NCLEX-RN Nursing — All Questions

A charge nurse is assigning tasks at the start of a shift. Which task is appropriate to delegate to unlicensed assistive personnel (UAP)?

• a.Adjusting the flow rate of a continuous IV infusion
• b.Taking vital signs on a stable postoperative client✓
• c.Performing the initial assessment of a newly admitted client
• d.Teaching a client how to use an incentive spirometer

UAP may perform routine, standardized tasks such as vital signs on stable clients. Assessment, IV titration, and client teaching require the judgment of a licensed nurse and cannot be delegated.

A nurse must see four clients. Which client should the nurse assess FIRST?

• a.A client requesting oral pain medication for a mild headache
• b.A client asking for help ambulating to the bathroom after lunch
• c.A client scheduled for discharge who still needs some teaching
• d.A client reporting new-onset shortness of breath and chest tightness✓

Airway and breathing problems take priority. New shortness of breath with chest tightness may signal a life-threatening event and must be evaluated before less urgent needs.

Which nursing task is appropriate to delegate to a licensed practical/vocational nurse (LPN/LVN)?

• a.Providing discharge teaching about a newly made diagnosis
• b.Administering an oral medication to a stable client✓
• c.Performing triage of new arrivals in the emergency department
• d.Developing the initial nursing plan of care for admission

LPNs/LVNs may administer many routine medications and reinforce teaching for stable clients. Care planning, initial teaching, and triage require the broader scope of the registered nurse.

The nurse is caring for four clients. Applying the ABC framework, which finding requires the most immediate action?

• a.Blood pressure of 148/88 mm Hg while seated
• b.Oxygen saturation of 86% on room air✓
• c.Reports of mild pain at the incision site
• d.Tympanic temperature of 100.8 F (38.2 C)

An oxygen saturation of 86% reflects a breathing and oxygenation emergency and takes priority over an elevated blood pressure, a low-grade fever, or mild pain.

A nurse delegates client hygiene to a UAP. Which statement reflects the nurse's continued accountability?

• a.No follow-up is required once the task is given to an experienced UAP
• b.The UAP is fully responsible for the outcome once the task is assigned
• c.Accountability shifts to the provider who wrote the client's orders
• d.The nurse remains accountable for the overall client outcome and must follow up✓

Delegation transfers the task, not the accountability. The RN retains responsibility for the outcome and must supervise and evaluate the delegated care.

Which situation is the highest priority for the nurse to report to the oncoming shift during handoff?

• a.A client whose surgical dressing was changed two hours ago
• b.A client with a newly inserted chest tube and unstable vital signs✓
• c.A client who ambulated in the hallway this evening without difficulty
• d.A client who ate 100% of the evening meal without nausea

Handoff should emphasize the least stable, highest-risk client. A new chest tube with unstable vital signs requires close monitoring and clear communication to ensure continuity of care.

A nurse observes a coworker preparing to administer a medication without checking the client's identification band. What is the nurse's best initial action?

• a.Say nothing for now, because no harm has come to the client yet
• b.Document the observation in the client's chart after the medication is given
• c.Report the coworker to the state board of nursing before speaking to anyone
• d.Remind the coworker to verify two client identifiers before administration✓

The immediate priority is client safety. Reminding the coworker to verify two identifiers prevents a potential error. Formal reporting is reserved for repeated or unresolved unsafe practice.

The nurse is planning care for a group of clients. Which client is most appropriate to assign to a newly graduated RN?

• a.A client requiring hourly titration of a vasoactive drip
• b.A client being emergently transferred to the intensive care unit
• c.A stable client needing routine postoperative care on day two✓
• d.A client actively receiving blood who is having a transfusion reaction

A new graduate should be assigned stable, predictable clients. Complex, rapidly changing situations such as drip titration, transfusion reactions, and ICU transfers require experienced staff.

A client refuses a prescribed treatment. Which action by the nurse best respects client autonomy?

• a.Administering the treatment because the provider ordered it
• b.Telling the client they will be discharged if they refuse
• c.Documenting the refusal and notifying the provider✓
• d.Waiting until a family member can convince the client

Competent clients have the right to refuse treatment. The nurse documents the informed refusal and notifies the provider, respecting autonomy while ensuring continuity of care.

Which of the following is the nurse's primary responsibility when a client signs a surgical consent form?

• a.Guaranteeing that the surgery will be successful before the signature
• b.Deciding whether the client should proceed with the planned surgery
• c.Verifying that the client's consent is voluntary and witnessing the signature✓
• d.Explaining the surgical risks, benefits, and alternatives to the client

The provider is responsible for explaining risks, benefits, and alternatives. The nurse verifies that consent is voluntary and informed and witnesses the signature.

A nurse is prioritizing care using Maslow's hierarchy of needs. Which client need should be met first?

• a.A client's difficulty maintaining a patent airway✓
• b.A client's concern about the cost of the hospital stay
• c.A client's need for reassurance about tomorrow's surgery
• d.A client's request for the hospital chaplain to visit

Physiological needs such as a patent airway are the base of Maslow's hierarchy and take priority over safety, love and belonging, esteem, and self-actualization needs.

The nurse receives report on four clients. Which client should the nurse plan to reassess first after receiving report?

• a.A client with chronic stable heart failure who is awaiting discharge
• b.A client who received IV morphine 15 minutes ago and is now very drowsy✓
• c.A client requesting a bedtime snack from the unit kitchen tonight
• d.A client with a healing surgical wound scheduled for a dressing change

A client who is increasingly drowsy after IV opioids may be developing respiratory depression and must be reassessed first to prevent harm.

Which task can the RN appropriately delegate to a UAP for a client on strict intake and output monitoring?

• a.Interpreting the significance of a low hourly urine output
• b.Emptying the urinary drainage bag and recording the amount✓
• c.Deciding whether to notify the provider about the low output
• d.Adjusting the client's prescribed fluid restriction

Measuring and recording output is a routine task suitable for UAP. Interpreting values, clinical decision-making, and modifying the plan of care remain RN responsibilities.

A nurse is coordinating a client's discharge. Which action best demonstrates effective case management?

• a.Arranging home health services and follow-up appointments before discharge✓
• b.Delaying discharge until every family question is answered in person
• c.Providing only verbal discharge instructions to save the client time
• d.Leaving the medication reconciliation to the community pharmacy later

Effective case management coordinates resources across the continuum of care. Arranging home health and follow-up appointments promotes continuity and reduces readmission risk.

The nurse identifies a near-miss medication error that did not reach the client. What is the appropriate action?

• a.Complete an incident and occurrence report to support system improvement✓
• b.Report it directly to the state licensing board so that they can investigate
• c.Ignore it entirely, since no harm reached the client and nothing needs filing
• d.Record the near miss in the client's medical record as a medication error

Near-miss and error events are documented on an incident report for quality improvement. The report is not filed in the medical record, and licensing boards address serious professional issues only.

A nurse is supervising a UAP. Which observed action requires the nurse to intervene?

• a.The UAP offers a bedpan to a client who is on strict bed rest
• b.The UAP reports a blood pressure reading to the nurse right away
• c.The UAP applies a vest restraint without a current provider order✓
• d.The UAP raises two side rails after repositioning a client

Restraints require a current provider order and specific criteria. Applying a restraint without an order is unsafe and unlawful, so the nurse must intervene immediately.

Which principle should guide the nurse when assigning client care during a staffing shortage?

• a.Distribute clients randomly to save time
• b.Give all unstable clients to a single nurse to concentrate care
• c.Match client acuity and complexity to staff competency✓
• d.Assign the most clients to the least experienced staff

Safe assignment matches client acuity to the skill and scope of the staff member. Overloading unstable clients on one nurse or assigning complex clients to novices threatens safety.

A nurse witnesses a colleague documenting care that was not actually provided. Which ethical principle is most directly violated?

• a.Beneficence
• b.Veracity✓
• c.Justice
• d.Autonomy

Veracity is the duty to tell the truth. Falsifying documentation violates veracity and is both an ethical breach and a legal risk.

During a unit outbreak of Clostridioides difficile, a nurse cares for a client on contact precautions. Which action is correct?

• a.Wear an N95 respirator to filter the spores
• b.Wash hands with soap and water after client contact✓
• c.Use alcohol-based hand rub after glove removal
• d.Place the client in a negative-pressure room

Alcohol does not remove C. difficile spores, and CDC encourages washing with soap and water after caring for these clients during an outbreak. Note the nuance: outside an outbreak CDC still prefers alcohol-based hand rub for routine care, because studies have not shown a clear prevention benefit for soap and water and dropping the rub lowers overall hand-hygiene compliance. In either setting the highest-value action is correct glove and gown use. C. difficile requires contact, not airborne, precautions.

Which client requires airborne precautions?

• a.A client with scabies on the hands and forearms
• b.A client with a draining surgical wound infection
• c.A client with seasonal influenza and fever
• d.A client with active pulmonary tuberculosis✓

Pulmonary tuberculosis is spread by airborne droplet nuclei and requires a negative-pressure room and an N95 respirator. Wound infections and scabies need contact precautions, and influenza needs droplet precautions.

When donning personal protective equipment (PPE), which sequence is correct?

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

The correct donning sequence is gown, then mask or respirator, then goggles or face shield, then gloves. The correct order reduces contamination risk to the wearer.

A nurse is assessing fall risk. Which client is at highest risk for falling?

• a.A 30-year-old ambulating independently in the hall
• b.An 82-year-old taking a sedative who is confused✓
• c.A 25-year-old awaiting discharge later today
• d.A 45-year-old on bed rest with two side rails raised

Advanced age, a sedating medication, and confusion together create a high fall risk. Interventions such as frequent rounding and bed alarms should be prioritized for this client.

Which action best prevents catheter-associated urinary tract infection (CAUTI)?

• a.Removing the indwelling catheter as soon as it is no longer needed✓
• b.Disconnecting the tubing at the catheter to obtain urine samples
• c.Keeping the drainage bag above the bladder so urine drains back slowly
• d.Routinely irrigating the catheter with sterile saline every shift

Early removal of an unnecessary catheter is the most effective way to prevent CAUTI. The bag should stay below the bladder, the system should remain closed, and routine irrigation is not recommended.

A nurse discovers a small fire in a client's trash can. Using the RACE protocol, what is the first action?

• a.Extinguish the fire with an extinguisher
• b.Rescue any clients in immediate danger✓
• c.Activate the fire alarm
• d.Confine the fire by closing doors

RACE stands for Rescue, Alarm, Confine, and Extinguish. The first priority is to rescue anyone in immediate danger before activating the alarm and containing the fire.

A client is receiving oxygen at 4 L/min by nasal cannula. Which instruction promotes safety?

• a.Increase the flow rate without an order if the client is anxious
• b.Apply petroleum-based lubricant to the client's dry lips and nares
• c.Allow smoking in the room if the client sits six feet from the tank
• d.Post no-smoking signs and keep open flames away from the oxygen✓

Oxygen supports combustion, so no smoking or open flames are permitted near it, and only water-based lubricants should be used. Flow rate changes require a provider order.

The nurse is preparing to move a heavy client up in bed. Which technique protects the nurse from injury?

• a.Keep the feet close together for a narrow base of support
• b.Use a friction-reducing device and additional staff✓
• c.Twist at the trunk to move the client without stepping
• d.Bend at the waist and lift using the back muscles

Safe patient handling uses mechanical aids and adequate help, a wide base of support, and the leg muscles rather than the back. Twisting and bending at the waist cause injury.

A nurse is verifying a client before a blood transfusion. Which action is essential to prevent a transfusion error?

• a.Verify the client and blood product with a second qualified nurse✓
• b.Use a standard IV line shared with a dextrose solution infusion
• c.Skip the baseline vital signs so the unit is not wasted
• d.Begin the transfusion rapidly so the unit does not spoil

Two qualified staff must independently verify the client identity and the blood product to prevent an ABO incompatibility reaction. Blood is infused with normal saline only, and baseline vital signs are required.

Which environmental modification best prevents falls for a confused older adult at home?

• a.Keeping the client in a dimly lit room to promote rest
• b.Using throw rugs to mark walking paths
• c.Removing clutter and ensuring adequate lighting✓
• d.Placing frequently used items on high shelves

Removing clutter and improving lighting reduces trip and fall hazards. Throw rugs, poor lighting, and out-of-reach items increase fall risk.

A nurse receives a client with a suspected external chemical exposure. What is the priority action?

• a.Decontaminate the client before further care✓
• b.Administer pain medication first
• c.Bring the client into the main unit for assessment
• d.Obtain a detailed medical history before any intervention

Decontamination prevents ongoing harm to the client and protects staff and other clients from secondary contamination. It precedes routine assessment and treatment.

The nurse is teaching a client about safe medication storage at home. Which statement indicates a need for further teaching?

• a.I will keep expired medications in case I need them later✓
• b.I will store all medicines in a locked cabinet away from children
• c.I will keep my medications in their original labeled containers
• d.I will not share my prescriptions with family members

Expired medications should be discarded because potency and safety cannot be assured. Keeping them for later use is unsafe and indicates a need for further teaching.

A nurse is caring for a client with a seizure disorder. Which item should be available at the bedside?

• a.A bright overhead light kept on at all times
• b.Functioning suction and oxygen equipment✓
• c.Wrist restraints to prevent movement
• d.A padded tongue blade to insert during a seizure

Suction and oxygen should be ready to maintain the airway during and after a seizure. Nothing should be inserted into the mouth, and restraints and constant stimulation are not appropriate.

Which client should be placed in a private room with droplet precautions?

• a.A client with methicillin-resistant Staphylococcus aureus in a wound
• b.A client with meningococcal meningitis✓
• c.A client with a Clostridioides difficile infection
• d.A client with measles

Meningococcal meningitis is transmitted by respiratory droplets and requires droplet precautions. MRSA wounds and C. difficile need contact precautions, and measles requires airborne precautions.

A nurse identifies a client with a latex allergy. Which action is appropriate?

• a.Assume powdered latex gloves are safe because the powder is a barrier
• b.Use only sterile latex gloves, since sterility prevents a reaction
• c.Ensure latex-free supplies and place an allergy alert on the chart✓
• d.Keep latex products at the bedside in case they are needed later

Clients with a latex allergy require latex-free supplies and clear allergy alerts to prevent an anaphylactic reaction. Powdered latex gloves increase airborne allergen exposure and are unsafe.

The nurse is applying restraints to an agitated client per provider order. Which action is correct?

• a.Leave the client alone in the room so that less stimulation calms the agitation
• b.Tie the restraint to the movable side rail so it moves with the client
• c.Secure the restraint with a quick-release knot to the bed frame✓
• d.Check circulation once every four hours with the routine vital signs

Restraints are tied with a quick-release knot to a fixed part of the bed frame, never the side rails. Circulation, skin, and needs must be checked frequently, typically every 15 to 30 minutes.

A nurse is teaching an adult about routine health screening. Which recommendation is appropriate for colorectal cancer screening in average-risk adults?

• a.Begin screening only after age 70
• b.Begin screening at age 25
• c.Begin screening at age 45✓
• d.Screening is unnecessary without symptoms

Current guidelines recommend that average-risk adults begin colorectal cancer screening at age 45. Waiting for symptoms delays detection of early, treatable disease.

A pregnant client at 12 weeks' gestation asks about weight gain. Which teaching is appropriate for a client of normal pre-pregnancy weight?

• a.Weight gain should be avoided during pregnancy
• b.Weight should be gained only in the first trimester
• c.A gain of 50 to 60 pounds is expected
• d.A total gain of 25 to 35 pounds is recommended✓

A woman with a normal pre-pregnancy body mass index is advised to gain about 25 to 35 pounds. Adequate, gradual gain supports fetal growth without excess maternal risk.

The nurse is teaching parents about infant nutrition. When is it generally appropriate to introduce solid foods?

• a.Around 6 months of age✓
• b.As soon as the newborn shows hunger cues
• c.At 2 months of age
• d.At 12 months of age

Solid foods are typically introduced around 6 months, when the infant can sit with support and has lost the tongue-thrust reflex. Earlier introduction increases the risk of choking and allergies.

A nurse is providing immunization teaching. Which vaccine is a live attenuated vaccine that is contraindicated during pregnancy?

• a.Measles, mumps, and rubella (MMR) vaccine✓
• b.Tetanus, diphtheria, and pertussis (Tdap) vaccine
• c.Hepatitis B vaccine
• d.Inactivated influenza vaccine

MMR is a live attenuated vaccine and is contraindicated during pregnancy. Inactivated influenza and Tdap are recommended in pregnancy to protect the mother and infant.

The nurse is assessing developmental milestones. Which gross motor skill is expected of a typical 12-month-old?

• a.Riding a tricycle independently outdoors
• b.Walking up a full flight of stairs independently
• c.Skipping on alternating feet while playing outside
• d.Pulling to stand and cruising along furniture✓

By about 12 months, infants typically pull to stand and cruise while holding furniture, and many take their first independent steps. Stair climbing, tricycle riding, and skipping are later skills.

A nurse teaches a postmenopausal client about osteoporosis prevention. Which action best supports bone health?

• a.Avoiding all weight-bearing activity so that fragile bones are not stressed
• b.Increasing daily caffeine and carbonated soda intake because their phosphate hardens bone
• c.Performing regular weight-bearing exercise and ensuring adequate calcium and vitamin D✓
• d.Limiting sun exposure completely and relying on stored vitamin D reserves

Weight-bearing exercise plus adequate calcium and vitamin D strengthens bone. Inactivity and excess caffeine or soda contribute to bone loss.

A nurse is counseling an adult on tobacco cessation. Which statement reflects effective health promotion?

• a.Setting a quit date and using support resources improves success✓
• b.Cutting back gradually is impossible, so it is not worth attempting
• c.Nicotine replacement never helps people quit and only prolongs the habit
• d.You must quit all tobacco today or the attempt is not worth making

Setting a specific quit date combined with behavioral support and, when appropriate, nicotine replacement improves cessation success. Supportive, nonjudgmental counseling promotes readiness to change.

The nurse teaches a new mother about breastfeeding. Which sign indicates the infant is adequately hydrated?

• a.A sunken anterior fontanel
• b.Dark, concentrated urine
• c.Fewer than two wet diapers per day
• d.Six or more wet diapers per day✓

Six or more wet diapers a day indicate adequate intake and hydration in a breastfeeding infant. Few wet diapers, concentrated urine, and a sunken fontanel suggest dehydration.

A nurse provides teaching about a heart-healthy diet. Which choice best fits this diet?

• a.Fried chicken with buttered mashed potatoes
• b.A processed deli meat sandwich with chips
• c.A cheeseburger with bacon and fries
• d.Baked salmon with steamed vegetables✓

Baked fish rich in omega-3 fatty acids with vegetables supports cardiovascular health. Fried, high-saturated-fat, and processed high-sodium foods increase cardiac risk.

The nurse is teaching an older adult about safe physical activity. Which recommendation is appropriate for most healthy older adults?

• a.Aim for about 150 minutes of moderate activity weekly plus balance exercises✓
• b.Avoiding all exercise to prevent injury, because rest alone preserves strength with age
• c.Exercising only when pain is present, using the pain as the signal to move
• d.Performing only high-intensity workouts, since moderate activity gives no benefit

Most healthy older adults benefit from about 150 minutes of moderate aerobic activity weekly plus muscle-strengthening and balance exercises to reduce falls and chronic disease risk.

A nurse assesses a 4-year-old's language development. Which finding is expected?

• a.Speaks in sentences of three to four words and is understood by strangers✓
• b.Reads simple printed storybook sentences aloud fluently and without adult help
• c.Speaks only in single words that family members interpret for others
• d.Uses no recognizable words and communicates only by pointing at items

A typical 4-year-old speaks in short sentences that strangers can generally understand. Single-word speech is expected earlier, and fluent reading comes later.

A nurse is teaching about skin cancer prevention. Which statement indicates correct understanding?

• a.A base tan protects me from sun damage for the rest of the summer
• b.Sunscreen is only needed on very hot days when the sun feels strong on my skin
• c.I will apply broad-spectrum sunscreen and reapply every two hours outdoors✓
• d.I only need sunscreen at the beach, not while running errands

Broad-spectrum sunscreen reapplied every two hours, plus protective clothing and shade, reduces skin cancer risk. Ultraviolet exposure occurs on cloudy and cool days, and a tan is a sign of skin damage.

The nurse discusses recommended cervical cancer screening. Which schedule is generally appropriate for an average-risk woman aged 30?

• a.Cervical screening is unnecessary at any age for a woman with no symptoms
• b.Screening should begin only after menopause, when cervical risk first appears
• c.A Papanicolaou (Pap) test every three years, or co-testing options per guidelines✓
• d.Daily self-collected home swabs that the client reads and interprets herself

Average-risk women aged 30 may have a Pap test every three years or human papillomavirus co-testing at extended intervals. Screening should not be delayed until menopause.

A nurse counsels an adult on alcohol use. Which statement reflects moderate drinking guidelines for health promotion?

• a.There is no upper limit to safe alcohol intake for an otherwise healthy adult
• b.Binge drinking on weekends is safe as long as no alcohol is taken on weekdays
• c.Some daily alcohol is required for everyone to protect the heart
• d.Moderate intake means up to one drink per day for women and two for men✓

Moderate drinking is defined as up to one drink per day for women and two for men. Binge drinking is harmful, and lower intake is generally healthier.

A client newly diagnosed with cancer says, 'I just can't believe this is happening to me.' Which response is most therapeutic?

• a.This must be very difficult for you. Tell me what you are feeling✓
• b.Many people do very well with this diagnosis, so try not to worry
• c.At least it was caught early, so staying positive will help you heal
• d.You should focus on your treatment plan instead of your feelings

Acknowledging the client's emotion and inviting them to share feelings uses empathy and open-ended communication. False reassurance and changing the focus block therapeutic dialogue.

A nurse is caring for a client with major depressive disorder who states, 'Life isn't worth living anymore.' What is the nurse's priority action?

• a.Directly ask the client if they are thinking of suicide✓
• b.Change the subject so the client is not upset
• c.Reassure the client that the feelings will pass
• d.Document the statement and continue with routine care

Safety is the priority. Directly asking about suicidal ideation assesses risk and does not increase the likelihood of self-harm; it opens the door to protective intervention.

