NCLEX-RN Nursing — All Questions

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 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.