NCLEX-RN Nursing — All Questions

A client on a behavioral health unit is pacing the day room, clenching both fists, and speaking loudly at another client. Which action should the nurse take first?

• a.Move quickly to the client's side and take hold of his arm.
• b.Approach calmly, stay two arm lengths back, and keep the exit clear.✓
• c.Ask several staff to surround the client and speak at once.
• d.Call for restraints before attempting to speak with him.

Noncoercive verbal de-escalation is the first-line response to escalating agitation, delivered by one person in a calm voice while keeping one to two arm lengths of space and unobstructed access to the door. Grabbing the client, crowding him with several voices, or going straight to restraints escalates the situation and skips the intervention that usually works.

A client with moderate dementia is being discharged home to a spouse who provides all of the care alone. Which assessment is most important before discharge teaching begins?

• a.Which relatives the couple sees during winter holidays.
• b.How many years the couple has lived in that house.
• c.How much help and relief time the spouse actually gets.✓
• d.Whether the spouse can name each of the client's medicines.

The plan of care depends on who is genuinely available to help and whether the sole caregiver gets any respite, because a caregiver with no support is the usual reason a discharge plan collapses. Naming medicines is a teaching outcome measured after teaching, and holiday visitors or length of residence do not describe day-to-day support.

A client who lost a job and health insurance six weeks ago returns to the clinic. Which statement indicates the client is coping adaptively?

• a.I decided not to think about the bills until they pile up.
• b.I called the clinic about a sliding-scale fee.✓
• c.I stopped answering calls because nobody understands this.
• d.I have a beer or two in the evening so I stop worrying.

Calling about a sliding-scale fee is problem-focused coping, which acts directly on the stressor and is associated with better outcomes and better treatment adherence. Drinking to stop worrying, withdrawing from contact, and putting the bills out of mind are avoidance and disengagement, the patterns linked to poorer mental health.

A nurse is writing the plan of care for a 32-year-old client with schizophrenia who has taken an antipsychotic for two years. Which observation should the nurse record as a negative symptom of the illness?

• a.He says a neighbor sends him coded messages through the radio
• b.He shows little facial expression and starts no activities✓
• c.He hears a voice that comments on what he is doing
• d.He shifts between unrelated topics in the middle of a sentence

Negative symptoms are the loss or reduction of normal function, such as diminished emotional expression and avolition, which is what reduced facial expression together with no self-started activity describes. Delusions, hallucinations, and disorganized speech are positive symptoms, added experiences rather than absent ones, and they usually respond better to antipsychotic medication than the negative symptoms do.

An 80-year-old client with age-related hearing loss is being taught to use a new inhaler in a room where a television is playing. Which nursing action best supports the teaching?

• a.Turn the television off and face the client while speaking.✓
• b.Raise your voice and repeat the same words more loudly.
• c.Hand over printed instructions and cut the explanation short.
• d.Stand behind the client to demonstrate over the shoulder.

Turning off background noise and letting the client see the speaker's face are the recommended adjustments for age-related hearing loss, since facial movement and expression carry part of the message. Shouting distorts speech sounds rather than clarifying them, and standing out of view or substituting a leaflet removes the visual cues and the chance to check understanding.

A client on an inpatient unit repeatedly leaves group therapy early and argues with staff about the posted unit schedule. Which approach reflects sound behavioral management?

• a.Extend the group by ten minutes whenever the client walks out.
• b.Let the client keep a personal schedule apart from the unit's.
• c.Raise the client's behavior with peers during the next group.
• d.State the rule consistently and praise each full session attended.✓

Behavior modification pairs a consistent limit on the unwanted behavior with reinforcement of the behavior you want, so a steady rule plus praise for full attendance is the technique. Lengthening the group punishes the whole group, an individual schedule removes the limit entirely, and raising the behavior with peers shames the client rather than shaping the behavior.

A nurse is assisting an 82-year-old client who has mild left-sided weakness after a stroke with a bed bath. The client washes his own face and chest but works slowly and pauses to rest. Which action by the nurse best supports the client's performance of this activity of daily living?

• a.Postpone the bath until the client can wash every area by himself
• b.Complete the entire bath quickly so the client is able to rest sooner
• c.Have the client repeat each area until he can do it without resting
• d.Let the client wash the areas he can reach and finish the others for him✓

Letting the client do what he is able to do and completing the rest preserves strength, mobility, and self-esteem, which is the goal of ADL assistance. Taking the whole bath over because it is faster is the most tempting alternative, but doing for a client what he can do for himself accelerates the decline in function that the nurse is trying to prevent.

A nurse is teaching a client who has weakness of the right leg how to walk with a single-point cane on level ground. What instruction should the nurse give about the cane?