A client experiencing a panic attack is hyperventilating and pacing. Which nursing action is most appropriate?

• a.Provide detailed teaching about the physiology of anxiety and its triggers
• b.Stay with the client and speak calmly using short, simple statements✓
• c.Leave the client alone in a quiet room until the hyperventilation stops
• d.Encourage the client to describe every worry in detail to release the tension

During a panic attack the nurse should stay with the client, remain calm, and use brief, clear communication. Complex teaching and detailed discussion overwhelm the client until the acute anxiety subsides.

A client with anorexia nervosa is admitted for treatment. Which finding is the priority concern?

• a.The client's preoccupation with calories
• b.The client's distorted body image
• c.The client's refusal to discuss feelings
• d.Bradycardia and electrolyte imbalance✓

Physiological instability such as bradycardia and electrolyte imbalance can be life-threatening in anorexia nervosa and takes priority over the important psychological issues.

A nurse uses therapeutic communication with a grieving client. Which technique best encourages the client to continue talking?

• a.Asking rapid closed-ended questions
• b.Offering personal opinions about the loss
• c.Reassuring the client that grief will pass quickly
• d.Using silence and attentive presence✓

Silence and attentive presence give the grieving client time to process and express feelings. Opinions, closed questions, and false reassurance interrupt therapeutic communication.

A client with schizophrenia says, 'The voices are telling me I am worthless.' Which response is most therapeutic?

• a.You should not listen to those voices, so keep your mind busy with the group activity
• b.Tell me what the voices sound like and try answering them aloud so that I can listen
• c.The voices are not real, so ignore them completely and they will soon stop bothering you
• d.I do not hear the voices, but I understand they seem real and upsetting to you✓

The nurse presents reality without arguing and acknowledges the client's experience and distress. Denying the client's perception or dismissing it damages trust.

A nurse is caring for a client in the manic phase of bipolar disorder. Which intervention supports the client's needs?

• a.Encourage participation in a competitive group game with peers
• b.Provide a calm, low-stimulation environment and finger foods✓
• c.Schedule several stimulating group activities back to back
• d.Serve large plated meals at a crowded communal table

During mania, clients are easily overstimulated and may not sit to eat. A low-stimulation environment and portable, high-calorie finger foods support rest and nutrition.

A client discloses a history of intimate partner violence. What is the nurse's priority action?

• a.Tell the client the abuse is not their fault and end the conversation
• b.Advise the client to leave the relationship immediately
• c.Assess the client's immediate safety and provide resources✓
• d.Contact the partner to discuss the situation

Assessing immediate safety and offering resources respects autonomy while protecting the client. Directing the client to leave or contacting the partner can increase danger.

A nurse is supporting a client through the stages of grief. A client who says, 'If I had only gone to the doctor sooner' is likely in which stage?

• a.Acceptance
• b.Bargaining✓
• c.Frustration
• d.Disbelief

Statements involving 'if only' and attempts to undo the loss reflect the bargaining stage of grief. Recognizing the stage helps the nurse respond supportively.

A client with alcohol use disorder is 12 hours into withdrawal. Which finding requires immediate attention?

• a.Mild hand tremors
• b.Requests for a cigarette
• c.Seizure activity✓
• d.Increased appetite

Seizures during alcohol withdrawal are a medical emergency and require immediate intervention. Mild tremors are common early findings but are less urgent.

A nurse is caring for a client experiencing acute confusion (delirium). Which intervention is most appropriate?

• a.Frequently reorient the client and provide familiar objects✓
• b.Restrain the client in bed to prevent wandering at night
• c.Keep the room dark and quiet at all times, even during the day
• d.Rotate caregivers each shift so the client gets variety

Frequent reorientation, familiar objects, and consistent caregivers reduce confusion in delirium. Restraints and frequent caregiver changes can worsen agitation.

A client is angry and shouting at the nurse about a delayed procedure. Which response best de-escalates the situation?

• a.You need to lower your voice right now or step out of the room
• b.If you keep yelling at me, I will have to leave the room until you calm down
• c.I can see you are frustrated. Let's talk about what is upsetting you✓
• d.There is nothing that I can do about the surgery schedule today

Acknowledging the client's feelings and inviting discussion de-escalates anger and builds rapport. Commanding or threatening the client escalates the conflict.

A nurse is assessing a client for postpartum depression. Which finding warrants further evaluation?

• a.Excitement about caring for and feeding the newborn at home each day
• b.Occasional tearfulness that resolves on its own within the first two weeks
• c.Persistent sadness and disinterest in the infant after three weeks✓
• d.Fatigue related to nighttime feedings that improves after a daytime nap

Persistent sadness and lack of interest in the infant beyond two weeks suggest postpartum depression rather than transient baby blues, and require further evaluation and support.

A nurse cares for a dying client's family. Which action best supports the family during end-of-life care?

• a.Providing privacy and encouraging expression of feelings✓
• b.Avoiding any discussion of the client's condition with the family
• c.Encouraging the family to stay positive in front of the client
• d.Limiting the family's visiting hours to reduce their fatigue

Providing privacy and encouraging the family to express feelings supports coping during end-of-life care. Restricting presence and avoiding honest discussion isolate the family.

A nurse is caring for a client at risk for pressure injuries. Which intervention is most effective for prevention?

• a.Keep the head of the bed elevated at 90 degrees continuously
• b.Use a doughnut-shaped cushion for sitting
• c.Reposition the client at least every two hours✓
• d.Massage bony prominences vigorously

Repositioning at least every two hours relieves pressure over bony prominences and prevents skin breakdown. Massaging bony areas and doughnut cushions can cause tissue damage.

A client has a new order for a clear liquid diet. Which item is appropriate?

• a.Melted vanilla ice cream
• b.Orange juice with pulp
• c.Cream of chicken soup
• d.Apple juice and gelatin✓

Clear liquids are transparent and leave little residue, such as apple juice and plain gelatin. Pulp, cream soups, and ice cream are not clear liquids.

A nurse is assisting a client with dysphagia to eat. Which action promotes safe swallowing?

• a.Position the client upright and encourage chin-tuck swallowing✓
• b.Encourage rapid eating so the meal is finished while food is warm
• c.Have the client lie flat while eating to relax the throat
• d.Offer thin liquids through a straw so that swallowing takes less effort

Sitting upright with a chin-tuck reduces aspiration risk in dysphagia. Lying flat, thin liquids, and rushing increase aspiration risk.

A nurse is providing oral care to an unconscious client. Which action is most important for safety?

• a.Use large amounts of water to rinse the mouth well
• b.Position the client side-lying to prevent aspiration✓
• c.Place the client supine with the head flat to see better
• d.Insert gloved fingers between the teeth to hold it open

A side-lying position allows secretions to drain and prevents aspiration during oral care in an unconscious client. Minimal fluid and safe technique protect the airway.

A nurse is caring for a client with a nasogastric tube for feeding. What action best confirms placement before feeding?

• a.Verify placement per facility protocol, often with pH testing or radiographic confirmation✓
• b.Ask the client whether the tube feels correctly placed before starting
• c.Auscultate over the stomach while injecting air through the tube with a syringe
• d.Place the end of the tube in a cup of water and watch for bubbles before feeding

Current standards rely on pH testing of aspirate and radiographic confirmation to verify tube placement. The auscultation and water-bubble methods are unreliable.

A client reports constipation. Which intervention should the nurse implement first?

• a.Restrict the client's oral intake to rest the bowel
• b.Administer a cleansing enema before trying other measures
• c.Increase fluid and fiber intake and encourage activity✓
• d.Request a prescription for a daily stimulant laxative first

Nonpharmacologic measures such as increasing fluids, fiber, and activity are first-line for constipation. Enemas and laxatives are used when conservative measures fail.

A nurse is measuring a client's urine output through an indwelling catheter. Which finding should be reported to the provider?

• a.Clear yellow urine totaling 60 mL over the past hour in a stable client
• b.Urine output of less than 30 mL per hour for two consecutive hours✓
• c.Slightly increased urine output an hour after a scheduled diuretic dose
• d.Pale straw-colored urine draining steadily into the closed drainage bag

Urine output below 30 mL per hour may indicate inadequate renal perfusion or obstruction and should be reported. Clear, adequate output is a normal finding.

A nurse is assisting a client to use crutches on level ground. Where should the top of the crutch rest?

• a.Directly under the axilla to bear the weight
• b.Level with the waist so the arms stay straight
• c.About two finger-widths below the axilla✓
• d.Against the mid-chest to steady the client

Crutch tops should rest about two finger-widths below the axilla to avoid pressure on the brachial nerves, with weight borne on the hands. Resting on the axillae can cause nerve damage.

A nurse is caring for a client on bed rest. Which intervention prevents venous thromboembolism?

• a.Placing pillows under the knees continuously to keep the legs supported
• b.Encouraging leg exercises and applying sequential compression devices✓
• c.Massaging the calves firmly to relieve stiffness and improve leg comfort
• d.Keeping the client's legs crossed at the ankles because it feels comfortable

Leg exercises and sequential compression devices promote venous return and prevent clot formation. Crossing the legs, calf massage, and continuous knee flexion impede circulation.

A nurse is providing perineal care for a female client with an indwelling catheter. Which technique is correct?

• a.Use the same section of the cloth for each stroke
• b.Apply powder around the catheter insertion site to keep it dry
• c.Clean from the urethra outward, away from the anus✓
• d.Clean from the anus toward the urethra with one stroke

Perineal care is performed from the cleanest area, the urethra, toward the anus to prevent introducing bacteria. A clean cloth section is used for each stroke.

A client is being repositioned to prevent complications of immobility. Which position best relieves pressure on the sacrum while maintaining alignment?

• a.Prone position for extended periods
• b.Supine with the head of the bed at 90 degrees
• c.The 30-degree lateral (side-lying) position✓
• d.High Fowler's position continuously

The 30-degree lateral position offloads the sacrum and trochanter while maintaining alignment. High Fowler's and prolonged supine positions increase shear and sacral pressure.

A nurse is caring for a client with a stage 2 pressure injury. Which description matches this stage?

• a.Intact, unbroken skin showing localized nonblanchable redness over a bony prominence
• b.Partial-thickness loss of the dermis presenting as a shallow open ulcer✓
• c.Skin loss covered entirely by eschar, so that the depth cannot be judged
• d.Full-thickness loss with exposed bone, tendon, or supporting muscle

A stage 2 pressure injury is partial-thickness skin loss involving the dermis, appearing as a shallow open ulcer or blister. Nonblanchable redness is stage 1 and exposed bone is stage 4.

A client who is NPO reports a dry mouth. Which comfort measure is appropriate?

• a.Offer frequent oral care and moisten the lips✓
• b.Encourage the client to drink small sips of juice
• c.Provide a large glass of water
• d.Give the client hard candy to suck

For an NPO client, oral care and lip moisture relieve dryness without violating the NPO status. Providing water, candy, or juice would break the NPO order.

A nurse is applying antiembolism stockings. Which action is correct?

• a.Apply the stockings while the client is lying down before rising✓
• b.Leave a few wrinkles in the stocking to allow for flexibility
• c.Apply the stockings after the client has been up walking in the hall
• d.Roll the top of the stocking down to create a snug, secure fit

Antiembolism stockings are applied before the client rises, while lying down, to prevent pooling of blood. Rolling the top or leaving wrinkles can create a tourniquet effect.

A client is prescribed warfarin. Which laboratory value is used to monitor its therapeutic effect?

• a.Prothrombin time and international normalized ratio (INR)✓
• b.Serum potassium and magnesium levels drawn before each dose
• c.Activated partial thromboplastin time (aPTT) drawn each morning
• d.Platelet count alone, repeated at weekly intervals during therapy

Warfarin is monitored using the prothrombin time and INR. The aPTT is used to monitor heparin, not warfarin.

A client receiving IV heparin has an aPTT far above the therapeutic range and is bleeding. Which medication is the antidote?

• a.Calcium gluconate
• b.Vitamin K injection
• c.Protamine sulfate✓
• d.Naloxone hydrochloride

Protamine sulfate reverses heparin. Vitamin K reverses warfarin, and naloxone reverses opioids.

A nurse is administering digoxin. Which finding requires the nurse to hold the dose and notify the provider?

• a.Temperature of 98.6 F (37 C)
• b.Respiratory rate of 16 breaths per minute
• c.Blood pressure of 118/72 mm Hg
• d.Apical heart rate of 52 beats per minute✓

Digoxin should be held for an apical heart rate below 60 beats per minute in adults because it can further slow the heart and may signal toxicity. The other vital signs are within normal limits.

A client is starting an angiotensin-converting enzyme (ACE) inhibitor. Which side effect should the nurse teach the client to report?

• a.Darkened urine that clears quickly
• b.Improved appetite
• c.Increased salivation
• d.A persistent dry cough✓

ACE inhibitors commonly cause a persistent dry cough due to bradykinin accumulation. Clients should report it, and angioedema, though rare, is an emergency.

A nurse prepares to administer an aminoglycoside antibiotic. Which parameters are most important to monitor?

• a.Renal function and drug peak and trough levels✓
• b.Serum calcium and serum phosphate levels each morning
• c.Thyroid hormone levels and the basal metabolic rate
• d.Blood glucose and hemoglobin A1c measured before each dose

Aminoglycosides are nephrotoxic and ototoxic, so renal function and peak and trough serum levels must be monitored to ensure safety and efficacy.

A client is prescribed 250 mg of a medication. The pharmacy supplies 125 mg tablets. How many tablets should the nurse administer?

• a.Four tablets
• b.Half a tablet
• c.One tablet
• d.Two tablets✓

Using desired over available, 250 mg divided by 125 mg per tablet equals two tablets. Accurate dose calculation prevents a medication error.

A nurse teaches a client taking an oral corticosteroid long term. Which instruction is correct?

• a.Take the medication on an empty stomach for best absorption
• b.Avoid monitoring blood glucose, since steroids do not affect it
• c.Do not stop the medication suddenly; taper as directed✓
• d.Stop the medication abruptly once symptoms improve

Long-term corticosteroids must be tapered to avoid adrenal insufficiency. They should be taken with food, and blood glucose should be monitored because they raise glucose.

A client is receiving IV furosemide. Which electrolyte imbalance should the nurse monitor for?

• a.Hypernatremia
• b.Hypercalcemia
• c.Hyperkalemia
• d.Hypokalemia✓

Loop diuretics such as furosemide promote potassium excretion and can cause hypokalemia. The nurse monitors potassium and watches for muscle weakness and cardiac dysrhythmias.

A client taking a monoamine oxidase inhibitor (MAOI) for depression requires dietary teaching. Which food should be avoided?

• a.Freshly steamed carrots
• b.Plain steamed white rice
• c.Fresh apples and pears
• d.Aged cheese and cured meats✓

Tyramine-rich foods such as aged cheese and cured meats can trigger a hypertensive crisis in clients taking MAOIs and must be avoided.

A nurse administers insulin lispro, a rapid-acting insulin. When should the nurse ensure the client is ready to eat?

• a.Meal timing does not matter with lispro
• b.About two hours after the injection
• c.Within about 15 minutes of the injection✓
• d.Only at bedtime with a light snack

Rapid-acting insulin such as lispro begins working within about 15 minutes, so food should be available promptly to prevent hypoglycemia.

A client is prescribed morphine for pain. Which assessment is most important before and after administration?

• a.Deep tendon reflexes and hand grip strength
• b.Skin turgor and oral mucous membrane color
• c.Respiratory rate and level of sedation✓
• d.Bowel sounds in all four quadrants

Opioids such as morphine can cause respiratory depression and sedation, so respiratory rate and sedation level must be assessed before and after administration.

A client taking phenytoin for seizures needs teaching. Which instruction is appropriate?

• a.Stop the drug if a rash appears without contacting the provider
• b.Expect the urine to turn blue
• c.Maintain good oral hygiene because of gum overgrowth risk✓
• d.Skip doses if you feel well

Phenytoin commonly causes gingival hyperplasia, so meticulous oral hygiene is important. Doses should not be skipped, and any rash should be reported because it may signal a serious reaction.

A nurse is administering a beta-blocker such as metoprolol. Which parameter should be checked before administration?

• a.Urine specific gravity and color
• b.Serum bilirubin and albumin levels
• c.Total white blood cell count
• d.Apical heart rate and blood pressure✓

Beta-blockers lower heart rate and blood pressure, so both should be assessed before administration and the dose held for significant bradycardia or hypotension per parameters.

A client on lithium for bipolar disorder reports vomiting, coarse tremors, and confusion. What does the nurse suspect?

• a.Normal side effects that require no action
• b.A therapeutic drug response
• c.A common cold
• d.Lithium toxicity✓

Vomiting, coarse tremors, and confusion are signs of lithium toxicity. The narrow therapeutic range makes level monitoring and adequate hydration essential.

A client is prescribed an oral tetracycline antibiotic. Which instruction is correct?

• a.Take it with milk or antacids to reduce stomach upset
• b.Take each dose only with grapefruit juice for absorption
• c.Double the next dose whenever a dose is missed to catch up
• d.Avoid dairy products and antacids near the time of the dose✓

Calcium in dairy and antacids binds tetracycline and reduces its absorption, so they should be separated from the dose. Doses should not be doubled if missed.

A nurse is preparing to administer a medication and notes the client has a documented allergy to it. What is the nurse's action?

• a.Hold the medication and notify the prescriber✓
• b.Give a smaller dose to test tolerance
• c.Give the medication and monitor closely
• d.Administer with an antihistamine to prevent a reaction

A documented allergy is a contraindication. The nurse holds the drug and notifies the prescriber to clarify or change the order, preventing a potentially life-threatening reaction.

A client is receiving an IV infusion of potassium chloride. Which action is essential for safety?

• a.Stop cardiac monitoring during the infusion to reduce alarms
• b.Administer the potassium by rapid IV push to correct the level
• c.Infuse diluted potassium slowly using an infusion pump✓
• d.Give the potassium undiluted so that it takes effect faster

IV potassium must always be diluted and infused slowly with a pump; it is never given by IV push because rapid administration can cause fatal cardiac arrest. Cardiac monitoring is important.

A client taking an opioid reports no bowel movement for three days. Which intervention should the nurse anticipate?

• a.Initiating a bowel regimen with a stool softener and increased fluids✓
• b.Discontinuing the opioid without consulting the provider who prescribed it
• c.Withholding oral fluids until the client passes a bowel movement alone
• d.Restricting all dietary fiber to rest the bowel until stooling returns

Opioids commonly cause constipation, so a prophylactic bowel regimen with stool softeners, fluids, and fiber is appropriate. Fluids and fiber should be increased, not restricted.

A nurse reviews a client's laboratory results. Which serum potassium value is within the normal range?

• a.7.2 mEq/L
• b.6.5 mEq/L
• c.2.8 mEq/L
• d.4.0 mEq/L✓

The normal serum potassium range is approximately 3.5 to 5.0 mEq/L, so 4.0 mEq/L is normal. Values of 6.5 and 7.2 indicate hyperkalemia, and 2.8 indicates hypokalemia.

A client with heart failure gains 3 pounds in two days and has new crackles in the lungs. Which condition does the nurse suspect?

• a.Fluid volume overload✓
• b.Severe hypokalemia
• c.Acute dehydration
• d.Metabolic alkalosis

Rapid weight gain and pulmonary crackles indicate fluid volume overload, common in a heart failure exacerbation. Prompt recognition allows diuretic and fluid management.

A nurse is caring for a client with diabetic ketoacidosis. Which arterial blood gas finding is expected?

• a.Metabolic alkalosis
• b.Respiratory acidosis
• c.Metabolic acidosis✓
• d.Respiratory alkalosis

Diabetic ketoacidosis produces excess ketoacids, causing metabolic acidosis with a low pH and low bicarbonate. Kussmaul respirations develop as compensation.

A client with chronic obstructive pulmonary disease has an oxygen saturation of 90%. Which oxygen delivery approach is appropriate?

• a.Administer high-flow oxygen at 10 L/min to raise the saturation
• b.Place the client on a nonrebreather mask as the routine choice
• c.Withhold oxygen entirely so the respiratory drive is preserved
• d.Provide low-flow oxygen and titrate to the target saturation✓

Clients with COPD are given controlled low-flow oxygen titrated to a target saturation, often around 88 to 92 percent, to avoid suppressing respiratory drive while treating hypoxemia.

A nurse assesses a client with hypocalcemia. Which finding is expected?

• a.Constipation, lethargy, and thirst
• b.Diminished deep tendon reflexes throughout
• c.Warm, dry, and flushed skin and face
• d.Positive Trousseau and Chvostek signs✓

Hypocalcemia increases neuromuscular excitability, producing positive Trousseau and Chvostek signs, muscle cramps, and tingling. Hypercalcemia causes the opposite findings.

A client presents with slurred speech, facial droop, and right-sided weakness. What is the nurse's priority action?

• a.Activate the stroke protocol and note the time of symptom onset✓
• b.Give the client oral fluids to check the swallowing reflex
• c.Administer aspirin immediately, before any brain imaging is done
• d.Encourage the client to rest and reassess in about an hour

These signs suggest an acute stroke. Rapid activation of the stroke protocol and documenting the symptom onset time are critical because treatment such as thrombolytics is time-dependent.

A nurse is caring for a client after a myocardial infarction. Which laboratory marker is most specific for cardiac muscle damage?

• a.Blood urea nitrogen
• b.Troponin✓
• c.Serum sodium
• d.Total white blood cell count

Troponin is the most specific and sensitive biomarker for myocardial injury and rises within hours of an infarction, guiding diagnosis and treatment.

A client has a nasogastric tube to continuous suction and develops muscle weakness. Which disturbance is most likely?

• a.Respiratory acidosis with hypernatremia
• b.Respiratory alkalosis with hypercalcemia
• c.Metabolic alkalosis with hypokalemia✓
• d.Metabolic acidosis with hyperkalemia

Loss of gastric acid and potassium through continuous suction leads to metabolic alkalosis and hypokalemia, which can cause muscle weakness and dysrhythmias.

A nurse reviews an arterial blood gas: pH 7.30, PaCO2 55 mm Hg, HCO3 24 mEq/L. How should the nurse interpret this?

