering the client's room?

• a.A gown and gloves donned on entry to the room
• b.A fit-tested N95 respirator donned on entry
• c.A surgical mask donned on entry to the room✓
• d.A face shield and gown donned on entry

Pertussis is transmitted by respiratory droplets, so droplet precautions are added to standard precautions and a mask is donned upon entry into the client's room. A fit-tested N95 respirator is reserved for airborne agents such as tuberculosis and measles, and gown and gloves belong to contact precautions.

A client with confirmed measles is placed in an airborne infection isolation room. Four nurses are working the shift. Which assignment should the charge nurse make?

• a.Assign the client to a nurse who is immune to measles✓
• b.Assign the client to a nurse given a measles vaccine dose today
• c.Assign the client to the nurse with the lightest client load
• d.Assign the client to a nurse wearing a surgical mask for care

CDC directs facilities to restrict susceptible personnel from the rooms of clients with measles when immune personnel are available, so the nurse who is already immune takes the assignment. A surgical mask does not protect the wearer from airborne measles virus, and protection from a vaccine dose given the same day has not yet developed.

The nurse reviews four newly admitted adults. Which client requires standard precautions only, with no transmission-based precautions added?

• a.A client with a productive cough, night sweats, and cavitary lung lesions
• b.A client with disseminated shingles spreading over the trunk and both arms
• c.A client with an intact immune system and localized shingles under a dressing✓
• d.A client with profuse watery diarrhea and a positive C. difficile toxin assay

CDC assigns standard precautions to localized herpes zoster in a client whose immune system is intact, provided the lesions can be covered. Disseminated zoster requires airborne and contact precautions, suspected pulmonary tuberculosis requires airborne precautions, and C. difficile requires contact precautions.

A client with scabies receives a topical scabicide at 0800 on Monday. At what point should the nurse plan to discontinue contact precautions?

• a.0800 Tuesday, 24 hours after the treatment✓
• b.2000 Monday, 12 hours after the treatment
• c.The morning the client is discharged home
• d.0800 Thursday, when the itching has stopped

CDC lists scabies as requiring contact precautions until 24 hours after effective therapy is initiated, so precautions may be lifted the following morning. Persistent itching is not the endpoint, because pruritus commonly continues for weeks after the mites have been killed.

A norovirus gastroenteritis outbreak has been declared on a nursing unit. Which hand hygiene method should the nurse use after caring for the affected clients?

• a.Applying hand rub and then donning gloves
• b.Washing the hands with soap and water✓
• c.Wiping the hands with an antiseptic towel
• d.Applying an alcohol-based hand rub and air drying

CDC identifies soap and water as necessary during outbreaks of norovirus and C. difficile, because alcohol-based hand rub does not reliably remove these agents from the hands. Adding gloves over rubbed hands does not correct the problem, since organisms remain on the skin underneath.

A nurse observes unlicensed assistive personnel remove gloves after emptying a bedpan and immediately pick up a meal tray for another client. Which action should the nurse take?

• a.Deliver the meal tray personally and reassign the worker for the shift
• b.Stop the worker and have hand hygiene performed before the next task✓
• c.Ask the worker to put on a fresh pair of gloves for the next task
• d.Record the observation and raise it at the next unit staff meeting

CDC states that gloves are not a substitute for hand hygiene, and hands must be cleaned immediately after gloves are removed because they can be contaminated during removal. Putting on new gloves over unwashed hands leaves that contamination in place and transfers it to the next client.

A nursing home resident with a long-term indwelling urinary catheter is placed on enhanced barrier precautions. Which action by the nurse is correct?

• a.Put on a gown and gloves before bathing the resident✓
• b.Put on a gown and gloves before every entry into the resident's room
• c.Move the resident to a private room for the duration of the stay
• d.Exclude the resident from the group dining room and activities

Enhanced barrier precautions require gown and gloves for high-contact care activities such as bathing, dressing, transferring, and device care, with the PPE removed and discarded after that encounter. Unlike contact precautions, they do not restrict the resident to a room and do not require a private room or removal from group activities.

A nurse in a nursing home is identifying residents for enhanced barrier precautions. Which resident meets the criteria when contact precautions do not otherwise apply?

• a.A resident with a healed incision and no indwelling devices
• b.A resident with a sacral wound that requires a daily dressing✓
• c.A resident with new watery stools and a positive C. difficile test
• d.A resident with a productive cough and a temperature of 38.5 C

Enhanced barrier precautions apply to residents who have a wound or an indwelling medical device even when no multidrug-resistant organism is known, as well as to residents colonized or infected with an MDRO. A resident with acute diarrhea from C. difficile is placed on contact precautions rather than enhanced barrier precautions.