• a.Hold it in the right hand and move it forward with the right leg
• b.Hold it in the left hand and move it forward with the left leg
• c.Hold it in the left hand and move it forward with the right leg✓
• d.Hold it in the right hand and move it forward with the left leg

The cane is held in the hand opposite the weaker leg and advanced at the same time as that weaker leg, so the cane and the weak limb share the load and the base of support widens. Holding the cane on the same side as the weak leg puts the support under the side that is already failing and narrows the stance.

A client who had a right total knee arthroplasty is learning to go down a flight of stairs using a cane and the handrail. Which sequence should the nurse teach the client to use?

• a.Cane first, then the left leg, then the right leg
• b.Left leg first, then the right leg, then the cane
• c.Right leg first, then the cane, then the left leg
• d.The cane first, then the right leg, then the left leg✓

Going down, the cane is set on the lower step first, the weaker (operative right) leg follows, and the stronger leg comes down last, which is the basis of the phrase 'up with the good, down with the bad.' Leading down with the stronger leg leaves the weak knee to absorb the full body weight on the descent.

A nurse is helping a client who has left hemiplegia after a stroke put on a front-opening shirt. Which action should the nurse take?

• a.Place the right arm into its sleeve before the left arm
• b.Pull the shirt over the head before placing either arm
• c.Place the left arm into the sleeve before the right✓
• d.Place both arms into their sleeves at the same time

The weaker limb goes into the garment first, while the sleeve is still loose and the stronger arm is free to guide it, which protects the affected shoulder and hand from strain. Dressing the strong arm first leaves the client trying to force the flaccid arm through a sleeve that is already anchored by the rest of the shirt; when undressing, the order reverses and the strong side comes out first.

Before giving an intermittent feeding, a nurse notes that the marking on the client's nasogastric feeding tube now sits 6 cm farther out of the nares than the length documented after the confirming x-ray. Which action should the nurse take?

• a.Hold the feeding and arrange for radiographic confirmation of the tube✓
• b.Start the feeding slowly and watch the client for coughing or gagging
• c.Inject 30 mL of air and listen over the stomach, then start the feeding
• d.Advance the tube 6 cm to the documented mark and start the feeding

A change in the external tube length means the tip may no longer be in the stomach, so the feeding is held and placement is re-established radiographically before anything is instilled. Auscultating an injected air bolus is the most tempting shortcut and is still taught in some texts, but air can be heard over the epigastrium even when the tube sits in the airway, so it is not an acceptable verification method.

A nurse has just finished administering a 300 mL intermittent gastric tube feeding to a client who is on bed rest. Which action should the nurse take next?

• a.Keep the head of the bed at 30 to 45 degrees for at least an hour✓
• b.Lower the head of the bed to 15 degrees once the feeding ends
• c.Lay the client flat for an hour so the formula empties evenly
• d.Turn the client fully prone for the next hour to aid digestion

Keeping the head of the bed at 30 to 45 degrees during the feeding and for at least an hour afterward uses gravity to keep formula in the stomach and is the core aspiration precaution for enteral feeding. Lowering the head of the bed right after a bolus, for any stated reason, puts gastric contents at the level of the esophagus while the stomach is still full.

A client dies unexpectedly two hours after admission, and the death is referred to the medical examiner. An endotracheal tube and two intravenous catheters are still in place. Which action should the nurse take?

• a.Clip the intravenous lines at the skin and cap the airway
• b.Take out the endotracheal tube and the intravenous lines
• c.Remove the lines and chart the location of each insertion site
• d.Leave the endotracheal tube and the intravenous lines in place✓

In a medical examiner or coroner case the therapeutic devices are part of the evidence, because their position tells the death investigator whether they were placed correctly; removing or altering them before the investigator documents them is considered alteration of evidence. Charting the sites carefully does not substitute for leaving the devices where the investigator can see them.

A nurse is preparing to irrigate an adult client's ear canal to remove impacted cerumen. Which action most directly prevents the client from becoming dizzy during the procedure?

• a.Warm the irrigating solution to body temperature✓
• b.Chill the irrigating solution to numb the ear canal first
• c.Direct the stream straight onto the tympanic membrane
• d.Deliver the whole solution in one rapid high-pressure push

Solution that is cooler or warmer than body temperature sets up convection currents in the semicircular canals and provokes the caloric response, producing vertigo, nystagmus, and nausea; warming the solution to roughly 37 degrees Celsius prevents this. Aiming the stream at the tympanic membrane or using high pressure is unsafe because it risks perforation, not because it causes dizziness.

A client arrives in the emergency department five minutes after an alkaline drain cleaner splashed into the right eye. The eye is tearing and the client is squinting. Which action should the nurse take first?

• a.Measure visual acuity in both eyes before any fluid is instilled
• b.Cover the eye with a dry sterile pad and wait for the provider
• c.Instill an antibiotic ointment and then flush the eye with saline
• d.Flush the eye with saline, directing flow from the inner corner outward✓

An alkali burn keeps saponifying tissue until it is diluted, so immediate copious irrigation comes before every other step, including visual acuity, and the flow runs from the inner canthus outward so contaminated fluid does not cross to the unaffected eye. Checking acuity first feels thorough but costs minutes of continuing corneal injury.