• a.Metabolic alkalosis
• b.Respiratory alkalosis
• c.Metabolic acidosis
• d.Respiratory acidosis✓

A low pH with an elevated PaCO2 and a normal bicarbonate indicates uncompensated respiratory acidosis, often from hypoventilation.

A client with cirrhosis develops confusion and asterixis. Which laboratory value best explains these findings?

• a.Decreased serum glucose
• b.Elevated serum ammonia✓
• c.Elevated serum calcium
• d.Decreased white blood cell count

Impaired liver function raises serum ammonia, causing hepatic encephalopathy with confusion and asterixis. Treatment such as lactulose lowers ammonia levels.

A nurse cares for a client with acute kidney injury and a serum potassium of 6.8 mEq/L. Which finding is the priority concern?

• a.Decreased urine output over the past shift
• b.Fatigue that improves with an afternoon rest
• c.Mild peripheral edema of both ankles and feet
• d.Peaked T waves on the electrocardiogram✓

Hyperkalemia can cause life-threatening cardiac dysrhythmias; peaked T waves signal cardiac effects and require immediate intervention. The other findings are important but less urgent.

A client is admitted with dehydration. Which assessment finding supports this diagnosis?

• a.Poor skin turgor and elevated urine specific gravity✓
• b.Moist mucous membranes and brisk capillary refill
• c.Bounding pulse and elevated blood pressure with crackles
• d.Jugular vein distention while sitting upright

Dehydration produces poor skin turgor, dry mucous membranes, and concentrated urine with a high specific gravity. Jugular distention and bounding pulses suggest fluid overload.

A nurse assesses a client with hypothyroidism. Which finding is expected?

• a.Weight loss with marked heat intolerance
• b.Fatigue, cold intolerance, and bradycardia✓
• c.Tachycardia and bulging exophthalmos
• d.Frequent diarrhea and hand tremors

Hypothyroidism slows metabolism, causing fatigue, cold intolerance, weight gain, and bradycardia. Weight loss, heat intolerance, and tachycardia occur in hyperthyroidism.

A client with type 1 diabetes is diaphoretic, shaky, and confused with a blood glucose of 54 mg/dL. What is the priority intervention?

• a.Withhold all food until the provider is notified
• b.Administer long-acting insulin
• c.Encourage the client to exercise
• d.Give 15 grams of a fast-acting carbohydrate✓

These are signs of hypoglycemia. For a conscious client, giving about 15 grams of fast-acting carbohydrate raises the glucose quickly; the level is then rechecked.

A nurse is monitoring a client after a total hip replacement. Which finding suggests a possible pulmonary embolism?

• a.Decreased appetite at the evening meal
• b.Gradual improvement in hip mobility
• c.Sudden dyspnea, chest pain, and tachycardia✓
• d.Mild incisional soreness with movement

Sudden dyspnea, pleuritic chest pain, and tachycardia after orthopedic surgery suggest a pulmonary embolism, a medical emergency requiring immediate action.

A client's laboratory results show a hemoglobin of 7.2 g/dL. Which assessment finding is most consistent with this value?

• a.Bradycardia and hypertension
• b.Increased energy and alertness
• c.Fatigue, pallor, and tachycardia✓
• d.Warm, ruddy skin and bounding pulses

A hemoglobin of 7.2 g/dL indicates anemia, producing fatigue, pallor, and compensatory tachycardia due to reduced oxygen-carrying capacity.

A nurse cares for a client with increased intracranial pressure. Which finding is an early sign?

• a.Fixed, dilated pupils that do not react
• b.Cushing's triad of vital sign changes
• c.Deep coma with no motor response
• d.A change in level of consciousness✓

A change in level of consciousness is the earliest and most sensitive sign of increased intracranial pressure. Fixed pupils and Cushing's triad are late, ominous findings.

A client with Addison's disease is at risk for adrenal crisis. Which finding requires immediate intervention?

• a.Occasional craving for salty foods
• b.Mild fatigue in the afternoon
• c.Slightly bronzed skin creases
• d.Severe hypotension and hyperkalemia✓

Adrenal crisis causes profound hypotension, hyperkalemia, and hyponatremia and is life-threatening, requiring immediate fluids and hydrocortisone. Bronzing and salt craving are chronic features.

A nurse reviews arterial blood gases: pH 7.50, PaCO2 30 mm Hg, HCO3 24 mEq/L. Which condition does this represent?

• a.Acute metabolic acidosis
• b.Metabolic alkalosis
• c.Respiratory alkalosis✓
• d.Respiratory acidosis

An elevated pH with a low PaCO2 and a normal bicarbonate indicates respiratory alkalosis, often caused by hyperventilation.

A client with gastroenteritis has had severe diarrhea for two days. Which electrolyte imbalance is most likely?

• a.Hypokalemia✓
• b.Hyperkalemia
• c.Hypernatremia
• d.Hypercalcemia

Prolonged diarrhea causes significant potassium loss through the stool, leading to hypokalemia, which can produce weakness and cardiac dysrhythmias.

A nurse assesses a client in the compensatory stage of hypovolemic shock. Which finding is expected?

• a.Increased heart rate and cool, clammy skin✓
• b.Slow, deep respirations with a normal pulse
• c.Elevated blood pressure with warm, flushed skin
• d.Bradycardia with warm, dry, pink skin

In compensated shock, the body increases the heart rate and constricts peripheral vessels, producing tachycardia and cool, clammy skin as it attempts to maintain perfusion.

A client with pneumonia has a fever and thick secretions. Which intervention best promotes airway clearance?

• a.Restrict oral fluid intake to reduce sputum production
• b.Keep the client lying flat in bed to conserve energy
• c.Encourage fluids and provide chest physiotherapy as ordered✓
• d.Suppress the productive cough with medication so the client rests

Adequate hydration thins secretions and chest physiotherapy mobilizes them, promoting airway clearance. Restricting fluids and suppressing a productive cough would worsen secretion retention.

A nurse cares for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which finding is expected?

• a.Hyponatremia and fluid retention✓
• b.High serum osmolality
• c.Dehydration and excessive thirst
• d.Hypernatremia and increased urine output

SIADH causes excessive water retention, leading to dilutional hyponatremia, low serum osmolality, and concentrated urine. Fluid restriction is a key treatment.

A client with a history of gout has an elevated serum uric acid level. Which dietary teaching is appropriate?

• a.Avoid all dairy products because they raise uric acid
• b.Restrict water intake to reduce joint swelling
• c.Limit purine-rich foods and increase fluid intake✓
• d.Increase intake of organ meats and shellfish for protein

Limiting purine-rich foods such as organ meats and shellfish and increasing fluids helps lower uric acid and prevent gout attacks. Adequate hydration promotes uric acid excretion.

A nurse reviews a client's coagulation results. Which value indicates the client is at increased risk for bleeding?

• a.Hemoglobin of 14 g/dL
• b.INR of 5.0✓
• c.Platelet count of 250,000/microliter
• d.INR of 1.0

An INR of 5.0 is well above the therapeutic range and indicates a high bleeding risk. An INR of 1.0 and a normal platelet count reflect normal clotting ability.

A client with liver failure has a prolonged prothrombin time. Which nursing action is appropriate?

• a.Implement bleeding precautions and use a soft toothbrush✓
• b.Administer intramuscular injections freely for comfort medications
• c.Ignore minor bruising and gum bleeding as unimportant
• d.Encourage vigorous tooth brushing with a firm-bristled brush

A prolonged prothrombin time indicates impaired clotting, so bleeding precautions such as a soft toothbrush and avoiding unnecessary injections reduce the risk of hemorrhage.

A nurse is admitting a 78-year-old client who lives alone and was hospitalized after a hip fracture. At what point should the nurse begin discharge planning for this client?

• a.At admission, by identifying the client's likely need for post-hospital services✓
• b.On the day of discharge, after the provider writes the order and names a destination
• c.Once the client can walk the hallway with the walker without assistance
• d.When the client's insurance company approves a post-acute rehabilitation placement

The federal discharge planning requirement directs hospitals to identify, early in the stay, clients likely to suffer adverse consequences without adequate planning, so needs such as home health or extended care are worked out from admission onward. Waiting for the discharge order compresses planning into a few hours and is a common cause of failed transitions and readmission.

A nurse is transferring a client from the intensive care unit to a medical unit. The client has a patient-controlled analgesia pump and an indwelling urinary catheter. Which action by the transferring nurse best supports a safe transfer?

• a.Ask the client's daughter to explain the pump to the new nurse on arrival
• b.Give a face-to-face report to the receiving nurse and allow time for questions✓
• c.Send the printed transfer summary and let the receiving nurse read it later
• d.Chart a transfer note after the client has been moved to the new room

The Joint Commission's hand-off alert directs senders to communicate critical content both verbally, preferably face to face, and in writing, with ample opportunity for the receiver to ask questions, and warns against hand-offs made solely through paper or electronic communication. A written summary alone is the tempting choice because the information is technically transmitted, but nothing confirms the receiver got what was needed to manage the pump and catheter.

A nurse is using the ISBAR format to call a provider about a client whose urine output has fallen. Which statement belongs in the recommendation portion of the report?

• a.I am Dana Ruiz, the nurse caring for the client in room 412 tonight.
• b.The client has put out only 60 mL of urine over the past four hours.
• c.The client had an open cholecystectomy two days ago and has no allergies.
• d.I would like you to assess the client now and consider a fluid order.✓

In ISBAR the recommendation names what the nurse wants the provider to do, which is what converts a report into a request for action. The urine-output figure is the most tempting wrong choice because it is the reason for the call, but a measured finding is the situation being described, not the recommendation; the surgical history is background and the nurse's name is identification.

A unit uses the I-PASS mnemonic to structure shift hand-off. Which action carries out the final element, synthesis by the receiver?

• a.The departing nurse repeats the report a second time before leaving
• b.The oncoming nurse restates the plan and to-do list back to the sender✓
• c.The departing nurse files the completed hand-off form in the client record
• d.The oncoming nurse signs the printed hand-off sheet before rounds begin

I-PASS stands for illness severity, patient summary, action list, situation awareness and contingency plans, and synthesis by receiver, so the closing step belongs to the person receiving the client: summarizing back what was heard while the sender is still there to correct it. Signing the hand-off sheet records that a report happened but does not test whether the information arrived intact.

A client with two surgical drains and a pain pump is being transferred to a rehabilitation unit. The client's spouse says he will explain the drains and the pump to the new staff when they arrive. Which action should the nurse take?

• a.Report the drains and pump to the receiving nurse with the spouse present✓
• b.Tell the spouse that device information is not shared with family members
• c.Thank the spouse and let him relay the device details to the receiving staff
• d.Write the device details on a note for the spouse to hand to the new staff

The Joint Commission encourages sharing hand-off information with the client and family present, yet states plainly that clinicians should not rely on the client or family to communicate vital information about their care to the providers receiving the hand-off. Sending the details on a note carried by the spouse has the same flaw: the transfer of clinical responsibility still has to happen nurse to nurse.

At the end of the shift an RN transfers responsibility for a client's care to the oncoming RN. Under the NCSBN and ANA national guidelines, this transfer is best described as which of the following?

• a.Delegation of a nursing responsibility to a delegatee
• b.A hand-off between licensed health care providers✓
• c.Supervision of one licensed nurse by another
• d.An assignment of routine care by a nurse leader

The national delegation guidelines state that they do not apply to the transfer of responsibility for care of a patient between licensed health care providers, such as RN to RN, which is considered a hand-off. Delegation is the narrower act of transferring one specific nursing activity to a delegatee who would not routinely perform it, and it never moves the whole client.

An RN is caring for a stable client with type 2 diabetes. Which responsibility may the RN delegate to an experienced assistive personnel (AP) with documented competency?

• a.Assessing a new area of redness the client reports on the heel
• b.Deciding whether the ordered sliding-scale insulin dose should be given
• c.Teaching the client how and why to rotate the insulin injection sites
• d.Obtaining a capillary blood glucose reading and reporting the value✓

A point-of-care glucose measurement performed to protocol and reported back to the nurse is a task an AP can be trained and validated to do. Choosing the insulin decision is tempting because the AP produced the number, but the national guidelines state that the licensed nurse cannot delegate nursing judgment or any activity involving critical decision making; teaching and assessment are retained on the same grounds.

An RN delegated a morning bath to an AP for a client who was stable at the start of the shift. The AP returns and reports that the client became dizzy and confused while sitting up. Which action should the RN take first?

• a.Have the AP recheck the client's vital signs again in one hour
• b.Reassess the client and decide whether the delegation is still appropriate✓
• c.Reassign the bath to a different AP who has more years of experience
• d.Direct the AP to finish the bath while staying with the client the whole time

The right circumstance requires that the client's condition be stable, and the guidelines state that when the condition changes the delegatee must communicate it and the licensed nurse must reassess the situation and the appropriateness of the delegation. Sending the AP back to finish is tempting because the AP is already at the bedside, but new dizziness and confusion are findings only the RN can evaluate.

A charge nurse asks an AP to apply and monitor sequential compression devices. The AP says she has not used the devices before and does not feel able to do it safely. Which action is correct?

• a.The AP proceeds after another AP describes how the devices are used
• b.The AP proceeds, because the nurse keeps accountability for the client
• c.The AP declines, and the nurse applies the devices or arranges training✓
• d.The AP documents the concern in the record and applies the devices

The guidelines state that a delegatee who does not believe he or she has the competency to complete a delegated responsibility should not accept it, and that when delegation is not appropriate the delegating nurse should perform the activity herself. The accountability answer is tempting and half true: the nurse does retain accountability, which is a reason for her to act, not a reason for an untrained delegatee to proceed.

An RN is distributing work on a unit staffed with RNs, LPN/VNs, and AP. Which responsibility is appropriate to assign to the LPN/VN?

• a.Writing the outcome goals in a newly admitted client's care plan
• b.Performing the admission assessment on a client arriving from surgery
• c.Reinforcing low-sodium diet instructions the RN taught yesterday✓
• d.Evaluating whether teaching about a new diagnosis was effective

Reinforcing instruction the RN has already delivered sits inside the LPN/VN role, while the initial assessment, development of the plan of care, and evaluation of teaching are clinical-judgment steps the RN retains. LPN/VN scope varies by state, so the reliable way to answer these items is to look for the retained RN core rather than to reason from a particular state's task list.

A state nurse practice act permits AP to remove peripheral IV catheters, but the hospital's written policy states that only licensed nurses may remove them. Which statement about the nurse's obligation is correct?

• a.The nurse follows the hospital policy, which may be more restrictive✓
• b.The nurse may delegate the removal once the AP has been checked off by an educator
• c.The nurse follows the practice act, which overrides the local policy
• d.The nurse may delegate the removal with the charge nurse's approval

The national guidelines require employer delegation policies to be consistent with the practice act and note that institution or employer policies can be more restrictive, but not less restrictive, than the act. A permissive practice act sets an outer boundary rather than a permission slip, and no individual nurse or charge nurse can waive a facility policy that withholds the task.

A nurse is giving discharge medication instructions to a client with limited English proficiency. The client's 15-year-old grandson offers to interpret. Which action should the nurse take?

• a.Ask a bilingual assistive personnel on the unit to interpret the instructions
• b.Give written instructions in the client's language and omit the verbal teaching
• c.Obtain a qualified interpreter through the hospital at no cost to the client✓
• d.Allow the grandson to interpret, since the client trusts him to be accurate

Federal rules require covered health programs to provide language assistance free of charge, accurately and in a timely way, and prohibit relying on a minor child to interpret except briefly in an emergency while a qualified interpreter is found. Asking bilingual staff is the closest wrong answer, because a staff member who speaks the language is not automatically qualified as an interpreter.

A client recovering from a stroke tells the nurse she wants to return to her own home with help, while her adult children have already toured a skilled nursing facility. Which action by the nurse best advocates for the client?

• a.Explain to the client that her children have picked the safer care setting for her
• b.Ask the children to spend more time persuading the client to agree to the plan
• c.Document the client's wish in the record and continue with the facility placement
• d.Bring the client's stated goal to the discharge planning team for evaluation✓

The discharge planning regulation requires a process that focuses on the client's own goals and treatment preferences and that treats the client and caregivers as active partners, so advocacy means getting the stated goal formally evaluated, including whether home health could meet the need. Documenting the wish and proceeding anyway is the near-miss answer: it creates a record without giving the client any part in her own plan.

Four clients on a surgical unit press their call lights at the same time. Which client should the nurse go to first?

• a.A client 2 days after abdominal surgery who is asking for an antiemetic
• b.A client 1 day after knee replacement rating incisional pain 6 of 10
• c.A client 3 days after bowel resection who has not yet passed any flatus
• d.A client 4 hours after thyroidectomy with a high-pitched inspiratory sound✓

A high-pitched inspiratory sound is stridor, described by MedlinePlus as caused by a blockage in the throat or larynx and treated as an emergency; after thyroidectomy it can mean the airway is narrowing from swelling or a hematoma, so it outranks pain, nausea, and delayed flatus. The other three findings need attention during the shift but none of them is an airway problem.

A nurse begins the shift with four clients. Which client is appropriate for the nurse to see last?

• a.A client reporting sudden pain and tightness in one calf while resting
• b.A client whose oxygen saturation fell from 96% to 89% on 2 L of oxygen
• c.A client with new confusion who was fully oriented at the previous shift
• d.A client waiting on routine morning labs before a planned discharge✓

Waiting on routine results before a planned discharge is the only situation with no change in the client's condition, while altered mental status and an oxygen saturation below 90% are both standard rapid-response calling criteria and new unilateral calf pain may signal a clot. Deciding who can wait uses the same acuity judgment as deciding who is first, applied from the other end of the list.

Two days after an ischemic stroke, a client coughs after sips of water and has a wet, gurgly voice at the end of the meal. Which action should the nurse take?

• a.Thicken the client's liquids and finish the rest of the meal at the bedside
• b.Have the assistive personnel feed the client slowly while sitting upright
• c.Record the finding and watch the client closely again at the next meal
• d.Stop oral intake and request an order for a swallowing evaluation✓

Coughing during or after drinking and a wet or gurgly voice are signs ASHA lists as warranting a swallowing assessment by a speech-language pathologist, and both that referral and any diet change need a provider order. Thickening the liquids is the most tempting wrong action because it feels protective, but it is a treatment decision outside the nurse's independent scope and ASHA notes thickened fluids may not eliminate aspiration risk.

A client with end-stage kidney disease is ready for discharge but has no stable housing and no way to get to outpatient dialysis three times a week. Which referral should the nurse initiate?

• a.Physical therapist, to build the endurance needed for the trip to dialysis
• b.Dietitian, to build a renal meal plan the client can follow at a shelter
• c.Social worker, to connect the client with housing and transport resources✓
• d.Occupational therapist, to adapt daily routines around the dialysis schedule

Social workers research, refer to, and advocate for community resources such as housing and health care, and health care social workers specifically help people move from the hospital back into their communities. The other three consults address real needs, but none of them removes the housing and transportation barrier that will otherwise stop the dialysis from happening at all.

A home health nurse determines that a client who is unsteady on stairs would benefit from gait training and a bedside commode. Which action should the nurse take next?

• a.Tell the family to buy a commode and to supervise the stairs at home
• b.Ask the home health aide to walk the client on the stairs each visit
• c.Add gait training to the plan of care and begin the exercises today
• d.Contact the provider to obtain orders for therapy and the equipment✓

Identifying the need is nursing judgment, but home health services are delivered under a plan of care established and signed by a physician or allowed practitioner that must specify the types of services, supplies, and equipment required, so the orders are what turn the assessment into delivered care. Starting gait training independently substitutes the nurse for the discipline whose scope covers it.

A care plan goal states that a client will ambulate 50 feet with a walker by postoperative day 3. On day 3 the client has walked only to the bathroom door. Which action reflects the evaluation step of the nursing process?

• a.Delete the mobility goal and document that the client declined it
• b.Record the goal as met, because the client did get out of bed today
• c.Identify what limited progress and revise the goal and interventions✓
• d.Keep the plan unchanged and re-evaluate the same goal on postoperative day 5

Evaluation means reassessing whether the desired outcome was achieved and then adapting the plan of care on the new data, so an unmet goal triggers revision of the goal and the interventions behind it. Recording the goal as met because the client moved at all is the tempting error, since it changes the documentation instead of the care.

At 0700 a nurse has these tasks: a client due in the operating room at 0730 who has not voided, an 0800 insulin dose, a 0900 dressing change, and a routine bed bath. Which task should the nurse do first?

• a.Complete the bed bath so that the rest of the morning stays clear
• b.Draw up and give the scheduled 0800 dose of the client's insulin
• c.Change the surgical dressing that is scheduled for 0900 this morning
• d.Assist the pre-operative client to void before transport at 0730✓

Organizing a workload means working outward from the deadlines that other departments own: the transport time is set by the operating room and cannot be moved, while the insulin and the dressing change have later windows and the bath has none. Doing the bath first to clear the morning is the classic error, because it spends the only uncommitted block on the only task with no deadline.

A nurse has six clients and two new admissions arriving within the hour, and one AP is available. Which approach best organizes the workload?

• a.Delegate the admission assessments so the nurse can finish the medication pass on time
• b.Delegate the tasks and check the results at the end of the shift report
• c.Delegate vital signs and hygiene for the stable clients, with reporting limits✓
• d.Keep every task, because explaining the work takes longer than doing it alone

Handing routine care for stable clients to the AP with specific values to report back frees the RN for the assessments and admissions only she can do, and it satisfies the right directions and communication element of delegation. Delegating the admission assessments fails the right task, and delegating without following up until report fails the right supervision and evaluation.

Over 20 minutes a client's respiratory rate rises from 18 to 30 and the client becomes confused. The nurse has paged the provider twice with no response. Which action should the nurse take?

• a.Raise the oxygen flow rate and reassess the client in 30 minutes
• b.Page the provider a third time and recheck the client in 15 minutes
• c.Ask the charge nurse to move the client closer to the nurses station
• d.Activate the rapid response team for the client's change in condition✓

Rapid response systems exist to bring critical care skill to a deteriorating client before an arrest, and their calling criteria include altered mental status, an abnormal respiratory rate, and a staff member's significant concern about the client, with no provider authorization required to call. Paging again while the client worsens is exactly the failure-to-rescue pattern these teams were built to interrupt.