A nurse finishing care for a client on contact precautions is wearing a gown, gloves, goggles, and a mask. In which order should the nurse remove this equipment?

• a.Mask, goggles, gloves, gown
• b.Gown, gloves, goggles, mask
• c.Goggles, gloves, mask, gown
• d.Gloves, goggles, gown, mask✓

CDC's removal sequence is gloves, then goggles or face shield, then gown, then mask or respirator, so the most heavily contaminated items come off before anything near the face is handled. Hand hygiene is performed immediately after all of the equipment has been removed.

A nurse is evaluating a newly hired graduate nurse's understanding of standard precautions. Which statement indicates that the teaching was effective?

• a.I use standard precautions once a client has a positive culture result
• b.I use standard precautions in place of isolation for clients in single rooms
• c.I use standard precautions mainly when a client's blood or fluids are visible
• d.I use standard precautions with every client I care for, whatever the diagnosis✓

CDC applies standard precautions to the care of all clients regardless of diagnosis or presumed infection status, based on a risk assessment of the exposure anticipated during each task. Transmission-based precautions are layered on top of standard precautions for specific pathogens and do not take their place.

A severely neutropenic client is admitted after allogeneic hematopoietic stem cell transplantation. Which room should the nurse arrange for this client?

• a.A negative-pressure room with the air exhausted outdoors
• b.A shared room with a client who has no known infection
• c.A standard single room with the door kept closed
• d.A positive-pressure room with HEPA-filtered air✓

A protective environment keeps the room under positive pressure relative to the corridor with HEPA-filtered incoming air and more than 12 air changes per hour, so fungal spores are kept away from a severely immunocompromised client. Negative pressure is the opposite arrangement and is used to contain airborne pathogens coming from an infectious client.

A client with suspected pulmonary tuberculosis arrives on the unit, and the facility's only airborne infection isolation room is occupied. Which action should the nurse take?

• a.Place the client in a private room with the door open and a fan blowing toward the hall
• b.Place the client in a double room with the curtain drawn and both clients masked
• c.Place the client in a private room with the door closed and alert infection prevention✓
• d.Keep the client in the emergency department hallway until the isolation room frees up

CDC directs that a client needing airborne precautions be placed in a private room with the door closed when an airborne infection isolation room is unavailable, while staff continue to wear a fit-tested N95 respirator and infection prevention arranges appropriate placement. Venting room air toward the corridor or sharing a room spreads droplet nuclei to others.

A client on airborne precautions for pulmonary tuberculosis is scheduled for a chest x-ray in the radiology department. Which action should the nurse take before transport?

• a.Place a fit-tested N95 respirator on the client for the trip to radiology
• b.Delay the study until three sputum smears have returned negative
• c.Cover the client with a sheet and move quickly without notifying radiology
• d.Place a surgical mask on the client and notify radiology of the precautions✓

The client wears a surgical mask so that droplet nuclei are contained at the source, and the receiving department is told in advance so it can limit the exposure of others. Fitting the client with an N95 is not the purpose of source control, and a medically necessary study is not postponed until smears clear.

A nurse has just given a subcutaneous injection with a syringe that has no safety shield. What should the nurse do with the needle and syringe?

• a.Detach the needle with forceps and discard the syringe separately
• b.Recap the needle with two hands and discard them in the trash
• c.Carry them uncapped to the sharps container in the utility room
• d.Discard them as a unit in the bedside sharps container✓

Contaminated sharps are discarded immediately at the point of use in a closable, puncture-resistant, labeled container located as close as feasible to the work area, with the needle left attached to the syringe. Recapping, detaching, and carrying an exposed needle across the unit are the manipulations most likely to cause a needlestick.

A nurse is changing bed linens that are soaked with a client's blood. Which action meets the requirements for handling contaminated laundry?

• a.Bag the linens in the client's room without sorting or rinsing them✓
• b.Rinse the visible blood out at the bedside before bagging the linens
• c.Carry the linens to the soiled utility room and sort them there
• d.Shake the linens open to check for sharps before bagging them

Contaminated laundry must be bagged or containerized at the location where it was used and must not be sorted or rinsed there, which limits both splash exposure and the spread of organisms through the unit. Shaking linens aerosolizes contamination and risks a sharps injury from an item hidden in the folds.

A nurse is supervising a nursing student performing a sterile dressing change. Which action by the student requires the nurse to intervene?