A client has continuous bladder irrigation after a transurethral resection of the prostate. During a 12-hour shift the nurse hangs three 2,000 mL bags of irrigating solution; at the end of the shift 400 mL is still in the hanging bag. The drainage bag output for the shift totals 6,150 mL. What is the client's urine output for the shift?

• a.150 mL
• b.550 mL✓
• c.5,600 mL
• d.6,150 mL

Everything instilled into the bladder drains back out, so urine equals total drainage minus irrigant actually infused. Irrigant infused = 3 bags x 2,000 mL = 6,000 mL hung, minus 400 mL still hanging = 5,600 mL. Urine = 6,150 mL - 5,600 mL = 550 mL. Checking it the other way: two bags ran in completely (4,000 mL) and 1,600 mL of the third ran in (2,000 - 400), giving the same 5,600 mL infused and the same 550 mL of urine. Subtracting all 6,000 mL hung, rather than the 5,600 mL infused, yields 150 mL and understates the output.

A nurse assesses a pressure injury over a client's ischial tuberosity. It is an open full-thickness ulcer with visible yellow subcutaneous fat and rolled wound edges; no fascia, muscle, tendon, or bone is visible or palpable, and the base is not obscured. How should the nurse stage this injury?

• a.Stage 2 pressure injury
• b.Stage 4 pressure injury
• c.Unstageable pressure injury
• d.Stage 3 pressure injury✓

Stage 3 is full-thickness skin loss in which adipose is visible and rolled edges (epibole) and granulation tissue are often present, while fascia, muscle, tendon, ligament, cartilage, and bone are not exposed. Stage 4 is the tempting alternative but requires those deeper structures to be visible or directly palpable, and visible fat rules out stage 2, in which adipose is not visible.

A nurse finds a 4 cm area of intact skin over a client's heel that is a persistent deep maroon color and does not blanch under pressure. The area feels boggy and warmer than the surrounding skin. How should the nurse document this finding?

• a.Stage 1 pressure injury
• b.Deep tissue pressure injury✓
• c.Stage 2 pressure injury
• d.Unstageable pressure injury

Persistent non-blanchable deep red, maroon, or purple discoloration of intact skin, often with a boggy texture and temperature change, is a deep tissue pressure injury caused by pressure and shear at the bone-muscle interface. Stage 1 is the closest look-alike, but its definition explicitly excludes purple or maroon discoloration, and unstageable requires an open full-thickness wound whose base is hidden by slough or eschar.

A client's stage 4 sacral pressure injury has filled in with granulation tissue over six weeks and is now shallow, with no bone or tendon palpable. How should the nurse document the injury at this point?

• a.As a healing stage 3 pressure injury
• b.As a resolved stage 4 pressure injury
• c.As a healing stage 4 pressure injury✓
• d.As a healing stage 2 pressure injury

The stage records the deepest tissue that was lost, and the staging system implies no progression in either direction, so an injury is not reverse staged or down staged as it fills in; it stays a stage 4 and is described as healing. Calling it a stage 3 or stage 2 is the common error, and it is wrong physiologically as well: full-thickness loss is replaced by scar tissue, not by the muscle and fat that were destroyed.

On the second postoperative day a nurse changes the pouch of a client who has a new descending colostomy. The stoma is dusky purple and dry rather than moist. Which action should the nurse take?

• a.Massage the stoma gently to improve its blood flow
• b.Record the appearance as expected for a new stoma
• c.Apply a warm compress and reassess in four hours
• d.Report the appearance of the stoma to the provider promptly✓

A viable stoma is moist and pink to dark red; a bluish, purple, black, or pale stoma signals impaired perfusion and must be reported without delay because the segment can become ischemic. Documenting it as normal is the trap here, since some swelling and oozing genuinely are expected on postoperative day two, but a colour change is not.

A nurse empties the drainage bag of a 70 kg adult client's indwelling urinary catheter at 0600 and again at 1400, measuring 208 mL for those eight hours. The urine is dark amber. Which action should the nurse take?

• a.Notify the provider; output averages about 26 mL per hour✓
• b.Notify the provider; output averages about 13 mL per hour
• c.Continue routine monitoring; output averages 42 mL per hour
• d.Continue routine monitoring; output averages 26 mL per hour

208 mL divided by 8 hours = 26 mL/hr; multiplying back, 26 x 8 = 208 mL, which confirms it. That is below the 30 mL/hr threshold for notifying the provider, and it is also below 0.5 mL/kg/hr, which for a 70 kg client is 35 mL/hr, so both benchmarks agree that this output must be escalated rather than simply monitored. Dividing 208 by 5 instead of 8 gives the incorrect 42 mL/hr.