A medical-surgical nurse is floated to an oncology unit and assigned to give an intravenous chemotherapy infusion she has not been trained to administer. Which action should the nurse take?

• a.Decline the entire float assignment and return to her home unit
• b.Give the infusion while an oncology nurse talks her through each step
• c.Tell the charge nurse she is not trained and ask for a different client✓
• d.Read the unit protocol and give the infusion at the scheduled time

A delegatee, including a licensed nurse, must accept only responsibilities she is trained and competent to carry out and must tell nursing leadership when she has not had adequate training, which lets the charge nurse move that client and give her work within her competence. Walking off the float assignment is the tempting overcorrection: recognizing a limitation means renegotiating the task, not leaving a short unit shorter.

A client with left-sided weakness after a stroke walks safely with a cane but cannot dress himself or manage utensils. Which team member should the nurse consult?

• a.Occupational therapist, for retraining in dressing and eating tasks✓
• b.Speech-language pathologist, for retraining in swallowing and speech
• c.Respiratory therapist, for retraining in breathing and airway clearance
• d.Physical therapist, for retraining in walking and stair-climbing tasks

Occupational therapists help clients relearn daily living tasks, including teaching a person who has had a stroke how to get dressed, and they recommend eating aids and other adaptive equipment. Physical therapy is the tempting pick after a stroke, but this client's gait is already safe with a cane and the deficit is in self-care activities.

A client with COPD has thick retained secretions and a weak cough, and the provider has ordered chest physiotherapy and a change in oxygen delivery. Which team member should the nurse collaborate with to carry out these orders?

• a.Registered dietitian, who plans the intake needed to support breathing
• b.Respiratory therapist, who gives chest physiotherapy and sets up oxygen✓
• c.Physical therapist, who gives endurance training and gait retraining
• d.Clinical social worker, who arranges home equipment and follow-up care

Respiratory therapists perform chest physiotherapy to move mucus out of the lungs and set up and monitor the equipment that delivers the correct amount of oxygen at the correct rate, which is precisely what these two orders require. The other consults are reasonable later in the stay, but none of them executes the ordered airway clearance.

A client scheduled for a laparoscopic cholecystectomy in 45 minutes tells the nurse, “I signed the paper, but I still don’t know what they plan to remove or what could go wrong.” The preoperative midazolam has not yet been given. Which action should the nurse take?

• a.Ask the client’s spouse to explain the procedure the surgeon described earlier
• b.Describe the procedure and its usual risks to the client and then proceed
• c.Give the midazolam as ordered and reinforce the teaching once the client is calm
• d.Notify the surgeon to discuss the procedure before sedation is given✓

The provider who will perform the procedure is responsible for explaining its nature, risks, benefits, and alternatives; the nurse verifies that the client understood and alerts the surgeon when that understanding is missing. Explaining the procedure in the surgeon’s place does not create valid informed consent.

A nurse is asked to witness a surgical consent signature 10 minutes after intravenous midazolam was given to the client. Which action should the nurse take?

• a.Ask a second nurse to co-sign the consent form to confirm the client was alert
• b.Decline to witness and tell the surgeon that consent must be obtained first✓
• c.Witness the signature and note in the record that midazolam was given first
• d.Witness the signature after the client repeats the name of the planned procedure

Consent signed while a client is under a sedating drug is not valid, because the client can no longer demonstrate understanding of what is being agreed to; the discussion and signature belong before sedation. Documenting the sedation or adding a second signature does not restore the client’s capacity to consent.

An unresponsive adult is brought to the emergency department after a motor vehicle crash and needs immediate surgery for internal bleeding. No family member or surrogate decision maker can be located. Which statement should guide the nurse’s action?

• a.Emergency treatment may proceed under the emergency exception to informed consent✓
• b.Surgery must be delayed until a family member is located and gives permission
• c.A court order is required before any surgical procedure may be performed
• d.Two staff members may sign the consent form on behalf of the unresponsive client

Informed consent may be waived when an emergency leaves no time to obtain it, the client cannot communicate, and no surrogate is available, because a reasonable person would be presumed to want life-saving care. Delaying hemorrhage surgery to locate a family member who cannot be found would cause the harm consent rules exist to prevent.

A 17-year-old client who is married and living independently presents alone for treatment of a fractured wrist. The client’s parents live in another state. Which action should the nurse take regarding consent?

• a.Treat the injury under implied consent because the client arrived alone
• b.Have the client sign the consent, because a married minor is emancipated✓
• c.Telephone a parent in the other state for permission before treating
• d.Ask the client’s spouse to sign the consent form for the wrist treatment

A minor who is legally emancipated — for example through marriage, military service, or a court order — gives their own informed consent for care. Implied consent covers emergencies in which the client cannot communicate a decision, which does not apply to an alert client with a wrist fracture.

A nurse is teaching a client about advance directives. Which client statement indicates that the teaching was effective?

• a.“An advance directive is required before the hospital can admit me for care.”
• b.“A durable power of attorney for health care names who speaks for me.”✓
• c.“My advance directive takes effect the moment I sign it in front of a notary.”
• d.“A living will lets my daughter choose my treatments while I am still alert.”

A durable power of attorney for health care designates a health care proxy to speak for the client, while a living will records treatment preferences without naming a decision maker. Advance directives take effect only when the client can no longer make or communicate decisions, and a facility may not require one as a condition of care.

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).

A nurse on a postpartum unit sees an unfamiliar woman in scrubs carrying a newborn down the hallway in her arms. What should the nurse do?

• a.Stop the woman at once and call security while checking her badge✓
• b.Report the observation to the charge nurse at the end of rounds
• c.Follow the woman to the nursery and confirm the infant's identity
• d.Return to the mother's room and confirm the infant was discharged

The National Center for Missing and Exploited Children lists as an essential guideline that infants are pushed in a bassinet rather than carried in anyone's arms, and that only staff wearing the distinctive infant-transport identification may move an infant, so carrying a newborn down a hallway is itself the warning sign. Because most hospital abductors impersonate staff and leave quickly, the nurse intervenes and summons security in the moment rather than tracking the infant afterward.

A nurse must move a 250-lb client who cannot bear any weight from the bed to a chair. Which approach best protects both the client and the staff?

• a.Use a draw sheet and lift the client with three staff members
• b.Use a gait belt and pivot the client with a second staff member
• c.Use a powered full-body lift with a second staff member assisting✓
• d.Use the overhead trapeze and coach the client to pull himself up

A client who cannot bear weight is transferred with a powered full-body sling lift, because OSHA identifies transfer and lifting devices as the key control for injury to both clients and staff during transfers. A gait belt and pivot transfer require the client to bear weight, and adding staff to a manual lift divides the load but still leaves each person handling more than manual technique makes safe.

At the bedside a nurse notices that a heparin syringe drawn up by another nurse holds ten times the ordered dose, and returns it to the pharmacy before any of it is given. What should the nurse do next?

• a.File an event report for the near miss in the facility's system✓
• b.Tell the other nurse privately and let her decide whether to report
• c.Document the correct dose given later in the client's medical record
• d.Wait to report unless the same error occurs again on the unit

A near miss is a patient safety event that did not reach the client, and AHRQ treats it as reportable precisely because near misses are far more common than adverse events and expose the system weaknesses that produce later harm. Charting the dose that was eventually given records nothing about what nearly happened, so documentation alone leaves the hazard invisible to the organization.

A nurse sees a colleague withdraw a full vial of hydromorphone, give a partial dose, waste none of the remainder, and put the syringe in her pocket. Which action should the nurse take?

• a.Ask the colleague to waste it with a witness at shift end
• b.Record the discrepancy in the controlled substance log only
• c.Report the observation to the charge nurse without delay✓
• d.Watch the colleague's practice over the next several shifts

Suspected diversion of a controlled substance is an immediate threat to clients, and NCSBN describes early recognition and reporting as the nurse's responsibility for keeping clients safe and getting the colleague help, so it is escalated to nursing leadership right away rather than investigated privately. Correcting the waste later or noting it only in the log leaves a possibly impaired colleague caring for clients in the meantime.

A nurse is teaching poison safety to the parents of a 2-year-old. Which statement by a parent indicates a need for further teaching?

• a.We keep pills in their original child-resistant bottles
• b.We call 1-800-222-1222 before we do anything else
• c.We keep syrup of ipecac on hand to make him vomit✓
• d.We store the drain cleaner in a locked cabinet up high

The American Academy of Pediatrics withdrew its recommendation for home ipecac in 2003 and advises that any ipecac already in the home be discarded, since inducing vomiting does not improve outcomes and carries its own risks. Calling Poison Help at 1-800-222-1222 first, locking up caustics out of reach, and leaving medicines in child-resistant packaging are all correct practices.

A nurse is discussing car seat use with the parent of a 14-month-old. Which statement by the parent indicates that the teaching was effective?

• a.She rides rear-facing until she outgrows the seat's height or weight limit✓
• b.She can turn forward-facing now that she is over one year old
• c.She can move to a booster seat as soon as she turns four years old
• d.She can ride in the front seat once she can buckle herself in

The AAP and NHTSA both frame rear-facing as a height-and-weight rule rather than a birthday: the child rides rear-facing until she reaches the highest weight or height her car safety seat allows, which for most convertible seats is well past age two. Turning a 14-month-old forward-facing because she has passed her first birthday applies an age-based rule that is no longer recommended, and the back seat remains the safest place for children younger than 13.

A nurse at a women's health clinic is counseling a 24-year-old client who plans to conceive within the next year. Which statement by the client indicates that the teaching about folic acid was effective?

• a.I should begin folic acid only if a prior baby had a birth defect.
• b.I should begin folic acid at the start of my second trimester.
• c.I should begin folic acid once a home pregnancy test is positive.
• d.I should take 400 micrograms of folic acid every day before I conceive.✓

CDC advises that all women capable of becoming pregnant take 400 mcg of folic acid daily, starting at least a month before conception, because the neural tube closes in the earliest weeks of pregnancy. Waiting for a positive pregnancy test is the most tempting error, but by then most of the window for preventing neural tube defects has already passed.

A client at 28 weeks' gestation received Tdap during a pregnancy two years ago and asks the nurse whether she needs the vaccine again. Which response by the nurse is correct?

• a.Tdap is given in the first trimester so antibodies have time to build.
• b.Tdap is given in every pregnancy, ideally between 27 and 36 weeks.✓
• c.Tdap is given after delivery, before you go home from the hospital.
• d.Tdap is given once every ten years, so you are not due for it now.

CDC recommends a Tdap dose during each pregnancy at 27 through 36 weeks' gestation, preferably early in that window, regardless of when the client last received Tdap or Td, because maternal antibodies cross the placenta and protect the infant before the infant's own pertussis series begins. The ten-year interval applies to tetanus boosters outside pregnancy and does not replace the dose given in each pregnancy.

A nurse is triaging telephone calls from clients in the third trimester. Which report requires the most immediate follow-up?

• a.Swelling of both ankles at the end of a long day on her feet
• b.Irregular tightening of the abdomen that stops when she walks
• c.A headache for two days that is worsening, with spots in her vision✓
• d.Heartburn after evening meals that eases when she sits upright

A persistent headache that is getting worse, together with visual changes, is an urgent maternal warning sign for preeclampsia and needs same-day evaluation. Dependent ankle edema, positional heartburn, and irregular tightening that resolves with activity are common third-trimester discomforts rather than emergencies.

A nurse palpates a laboring client's contractions. One contraction begins at 0800 and ends at 0800:45; the next begins at 0804 and ends at 0805. How should the nurse document the frequency of these contractions?

• a.Every 5 minutes
• b.Every 4 minutes✓
• c.Every 3 minutes
• d.Every 45 seconds

Frequency is timed from the beginning of one contraction to the beginning of the next, so 0800 to 0804 is a frequency of every 4 minutes. Timing from the end of the first contraction to the start of the next (0800:45 to 0804, about 3 minutes) measures the resting interval, and 45 seconds is the duration of the first contraction, not its frequency.

Four hours after a vaginal birth, a nurse palpates the client's fundus two fingerbreadths above the umbilicus and displaced to the right. The fundus is firm, lochia rubra is moderate, and the oxytocin infusion is running at the ordered rate. Which action should the nurse take first?

• a.Increase the oxytocin infusion rate per the standing order
• b.Assist the client to the bathroom to empty her bladder✓
• c.Massage the uterine fundus with a cupped hand for 15 seconds
• d.Notify the provider of the fundal height and position now

A fundus that is firm but sits high and off midline points to a distended bladder displacing the uterus, and having the client void is the intervention the nurse can carry out independently; an overdistended bladder inhibits involution and raises the risk of postpartum hemorrhage. Fundal massage and more oxytocin treat uterine atony, which is not the problem here because the fundus is already firm, and calling the provider before the client voids delays the action that fixes the finding.

A nurse is completing discharge teaching with a client on postpartum day 2. Which statement by the client indicates that the teaching about when to call the provider was effective?

• a.I will call if I feel cramping while my newborn is breastfeeding.
• b.I will call if I soak through a pad in an hour or less.✓
• c.I will call if my discharge turns pinkish-brown later this week.
• d.I will call if my breasts feel full and firm on the third day.

Soaking one or more pads in an hour is an urgent maternal warning sign for postpartum hemorrhage and warrants immediate contact with the provider. The change to pinkish-brown lochia serosa around days 4 to 10, afterpains during breastfeeding, and breast fullness on about the third day are all expected postpartum findings.

On the first day after an uncomplicated birth, a client repeatedly retells the story of her labor and asks the nurse to bathe the newborn for her. The nurse plans newborn care teaching. Which action is most appropriate?

• a.Document that the client is showing impaired bonding with her newborn
• b.Have the client perform the bath now so she practices before discharge
• c.Give the client written bath instructions and ask her to read them today
• d.Meet the client's own comfort needs now and demonstrate the bath tomorrow✓

During Rubin's taking-in phase in the first one to three days, the client is focused on her own recovery and on processing the birth, so she is not yet ready to learn; readiness returns in the taking-hold phase around days 4 to 10, when clients actively seek newborn care instruction. Dependent behavior this early is expected and by itself is not evidence of impaired bonding.

At 1 minute of life a term newborn has a heart rate of 128, a weak irregular cry with slow respirations, some flexion of the extremities, a grimace when the nares are suctioned, and a pink trunk with blue hands and feet. What Apgar score should the nurse assign?

• a.5
• b.7
• c.8
• d.6✓

Scoring 2 for a heart rate above 100, 1 for slow and weak respiratory effort, 1 for some flexion, 1 for a grimace, and 1 for acrocyanosis totals 6. Awarding 2 for color is the common error: a pink body with blue hands and feet scores 1, and only a completely pink newborn scores 2.

A nurse is evaluating a new parent's understanding of safe infant sleep. Which statement indicates that the teaching was effective?

• a.My baby will sleep in our bed so I can reach him during the night.
• b.My baby will sleep in his crib with a thin bumper pad around it.
• c.My baby will sleep on his side with a rolled blanket at his back.
• d.My baby will sleep on his back in his own crib in our bedroom.✓

Back sleeping on a firm, flat surface in the infant's own crib or bassinet kept in the parents' room is the recommended arrangement, and room sharing without bed sharing substantially lowers the risk of sleep-related infant death. Side positioning is not protective because infants roll to the stomach, and rolled blankets, bumper pads, and the adult bed all add suffocation and entrapment hazards.

A newborn is delivered to a client whose prenatal laboratory results show a positive hepatitis B surface antigen. Which intervention should the nurse anticipate for this newborn?

• a.Hepatitis B vaccine alone, with the immune globulin held until 2 months of age
• b.Hepatitis B testing of the newborn's cord blood before any product is given
• c.Hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth✓
• d.Hepatitis B immune globulin alone, with the vaccine series begun at 2 months

An infant born to a client who is hepatitis B surface antigen positive needs both active and passive protection, hepatitis B vaccine plus hepatitis B immune globulin, within 12 hours of birth. Giving only one of the two agents, or waiting on cord blood testing, leaves the newborn unprotected during the hours when perinatal transmission is prevented.

A nurse performs developmental screening at a 9-month well-child visit. Which finding should the nurse report to the provider for further evaluation?

• a.The infant cries when a stranger holds her.
• b.The infant cannot sit without support.✓
• c.The infant is not yet walking across the room.
• d.The infant has not said a clear first word yet.

Sitting without support is a CDC movement milestone for 9 months, so an infant who cannot do it needs further evaluation. Being shy or fearful with strangers is an expected 9-month social milestone, and walking independently and saying a first special name are milestones for later ages, so their absence at 9 months is not a red flag.

A nurse is counseling the parent of a 7-month-old who has started eating solid foods. Which statement by the parent requires correction by the nurse?

• a.I give him soft cooked vegetables cut into small pieces.
• b.I keep offering breast milk along with his new solid foods.
• c.I offer him iron-fortified cereal thinned with breast milk.
• d.I dip his pacifier in honey when he is fussy about teething.✓

Honey, including honey placed on a pacifier, can contain Clostridium botulinum spores and must not be given to a child younger than 1 year because of the risk of infant botulism. Iron-fortified cereal, soft cooked vegetables in small pieces, and continued breast milk alongside complementary foods are all appropriate at 7 months.

The parent of a healthy 4-year-old who weighs 40 pounds tells the nurse she plans to move the child from a forward-facing car seat to a booster seat this week. Which response by the nurse is correct?

• a.Move her to a booster now, because 4 years is the age for a booster seat
• b.Keep her in the harnessed seat until she outgrows its height or weight limit✓
• c.Move her to a booster in the front seat so the shoulder belt fits her
• d.Move her back to a rear-facing seat until she turns 5 years of age

CDC guidance is to keep a child in a forward-facing seat with a harness and top tether until the child reaches the manufacturer's maximum height or weight limit, which for most children is well past age 4, so age alone does not trigger the move to a booster. Children stay buckled in the back seat until age 13, so moving her to the front seat is not an option.

The parent of a healthy 2-year-old tells the nurse she worries her son is behind the other children at his daycare. Which behavior should the nurse identify as an expected milestone for his age?

• a.He names several colors when shown a set of blocks
• b.He puts two words together, such as saying 'more milk'✓
• c.He tells a stranger his own first name when asked
• d.He draws a person with three or more body parts

Saying at least two words together, such as 'more milk,' is a CDC language milestone for 2 years, so this child is on track. Giving one's own first name on request belongs to the 3-year list, and naming colors and drawing a person with three or more body parts are 4-year milestones, so their absence at 2 years is expected.

An 8-year-old is hospitalized for two weeks in traction after a femur fracture. Which nursing action best supports this child's psychosocial development?

• a.Limit visits from classmates so that he can rest and recover faster
• b.Encourage his parents to make his daily care choices for him for now
• c.Arrange schoolwork and let him finish projects he can show others✓
• d.Offer a choice of two pajama colors to give him a sense of control

A school-age child is in Erikson's industry versus inferiority stage, so chances to complete tasks and be recognized for accomplishments protect self-esteem during a long admission. Simple either-or choices are what a toddler working on autonomy needs, and removing peer contact and decision making both deepen a sense of inferiority.

A school nurse is planning a health education session for parents of fifth graders. Which physical activity recommendation should the nurse present for children this age?

• a.150 minutes of moderate activity spread across the whole week
• b.20 minutes of vigorous activity on three or four days each week
• c.30 minutes of moderate activity on at least five days each week
• d.60 minutes or more of moderate-to-vigorous activity every day✓

CDC guidance for ages 6 through 17 is at least 60 minutes of moderate-to-vigorous physical activity daily, including vigorous, muscle-strengthening, and bone-strengthening activity on at least 3 of those days. The 150-minutes-per-week figure is the adult aerobic target and understates what school-age children need.

A 38-year-old client already walks briskly for 30 minutes on five days each week. Which addition should the nurse recommend so the client meets the physical activity guidelines for adults?

• a.Muscle-strengthening activity on at least two days each week✓
• b.Balance training on at least three days of each week
• c.An additional 150 minutes of brisk walking spread over the week
• d.Static stretching before and after each walking session

CDC guidance for adults is 150 minutes of moderate-intensity aerobic activity per week plus muscle-strengthening activity on 2 or more days a week; this client already meets the aerobic target and is missing only the strengthening component. Balance training is emphasized for older adults at risk of falling, and stretching does not count toward either requirement.

During a routine visit, a 34-year-old client screens positive for risky drinking on a validated alcohol screening tool and has no signs of alcohol dependence. Which action should the nurse take?

• a.Refer the client directly to an inpatient medical detoxification unit
• b.Reassure the client that a daily drink carries no health risk
• c.Provide a brief behavioral counseling intervention about drinking✓
• d.Repeat the screening tool at the client's visit in twelve months

USPSTF recommends screening adults 18 and older for unhealthy alcohol use and providing brief behavioral counseling to those who screen positive for risky or hazardous drinking, which is exactly this client's result. Inpatient detoxification is aimed at withdrawal risk in dependence, and postponing the conversation for a year forgoes the intervention the screening was done to trigger.

A nurse is planning care for a 74-year-old who lives alone and has fallen twice in the past year. Which intervention has the strongest preventive evidence for this client?

• a.Set up a bed alarm in the client's home each night
• b.Advise the client to limit walking outside the home
• c.Enroll the client in a supervised exercise program✓
• d.Arrange a weekly telephone check from clinic staff

USPSTF gives exercise interventions a B recommendation to prevent falls in community-dwelling adults 65 years or older who are at increased risk, and two falls in the past year establishes that risk. Restricting walking is counterproductive because deconditioning raises fall risk, while alarms and telephone checks may detect a fall but do nothing to prevent one.

A home health nurse visits an 80-year-old who walks with a rolling walker and reports poor night vision. Which finding in the home should the nurse address first?

• a.A pill organizer refilled by a neighbor each Sunday
• b.Expired canned goods stored in a kitchen cupboard
• c.Loose throw rugs along the hallway to the bathroom✓
• d.A cordless telephone kept in the living room only

Loose rugs in the path a walker must cross are the immediate fall hazard for a client with an assistive device and poor night vision, and removing them is a first-line home modification alongside better lighting and clutter reduction. The other findings deserve follow-up, but none of them is likely to put this client on the floor tonight.