• a.The student opens the first flap of the sterile package away from the body
• b.The student places the sterile gauze in the center of the field
• c.The student turns away from the sterile field to reach supplies on the cart✓
• d.The student holds gloved hands above the waist and in front of the body

A sterile field that has not been kept in direct view is considered contaminated, so turning away from it breaks sterile technique and the field must be set up again. Opening the first flap away from the body, keeping gloved hands above waist level and in sight, and placing items well inside the 1-inch border are all correct practice.

A nurse is planning care for four clients. Which procedure requires the nurse to use sterile technique rather than clean technique?

• a.Emptying a urinary drainage bag into a graduated container
• b.Giving an intramuscular injection into the deltoid muscle
• c.Changing the dressing over a central venous catheter site✓
• d.Administering a bolus feeding through a gastrostomy tube

A central line dressing change is done with sterile technique because the catheter gives any organism introduced at the site direct access to the bloodstream. Emptying a drainage bag, feeding through an established gastrostomy tube, and giving an intramuscular injection are carried out with clean technique.

A provider writes the following order for a hospitalized adult who has been striking at staff: "Soft wrist restraints PRN for agitation." Which action should the nurse take?

• a.Apply the restraints now and remove them when the client settles
• b.File the order in the record and use it over the next 24 hours
• c.Apply the restraints only if the client strikes at staff again
• d.Contact the provider for a new order written for this episode✓

Federal hospital requirements state that orders for restraint or seclusion must not be written as a standing order or on an as-needed (PRN) basis, so this order cannot be carried out as written; the nurse obtains an order specific to this episode after less restrictive interventions have been found ineffective. Waiting for the client to strike out again and then applying the restraints is still executing a prohibited PRN order.

A 12-year-old client is placed in physical restraints for violent behavior that jeopardizes the immediate physical safety of staff. Under federal hospital requirements, each order for this restraint may last no longer than:

• a.1 hour
• b.8 hours
• c.2 hours✓
• d.4 hours

42 CFR 482.13(e)(8) caps each order for restraint or seclusion used to manage violent or self-destructive behavior at 4 hours for adults 18 and older, 2 hours for children and adolescents 9 to 17 years of age, and 1 hour for children under 9, with renewal permitted up to a total of 24 hours. A 12-year-old falls in the 9-to-17 band, so the 4-hour limit would apply only if the client were an adult.

An adult client is placed in seclusion for violent, self-destructive behavior. Federal hospital requirements direct that a face-to-face evaluation of this client be completed within what timeframe, and by whom?

• a.Within 1 hour of initiation, by a physician or a trained registered nurse✓
• b.Within 1 hour of initiation, by the nurse manager of the unit
• c.Within 24 hours of initiation, by the attending physician of record
• d.Within 4 hours of initiation, by a physician or a trained registered nurse

42 CFR 482.13(e)(12) requires that a client restrained or secluded for violent or self-destructive behavior be seen face-to-face within 1 hour of initiation by a physician or other licensed practitioner, or by a registered nurse trained under the hospital's restraint training requirements. Training under that provision, not a management title, is what qualifies a nurse to do the evaluation, and 4 hours is the adult order renewal limit rather than the evaluation window.

A confused 82-year-old client repeatedly tries to climb out of bed during the night shift. Which nursing action best reduces the client's risk of serious injury?

• a.Notify the provider and request an order for a vest restraint
• b.Leave the bed at working height and raise the upper side rails
• c.Keep the bed in its lowest position with a floor mat beside it✓
• d.Raise all four side rails and reposition the client every 2 hours

Lowering the bed and cushioning the floor shortens the distance the client can fall without confining him, which is the least restrictive option. Raising all four side rails to keep a client in bed meets the federal definition of a restraint, and the FDA has documented hundreds of reports of clients caught, trapped, or strangled in hospital bed systems; a vest restraint is not the first step when a non-restrictive measure has not been tried.

A nurse is preparing to draw a blood specimen and label the tubes at the bedside. Which pair of identifiers meets the National Patient Safety Goal for identifying the client?

• a.The client's bed number and diagnosis
• b.The client's full name and date of birth✓
• c.The client's room number and full name
• d.The client's room number and bed number

NPSG.01.01.01 requires at least two person-specific identifiers, such as the individual's name, date of birth, or an assigned identification number, and The Joint Commission states that the client's room number or physical location is not used as an identifier. Pairing the name with a room number therefore supplies only one acceptable identifier, and a diagnosis is not person-specific.

A nurse is transcribing newly written orders. Which order should the nurse clarify with the prescriber before transcribing it?