Six hours after a short-arm fiberglass cast is applied for a radius fracture, a client reports deep forearm pain that is worse than before and is not relieved by the prescribed opioid. Passive extension of the fingers reproduces severe pain. Which action should the nurse take first?

• a.Give the next scheduled opioid dose early, then reassess
• b.Contact the provider at once about splitting the cast✓
• c.Raise the arm well above heart level and reassess later
• d.Apply ice over the cast and have the client make a fist

Pain out of proportion to the injury and pain on passive stretch of the digits are the earliest signs of acute compartment syndrome, and the restrictive cast must be bivalved or split, which requires the provider now; pulselessness, pallor, and paralysis are late findings and waiting for them costs the limb. Elevating above heart level is the tempting comfort measure but reduces arterial inflow, so the limb is kept at heart level.

A nurse finds that the weights of a client's balanced skeletal traction are resting on the floor because the client has slid toward the foot of the bed. Which action should the nurse take?

• a.Add a weight to restore the pull the traction has now lost
• b.Shorten the rope so the weights clear the floor by an inch
• c.Reposition the client up in bed so the weights hang free✓
• d.Remove the weights until the client is repositioned in bed

Traction pulls only while the weights hang freely, so the nurse restores the pull by moving the client back up in bed, keeping the prescribed weight and rope untouched. Lifting or removing weights from a client with a fracture releases the reduction and causes muscle spasm, and it is done only on the provider's order or in an emergency.

A nurse is giving a complete bed bath to a client in a semiprivate room while the client's roommate has visitors. Which action best protects the client's dignity and privacy?

• a.Work as fast as possible so that the exposure time is shortened
• b.Draw the curtain and uncover only the area being washed✓
• c.Leave the privacy curtain open so the client can see the doorway
• d.Draw the privacy curtain and remove the gown for the whole bath

Screening the client and keeping a bath blanket over everything except the part actively being washed protects modesty throughout the procedure. Pulling the curtain but stripping the client for the whole bath is the closest wrong answer because it does half the job: the curtain alone does not prevent unnecessary exposure to the nurse or to anyone who steps through it.

A nurse cares for a client with advanced dementia who can no longer report pain in words. During repositioning the client grimaces, moans, and pushes the nurse's hands away. Which action should the nurse take?

• a.Score the pain with a validated behavioral scale✓
• b.Chart that pain cannot be rated because of the dementia
• c.Judge the pain from the heart rate and the blood pressure
• d.Ask the client to point to a number on a 0 to 10 scale

A client's own report is the standard whenever one can be given, but for a client who cannot self-report the nurse substitutes an observational tool such as PAINAD, which scores exactly these behaviors. Vital signs are the tempting objective measure and are unreliable for pain, and a 0-to-10 numeric scale demands an abstraction this client can no longer perform.

A client is one day after an open cholecystectomy and rates incisional pain 4 out of 10 an hour after an oral analgesic. The client asks for something other than more medicine. Which nursing action is appropriate?

• a.Reposition the client and begin guided imagery with slow breathing✓
• b.Postpone the next pain assessment until the next medication is due
• c.Hold the remaining analgesic orders while the imagery is being used
• d.Explain that comfort measures help only pain that is rated 2 or less

Repositioning, guided imagery, music, distraction, and heat or cold are used alongside analgesics; consistent with gate control theory, competing input and relaxation reduce how much pain reaches awareness. Withholding the ordered analgesics is the tempting distractor because the client asked for a nondrug option, but the client asked to add one, not to lose access to the prescribed regimen.

A client with stage 4 chronic kidney disease has been taught to limit dietary potassium. Which lunch selection indicates that the teaching was effective?

• a.Turkey on white bread, a fresh banana, and orange juice
• b.Turkey on white bread, canned pears, and grape juice✓
• c.Turkey on white bread, a baked potato, and tomato juice
• d.Turkey on white bread, dried apricots, and prune juice

Pears and grape juice are on the lower-potassium list for chronic kidney disease, so this tray shows the teaching took hold. Bananas, oranges and orange juice, potatoes, tomatoes and tomato juice, and dried fruit such as apricots and prunes are all named as high-potassium foods to limit, and dried fruit is especially concentrated because the water has been removed.

An older adult client reports lying awake for hours after getting into bed and feeling exhausted the next day. Which statement by the client indicates that teaching about sleep habits was effective?

• a.I will have a glass of wine at bedtime to help me drop off
• b.If I am still awake after about 20 minutes, I will get up and read✓
• c.I will take a two-hour nap each afternoon to catch up on rest
• d.I will stay in bed until I fall asleep, however long that takes

Getting out of bed after about 20 minutes of wakefulness and doing something quiet keeps the bed associated with sleep instead of with frustration, which is the point of reserving the bed for sleep. Lying there waiting does the opposite, daytime naps reduce the drive to sleep at night, and alcohol is not a sleep aid and is specifically cautioned against for older adults who may also be taking sleep medication.