A 41-year-old client with no personal or family history of breast cancer asks when she should begin screening mammograms. Which response by the nurse reflects current USPSTF guidance?

• a.Begin now and repeat the mammogram every two years through age 74✓
• b.Begin at age 50 and repeat the mammogram every two years to 74
• c.Begin at age 45 and repeat the mammogram every year until age 54
• d.Begin screening now and repeat the mammogram every year to age 74

USPSTF recommends biennial screening mammography for women aged 40 to 74 years, so an average-risk 41-year-old should start now and be screened every other year. Annual screening and a start age of 50 reflect other organizations' guidance or the superseded 2016 USPSTF statement rather than the current recommendation.

A nurse is reviewing preventive services for a 4-year-old at a well-child visit. Which screening does USPSTF recommend for a child of this age?

• a.Vision screening to detect amblyopia and its risk factors✓
• b.Depression screening with a standardized adolescent tool
• c.Scoliosis screening of the spine in a forward bend position
• d.Hearing screening repeated at every visit from age 3 to 5

USPSTF recommends vision screening at least once in all children aged 3 to 5 years to detect amblyopia or its risk factors, and concludes evidence is insufficient for children younger than 3. Depression screening is the tempting choice, but its B recommendation begins at age 12, and neither repeated preschool hearing screening nor scoliosis screening at this age is a USPSTF recommendation.

A nurse is setting up preventive services at a school-based health center. For which group does USPSTF recommend routine screening for major depressive disorder?

• a.Students of any age each school year
• b.Children 8 to 11 years of age
• c.Adolescents with a prior diagnosis only
• d.Adolescents 12 to 18 years of age✓

USPSTF gives a B recommendation to screening adolescents 12 to 18 years for major depressive disorder and an I statement for children 11 years and younger, where the evidence is insufficient. Screening is intended for students without a recognized diagnosis, so limiting it to those already diagnosed would defeat its purpose.

A client at her first prenatal visit reports regular 28-day cycles and states that her last menstrual period began on August 1, 2026 and that the flow lasted five days. Using Naegele's rule, which estimated date of delivery should the nurse record?

• a.May 1, 2027
• b.May 8, 2027✓
• c.May 12, 2027
• d.April 24, 2027

Naegele's rule is applied to the first day of the last menstrual period: August 1, 2026 plus 1 year and 7 days, minus 3 months, gives May 8, 2027, which is also the 280th day after that date. Counting from the last day of the flow rather than the first day, subtracting the 7 days instead of adding them, or leaving the 7 days out altogether are the three errors that produce the other dates.

A community health nurse visits a family whose 2-year-old lives in a house built in 1955 that is being repainted. Which teaching addresses this child's greatest environmental risk?

• a.Keep the child away from paint chips and dust during the work✓
• b.Wash the child's hands after outdoor play in the fenced yard
• c.Give the child a calcium supplement during the renovation work
• d.Keep the child's bedroom window open while the work is done

Paint in a home built before 1978 should be assumed to contain lead, and lead-contaminated paint chips and dust generated during renovation are the major source of childhood lead exposure, so keeping a child younger than 6 out of the work area is the priority teaching. Opening a window does not control settled dust, and no supplement substitutes for removing the exposure itself.

A 54-year-old client waiting for breast biopsy results tells the nurse, 'I keep imagining the worst thing they could tell me.' Which response by the nurse is therapeutic?

• a.Tell me more about what you have imagined.✓
• b.Try not to dwell on it before you know.
• c.Has your family arranged a ride home for you?
• d.Why let yourself think that way now?

Inviting the client to say more about the specific fear is an open, exploring response that keeps her talking about her own experience. Telling her not to dwell on it minimizes the fear, 'why let yourself think that way' asks her to justify a feeling, and the question about a ride home changes the subject.

A client whose permanent colostomy was created four days ago turns away during the pouch change and says, 'My wife is not going to want to be near me now.' Which response by the nurse is therapeutic?

• a.Your wife has visited every day, so she clearly still cares.
• b.You sound worried about how your wife will see you.✓
• c.Are you able to look at the stoma without feeling upset?
• d.Ask your wife to join the next teaching session.

Restating the client's concern as a feeling is reflection, and it invites him to expand on the fear he just raised. Pointing to the visits is false reassurance, telling him to bring his wife to teaching is advice rather than exploration, and a yes-or-no question about looking at the stoma limits him to one word.

A nurse manager listens while a newly hired nurse interviews a client who stopped taking a prescribed antihypertensive. Which statement by the new nurse requires follow-up by the manager?

• a.Walk me through a usual day with your medicines.
• b.Why did you decide to stop taking the medication?✓
• c.Tell me what you noticed after your last refill.
• d.What was going on around the time that you stopped?

A 'why' question asks the client to justify a decision and typically produces defensiveness or silence instead of history, so it is the statement the manager must address. The other three are open invitations that gather the same information without putting the client on the defensive.

A home health nurse visits an 84-year-old client who lives with an adult child. Which finding most strongly suggests neglect?

• a.The client keeps a cane beside the recliner and walks slowly.
• b.The client is dehydrated and has a stage 3 sacral pressure injury.✓
• c.The client has a bruise on the shin from bumping a coffee table.
• d.The client's child manages the mail and pays the household bills.

Neglect is the failure to meet an older adult's basic needs for food, water, hygiene, and medical care, and dehydration together with an advanced pressure injury shows those needs went unmet. Handling a parent's mail is not by itself financial exploitation, and a shin bruise with a matching explanation or a cane in regular use are ordinary findings.

An emergency department nurse cares for a 3-year-old who has spiral fractures of both forearms, and the caregiver's account of the injury changes twice during the visit. What should the nurse do?

• a.Wait for the radiologist to confirm the fracture pattern.
• b.Confront the caregiver about the changing account.
• c.Collect photographs of the injuries before reporting.
• d.Report the suspicion to child protective services.✓

A nurse is a mandated reporter and the legal threshold is reasonable suspicion, so the report is made now; confirming abuse is the investigating agency's job, not the nurse's. Gathering photographs or waiting for a radiology reading builds a case the nurse is not required to build and delays a report the nurse must personally make, and confronting the caregiver can place the child at greater risk.

A clinic nurse suspects intimate partner violence in a 29-year-old client whose partner answers every question for her and will not leave the room. Which action should the nurse take first?

• a.Ask the partner to describe how the injuries happened.
• b.Give the client a shelter brochure to take home.
• c.Interview the client alone in a private room.✓
• d.Document that the partner appears to be controlling.

Screening only produces a truthful answer when it happens in a safe, private setting, so separating the client from the partner comes before any other step. A brochure carried home can be found by the partner and increase danger, and questioning the partner or charting an impression never obtains the client's own account.

A client hospitalized for pancreatitis reports the last alcoholic drink was three days ago. The client is now disoriented to place, grabbing at objects that are not there, temperature 38.4 C (101.1 F), heart rate 128. Which action should the nurse take first?

• a.Apply soft wrist restraints to stop the grabbing.
• b.Dim the lights and let the client rest undisturbed.
• c.Reorient the client and recheck the vital signs in an hour.
• d.Notify the provider of alcohol withdrawal delirium.✓

Disorientation with hallucinations, fever, and tachycardia appearing more than 48 hours after the last drink describes delirium tremens, which is treated urgently with benzodiazepines and carries mortality up to about 37% when untreated, so the provider is told now. Reorienting and rechecking in an hour delays that treatment, and darkness or restraints address neither the autonomic instability nor its cause.

A client with long-standing alcohol use disorder is admitted with confusion, nystagmus, and an unsteady gait. Orders include IV thiamine and IV dextrose 5% in water. Which action by the nurse is correct?

• a.Ask the provider to switch to oral thiamine.
• b.Hold the thiamine until the gait is retested.
• c.Start the dextrose first to lift the confusion.
• d.Give the thiamine before the dextrose.✓

Confusion, abnormal eye movements, and ataxia are the classic triad of Wernicke encephalopathy from thiamine deficiency, and glucose oxidation consumes the thiamine that remains, so parenteral thiamine goes in first. Delaying it for another gait check or switching to an oral dose delays the only treatment that prevents the permanent memory loss of Korsakoff syndrome, which follows in about 80% of untreated survivors.

Fourteen hours after admission a client has dilated pupils, runny nose, gooseflesh, repeated yawning, abdominal cramping, and three loose stools. Which condition do these findings indicate?

• a.Anticholinergic toxicity
• b.Neuroleptic malignant syndrome
• c.Opioid overdose toxicity
• d.Opioid withdrawal syndrome✓

Dilated pupils with rhinorrhea, piloerection, yawning, cramping, and diarrhea are the autonomic and gastrointestinal signs scored on the Clinical Opiate Withdrawal Scale. Opioid toxicity produces the opposite pupil finding, pinpoint pupils with respiratory depression, and anticholinergic toxicity dilates pupils but dries secretions and slows the gut instead of causing rhinorrhea and diarrhea.

A nurse screens a 38-year-old male client for risky alcohol use at a community clinic. Which report by the client meets the definition of binge drinking and calls for a fuller assessment?

• a.Six beers within three hours at a Saturday cookout✓
• b.One beer with dinner on most evenings of the week
• c.Two glasses of wine on Friday and two more on Sunday
• d.Three beers spread across an entire weekend camping trip

The CDC defines binge drinking as five or more drinks for a man on a single occasion, so six beers in three hours is a positive screen and warrants a fuller assessment of the client's drinking. One beer with dinner most evenings stays within the moderate-drinking limit of two drinks in a day for men and is not a binge episode.

A client with moderate Alzheimer disease becomes upset at the dinner table and insists she must leave to pick up her children from school. Which response by the nurse is most appropriate?

• a.Ask her why she believes school is letting out right now.
• b.Explain that her children are grown adults with families.
• c.Tell her to sit down and finish the meal before leaving.
• d.Acknowledge her worry and walk with her down the hall.✓

Guidance for dementia care is to stay calm, avoid arguing or correcting, and redirect, because the person cannot reason her way out of the belief and being corrected increases distress. Telling her the children are grown argues with the illness, a 'why' question demands reasoning she no longer has, and a command escalates the agitation.

A 19-year-old admitted with anorexia nervosa and a body mass index of 13 begins nutritional rehabilitation. Which laboratory value should the nurse monitor most closely during the first 72 hours?

• a.Serum bilirubin level
• b.Serum amylase level
• c.Serum uric acid level
• d.Serum phosphorus level✓

Hypophosphatemia is the hallmark of refeeding syndrome: reintroduced carbohydrate triggers insulin release that drives phosphate into cells, and the resulting deficit can cause cardiac and respiratory failure. High-risk clients have phosphorus checked before feeding and about every 12 hours for the first three days, while bilirubin, uric acid, and amylase do not track this risk.

During a screening on a medical unit, a client states a plan to overdose on the bottle of sleeping pills in the bag at the bedside. Which action should the nurse take first?

• a.Place the client on hourly safety checks.
• b.Schedule a psychiatric consult for morning.
• c.Ask the client to sign a no-harm contract.
• d.Stay with the client and secure the pills.✓

A client with a specific plan and the means within reach cannot be left alone; continuous observation combined with removing the means is the immediate intervention, and the urgent mental health evaluation follows. Hourly checks leave unwatched intervals, a morning consult delays an evaluation needed now, and no-harm contracts have not been shown to keep clients safe.

A client assessed as high risk for suicide is admitted to a medical unit that is not ligature resistant and is awaiting transfer to a behavioral health facility. Which action best reduces the environmental risk?

• a.Remove cords, belts, and glass items from the room.✓
• b.Let the family keep personal belongings at the bedside.
• c.Close the door so the client has a quiet space to rest.
• d.Assign the room farthest from the nurses' station.

In a setting that is not ligature resistant the expectation is an environmental risk assessment, removal of objects that could be used for self-harm, and continuous monitoring in a safe location while the client waits for transfer. A distant room and a closed door both reduce observation, and leaving belongings at the bedside leaves the means available.

A nurse meets with a client in the emergency department two hours after the client's home and belongings were destroyed by a fire. The client is tearful and says she does not know what to do next. Which nursing action reflects crisis intervention?

• a.Explore how losses in her childhood shaped this reaction
• b.Help her decide where she will sleep for two nights✓
• c.Begin insight-oriented therapy to change her personality
• d.Postpone planning until she meets a therapist next week

Crisis intervention is short-term work that steadies the client and returns her toward her baseline, so helping her settle a concrete, immediate problem such as where she will sleep tonight is the action that fits. Exploring childhood losses is insight-oriented work belonging to longer-term therapy and does nothing about the practical problem she faces in the next few hours.

A nurse is planning care for a client who has told the admitting nurse that a religious observance important to the client falls during this hospital stay. Which action best incorporates the client's beliefs into the plan of care?

• a.Ask the client which practices to include this week.✓
• b.Ask a relative what the client's community usually does.
• c.Consult a reference describing that faith's dietary rules.
• d.Follow the unit's standard plan for clients of that faith.

People differ within any religious or cultural group in which practices they keep and how strictly, so the client is the only reliable source and asking directly is what individualizes the plan. A standard plan for a faith, a relative's account, and a reference book each substitute an assumption about the group for this client's stated preference.

The adult children of a dying client sit silently at the bedside because their father no longer responds to them. Which instruction should the nurse give the family?

• a.Wait for the chaplain before you say your goodbyes.
• b.Step out until he shows a response to your voices.
• c.Talk to your father as though he can still hear you.✓
• d.Discuss his care in the hallway where he cannot hear.

Families are encouraged to speak to a dying person as if the person can hear them, because awareness of others may persist after responsiveness is lost, and voice, touch, and presence are the comfort measures still available. Leaving the room or waiting for someone else removes the family at the point their presence matters most.

A hospice client who is close to death has loud, wet-sounding respirations. The spouse asks whether the client is drowning. Which nursing action is most appropriate?

• a.Suction the oropharynx deeply whenever the sound returns.
• b.Reposition the client and explain that the sound is expected.✓
• c.Seat the spouse in the hallway until the sound settles.
• d.Increase the intravenous fluid rate to thin the secretions.

Secretions pooling in the airway near death do not appear to distress the client but are frightening to the family, so repositioning plus a plain explanation is the intervention; drug trials for this symptom have been negative. Deep suctioning is traumatic and the sound returns, and extra intravenous fluid in the final days increases the secretions.

Three weeks after her husband's death, a client tells the nurse she cries in waves that pass after about half an hour and that her sleep is broken. She is eating normally and has returned to work. Which action is appropriate?

• a.Tell her the crying should have stopped by now.
• b.Request an antidepressant prescription for the client.
• c.Acknowledge these as usual features of early grief.✓
• d.Refer her for prolonged grief disorder treatment.

Waves of intense sadness lasting twenty to thirty minutes, disturbed sleep, and yearning are ordinary in the first weeks of bereavement and generally ease over the following months, so the nurse normalizes and supports. Prolonged grief disorder is diagnosed when impairing grief persists roughly a year after the death, and antidepressants alone have little effect on grief intensity.

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.

A nurse must give three oral medications through a client's gastrostomy tube during a continuous tube feeding. Which action is correct?

• a.Give the three medications one after another without flushing between
• b.Add the three medications to the enteral formula bag before hanging it
• c.Give each medication separately, flushing with water between them✓
• d.Mix the three medications and give them in one syringe

ISMP and ASPEN direct the nurse to stop the feeding, flush the tube with water before, between, and after each medication, and prepare and give each medication separately, because combining drugs in one syringe creates a mixture whose compatibility no one has established and is a leading cause of tube occlusion. Adding medications to the formula bag is specifically warned against, since drug-nutrient interactions and blockage follow.

A nurse is giving an intramuscular vaccine in the deltoid to an adult woman who weighs 230 lb (104 kg). Which needle should the nurse select?

• a.A 22- to 25-gauge needle, 1.5 inches long✓
• b.A 20- to 22-gauge needle, 2 inches long
• c.A 23- to 25-gauge needle, 5/8 inch long
• d.A 22- to 25-gauge needle, 1 inch long

CDC's needle-length table specifies a 22- to 25-gauge, 1.5-inch (38 mm) needle for an intramuscular deltoid injection in a woman weighing more than 200 lb, because the needle has to pass through subcutaneous fat and reach muscle. The 1-inch needle is the length listed for adults up to about 152 lb and is the most tempting choice, but at this weight it risks depositing the vaccine subcutaneously, where absorption and the immune response are poorer and local reactions are more common; the 5/8-inch, 23- to 25-gauge needle is the subcutaneous specification.

A nurse is giving a deep intramuscular injection of a dark, staining medication whose label directs that it be given by Z-track. Which action is part of this technique?

• a.Press the skin down over the site and apply a pressure dressing afterward
• b.Displace the skin and tissue laterally, hold it during the injection, then release✓
• c.Pinch the skin and tissue upward and release it just before the needle comes out
• d.Stretch the skin taut over the site and massage the area firmly afterward

The iron dextran labeling describes Z-track as displacement of the skin laterally before injection, and the tissue is held displaced until after the needle is withdrawn so the layers slide back over one another and seal the needle track, which keeps a staining or irritating drug from leaking up into subcutaneous tissue. Pinching tissue upward is the subcutaneous technique, and massaging the site afterward is the most tempting wrong step because it is routine for some injections: here it pushes drug back along the track that the technique was meant to close.

A client with COPD received a scheduled dose of an inhaled short-acting bronchodilator 15 minutes ago. Which finding best indicates the intended response?

• a.The client's oral temperature has fallen from 38.1 C to 37.2 C since the dose
• b.The client reports that the mouth feels less dry than it did before the dose
• c.The client's heart rate has risen from 78 to 96 beats per minute since the dose
• d.The client speaks a full sentence without pausing, and wheezing has decreased✓

A short-acting bronchodilator is given to open the airways, so the evidence that it worked is an airway finding: less wheezing and enough breath to finish a sentence. The rise in heart rate is the most tempting distractor because it is a real, measurable change caused by the drug, but tachycardia is a beta-adrenergic side effect rather than the therapeutic goal, and temperature and mouth dryness measure outcomes the drug was not given to change.

A nurse is orienting a newly hired nurse to the administration of intravenous potassium chloride from a concentrate vial. Which statement by the newly hired nurse indicates correct understanding?

• a.I will give it only as a diluted infusion controlled by a pump.✓
• b.I will push the concentrate slowly over five minutes into a large vein.
• c.I will infuse it undiluted through a central line to protect the veins.
• d.I will regulate the diluted infusion by gravity and count the drip rate.

Potassium chloride concentrate must be diluted before use and infused at a controlled rate, because direct injection of the concentrate may be instantaneously fatal. Giving the concentrate by push or infusing it undiluted through a central line both deliver an undiluted bolus, and gravity tubing cannot guarantee the rate limit.

A client is prescribed 8 units of NPH human insulin and 4 units of regular human insulin, to be mixed in one syringe and given subcutaneously. Which action should the nurse take?

• a.Draw the NPH insulin into the syringe before the regular insulin.
• b.Draw the NPH insulin first and roll the filled syringe between the palms.
• c.Draw the regular insulin first and store the filled syringe for one hour.
• d.Draw the regular insulin into the syringe before the NPH insulin.✓

Both manufacturers' labelling states that when regular human insulin is mixed with NPH, the regular insulin is drawn into the syringe first and the injection is given immediately after mixing. Drawing NPH first risks carrying the cloudy suspension back into the clear regular vial, and holding the mixed syringe for an hour ignores the instruction to inject immediately.

A client's prescriptions include insulin glargine at bedtime and insulin lispro before meals. The bedtime dose is due. Which action should the nurse take?

• a.Add the glargine to the running intravenous fluid at bedtime.
• b.Give the glargine in its own syringe, not mixed with another insulin.✓
• c.Mix the glargine with the lispro dose, drawing the lispro up first.
• d.Dilute the glargine with sterile water before drawing the dose.

Insulin glargine labelling directs that it not be diluted or mixed with any other insulin or solution, and that it not be given intravenously, so it is drawn and injected on its own. The lispro is a separate subcutaneous injection, not a syringe partner.

A client on day 6 of a continuous IV heparin infusion has a platelet count of 68,000/mm3; the count before therapy was 210,000/mm3. Which action should the nurse take?

• a.Continue the infusion and request an order for protamine sulfate.
• b.Hold the infusion and report the platelet count to the provider.✓
• c.Continue the infusion and recheck the platelet count in 24 hours.
• d.Slow the infusion by half and apply a pressure dressing to the site.

Heparin labelling directs that heparin be promptly discontinued and the client evaluated for heparin-induced thrombocytopenia if the platelet count falls below 100,000/mm3, so the nurse holds the drug and reports the value. Continuing or merely slowing the infusion leaves the client exposed to the antibody-mediated thrombosis that makes this reaction dangerous.

A client has an indwelling epidural catheter for postoperative analgesia and is receiving subcutaneous enoxaparin. Which finding requires immediate follow-up?

• a.A 2-cm bruise at the abdominal injection site.
• b.New numbness of both legs with an inability to void.✓
• c.An aPTT that is unchanged from the pretreatment value.
• d.Mild soreness at the epidural insertion site.

The boxed warning for enoxaparin describes spinal or epidural hematoma that can cause long-term or permanent paralysis, and directs frequent monitoring for neurological impairment; new bilateral leg numbness with urinary retention is that emergency. An unchanged aPTT is expected, because labelling states the aPTT is not adequate for monitoring enoxaparin.

A mechanically ventilated client in the intensive care unit is receiving a continuous vecuronium infusion. Which action should the nurse take?

• a.Reserve sedation for the times when the client's heart rate climbs above 100.
• b.Give sedation and analgesia, because vecuronium does not relieve pain.✓
• c.Withhold the ordered sedation, because vecuronium produces unconsciousness.
• d.Stop the infusion each shift to assess the client's pain verbally.

Vecuronium labelling states the drug has no known effect on consciousness, the pain threshold, or cerebration, and that administration must be accompanied by adequate anesthesia or sedation. A paralyzed client cannot report pain, so waiting for a verbal report or for a rise in heart rate leaves the client aware and untreated.