• a.Enoxaparin 40 mg subcutaneously every 24 hours
• b.Potassium chloride 20 mEq PO twice daily
• c.Levothyroxine .05 mg PO every morning✓
• d.Furosemide 20 mg IV push twice daily

The Joint Commission's official "Do Not Use" list prohibits a decimal written without a leading zero, because ".05 mg" is readily misread as "5 mg" once the decimal point is missed. The order must be clarified and rewritten as 0.05 mg; the other three orders express drug, dose, route, and frequency without an ambiguous abbreviation or decimal.

During a preoperative interview, a client reports that eating banana, avocado, or kiwi makes her lips itch and swell. Which action should the nurse take?

• a.Request an order for an antihistamine before the client goes to surgery
• b.Flag the chart for latex precautions and notify the surgical team✓
• c.Document a food allergy and continue the routine preoperative plan
• d.Ask dietary services to remove those fruits from the client's trays

Banana, avocado, kiwi, and chestnut are the foods most often implicated in latex-fruit syndrome, and roughly 30 to 50 percent of people allergic to natural rubber latex react to these plant foods because they share chitinase allergens with latex. Those reported reactions are a screening clue that a latex-safe environment must be arranged, so treating this purely as a dietary matter leaves the client exposed to latex gloves, tourniquets, and catheters in the operating room.

A hospitalized client suddenly becomes rigid and begins generalized tonic-clonic jerking while sitting in a bedside chair. Which action should the nurse take?

• a.Ease the client to the floor and turn him onto his side✓
• b.Return the client to bed and raise all four side rails
• c.Hold the client's arms still and call for the rapid response team
• d.Insert a padded tongue blade between the client's teeth

Easing the client down prevents a fall from the chair, and turning him onto his side with the mouth toward the floor lets saliva drain so the airway stays clear. The CDC directs rescuers not to hold a seizing person down, because restraining the movements can injure the client or the rescuer, and nothing is placed in the mouth of a seizing client.

A nurse is observing unlicensed assistive personnel feed a client who has dysphagia following a stroke. Which observation requires the nurse to intervene?

• a.The client is seated fully upright in a chair for the entire meal
• b.The client is laid flat immediately after the meal is finished✓
• c.The client is offered small bites and is not hurried between them
• d.The client is asked to tuck his chin toward his chest to swallow

Laying a client with dysphagia flat right after eating allows residue pooled in the pharynx, or refluxed gastric contents, to enter the airway, so the client is kept upright during the meal and for a period afterward. Full upright positioning, small unhurried bites, and a chin-tuck are all standard aspiration precautions and require no correction.

A nurse is teaching a client who is starting continuous oxygen therapy at home. Which statement by the client indicates that the teaching was effective?

• a.I'll store the spare tank in the hall closet so it stays cool
• b.I'll use petroleum jelly on my nose when the cannula dries it
• c.I'll let my brother smoke by the window while I wear my cannula
• d.I'll keep the concentrator at least 6 feet from my gas stove✓

MedlinePlus instructs clients to keep oxygen 6 feet away from heat sources and open flame, which includes a gas stove, because oxygen makes anything already burning burn far faster. Petroleum-based products on the face, storage in a small closet, and anyone smoking in the room where oxygen is running are each fire hazards that show the teaching is not yet complete.

A nurse has moved the clients to safety, activated the alarm, and closed the doors, and is now discharging a fire extinguisher at a small waste-basket fire. Where should the nurse direct the nozzle?

• a.At the base of the flames, sweeping side to side✓
• b.At the top of the flames, sweeping side to side
• c.At the center of the flames, in a steady stream
• d.At the wall behind the fire, in a steady stream

In the PASS sequence the nurse pulls the pin, aims at the base of the fire, squeezes the handle, and sweeps side to side. Discharging the agent into the flames themselves puts it above the burning fuel, so the fuel keeps feeding the fire.

A nurse is triaging casualties at the scene of a building collapse using the START system. Which client should be tagged immediate (red)?

• a.An adult who walked to the collection point with a scalp laceration
• b.An adult with a femur fracture who breathes at 20 and follows commands
• c.An adult with a respiratory rate of 36 and a radial pulse✓
• d.An adult who has no respirations after the airway is repositioned

In START, a spontaneously breathing adult with a respiratory rate over 30 is tagged immediate (red) no matter what else is found. Anyone who can walk to the collection point is tagged minor (green), a client who follows commands with a palpable radial pulse and an adequate rate is delayed (yellow), and a client who still has no respirations after the airway is repositioned is tagged expectant (black).