During an eight-hour shift a client takes 6 oz of apple juice, 4 oz of coffee, 8 oz of clear broth, and 12 oz of ice chips. The facility records 1 oz as 30 mL and records ice chips as half of their volume. How much intake should the nurse document for the shift?

• a.900 mL
• b.540 mL
• c.720 mL✓
• d.600 mL

Liquids: 6 + 4 + 8 = 18 oz, and 18 x 30 = 540 mL. Ice chips: 12 oz x 30 = 360 mL of ice, recorded at half, which is 180 mL. Total = 540 + 180 = 720 mL. Checking a second way, the ice counts as the equivalent of 6 oz, so the shift total is 18 + 6 = 24 oz, and 24 x 30 = 720 mL. Counting the ice chips at their full 360 mL gives 900 mL, and leaving the coffee out of the tally gives 600 mL.

A nurse totals a client's 24-hour record. Intake: a continuous tube feeding running at 55 mL/hr for all 24 hours, four 30 mL water flushes, and 1,000 mL of intravenous fluid. Output: 1,850 mL of urine, 200 mL of emesis, and 125 mL from a closed wound drain. What is the client's 24-hour fluid balance?

• a.Positive 265 mL✓
• b.Positive 390 mL
• c.Positive 465 mL
• d.Positive 145 mL

Intake: 55 x 24 = 1,320 mL of formula, plus 4 x 30 = 120 mL of flushes, plus 1,000 mL intravenous = 2,440 mL. Output: 1,850 + 200 + 125 = 2,175 mL. Balance = 2,440 - 2,175 = positive 265 mL. Recomputed independently: 55 x 20 = 1,100 and 55 x 4 = 220, so the feeding is 1,320 mL; 1,320 + 120 + 1,000 = 2,440; 1,850 + 200 = 2,050 and 2,050 + 125 = 2,175; 2,440 - 2,175 = 265 mL. Leaving the emesis out of output gives 465 mL, leaving the flushes out of intake gives 145 mL, and leaving the drain out gives 390 mL.

A client who takes sertraline for depression tells the clinic nurse about starting St. John's wort bought at a health food store. Which response by the nurse is accurate?

• a.Combining it with sertraline can push serotonin up to a harmful level✓
• b.It interacts only with warfarin, so sertraline is not a concern here
• c.Combining it with sertraline makes the antidepressant work faster
• d.Herbal products are regulated as drugs, so this pair is safe to use

St. John's wort combined with a serotonergic antidepressant can cause a potentially life-threatening rise in serotonin, so this combination is reported to the prescriber rather than continued. It is not a warfarin-only problem either: the herb also speeds the metabolism of oral contraceptives, cyclosporine, digoxin, indinavir, and irinotecan, weakening all of them.

A prescription reads: 'Give 1.5 g of an oral medication by mouth twice daily.' The pharmacy supplies scored 500 mg tablets. How many tablets should the nurse give for one dose?

• a.Administer 6 tablets
• b.Administer 1.5 tablets
• c.Administer 3 tablets✓
• d.Administer 0.3 tablet

Convert before dividing: 1.5 g = 1,500 mg, and 1,500 mg / 500 mg per tablet = 3 tablets per dose; checked a second way, each tablet is 0.5 g and 1.5 g / 0.5 g = 3. The most tempting wrong answer is 1.5 tablets, which comes from dividing as though each tablet held 1 g instead of converting grams to milligrams first; 6 tablets is the whole 24-hour amount given at once, and 0.3 tablet is the inverted ratio (500 / 1,500 = 0.33) rounded to a tenth. Tablets are counted in whole or half units here, so no decimal rounding is involved.

A prescription reads: 'Give 40 mg of a medication intramuscularly now.' The vial is labeled 100 mg per 2 mL. How many milliliters should the nurse draw up?

• a.Administer 0.4 mL
• b.Administer 5 mL
• c.Administer 2 mL
• d.Administer 0.8 mL✓

The vial holds 100 mg / 2 mL = 50 mg per mL, so 40 mg / 50 mg per mL = 0.8 mL; worked a second way, 40 mg x 2 mL / 100 mg = 0.8 mL. The tempting error is 0.4 mL, produced by dividing 40 by 100 and forgetting to multiply by the 2 mL the drug is dissolved in; 2 mL is the whole vial and 5 mL is the ratio inverted (100 / 40 x 2). Doses below 1 mL are written with a leading zero as 0.8 mL, because .8 mL can be read as 8 mL if the decimal point is missed.

A child weighs 44 lb. The prescriber orders an oral antibiotic at 30 mg/kg/day, to be given in equally divided doses every 8 hours. How many milligrams should the nurse give per dose?