During a peripheral infusion of vincristine, a client reports burning at the IV site, and the nurse finds swelling and no blood return. Which action should the nurse take first?

• a.Stop the infusion, leave the catheter in, and aspirate residual drug.✓
• b.Slow the infusion and raise the arm above the level of the heart.
• c.Remove the catheter and apply firm pressure over the swollen area.
• d.Flush the catheter with 10 mL of 0.9% sodium chloride to clear the vein.

Vincristine is a vesicant; the described protocol is to halt and disconnect the infusion while leaving the needle or cannula in position and gently aspirating the extravasated solution without flushing the line. Flushing pushes more vesicant into the tissue, and pulling the catheter first gives up the access needed to aspirate.

A 76-year-old client takes digoxin and furosemide daily and now reports nausea, poor appetite, and yellow-green halos around lights. In addition to the serum digoxin concentration, which laboratory value should the nurse review?

• a.Serum bilirubin level
• b.Serum albumin level
• c.Serum amylase level
• d.Serum potassium level✓

Digoxin labelling lists hypokalemia, hypercalcemia, and hypomagnesemia as conditions that predispose to digoxin toxicity, and a loop diuretic such as furosemide wastes potassium, so the potassium level is the value that explains toxic symptoms at an ordinary dose. Bilirubin, amylase, and albumin do not change digoxin sensitivity.

A client who takes phenytoin for a seizure disorder has a total serum phenytoin concentration of 27 mcg/mL. Which assessment finding should the nurse expect?

• a.Flushing of the face and neck with itching
• b.Yellow-green halos around bright lights
• c.Nystagmus when the eyes track to the side✓
• d.Coarse hand tremor with repeated vomiting

Phenytoin labelling places the usual therapeutic total concentration at 10 to 20 mcg/mL and states that nystagmus on lateral gaze usually appears at 20 mcg/mL, so a level of 27 mcg/mL should produce it. Yellow-green vision suggests digoxin toxicity, coarse tremor with vomiting suggests lithium toxicity, and upper-body flushing follows a rapid vancomycin infusion.

The pharmacy sends vancomycin 1 g in 250 mL of dextrose 5% in water labelled to infuse over 30 minutes. Which action should the nurse take?

• a.Start the infusion as sent and draw a trough level 30 minutes afterward.
• b.Question the rate, since a dose is infused over at least 60 minutes.✓
• c.Infuse it by gravity and count the drip rate every 15 minutes.
• d.Premedicate with diphenhydramine and infuse the dose over 30 minutes.

Vancomycin labelling directs that each dose be given at no more than 10 mg/min or over a period of at least 60 minutes, because rapid infusion can cause exaggerated hypotension and flushing of the upper body. Premedicating does not make an unsafe rate safe, and a trough drawn immediately after the dose does not address the rate at all.

A client who had a mechanical mitral valve replacement is taking warfarin. Today's INR is 1.6. How should the nurse interpret this result?

• a.Below the target range of 2.5 to 3.5 for a mechanical mitral valve✓
• b.Within the target range of 1.5 to 2.0 for a mechanical mitral valve
• c.Within the target range of 1.6 to 2.5 for a mechanical mitral valve
• d.Above the target range of 1.0 to 1.5 for a mechanical mitral valve

Warfarin labelling sets a target INR of 3.0 with a range of 2.5 to 3.5 for a mechanical mitral valve, so an INR of 1.6 is subtherapeutic and leaves the client at risk for valve thrombosis. The lower ranges offered belong to no labelled warfarin indication; even venous thromboembolism and atrial fibrillation are anticoagulated to 2.0 to 3.0.

A client takes lithium carbonate at 0800 and at 2000. The provider orders a serum lithium level. When should the nurse arrange the blood draw?

• a.Just before the 0800 dose, 8 to 12 hours after the evening dose✓
• b.Just after the 2000 dose, at the end of the dosing day
• c.One hour after the 0800 dose, when absorption is complete
• d.At about 1400, roughly midway between the two scheduled doses

Lithium labelling directs that blood samples be drawn immediately prior to the next dose, 8 to 12 hours after the previous dose, when concentrations are relatively stable. A sample drawn soon after a dose reflects the absorption peak and can look falsely toxic, which may lead to an unnecessary dose reduction.

A client with heart failure takes lisinopril daily and has a new prescription for spironolactone. This morning's serum potassium is 5.9 mEq/L. Which action should the nurse take?

• a.Give both drugs and add an oral potassium supplement at noon.
• b.Hold the spironolactone and report the potassium result.✓
• c.Hold the lisinopril and give the spironolactone as prescribed.
• d.Give the spironolactone and recheck the potassium in 3 days.

Spironolactone is contraindicated in hyperkalemia, and its labelling warns that the risk rises when it is combined with an ACE inhibitor such as lisinopril; a potassium of 5.9 mEq/L is above the upper limit of normal, so the dose is held and reported. Substituting one of the two drugs for the other still adds a potassium-raising agent to an already elevated level.

A client with rheumatoid arthritis is going home on oral methotrexate. Which statement by the client indicates that the teaching about the regimen was effective?

• a.I take one tablet each morning with my breakfast.
• b.I take an extra dose on days my joints ache more.
• c.I have my blood counts checked once a year.
• d.I take the whole dose on one day each week.✓

Methotrexate for rheumatoid arthritis is prescribed once weekly, and the labelling states plainly that mistaken daily use of the recommended dose has led to fatal toxicity, so taking the full amount on a single day of the week shows the teaching took hold. Daily or extra dosing is the dangerous error the warning exists for, and blood counts are followed at least monthly during therapy rather than yearly.

A client with severe preeclampsia is receiving IV magnesium sulfate. The nurse finds the patellar reflex absent, respirations 10 breaths per minute, and urine output 20 mL over the past hour. Which action should the nurse take first?

• a.Stop the magnesium infusion and prepare to give calcium gluconate.✓
• b.Continue the infusion and recheck the patellar reflex in one hour.
• c.Give a 500 mL fluid bolus and recheck the urine output in 2 hours.
• d.Increase the magnesium rate and turn the client onto her left side.

Magnesium sulfate labelling names the presence of the patellar reflex, respirations of about 16 or more per minute, and urine output of 100 mL every 4 hours as indicators of a safe regimen, and directs that an injectable calcium salt be immediately available to counteract magnesium intoxication. Continuing or increasing the infusion while reflexes are gone risks respiratory paralysis.

A client who received naloxone for respiratory depression after a dose of extended-release morphine is now awake with a respiratory rate of 16. Which action should the nurse take?

• a.Restart the morphine infusion at half of the previous rate.
• b.Give the next morphine dose now that the client is awake.
• c.Document the recovery and resume routine shift assessments.
• d.Keep monitoring, since the morphine may outlast the naloxone.✓

Naloxone labelling warns that the duration of action of most opioids may exceed that of naloxone, so respiratory and central nervous system depression can return after an initial improvement and the client needs continued surveillance and possibly repeat doses. Returning to routine assessments or redosing the opioid treats the improvement as permanent.

A postoperative client who received IV midazolam and IV hydromorphone is difficult to arouse with a respiratory rate of 7. Flumazenil is prescribed. Which understanding should guide the nurse's care?

• a.It reverses the hydromorphone and leaves the midazolam fully active.
• b.It reverses both drugs, so no other reversal agent is needed.
• c.It will work only after the hydromorphone has been fully metabolized.
• d.It reverses the midazolam but has no effect on the hydromorphone.✓

Flumazenil labelling states that it reverses the sedative effects of benzodiazepines and does not reverse the effects of opioids, so opioid-related respiratory depression persists and naloxone may still be required. Labelling also directs monitoring for resedation for up to 120 minutes after flumazenil is given.

Fifteen minutes into a transfusion of packed red blood cells, a client has shaking chills, flank pain, dark red urine, and a temperature that has risen from 37.6 C to 39.1 C. Which action should the nurse take first?

• a.Change the infusing solution to lactated Ringer's and continue the unit slowly.
• b.Stop the transfusion and keep the vein open with 0.9% sodium chloride through new tubing.✓
• c.Give the prescribed antipyretic and continue the transfusion at the ordered rate.
• d.Slow the transfusion to 50 mL per hour and recheck the temperature and pulse in 15 minutes.

When a transfusion reaction occurs the transfusion must be discontinued immediately; fresh tubing and 0.9% sodium chloride preserve venous access without delivering any more of the implicated unit, and these findings suggest an acute hemolytic reaction. Lactated Ringer's contains calcium and should not be infused through the same tubing as a citrated blood component.

An 82-year-old client with chronic anemia and heart failure receives 2 units of packed red blood cells over 2 hours. One hour later the client has dyspnea, crackles, jugular venous distention, blood pressure 178/96 mm Hg, and oxygen saturation 87%. Which complication do these findings most suggest?

• a.Transfusion-associated circulatory overload✓
• b.Acute hemolytic transfusion reaction
• c.Febrile nonhemolytic transfusion reaction
• d.Transfusion-related acute lung injury

Circulatory overload follows volumes or rates the heart cannot accommodate and shows hydrostatic pulmonary edema with hypertension and jugular venous distention, and the elderly and clients with chronic anemia or cardiac disease are at particular risk. Transfusion-related acute lung injury also causes hypoxemia within 6 hours but produces noncardiogenic edema with hypotension rather than the volume-overload picture described.

A nurse is 10 minutes into a client's first intravenous dose of a cephalosporin antibiotic. Which finding requires immediate intervention?

• a.A blood pressure of 126/78 and a pulse of 94
• b.Hoarseness and wheezing with swollen lips✓
• c.A small bruise where the catheter was inserted
• d.A dull headache that began before the infusion

Mucosal swelling together with airway findings such as hoarseness and wheezing minutes after a drug exposure meets the clinical criteria for anaphylaxis, so the infusion is stopped and intramuscular epinephrine, 0.3 to 0.5 mL of the 1:1,000 concentration into the mid-outer thigh, is given without delay; antihistamines are adjuncts whose benefit in anaphylaxis is unproven and they do not protect the airway. The other findings are unremarkable vital signs, a local mark at the insertion site, and a symptom that started before the drug was hung.

A client's continuous parenteral nutrition bag empties and the replacement bag is delayed in the pharmacy. For which complication should the nurse assess this client?

• a.Hypernatremia with dry mucous membranes
• b.Hypercalcemia with severe muscle weakness
• c.Hyperkalemia with peaked T waves on the ECG
• d.Hypoglycemia with diaphoresis and tremor✓

Sudden discontinuation of parenteral nutrition can lead to hypoglycemia, because circulating insulin remains high after the concentrated dextrose infusion stops. The nurse checks a capillary glucose, watches for diaphoresis and tremor, and obtains the replacement solution without delay.

A nurse enters the room of a client using an intravenous patient-controlled analgesia pump and finds the client's daughter pressing the demand button while the client sleeps. Which action should the nurse take?

• a.Stop the daughter and teach that only the client presses the button.✓
• b.Tell the daughter to press it once an hour through the overnight shift.
• c.Thank the daughter for helping the client stay ahead of the pain overnight.
• d.Ask the daughter to press it only when the client moans in pain.

Dosing by anyone other than the client removes the built-in safeguard that a sedated client cannot press the button, and this practice has been documented to cause respiratory depression. Teaching the family before and during therapy that only the client presses the button is the intervention; setting a schedule for the daughter keeps the hazard in place.

A nurse is caring for a client on the first postoperative day after an open abdominal hysterectomy. The nurse records three sets of vital signs: 0800 — heart rate 86, blood pressure 126/74, respirations 16 0900 — heart rate 104, blood pressure 112/70, respirations 20 1000 — heart rate 124, blood pressure 94/72, respirations 26 The abdominal dressing is dry and intact, and the client is restless. Which action should the nurse take?

• a.Assist the client to use the incentive spirometer for the rapid respirations.
• b.Raise the head of the bed and offer oral fluids to correct the dehydration.
• c.Notify the surgeon at once and prepare for intravenous fluid resuscitation.✓
• d.Give the ordered as-needed analgesic and reassess the vital signs in an hour.

A heart rate and respiratory rate that climb while the systolic pressure falls and the pulse pressure narrows from 52 to 22 mm Hg across three sets is the progression of hemorrhagic shock; tachycardia is the first abnormal vital sign, so by the time the pressure drops the blood loss is already large and surgical evaluation cannot wait. A dry dressing does not exclude intra-abdominal bleeding, and using the spirometer treats the fast breathing as a lung problem while the client continues to bleed.

A nurse is monitoring an adult during a colonoscopy performed with intravenous midazolam and fentanyl. The nurse records: 0930 — respirations 14, oxygen saturation 98% on 2 L nasal cannula, end-tidal carbon dioxide 38 mm Hg 0935 — respirations 10, oxygen saturation 94%, end-tidal carbon dioxide 47 mm Hg 0940 — respirations 7, oxygen saturation 87%, end-tidal carbon dioxide 58 mm Hg The client does not respond to a loud voice. Which action should the nurse take first?

• a.Withhold further sedative, open the airway, and increase the oxygen flow.✓
• b.Raise the head of the bed and ask the endoscopist to hurry the procedure.
• c.Apply a nonrebreather mask and continue the planned sedative dosing.
• d.Give intravenous flumazenil and naloxone before any other intervention.

A falling respiratory rate with a rising end-tidal carbon dioxide and a dropping saturation is progressive sedation-related hypoventilation, so the monitoring nurse stops giving sedative, opens the airway, and increases oxygen — measures that work in seconds and are squarely within the nurse's role. Reversal agents have a place if airway support and stopping the drug do not restore ventilation, but giving them first delays the airway maneuver that actually corrects the problem.

A nurse is caring for a client on the second postoperative day after a bowel resection. The nurse records: 1400 — temperature 37.2 °C (99.0 °F), heart rate 92, blood pressure 122/72, respirations 18 1800 — temperature 38.5 °C (101.3 °F), heart rate 114, blood pressure 106/64, respirations 24 2200 — temperature 39.1 °C (102.4 °F), heart rate 128, blood pressure 88/52, respirations 30 The client is drowsy and answers questions slowly. Which action should the nurse take?

• a.Call the rapid response team and obtain a serum lactate and blood cultures.✓
• b.Hold the morning antihypertensive dose and continue hourly observations.
• c.Give the ordered acetaminophen and recheck the temperature in four hours.
• d.Apply a cooling blanket and restrict oral fluids until the fever breaks.

Fever with worsening tachycardia, a respiratory rate of 30, a systolic pressure that has fallen below 100 mm Hg, and new slowed mentation meets sepsis screening criteria, and a lactate plus blood cultures drawn before antibiotics are the time-critical first steps. Treating the temperature alone with an antipyretic leaves the infection and the developing hypoperfusion untreated while the client keeps deteriorating.

A client with type 2 diabetes who takes metformin is scheduled for a contrast-enhanced computed tomography scan this afternoon. The nurse reviews the serum creatinine record: Monday — 0.9 mg/dL Tuesday — 1.5 mg/dL Wednesday (today) — 2.2 mg/dL The estimated glomerular filtration rate today is 38 mL/min/1.73 m². Which action should the nurse take?

• a.Give the metformin with the scan and recheck the creatinine in two weeks.
• b.Give the metformin dose early so that it clears before the contrast is given.
• c.Hold the metformin for 48 hours after the scan but give today's dose now.
• d.Hold the metformin at the time of the scan and report the rising creatinine.✓

The metformin labeling directs that the drug be discontinued at the time of, or before, an iodinated contrast imaging procedure when the estimated glomerular filtration rate is 30 to 60 mL/min/1.73 m², with the filtration rate re-evaluated 48 hours later before restarting, because contrast-associated kidney injury can precipitate lactic acidosis. Holding it only after the scan leaves metformin on board through the period of greatest renal risk, which is exactly the exposure the warning exists to prevent, and the creatinine that has more than doubled in two days is itself an acute change the provider needs to know about before contrast is given.

A nurse is monitoring a client at 39 weeks' gestation who is in active labor. No oxytocin is infusing. The fetal monitor shows a baseline of 140 beats/min with a gradual fall in the fetal heart rate to 110 beats/min whose lowest point occurs after the peak of each contraction, returning to baseline after the contraction ends. Which action should the nurse take first?

• a.Record the pattern and reassess the fetal heart rate in thirty minutes.
• b.Apply a fetal scalp electrode to obtain a clearer tracing of the pattern.
• c.Turn the client onto her side to relieve pressure on the vena cava.✓
• d.Ask the client to begin pushing with the next contraction to speed birth.

A gradual deceleration whose nadir falls after the peak of the contraction is a late deceleration, which reflects uteroplacental insufficiency; the first intrauterine resuscitation measure is maternal repositioning to a lateral or knee-chest position, which relieves caval compression and increases uteroplacental blood flow. Waiting thirty minutes to reassess treats a pattern associated with developing fetal acidemia as though it were benign.

A nurse reviews the electronic fetal monitor strip of a client in active labor. The baseline fetal heart rate is 138 beats/min, variability is 10 beats/min, accelerations are present, and the fetal heart rate falls gradually with each contraction and reaches its lowest point at the same time as the peak of the contraction. Which action should the nurse take?

• a.Place the client in a knee-chest position and call the birth attendant.
• b.Continue the current plan of care and keep monitoring the tracing.✓
• c.Give the client a bolus of lactated Ringer's and apply oxygen by mask.
• d.Prepare the client for an immediate operative birth in the delivery room.

A baseline of 110 to 160 beats/min, moderate variability of 6 to 25 beats/min, accelerations, and decelerations whose nadir coincides with the peak of the contraction describe early decelerations within a Category I tracing, which is normal and calls for no intervention. Early decelerations come from fetal head compression rather than from reduced placental perfusion, so repositioning, fluids, and oxygen would be treating a problem this strip does not show.

A nurse is teaching an adult who is scheduled for an elective knee replacement under general anesthesia about fasting before the operation. Which statement by the client indicates that the teaching has been effective?

• a.I can have a glass of milk up to two hours before my surgery.
• b.I can have a light breakfast up to two hours before my surgery.
• c.I have to stop drinking water at midnight the night before surgery.
• d.I can drink clear apple juice up to two hours before my surgery.✓

Current anesthesia fasting guidance permits clear liquids — water, pulp-free juice, black coffee or tea — until 2 hours before induction, while a light meal requires about 6 hours and milk is not a clear liquid because it slows gastric emptying. The older blanket rule of nothing by mouth after midnight leaves clients needlessly thirsty and dehydrated and is no longer the standard.

A nurse enters a client's room to witness the signature on a surgical consent form. The client says, 'I agreed to this, but I still do not know whether they are taking out the whole gallbladder or only the stones.' Which action should the nurse take?

• a.Stop the signing and ask the surgeon to return to explain the operation.✓
• b.Ask the client's adult daughter to sign the consent form for the client.
• c.Describe the two operations to the client and then witness the signature.
• d.Witness the signature and record the client's questions in the chart.

Disclosing the nature, risks, benefits, and alternatives of a procedure is the responsibility of the clinician who will perform it, and the nurse's signature attests only that the client signed voluntarily; a client who cannot say what operation is planned is not yet informed, so the surgeon must finish the discussion first. The nurse reinforces and clarifies what the surgeon explained but cannot substitute her own explanation for that disclosure, and a competent adult's consent cannot be handed to a relative.

A nurse teaches a client to use an incentive spirometer after upper abdominal surgery. Which statement by the client indicates that the teaching has been effective?

• a.I will blow out hard and fast into the mouthpiece ten times.
• b.I will use the device once each morning before I eat breakfast.
• c.I will inhale slowly and hold the breath for about three seconds.✓
• d.I will lie flat on my back so that my lungs can expand more fully.

Correct technique is a slow, deliberate inhalation through the mouthpiece with a breath hold of at least 2 to 3 seconds at full inspiration, roughly ten breaths every hour while awake, done sitting or standing upright. Blowing out into the device reverses the manoeuvre — the spirometer trains inspiration in order to re-expand collapsed alveoli, not forced exhalation.

A nurse is preparing to transfer clients out of the post-anesthesia care unit. Which client should the nurse recognize as not yet ready to leave the unit?

• a.A client whose shivering resolved after warmed blankets were applied.
• b.A client whose midazolam was reversed with flumazenil ten minutes ago.✓
• c.A client who is awake and oriented with stable vital signs after knee repair.
• d.A client who reports incisional pain of 3 of 10 after receiving morphine.

Flumazenil's effect can wear off before the benzodiazepine it reversed, so the labeling directs monitoring for resedation and respiratory depression for an appropriate period of up to 120 minutes; ten minutes is nowhere near long enough to call the client recovered. Being awake and oriented with stable vital signs, having pain controlled, and having shivering resolve are the expected recovery findings and do not by themselves hold up transfer.

A nurse is preparing to assist with a bedside procedure for which the client will receive moderate sedation. Which action is essential before the first dose of sedative is given?

• a.Confirm that the client's family has received the recovery instructions.
• b.Confirm that the client has emptied the bladder within the past hour.
• c.Confirm that the client's last solid meal was more than two hours ago.
• d.Confirm that oxygen, suction, and reversal agents are at the bedside.✓

Rescue capability — supplemental oxygen, suction, airway equipment, and reversal agents immediately at hand — must be in place before sedation starts, because respiratory depression and airway obstruction are the expected complications and are managed in seconds. A recent solid meal is the opposite of what is wanted, since elective sedation follows roughly a 6-hour fast for solids and 2 hours for clear liquids.

An adult walks into the emergency department reporting crushing chest pressure that started 40 minutes ago. Within what time frame should the nurse ensure that a 12-lead electrocardiogram is obtained and interpreted?

• a.Within 30 minutes of the client's arrival in the department.
• b.Within 10 minutes of the client's arrival in the department.✓
• c.Within 60 minutes of the client's arrival in the department.
• d.After the first troponin result returns from the laboratory.

For anyone with symptoms suggesting acute coronary syndrome, the 12-lead electrocardiogram should be obtained and interpreted by a trained clinician within 10 minutes of arrival, because it is what identifies ST-elevation infarction and starts the clock on reperfusion. Waiting for troponin delays that decision, and a conventional troponin can still be normal in the first hours after symptom onset.

A nurse is about to obtain a capillary blood glucose reading from an adult who has just finished peeling and eating an orange. Which action should the nurse take?

• a.Wait two hours after the fruit, then obtain the capillary blood sample.
• b.Wipe the fingertip twice with an alcohol swab and let it air dry completely.
• c.Draw the sample from the arm above the client's running intravenous line.
• d.Wash the client's hands with soap and water before the fingertip puncture.✓

Sugar left on the skin after handling fruit produces a falsely high capillary glucose, and washing the hands with water is what removes it; in the study that described this effect, wiping the fingertip with an alcohol swab, even repeatedly, did not correct the false elevation. Delaying the test for two hours would return a value that no longer answers the question the provider ordered.

A nurse is caring for a client two hours after a cardiac catheterization performed through the right femoral artery. Which finding requires immediate follow-up?

• a.New flank and back pain with a heart rate that has risen to 118.✓
• b.Bruising and mild tenderness around the femoral puncture site.
• c.A 2 cm area of dried blood on the dressing over the puncture site.
• d.Voiding of 450 mL of clear yellow urine since the procedure ended.

Retroperitoneal hemorrhage after femoral access shows itself as back or flank pain with tachycardia and hemodynamic change, often with no visible swelling at the groin, so an unremarkable-looking site does not rule it out and this combination needs urgent evaluation and imaging. A little dried blood on the dressing and local bruising are common findings that can be watched, and good urine output is reassuring.

A nurse is monitoring a client who had a thoracentesis of the right pleural space thirty minutes ago. Which finding should the nurse report to the provider immediately?

• a.Sudden shortness of breath with absent breath sounds on the right.✓
• b.A dry cough that began as the pleural fluid was being withdrawn.
• c.A small amount of serous drainage seen on the puncture site dressing.
• d.Discomfort at the puncture site rated 3 on a 0 to 10 scale.

Pneumothorax is the most common complication of thoracentesis and appears during or shortly after the procedure as new dyspnea and pleuritic pain with diminished or absent breath sounds over the punctured side; it needs prompt imaging and may require a chest tube. A dry cough as fluid is drawn off and mild soreness at the site are expected and do not indicate a collapsed lung.

A nurse assesses a client four hours after a long leg cast was applied for a tibial fracture. Which finding requires immediate action?

• a.Toes that are pink and warm with capillary refill of about two seconds.
• b.A cast that still feels warm and slightly damp four hours after it was applied.
• c.Reports of itching under the cast at the level of the mid-calf area.
• d.Calf pain that increases with passive toe extension and continues after opioids.✓

Pain out of proportion to the injury that is worsened by passive stretch of the muscles in the compartment and is not relieved by opioids is the earliest reliable sign of acute compartment syndrome; the cast must be released and the surgeon notified, because fasciotomy is time-critical. Pulselessness and pallor are late findings, so pink warm toes with normal capillary refill do not make this pain safe to observe.

A client who had a flexible bronchoscopy with topical lidocaine sprayed to the throat one hour ago asks the nurse for a drink of water. Which action should the nurse take?

• a.Tell the client that oral fluids are withheld until the next morning.
• b.Raise the head of the bed fully and give small sips of cool water.
• c.Test for return of the gag reflex before giving anything by mouth.✓
• d.Give ice chips first because they are less likely to be aspirated.

Topical anesthetic relaxes the pharyngeal and laryngeal muscles and blunts the gag and cough reflexes, so anything swallowed before those reflexes return can be aspirated; the nurse checks that the gag reflex has come back before offering fluids. Ice chips and sitting upright do not restore the protective reflex, and keeping the client fasting until morning is far longer than the anesthetic effect lasts.

A client who had a right modified radical mastectomy with axillary lymph node dissection two years ago now has a continuous IV infusion running in the left antecubital vein. The surgeon's orders state that the right arm is not to be used for venipuncture. The nurse must obtain a venous blood specimen. Which site should the nurse use?

• a.A vein in the left hand, distal to the infusion, 2 minutes after it is paused✓
• b.A vein in the right antecubital fossa, on the arm that has no infusion running
• c.The existing IV catheter in the left arm, drawn back while fluid is infusing
• d.A vein in the left upper arm, proximal to the infusion, while it keeps running

The arm on the side of a mastectomy with lymph node dissection is avoided for venipuncture because lymphatic drainage is impaired, so drawing from the right arm is not an option here. Blood is not drawn proximal to (above) a running infusion because the sample is diluted by the infusate; when the opposite arm is unusable, the accepted alternative is a site distal to the IV after the infusion has been stopped for at least 2 minutes, with the first volume discarded. Pausing the line and drawing immediately is not enough — the infusate has to clear the vein first.

A nurse is performing a single venipuncture to collect a set of blood cultures, a prothrombin time in a light blue sodium citrate tube, and a complete blood count in a lavender EDTA tube. In which order should the nurse fill the containers?

• a.The blood culture bottles, then the lavender EDTA tube, then the light blue citrate tube
• b.The light blue citrate tube, then the blood culture bottles, then the lavender EDTA tube
• c.The blood culture bottles, then the light blue citrate tube, then the lavender EDTA tube✓
• d.The lavender EDTA tube, then the light blue citrate tube, then the blood culture bottles

In the CLSI order of draw, culture bottles are filled first to protect sterility, and the sodium citrate tube precedes the EDTA tube. Filling EDTA before citrate lets EDTA carry over on the needle; EDTA binds calcium and falsely prolongs coagulation results, which is why swapping those two tubes is the most tempting wrong sequence.

A provider orders a urine culture for a client whose indwelling urinary catheter was inserted three days ago. How should the nurse obtain the specimen?

• a.Separate the catheter from the drainage tubing and collect urine from the open end
• b.Clamp the drainage tubing for two hours and then empty the bag into the container
• c.Pour urine collected in the drainage bag into a sterile specimen container at the bedside
• d.Disinfect the needleless sampling port and aspirate fresh urine with a sterile syringe✓

CDC directs that a small volume of fresh urine for urinalysis or culture be aspirated from the needleless sampling port with a sterile syringe after the port is disinfected. Urine standing in the drainage bag is contaminated and yields a misleading culture, and opening the catheter–tubing junction breaks the closed system, which raises the risk of catheter-associated infection.

On postoperative day 2 after open reduction of a femur fracture, a client remains hemodynamically stable with adequate urine output. The indwelling catheter placed in surgery is still draining, and the off-going nurse reports it is being kept because the client is incontinent. Which action should the nurse take?

• a.Replace the catheter and drainage bag now, and again every seven days after that
• b.Irrigate the catheter with sterile normal saline once a shift to keep it draining
• c.Request an order to remove the catheter and start a scheduled toileting plan✓
• d.Keep the catheter in place to protect the surgical incision from urine contact

CDC lists management of incontinence as an inappropriate indication for an indwelling catheter and states that catheters should be left in place only as long as needed, so advocating for removal is the intervention here. Changing catheters and bags at fixed intervals and routine irrigation are both specifically not recommended and do nothing to lower infection risk.

A client is 6 hours into a 24-hour urine collection when the nursing assistant reports that one voiding was accidentally flushed down the toilet. Which action should the nurse take?

• a.Continue the collection and send it with a note that one voiding was not saved
• b.Continue the collection and extend the ending time by 6 hours to make up for it
• c.Discard the collection, restart it, and record a new start time on the container✓
• d.Continue the collection and document the estimated volume of the voiding that was lost

A 24-hour collection measures the total amount of a substance excreted over an exact timed interval, so any voiding that is not in the container makes the total falsely low and the collection must be started over. Estimating or documenting the lost volume is tempting but cannot reconstruct it, and extending the end time changes the interval the result is calculated against.

A nurse teaches a female client how to collect a clean-catch midstream urine specimen at the clinic. Which statement indicates that the teaching was effective?

• a.I'll wipe from front to back, then collect everything I pass from start to finish
• b.I'll hold my labia apart, wipe from front to back, then catch urine from mid-stream✓
• c.I'll wipe from front to back, then catch the last urine after my bladder empties
• d.I'll wipe from back to front, then catch the very first urine that leaves my body

Separating the labia and wiping front to back keeps perineal flora away from the urethral opening, and letting the first portion of the stream clear the urethra before collecting is what makes the specimen midstream. Collecting the first urine washes urethral contaminants straight into the cup, and wiping back to front carries organisms from the anus toward the urethra.

A nurse instructs a client on collecting an expectorated sputum specimen for culture. Which statement by the client indicates a need for further teaching?

• a.I'll rinse my mouth with plain water, then breathe deeply and cough hard
• b.I'll collect it first thing in the morning, before I eat or drink anything at all
• c.I'll keep coughing until I've brought up about a teaspoon of thick material
• d.I'll gargle with my antiseptic mouthwash right before I cough the specimen up✓

Mouthwash and toothpaste contain antimicrobials that alter the organisms in the sample, so the mouth is rinsed with plain water only; that statement shows the teaching did not take. Early-morning collection captures secretions pooled overnight, and roughly 5 mL of thick material from a deep cough distinguishes true sputum from watery saliva.

A nurse is obtaining a throat swab for culture from an adolescent with a sore throat and fever. Which technique should the nurse use?

• a.Rub the swab over the lips, gums, and the front surface of the tongue
• b.Ask the client to swallow, then swab the uvula with light, brief pressure
• c.Rub the swab along the inner cheeks and beneath the tongue for 5 seconds
• d.Rub the swab across both tonsillar areas and the back of the throat✓

Group A streptococcus colonizes the tonsillar pillars and posterior oropharynx, so the swab is rubbed over both tonsillar areas and the back of the throat while avoiding the tongue, teeth, and gums. Sampling the cheeks, gums, or tongue collects normal oral flora and produces a falsely negative culture.

A nurse is obtaining a swab culture from a chronic sacral wound that has purulent drainage on the surface and a rim of dry eschar at one edge. Which action should the nurse take?

• a.Swab the dry eschar at the wound edge, then irrigate with sterile normal saline
• b.Apply an antiseptic to the wound bed, then swab the center of the cleansed area
• c.Irrigate with sterile normal saline, then rotate the swab on viable wound tissue✓
• d.Swab the purulent drainage first, since organisms are most concentrated there

In the Levine technique the wound is first irrigated with normal saline to remove drainage and debris, then the swab is pressed and rotated over about 1 cm of clean, viable tissue so it samples the organisms actually invading the wound. Swabbing exudate or eschar returns surface colonizers rather than the pathogen, and antiseptic kills organisms before they can be cultured.

A client receiving broad-spectrum antibiotics passes a formed, brown stool. The nursing assistant asks whether to send the specimen for Clostridioides difficile testing. Which response by the nurse is correct?

• a.A formed stool is sent because the test detects carriers before diarrhea develops
• b.Only unformed stool from a client who has diarrhea is sent for C. difficile testing✓
• c.A formed stool is sent each day until three specimens have been reported negative
• d.Any stool from a client on broad-spectrum antibiotics goes for C. difficile testing

CDC directs laboratories to test only unformed stool, because a person who is colonized with C. difficile but has no diarrhea will test positive without having infection, and treating that result exposes the client to antibiotics they do not need. For the same reason, testing is not repeated to prove cure after treatment, since the test can stay positive for six weeks or longer.

A nurse has just inserted a small-bore nasogastric feeding tube for a client who is to begin enteral feeding. The nurse aspirates a small amount of cloudy tan fluid that tests at a pH of 5.0. Which action should the nurse take next?

• a.Inject 30 mL of air and listen over the stomach for a rush of air before feeding
• b.Start the feeding, because an aspirate pH of 5.0 confirms placement in the stomach
• c.Keep the tube clamped and unused until a radiograph confirms its full course✓
• d.Advance the tube another 5 centimeters and retest the aspirate pH before feeding

AACN states that placement of a blindly inserted feeding tube must be confirmed with a radiograph visualizing the entire course of the tube before it is first used for feeding or medication; aspirate pH and appearance are supportive bedside checks, not initial confirmation. Auscultating an insufflated air bolus is still taught in many nursing texts, but it cannot distinguish a tube in the stomach from one in the lung or esophagus and AACN directs nurses not to use it.

A client is being discharged after a total hip replacement done through a posterior approach, and the surgeon has prescribed hip precautions for the next six weeks. Which statement by the client indicates that the teaching about protecting the new joint was effective?

• a.I will keep a pillow between my thighs when I turn in bed.✓
• b.I will settle into the low, soft armchair to watch television.
• c.I will bend forward at the waist to pull my own socks on.
• d.I will cross my ankles when I put my feet up to rest.

Keeping a pillow between the thighs holds the operated leg from crossing midline, because adduction combined with flexion past 90 degrees and internal rotation is the position that levers a posterior-approach prosthesis out of its socket. Bending forward at the waist to reach the feet is the most tempting wrong choice since it feels routine, yet it carries the hip far past 90 degrees of flexion, which is exactly why a sock aid and a reacher are supplied at discharge. Discharge instructions also direct the client to sit in a firm chair with the hips higher than the knees and to keep the legs and ankles uncrossed when sitting, standing, or lying down.

A nurse cannot flush a client's percutaneous endoscopic gastrostomy tube and finds it occluded. Which action should the nurse take first?

• a.Push saline firmly through the tube with a 3 mL syringe for greater pressure
• b.Gently push and pull warm water through the tube with a 60 mL syringe✓
• c.Gently push and pull cranberry juice through the tube with a 60 mL syringe
• d.Gently push and pull carbonated cola through the tube with a 30 mL syringe

Warm water instilled with a gentle push-pull motion is the first-line method for an occluded feeding tube. Cranberry juice and cola are widely repeated bedside remedies, but their acidity precipitates the protein in enteral formula and can harden the clog, and a small-barrel syringe generates high pressure that may rupture the tube.

A provider orders knee-high antiembolism stockings for a 78-year-old client. On assessment the nurse finds absent dorsalis pedis pulses, shiny hairless shins, and a documented history of peripheral arterial disease. Which action should the nurse take?

• a.Apply the stockings and assess the feet for warmth every hour
• b.Hold the stockings and discuss the arterial findings with the provider✓
• c.Apply the stockings at night only, while the client is lying flat in bed
• d.Apply a larger size so the stockings sit more loosely on the lower leg

Peripheral arterial disease is a listed contraindication to graduated compression stockings, because external compression on a limb that already has reduced arterial inflow can drive tissue ischemia and skin necrosis. Frequent circulation checks are appealing but do not make a contraindicated device safe, and sizing up simply removes the graduated pressure the stocking exists to deliver.

A client has worn knee-high antiembolism stockings for two days after abdominal surgery. Which finding requires the nurse to remove the stockings and contact the provider?

• a.Faint indentation lines on the calf just after the stockings come off
• b.A report that the stockings feel snug when they are first pulled on
• c.Dry, flaking skin on both heels seen during the morning bath
• d.New numbness of the toes, with cool and dusky skin on that foot✓

New numbness with cool, dusky toes signals that the stocking is compromising arterial perfusion and nerve function distally, so it is removed and the finding is reported. Transient indentation marks, a snug sensation on application, and dry heel skin are expected or minor findings managed with skin care and a recheck of sizing, not with escalation.

A client with a complete spinal cord injury at T4 suddenly reports a pounding headache. The blood pressure is 186/104 mm Hg from a baseline of 104/62 mm Hg, the heart rate is 50, the face and neck are flushed and sweaty, and both legs are cool and pale. Which action should the nurse take first?

• a.Lay the client flat and raise both legs on two pillows
• b.Notify the provider and recheck the pressure in 15 minutes
• c.Sit the client upright and lower both legs below the heart✓
• d.Give the prescribed acetaminophen for the client's headache

These findings are autonomic dysreflexia, an exaggerated sympathetic response to a stimulus below the level of injury that occurs with lesions at or above T6; sitting the client upright with the legs down is the first step because it pools blood in the legs and lowers the pressure within seconds, while the nurse looks for the trigger, most often a distended bladder or a blocked catheter. Lying the client flat with the legs raised drives the pressure higher, and waiting on a provider call or an analgesic leaves a hypertensive emergency that can cause seizure or stroke untreated.

A client with cirrhosis and tense ascites is scheduled for a bedside abdominal paracentesis. Which action should the nurse take immediately before the procedure?

• a.Position the client on the left side with the knees drawn up to the chest
• b.Have the client drink 500 mL of water just before the needle is inserted
• c.Position the client prone with a pillow placed under the abdomen
• d.Have the client empty the bladder just before the needle is inserted✓

The paracentesis needle enters the lower abdomen, and a distended bladder rises into that field, so having the client void immediately beforehand is the specific precaution that prevents bladder perforation. Drinking fluid does the opposite by filling the bladder; the prone and knee-to-chest positions belong to other procedures and do not expose the puncture site.

A client has a chest tube connected to a closed drainage system after a lobectomy. Midway through the shift the nurse observes continuous bubbling in the water seal chamber that was not present earlier. How should the nurse interpret this finding?

• a.The client's lung has fully re-expanded and the tube can now be removed.
• b.Air is leaking into the system between the client and the unit.✓
• c.A clot is obstructing the tubing and blocking fluid from draining.
• d.The prescribed suction level is too low for the size of the pneumothorax.

Continuous bubbling in the water seal chamber signals an air leak, and the nurse traces the tubing from the chest wall toward the drainage unit to locate it. Full lung re-expansion produces the opposite picture, because bubbling and tidaling stop when the pleural space is no longer venting air.

A client's chest tube is accidentally pulled out of the chest wall while the client is being repositioned in bed. What should the nurse do immediately?

• a.Place the end of the dislodged tube into a bottle of sterile water.
• b.Cover the site with a sterile occlusive dressing taped on three sides.✓
• c.Reinsert the tube into the same opening and secure it with wide silk tape.
• d.Seal the site with a sterile occlusive dressing taped on all four sides.

Taping a sterile occlusive dressing on three sides lets trapped air escape through the untaped edge, which prevents a tension pneumothorax; sealing all four sides traps air in the pleural space and can cause the very emergency the dressing is meant to prevent. Submerging the tube end in sterile water is the maneuver for a broken drainage unit, not for a tube that has come out of the client.

A preceptor observes a newly hired nurse caring for a client with a chest tube after thoracic surgery. Which action by the new nurse requires the preceptor to intervene?

• a.Squeezing the tubing hand over hand to move a clot along.✓
• b.Coiling excess tubing flat on the bed with no dependent loops.
• c.Keeping the unit upright and below the level of the client's chest.
• d.Marking the drainage level on the chamber with the date and time.

Stripping or milking chest tube tubing generates extremely high negative intraluminal pressure that can injure lung tissue, so it is not part of routine care. Marking drainage, keeping the unit upright below chest level so gravity drains the pleural space, and avoiding dependent loops are all correct chest tube management.

The nurse is suctioning a client's tracheostomy using an open suction catheter. Which action indicates the nurse needs further instruction on the procedure?

• a.Limiting each suction pass to 15 seconds or less of applied suction.
• b.Allowing the client to recover between passes and using no more than two.
• c.Applying suction while advancing the catheter into the tracheostomy tube.✓
• d.Preoxygenating the client with 100% oxygen for 30 seconds before the pass.

Suction is applied only as the catheter is withdrawn; applying it during insertion removes oxygen from the airway for the whole pass and abrades the tracheal mucosa. Preoxygenation with 100% oxygen, passes of 15 seconds or less, and limiting the number of passes with recovery time between them are all correct technique.

A tracheostomy tube placed surgically two days ago becomes dislodged when the client pulls at the ties. The client is dyspneic and the oxygen saturation is falling. What should the nurse do?

• a.Call for emergency help and ventilate by mask over the face and nose.✓
• b.Reinsert the same tube with the obturator and auscultate the chest.
• c.Place the client in Trendelenburg and wait for the surgeon to arrive.
• d.Pass a suction catheter through the stoma and apply continuous suction.

A tracheostomy tract is not considered mature until roughly five to seven days after surgery, and blind reinsertion into an immature tract can create a false passage in the soft tissue of the neck, causing subcutaneous emphysema and loss of the airway. The nurse oxygenates from above with a bag-valve mask over the mouth and nose while emergency airway support is summoned; reinsertion with an obturator is appropriate only once the stoma is well formed.

The high-pressure alarm sounds on the ventilator of an intubated client who is coughing and has coarse crackles over the large airways. Which action should the nurse take first?

• a.Silence the alarm and increase the set tidal volume by 100 mL.
• b.Reconnect the ventilator circuit at the endotracheal tube adapter.
• c.Deflate the endotracheal tube cuff until the alarm stops.
• d.Suction the endotracheal tube to clear the secretions.✓

A high peak pressure alarm means resistance to airflow has risen, and secretions in a coughing client with coarse breath sounds are a cause the nurse can correct directly by suctioning. The cause of a ventilator alarm is identified before the alarm is silenced, and adjusting the tidal volume or cuff does not remove the obstruction.

An intubated client on a ventilator suddenly desaturates to 84%, and the nurse cannot identify the cause of the alarm after a rapid bedside check. Which action should the nurse take?

• a.Disconnect the ventilator and ventilate by hand with a bag-valve device.✓
• b.Raise the FiO2 setting on the ventilator and recheck in five minutes.
• c.Silence the alarm and observe the client for another three minutes.
• d.Reposition the pulse oximeter probe and repeat the reading in two minutes.

When a ventilated client deteriorates and the cause is not immediately apparent, the client is taken off the machine and ventilated manually with 100% oxygen while displacement, obstruction, pneumothorax and equipment failure are worked through. Adjusting settings or watching the monitor leaves the client dependent on a device that may itself be the source of the failure.

Which intervention should the nurse include in the plan of care for a mechanically ventilated client to reduce the risk of ventilator-associated pneumonia?

• a.Keep the head of the bed elevated 30 to 45 degrees unless it is contraindicated.✓
• b.Position the client flat with the head of the bed lowered to 0 degrees.
• c.Replace the ventilator circuit tubing at the start of every eight-hour shift.
• d.Instill sterile saline into the endotracheal tube before every suction pass.

Elevating the head of the bed to 30 to 45 degrees reduces aspiration of gastric and oropharyngeal secretions, which is the main route by which ventilated clients acquire pneumonia. Lying flat increases that aspiration risk rather than reducing it, and routine circuit changes and saline instillation are not recommended preventive measures.