• a.440 mg per dose
• b.600 mg per dose
• c.200 mg per dose✓
• d.300 mg per dose

44 lb / 2.2 lb per kg = 20 kg; 20 kg x 30 mg/kg/day = 600 mg for the day; every 8 hours is 3 doses, so 600 mg / 3 = 200 mg per dose (rechecked: 30 x 20 = 600, 600 / 3 = 200). The 440 mg answer is what you get by treating the 44 lb as 44 kg, the exact confusion that led ISMP and NCC MERP to recommend that weights be measured and documented in kilograms only. The 600 mg answer gives the full day at once and 300 mg divides the day into two doses instead of three.

A child weighs 33 lb. The safe range for the prescribed medication is 10 to 15 mg/kg per dose. The prescriber writes an order for 250 mg per dose. What should the nurse do?

• a.Withhold the dose and contact the prescriber to have the amount reduced✓
• b.Give the dose as written, since it is within the range for this child's weight
• c.Give the dose as written and monitor the child closely for toxic effects
• d.Give 225 mg now and ask the prescriber to rewrite the order afterward

33 lb / 2.2 = 15 kg, so this child's safe range is 15 x 10 = 150 mg to 15 x 15 = 225 mg per dose, and the ordered 250 mg is above the maximum, so the nurse holds it and contacts the prescriber. Trimming the amount to 225 mg is the most tempting wrong action because the number is right: changing a dose is prescribing rather than administering, and the nurse who silently corrects an order leaves no record for the next clinician. Giving an unsafe dose and watching for toxicity treats harm as acceptable when it was preventable.

A prescriber orders 250 mL of 0.9% sodium chloride to infuse over 90 minutes. The volumetric pump accepts whole milliliters per hour. What rate should the nurse set?

• a.Set the pump at 125 mL/hr
• b.Set the pump at 375 mL/hr
• c.Set the pump at 250 mL/hr
• d.Set the pump at 167 mL/hr✓

250 mL / 90 min x 60 min per hr = 166.7, which the nurse rounds to 167 mL/hr because this pump takes whole numbers; checked a second way, 90 minutes is 1.5 hours and 250 / 1.5 = 166.7. The 125 mL/hr answer comes from rounding 90 minutes up to 2 hours, 250 mL/hr from treating 90 minutes as an hour, and 375 mL/hr from multiplying by 1.5 instead of dividing by it.

A client is to receive 1,000 mL of lactated Ringer's over 10 hours by gravity. The tubing package states a drop factor of 15 gtt/mL. How many drops per minute should the nurse count?

• a.Regulate the flow at 33 gtt/min
• b.Regulate the flow at 100 gtt/min
• c.Regulate the flow at 25 gtt/min✓
• d.Regulate the flow at 17 gtt/min

1,000 mL x 15 gtt/mL = 15,000 drops over 600 minutes = 25 gtt/min; checked a second way, 1,000 mL / 10 hr = 100 mL/hr = 1.67 mL/min, and 1.67 x 15 = 25 gtt/min. Each wrong answer is the same problem worked with the wrong drop factor, which is why the factor is read off the tubing package every time: a 10 gtt/mL set gives 17, a 20 gtt/mL set gives 33, and a 60 gtt/mL microdrip set gives 100. A fraction of a drop cannot be delivered, so drip rates are rounded to the nearest whole drop.

A continuous infusion of aqueous penicillin G 4,000,000 units in 250 mL of dextrose 5% in water is running by pump at 50 mL/hr. How many units is the client receiving each hour?

• a.800,000 units/hr✓
• b.4,000,000 units/hr
• c.16,000 units/hr
• d.20,000,000 units/hr

The bag holds 4,000,000 units / 250 mL = 16,000 units per mL, and at 50 mL/hr that is 16,000 x 50 = 800,000 units/hr; checked a second way, 50 mL is one fifth of the 250 mL bag, and one fifth of 4,000,000 is 800,000. Reporting 16,000 units/hr stops at the concentration and never multiplies by the rate, which is the most common slip here; 4,000,000 units/hr assumes the whole bag runs in one hour, and 20,000,000 units/hr comes from inverting the rate and the volume (250 / 50 rather than 50 / 250).

A vial of powdered antibiotic reads: 'Add 8.6 mL of sterile water for injection to yield 1 g per 10 mL.' The order is for 600 mg IV. After reconstituting the vial, how much should the nurse withdraw?

• a.Withdraw 5.2 mL
• b.Withdraw 8.6 mL
• c.Withdraw 6 mL✓
• d.Withdraw 0.6 mL

The reconstituted vial holds 1 g (1,000 mg) in 10 mL, which is 100 mg per mL, so 600 mg / 100 mg per mL = 6 mL; checked a second way, 600 mg is 0.6 of a gram and 0.6 x 10 mL = 6 mL. The most tempting error is 8.6 mL, the volume of diluent added rather than the volume of the dose: the powder itself occupies space, so the final volume of 10 mL is larger than the 8.6 mL of water and the dose is always calculated from the final volume printed on the label. Using 8.6 mL as the final volume yields 5.2 mL, and dropping the 10 mL entirely yields 0.6 mL.

An infant weighs 9.5 kg. The prescriber orders an oral suspension at 20 mg/kg per dose. The bottle is labeled 250 mg per 5 mL. How many milliliters should the nurse give, rounded to the nearest tenth?

• a.Administer 3.8 mL✓
• b.Administer 19 mL
• c.Administer 6.6 mL
• d.Administer 0.76 mL

9.5 kg x 20 mg/kg = 190 mg per dose; the suspension is 250 mg / 5 mL = 50 mg per mL, so 190 mg / 50 mg per mL = 3.8 mL, and checked a second way 190 x 5 / 250 = 3.8 mL. Oral liquid volumes above 1 mL are rounded to the tenth, so 3.8 mL is what the nurse draws into an oral syringe. The 0.76 mL answer divides 190 by 250 and never multiplies by the 5 mL, 19 mL applies the 5 mL a second time after already converting to 50 mg per mL, and 6.6 mL inverts the ratio (250 / 190 x 5).

A nurse is about to give a scheduled oral medication on a busy medical unit. Which method of identifying the client meets the National Patient Safety Goal for medication administration?

• a.Ask the client to state their name and date of birth✓
• b.Ask the client to confirm the name on the medication record
• c.Check the room and bed number listed on the medication record
• d.Confirm the name with the nursing assistant assigned to the room

NPSG.01.01.01 requires at least two person-specific identifiers, such as the name plus an assigned number or date of birth, and states explicitly that the client's room number or physical location is not used as an identifier. Asking the client to confirm a name read aloud is a single identifier and invites a drowsy, anxious, or hard-of-hearing client to agree to the wrong one; having the client state the information and matching it against the record is what catches a wrong-client error.

A 70-year-old client with osteoporosis is discharged with a new prescription for oral alendronate once weekly. Which statement by the client indicates that teaching about how to take the tablet was effective?

• a.I'll swallow it with coffee when the breakfast tray comes and sit up.
• b.I'll take it with plain water on waking and stay upright 30 minutes.✓
• c.I'll swallow it with plain water at bedtime and lie down to sleep.
• d.I'll swallow it with plain water and my calcium tablet together.

Alendronate labelling directs that the tablet be taken on arising for the day, at least 30 minutes before the first food, drink or other medication, swallowed whole with a full glass (180 to 240 mL) of plain water, and that the client not lie down for at least 30 minutes and until after the first food of the day; a tablet that lingers in the esophagus can cause ulceration. The morning empty-stomach timing is what makes the upright interval work, so a correct answer has to carry both halves. Taking it at the same time as a calcium tablet is the most tempting error, since calcium and other multivalent cations bind the drug in the gut and block its absorption; calcium, antacids and other oral medications must be separated from the dose by at least 30 minutes.

A client is admitted to a medical unit. Which action by the nurse best meets the medication reconciliation requirement?

• a.Order every medication the client names at home to be continued during this stay
• b.Compare the medications the client takes at home with the admission orders✓
• c.File the pharmacy refill history for the prescriber to review later
• d.Copy the medication list from the client's most recent hospital discharge summary

NPSG.03.06.01 asks the nurse to obtain the medications the client is currently taking, including as-needed and over-the-counter products, and then compare that information with what has been ordered so that omissions, duplications, and interactions are identified and resolved. An earlier discharge summary is not the current list, and copying it forward carries the last admission's errors into this one; a refill history filed for later review completes no comparison at all.

A nurse withdraws and gives the ordered 4 mg from a single-dose vial containing 10 mg of a Schedule II analgesic. What should the nurse do with the medication left in the vial?

• a.Return the vial to the automated dispensing cabinet for the client's next dose
• b.Place the vial in the sharps container and document the amount that was given
• c.Waste it into the pharmaceutical waste container with a second nurse witnessing and cosigning✓
• d.Empty it into the sink at the end of the shift and record it on the count sheet

ISMP's guidance is to draw the remaining medication out of the vial with a witness present, have the witness verify the volume, empty it into a pharmaceutical waste container while the witness watches, and document the amount with the witness's cosignature. Dropping the vial into the sharps container is the common shortcut and is unsafe, because the drug is still recoverable from the vial and no one has verified what was actually wasted. Waste is done at the time of administration, not saved for the end of the shift.

A client is discharged with fentanyl transdermal patches. Which statement by the client indicates that teaching about handling the patches was effective?

• a.'I'll leave the old patch on for a few hours after the new one goes on to avoid a gap.'
• b.'I'll put the used patch back in its pouch and drop it in the kitchen trash can.'
• c.'If the patch stops helping, I'll lay a heating pad over it to move the medicine along.'
• d.'When I take a patch off, I'll fold it so the sticky sides stick together and flush it.'✓

The fentanyl transdermal system labeling tells users to fold the used system so the adhesive side sticks to itself and flush it down the toilet immediately after removal, and FDA keeps fentanyl on its flush list precisely because a used patch holds enough drug to kill a child or pet who finds it in the trash. Heat is the most dangerous misconception here: the label warns against heating pads, electric blankets, saunas, and hot tubs over the site because external heat increases absorption and can cause overdose, and the previous patch is removed before a new one goes on a different site.