A nurse cares for a client whose tracheostomy was placed four days ago. During the shift the client's secretions become thick and crusted and are increasingly difficult to clear. Which action should the nurse take?

• a.Restrict the client's oral fluids so that fewer tracheal secretions form
• b.Deliver humidified gas by tracheostomy collar and encourage oral fluids✓
• c.Suction the tracheostomy each hour overnight whether or not it is needed
• d.Loosen the tracheostomy ties so the tube can move freely within the stoma

A tracheostomy bypasses the nose, which normally warms and moistens inspired air, so humidified gas at the tracheostomy collar together with adequate fluid intake is what keeps secretions thin and prevents mucous plugging. Restricting fluids works in the opposite direction and thickens secretions further, and suctioning is done when secretions are present rather than on a fixed hourly schedule.

The nurse observes that the reservoir bag on a client's non-rebreather mask collapses completely each time the client inhales. Which action should the nurse take?

• a.Lower the flow rate so the bag can refill between breaths.
• b.Document the finding as the expected response to inhalation.
• c.Increase the oxygen flow rate until the bag stays partly inflated.✓
• d.Remove the one-way valve between the bag and the mask.

The reservoir bag on a non-rebreather must not fully deflate; a bag that empties on inspiration means the flow is below the client's inspiratory demand, so the nurse raises the flow, generally to 10 to 15 L/min, until the bag remains partly inflated. Lowering the flow or removing a valve would let the client rebreathe exhaled carbon dioxide.

A provider prescribes postural drainage with chest percussion for several clients on a medical unit. For which client should the nurse question the prescription?

• a.A client with cystic fibrosis and thick, tenacious sputum in both lungs.
• b.A client with bronchiectasis who expectorates thick sputum each morning.
• c.A client with COPD and retained secretions in the lower lobes.
• d.A client with multiple rib fractures after a motor vehicle crash.✓

Percussion delivered over a chest wall with recent rib fractures can displace fracture fragments and worsen the injury, so the nurse questions that prescription before carrying it out. Cystic fibrosis, bronchiectasis and retained lower-lobe secretions are exactly the mucus-clearance problems chest physiotherapy is intended to treat.

On the sixth postoperative day after abdominal surgery, a client coughs forcefully and a loop of bowel protrudes through the incision. What should the nurse do first?

• a.Cover the incision with a dry sterile dressing and reposition the client.
• b.Irrigate the exposed bowel with povidone-iodine and cover it with dry gauze.
• c.Cover the bowel with sterile gauze moistened with sterile normal saline.✓
• d.Gently replace the bowel into the abdomen and apply a snug binder.

Evisceration is a surgical emergency, and the nurse keeps the exposed viscera covered with saline-moistened sterile gauze to prevent drying and fluid loss until the surgeon returns the bowel to the abdomen in the operating room. Pushing the bowel back in at the bedside risks perforation and peritoneal contamination, and a dry dressing lets the tissue desiccate.

Six hours after surgery the nurse finds a client's Jackson-Pratt bulb fully expanded and containing 15 mL of serosanguineous drainage. Which action should the nurse take?

• a.Empty and measure the drainage, then compress the bulb and replug it.✓
• b.Notify the surgeon that the drainage system has stopped working properly.
• c.Connect the bulb to low continuous wall suction to restore the vacuum.
• d.Irrigate the drain with 10 mL of sterile normal saline to clear it.

A Jackson-Pratt drain generates its own vacuum from the bulb being squeezed flat and stoppered, so an expanded bulb has simply lost that vacuum; the nurse empties and measures the output, recompresses the bulb, and reseals the port. This is a nursing action rather than a reason to call the surgeon, and the closed bulb system is not attached to wall suction.

A client has a stage 3 pressure injury that soaks through its dressing between scheduled changes. Which dressing should the nurse anticipate applying?

• a.A hydrocolloid dressing left in place for up to five days.
• b.A calcium alginate dressing covered with a secondary pad.✓
• c.A dry woven gauze dressing taped over the wound daily.
• d.A transparent film dressing changed every seven days.

Alginate dressings are highly absorptive and are chosen for wounds producing heavy exudate, drawing fluid away while keeping the wound bed moist. A transparent film has essentially no absorptive capacity, so exudate would pool beneath it and macerate the surrounding skin.

The nurse reviews the record of a client scheduled to begin negative pressure wound therapy. Which finding should the nurse report to the provider before the therapy is started?

• a.The wound was sharply debrided at the bedside yesterday.
• b.The wound bed is covered by adherent black eschar.✓
• c.The wound base has healthy red granulation tissue throughout.
• d.The client ambulates in the hallway three times a day.

Necrotic tissue and eschar must be debrided before negative pressure wound therapy is applied, because the therapy cannot draw granulation tissue up through devitalized tissue and infection can be driven deeper. A wound that has already been debrided and shows red granulation tissue is an appropriate candidate for the therapy.

The nurse assesses a client on the first day after creation of a colostomy. Which finding should the nurse report to the surgeon immediately?

• a.The stoma is beefy red and bleeds slightly when cleansed.
• b.The stoma is dusky purple and dry rather than moist.✓
• c.The pouch contains a small amount of loose brown output.
• d.The peristomal skin is slightly pink under the adhesive edge.

A viable stoma is moist and pink to beefy red; a dusky, purple or black stoma that is dry indicates compromised blood supply and needs immediate surgical evaluation. Slight bleeding when the stoma is cleansed is expected because stomal tissue is highly vascular.

Which statement by a client who is learning to care for a new colostomy indicates that the teaching was effective?

• a.I will empty the pouch when it is about one-third full of stool.✓
• b.I will change the whole pouching system every single morning.
• c.I will cut the barrier opening one inch wider than my stoma.
• d.I will wait until the pouch is completely full to empty it.

Emptying at about one-third full keeps the weight of the effluent from peeling the skin barrier away from the skin and causing leaks. The barrier opening should clear the stoma by only about one-sixteenth to one-eighth of an inch, and the pouching system is generally changed every five to seven days rather than daily.

On the first day after upper abdominal surgery a client has an oxygen saturation of 92%, diminished breath sounds at both lung bases, and reports incisional pain rated 7 out of 10. Which action should the nurse take first?

• a.Give the prescribed analgesic so the client can deep breathe and cough.✓
• b.Collect a sputum specimen and send it for culture and sensitivity.
• c.Lay the client flat and apply oxygen by non-rebreather mask.
• d.Limit oral fluids so that pulmonary secretions do not increase.

Basilar atelectasis after upper abdominal surgery comes from shallow, splinted breathing, and unrelieved incisional pain is what stops the client from taking the deep breaths and coughs that re-expand alveoli, so treating the pain is what makes the pulmonary hygiene possible. Lying the client flat reduces lung expansion further and worsens the underlying problem.

A conscious adult client in the dining room suddenly clutches the throat and is unable to speak or cough. Following current American Heart Association guidance, what should the nurse do?

• a.Encourage forceful coughing and observe until the client becomes unresponsive.
• b.Deliver five back blows, then five abdominal thrusts, and repeat the cycles.✓
• c.Begin chest compressions at once and continue until help reaches the client.
• d.Deliver abdominal thrusts only, repeating them until the object comes out.

The 2025 American Heart Association guidelines direct rescuers to alternate five back blows with five abdominal thrusts for a responsive choking adult until the object is expelled or the person becomes unresponsive; abdominal thrusts alone reflect the older guidance. A client who cannot speak or cough has a complete obstruction, so coughing cannot be encouraged and waiting costs the client oxygen.

While the nurse is changing the injection cap on a client's central venous catheter, the client becomes acutely dyspneic, hypotensive, and confused. After clamping the catheter, what should the nurse do next?

• a.Sit the client upright and have the client bear down forcefully.
• b.Place the client flat in bed and elevate both legs above the level of the heart.
• c.Turn the client onto the right side with the head of the bed elevated.
• d.Turn the client onto the left side with the head of the bed lowered.✓

These findings suggest venous air embolism; the left lateral decubitus position with the head down traps air at the apex of the right ventricle so it cannot obstruct the pulmonary outflow tract, and 100% oxygen is given at the same time. Turning to the right with the head raised does the opposite and helps air move on into the pulmonary circulation.

A client with end-stage kidney disease has a serum potassium of 7.2 mEq/L. The cardiac monitor shows tall peaked T waves and a QRS complex that has widened over the last hour. The provider writes four prescriptions. Which one should the nurse administer first?

• a.Nebulized albuterol by mouthpiece
• b.Intravenous calcium gluconate 10%✓
• c.Intravenous regular insulin with dextrose
• d.Oral sodium polystyrene sulfonate

Calcium does not lower the serum potassium at all; it raises the threshold potential and stabilizes the myocardium, which is what the widening QRS demands right now, so it goes first whenever hyperkalemia has produced ECG changes. Insulin with dextrose genuinely does lower potassium by shifting it into cells, but it works over roughly 15 to 30 minutes and leaves the heart unprotected in the meantime.

A client on long-term furosemide is admitted with a serum potassium of 2.4 mEq/L. After two doses of oral potassium chloride the repeat potassium is 2.5 mEq/L. The nurse notes the serum magnesium is 1.1 mg/dL. Which action should the nurse anticipate?

• a.Switching to an enteric-coated potassium tablet
• b.Replacing magnesium before more potassium✓
• c.Holding potassium until the morning laboratory draw
• d.Doubling the next dose of oral potassium chloride

A serum magnesium of 1.1 mg/dL is below the normal 1.7 to 2.2 mg/dL, and low magnesium drives renal potassium wasting, so potassium replacement stays ineffective until the magnesium is corrected. Giving a larger potassium dose treats the number rather than the reason the number will not rise, and risks overshooting once magnesium is restored and the kidney stops dumping potassium.

A client who was cooled with targeted temperature management after cardiac arrest is now being rewarmed at a controlled rate. Which finding requires the nurse's immediate action?

• a.Blood pressure falls to 76/40 mm Hg✓
• b.Heart rate rises from 52 to 78 beats/min
• c.Urine output of 50 mL in the past hour
• d.Oxygen saturation reads 96% on 4 L/min

Rewarming produces peripheral vasodilation and redistribution of blood volume, so hypotension is the expected complication, and a pressure of 76/40 mm Hg falls below the normal adult range and must be treated at once to protect tissue oxygen delivery. A heart rate moving from 52 to 78 beats/min is the anticipated resolution of hypothermic bradycardia and sits inside the normal 60 to 100 range, while the urine output and oxygen saturation are adequate.

A severely malnourished client with a body mass index of 14 is started on enteral tube feedings. Two days later the nurse reviews new laboratory results. Which value requires the most immediate follow-up?

• a.Serum phosphorus 1.2 mg/dL✓
• b.Serum magnesium 1.9 mg/dL
• c.Serum calcium 9.1 mg/dL
• d.Serum sodium 137 mEq/L

Reintroducing nutrition raises insulin, which drives phosphate into cells, and a phosphorus of 1.2 mg/dL against a normal adult range of 2.8 to 4.5 mg/dL is low enough to cause respiratory muscle failure and arrhythmias. The magnesium, calcium, and sodium values given all sit inside their normal ranges and call for continued monitoring rather than intervention.

A client in the intensive care unit has a blood pressure of 88/50 mm Hg. The nurse calculates the mean arterial pressure (MAP). Rounded to the nearest whole number, what is the client's MAP?

• a.69 mm Hg
• b.38 mm Hg
• c.63 mm Hg✓
• d.75 mm Hg

MAP equals the diastolic pressure plus one third of the pulse pressure: 88 minus 50 is a pulse pressure of 38, one third of 38 is 12.7, and 50 plus 12.7 is 62.7, which rounds to 63 mm Hg. Simply averaging the systolic and diastolic pressures yields 69 mm Hg, adding two thirds of the pulse pressure yields 75 mm Hg, and 38 mm Hg is the pulse pressure itself.

A client being treated for gram-negative sepsis develops oozing from two peripheral intravenous sites and petechiae across the trunk. Laboratory results show a platelet count of 38,000/mcL, a fibrinogen of 90 mg/dL, and a markedly elevated D-dimer. Which complication should the nurse suspect?

• a.Immune thrombocytopenic purpura relapse
• b.Vitamin K deficiency coagulopathy
• c.Disseminated intravascular coagulation✓
• d.Heparin-induced thrombocytopenia type II

Widespread microvascular clotting consumes platelets and fibrinogen while the clots that form are broken down, which is why the platelet count of 38,000/mcL and the fibrinogen of 90 mg/dL are both far below their normal ranges at the same moment the D-dimer is high; sepsis is the single most common trigger. Heparin-induced thrombocytopenia also drops the platelet count, but it causes clotting with a preserved fibrinogen rather than the diffuse oozing seen here.

A nurse responds to a telemetry client who is unresponsive, apneic, and without a palpable carotid pulse. Asystole is confirmed in two leads. Which action should the nurse take?

• a.Give amiodarone 300 mg by IV push
• b.Deliver a synchronized shock at 50 J
• c.Start high-quality chest compressions✓
• d.Deliver an unsynchronized shock at 200 J

Asystole is a nonshockable rhythm, so a shock has no organized electrical activity to terminate; the treatment is uninterrupted high-quality CPR with epinephrine every 3 to 5 minutes while reversible causes are sought. Defibrillation is reserved for ventricular fibrillation and pulseless ventricular tachycardia, and shocking asystole only pulls the rescuer's hands off the chest.

A client on telemetry converts to atrial fibrillation with a ventricular rate of 168 beats per minute. The client is diaphoretic, reports crushing chest pressure, and has a blood pressure of 76/44 mm Hg with a palpable pulse. For which intervention should the nurse prepare the client?

• a.Vagal maneuvers with bearing down
• b.Synchronized cardioversion✓
• c.Unsynchronized defibrillation
• d.Adenosine 6 mg by IV push

The client has a pulse but is hemodynamically unstable, and every unstable tachycardia with a pulse is treated with synchronized cardioversion, which times the shock to the R wave and avoids delivering it on the T wave. Defibrillation is unsynchronized and belongs to pulseless rhythms; used here it risks the R-on-T phenomenon and ventricular fibrillation.

A client on telemetry has a heart rate of 38 beats per minute and a blood pressure of 82/48 mm Hg, reports dizziness, and has cool, clammy skin. Which prescription should the nurse expect the provider to order first?

• a.Adenosine 6 mg IV push
• b.Metoprolol 5 mg by IV push
• c.Transcutaneous pacing at 70
• d.Atropine 1 mg by IV push✓

Atropine 1 mg intravenously is the first-line intervention for symptomatic bradycardia, and transcutaneous pacing is a reasonable second-line measure when atropine does not raise the rate or is unavailable. Metoprolol would slow an already dangerous rate further, and adenosine is used to interrupt fast supraventricular rhythms, not a rate of 38.

A monitor technician calls to report that a telemetry client's rhythm has gone to a flat line. The nurse enters the room and finds the client sitting upright, brushing her teeth, and talking normally. Which action should the nurse take?

• a.Charge the defibrillator to 200 J
• b.Activate the rapid response team
• c.Check the electrodes and lead wires✓
• d.Begin chest compressions immediately

A client who is awake, talking, and moving has a perfusing rhythm, so a flat tracing represents a disconnected or dried-out electrode rather than asystole, and the nurse corrects the equipment problem she can see. Starting compressions or shocking a conscious client causes real injury and does nothing about the loose lead that produced the tracing.

A client has a temporary transvenous pacemaker set at a rate of 70. The nurse sees regular pacing spikes at 70 on the monitor, but most of the spikes are not followed by a QRS complex, and the palpated radial pulse is 44. How should the nurse interpret this finding?

• a.The pacemaker is failing to capture✓
• b.The pacemaker is failing to sense
• c.The pacemaker is oversensing signals
• d.The pacemaker is failing to output

Failure to capture means the impulse is delivered but does not depolarize the myocardium, which is exactly a spike with no QRS after it and a pulse slower than the programmed rate. An output failure would show no pacing spikes at all on the tracing, and failure to sense would show spikes landing on top of the client's own intrinsic beats.

A client is being discharged after implantation of a permanent pacemaker. Which statement by the client indicates that the discharge teaching was effective?

• a.I will stop counting my own pulse now that the device sets the rate.
• b.I will tell any provider about my pacemaker before an MRI.✓
• c.I will give up using the microwave oven in my kitchen from now on.
• d.I will carry my mobile phone in the shirt pocket over the device.

Magnetic resonance imaging can alter the programmed settings and heat the lead tips, so scanning is done only when the device is MRI-conditional and a specific protocol is followed, which makes disclosing the pacemaker beforehand the safest habit. A household microwave oven is not a hazard, the phone is kept on the opposite side of the chest, and the client still checks the pulse and reports a rate below the set rate.

A nurse raises the head of a client's bed and then notices that the arterial line transducer is taped to the IV pole about 10 cm above the client's phlebostatic axis. The displayed arterial pressure has dropped since the position change. Which action should the nurse take?

• a.Notify the provider of the falling arterial pressure
• b.Relevel the transducer to the phlebostatic axis and rezero it✓
• c.Obtain a cuff pressure and chart it in place of the line
• d.Flush the arterial line and repeat the square wave test

A transducer sitting above the phlebostatic axis has a shorter fluid column pressing on it and therefore reports pressures that are falsely low, so releveling to the phlebostatic axis and rezeroing is what restores an accurate number. Escalating a reading produced by transducer position, or substituting a cuff, responds to an artifact instead of correcting it.

A nurse admits a client who has an arteriovenous fistula in the left forearm and receives hemodialysis three times a week. Which direction should the nurse give the unlicensed assistive personnel (UAP) assigned to this client?

• a.Keep the left arm elevated on two pillows.
• b.Apply a warm compress to the fistula.
• c.Take blood pressures in the right arm only.✓
• d.Report any bruit heard over the fistula.

The access arm is kept free of blood pressure cuffs, venipuncture, and intravenous lines because compression and puncture threaten the fistula, so pressures are taken in the opposite arm. A bruit over the fistula is the expected sound of flowing blood; its absence, not its presence, is the finding that must be reported.

Before a scheduled hemodialysis session, a nurse assesses a client's arteriovenous fistula and can no longer palpate a thrill or auscultate a bruit over the site. The client states the arm feels the same as always. Which action should the nurse take?

• a.Chart the finding and continue care
• b.Notify the provider immediately✓
• c.Apply warm soaks to the arm
• d.Recheck the site in four hours

The thrill felt and the bruit heard over a fistula are the evidence that blood is moving through it, so losing both suggests the access has thrombosed and needs urgent evaluation if it is to be salvaged and dialysis is to proceed. A normal-feeling arm is reassuring about perfusion but says nothing about the access, so waiting to reassess or applying heat only spends the time the fistula does not have.

A client who performs continuous ambulatory peritoneal dialysis at home telephones the clinic. Which report requires the most immediate follow-up?

• a.The exit site dressing was changed twice.
• b.The drained fluid is pale straw colored.
• c.The drained fluid has become cloudy.✓
• d.The last outflow took ten minutes longer.

Cloudy effluent is the hallmark of peritoneal dialysis peritonitis, present in nearly every case, and it must be evaluated with a cell count and culture of the drained fluid before the infection worsens. Pale straw-colored effluent is the normal appearance, and a drain that ran slightly long is common and not urgent on its own.

A client with a blood urea nitrogen of 180 mg/dL is receiving a first hemodialysis treatment. Ninety minutes into the session the client develops a headache, nausea, and restlessness and cannot state where he is. The blood pressure is unchanged from baseline. Which complication should the nurse suspect?

• a.Hemolysis of the circulating blood
• b.An intradialytic hypotension episode
• c.Air embolism from the blood circuit
• d.Dialysis disequilibrium syndrome✓

Rapid clearance of urea leaves the brain relatively hyperosmolar compared with the blood, water shifts into brain cells, and the client develops headache, nausea, restlessness, and confusion; a very high starting blood urea nitrogen during a first session is the classic setup. Intradialytic hypotension can also cause nausea and light-headedness, but it is defined by a marked fall in blood pressure, and this client's pressure has not changed.

Forty minutes into a general anesthetic with sevoflurane and succinylcholine, the nurse notes that the end-tidal carbon dioxide has climbed steadily, the heart rate is 148 beats per minute, and the jaw is rigid. The core temperature is 37.4 C (99.3 F). Which action should the team take first?

• a.Treat the tachycardia with IV esmolol
• b.Begin surface cooling with ice packs
• c.Stop the sevoflurane and succinylcholine✓
• d.Recheck the core temperature in 15 minutes

A steadily rising end-tidal carbon dioxide with tachycardia and masseter rigidity is malignant hyperthermia, and because temperature elevation is a late sign the team does not wait for a fever; the triggering volatile agent and succinylcholine are discontinued at once while dantrolene 2.5 mg/kg is drawn up. Cooling and rate control address downstream effects while the trigger keeps driving the hypermetabolic crisis.

A nurse is caring for a client with a severe traumatic brain injury and an intraventricular intracranial pressure monitor in place. Which nursing action best supports control of the client's intracranial pressure?

• a.Keep the head of the bed at 30 degrees, head midline.✓
• b.Place the client in Trendelenburg two hours each shift.
• c.Position the client flat in bed with the neck rotated.
• d.Lower the head of the bed for one hour after each turn.

Elevating the head of the bed to about 30 degrees while keeping the head and neck in neutral midline alignment lets blood drain freely out of the skull through the jugular veins, which lowers cerebral blood volume and intracranial pressure. Flat and head-down positions raise venous pressure inside the head, and rotating or flexing the neck kinks the jugular outflow the position is meant to protect.

A newborn at 40 hours of life is placed under overhead phototherapy for hyperbilirubinemia. Which action by the nurse is correct?

• a.Apply an oil-based lotion to the exposed skin surfaces.
• b.Apply eye shields and leave the newborn in only a diaper.✓
• c.Withhold feedings until the phototherapy ends.
• d.Swaddle the newborn in a light blanket under the lights.

Phototherapy only works on skin the light reaches, so the newborn is undressed to a diaper to maximize the treated surface area, and the eyes are shielded because the light can damage the retina. Swaddling covers the very skin the therapy depends on, and feedings are continued and encouraged because phototherapy increases fluid loss and bilirubin leaves the body in urine and stool.