A nurse checks a peripheral IV infusing 0.9% sodium chloride into a client's forearm. The site is swollen and pale, the skin is cool and taut, and the pump keeps alarming. What should the nurse do first?

• a.Stop the infusion and remove the catheter, then elevate the arm✓
• b.Flush the catheter with saline to see whether the line clears
• c.Notify the provider and continue the infusion until orders arrive
• d.Apply a warm compress and slow the infusion to a keep-open rate

Swelling with cool, taut, pale skin and a sluggish or alarming infusion is infiltration, a non-vesicant solution leaking into the tissue around the vein, and the first action is to stop the infusion and remove the catheter so no more fluid enters the tissue. Flushing is the tempting wrong move because it looks like troubleshooting an occlusion: it forces more fluid into the tissue, and no flush can restore a catheter whose tip is out of the vein. Escalation is not the first step when the nurse can stop the harm immediately.

A client returns to the clinic six weeks after starting atorvastatin for hyperlipidemia. Which report by the client requires the nurse to notify the provider?

• a.Loose stools on two mornings that settled after breakfast
• b.Heartburn on several evenings after a large late meal
• c.Trouble falling asleep on nights after drinking coffee
• d.Aching and weakness in both thighs over the past week✓

Unexplained aching and weakness in the large proximal muscles is how statin-associated myopathy presents, and it can progress to rhabdomyolysis, so the atorvastatin labelling directs clients to report unexplained muscle pain, tenderness, or weakness promptly; the provider can then check a creatine kinase level and decide whether to stop the drug. Loose stools are the most tempting of the other reports because diarrhea really is a statin effect, but diarrhea, dyspepsia, and insomnia sit among the common adverse reactions in the labelling and are handled with reassurance rather than a call.

A nurse is preparing to give an IV push medication through the needleless connector of a client's central venous catheter. What should the nurse do immediately before attaching the syringe?

• a.Take down the dressing to inspect the insertion site
• b.Scrub the connector with an antiseptic and let it dry✓
• c.Replace the needleless connector before each medication
• d.Wipe the connector with sterile gauze moistened with saline

CDC's intravascular catheter guideline directs the nurse to perform hand hygiene before accessing a catheter and to scrub the access port with an appropriate antiseptic such as chlorhexidine, an iodophor, or 70% alcohol, accessing the port only with sterile devices; the connector must then be allowed to dry, because an antiseptic that is still wet has not finished working. Saline is not an antiseptic, and neither swapping an intact connector nor taking down an intact dressing is part of accessing the line for a dose.

An IV nitroglycerin infusion is ordered for chest pain: start at 5 mcg/min, increase by 5 mcg/min every 5 minutes until the pain is relieved, maximum 40 mcg/min, and hold for a systolic blood pressure below 100 mm Hg. The infusion is at 20 mcg/min, the client still rates the pain 6 out of 10, and the systolic pressure is now 94 mm Hg. What should the nurse do?

• a.Increase the rate to 25 mcg/min, because the chest pain has not yet been relieved
• b.Keep the rate at 20 mcg/min and recheck the blood pressure at the end of the shift
• c.Increase the rate to the 40 mcg/min maximum to relieve the chest pain sooner
• d.Hold the next increase and notify the provider, since the systolic pressure is below 100 mm Hg✓

A titration order contains both a target to treat toward and a safety parameter that stops the titration, and a parameter that has been crossed outranks a target that has not yet been reached, so the nurse does not give the next increment at a systolic pressure of 94 mm Hg. The tempting error is to keep titrating because the pain is unrelieved; nitroglycerin can produce severe hypotension at even small doses, and driving the pressure lower reduces coronary perfusion rather than improving it. Because the pain persists at a dose that can no longer be raised, this is a situation where the provider genuinely does need to be called.

A nurse teaches an older adult to instill two different prescribed eye drops into the same eye. Which statement indicates that the teaching was effective?

• a.'I'll rest the bottle tip on my lashes so the drop lands in one place.'
• b.'I'll drop it right onto the middle of my eye so it spreads over the surface.'
• c.'I'll put in the second drop right after the first one so I do not forget it.'
• d.'I'll put the drop in the pocket of my lower lid and press the inner corner.'✓

The drop belongs in the pocket formed by pulling down the lower lid rather than on the cornea, and closing the eye and pressing gently over the tear duct at the inner corner keeps the drug in the eye instead of draining it into the nose and bloodstream. Instilling the second drop immediately is the most tempting error because it feels efficient: it washes the first drug out, and MedlinePlus instructs waiting at least 5 minutes between drops in the same eye. Touching the bottle tip to lashes or lid contaminates the dropper.