HEALTHSTREAM JANE ASSESSMENT TEST 2026 |
Questions and Answers 2026/2027 | Verified Edition | Nursing
Competency | Pass Guaranteed - A+ Graded
Section 1: Patient Safety & Infection Control (Questions 1-15)
Q1: A nurse is preparing to administer a blood transfusion to a patient. The patient
states, "I think that's my name, but I'm not sure." The wristband is smudged but appears
to match. What is the nurse's priority action?
A. Proceed with the transfusion since the wristband appears to match and the patient is
uncertain
B. Ask the patient to state their date of birth and compare it to the medical record while
verifying the wristband
C. Hold the transfusion and obtain a new wristband with the patient's full cooperation
before proceeding [CORRECT]
D. Ask the patient's roommate to confirm the patient's identity
Correct Answer: C
Rationale: Per HealthStream Patient Safety Standards and The Joint Commission
NPSG.01.01.01, two reliable patient identifiers (name, DOB, or MRN) must be used
before any high-risk procedure. A smudged wristband and patient uncertainty constitute
an identification failure requiring immediate correction. Blood transfusions are
high-alert procedures where identification errors can be fatal. Option B is incorrect
because a compromised wristband cannot serve as a valid identifier. Option A violates
safety protocols. Option D breaches HIPAA and is not a valid identifier.
,Q2: A 78-year-old patient with Parkinson's disease and a history of falls is admitted. The
Morse Fall Scale score is 65. Which intervention is most appropriate for this fall risk
level?
A. Place bed alarm and hourly rounding only
B. Bed alarm, non-slip socks, bed in low position, call light within reach, and hourly
rounding addressing the 4 Ps [CORRECT]
C. Apply bilateral soft wrist restraints to prevent unplanned bed exits
D. Move patient to a room closest to the nurses' station and check every 15 minutes
Correct Answer: B
Rationale: A Morse Fall Scale score ≥50 indicates high fall risk per HealthStream
Competency Module. The evidence-based fall bundle includes: bed/chair alarms,
non-slip footwear, bed in lowest position with brakes locked, call light and personal
items within reach, and hourly rounding addressing Pain, Potty, Position, and
Possessions (4 Ps). Option A is insufficient for high-risk patients. Option C is
inappropriate—restraints require a physician order and are last resort. Option D is not a
standard fall prevention intervention.
Q3: During a time-out procedure before a right knee arthroscopy, the circulating nurse
notes the consent form says "left knee" but the site marking and team verbal
confirmation indicate "right knee." What is the correct action?
A. Proceed with the right knee procedure since the site marking matches the team's
verbal confirmation
,B. Stop the procedure, verify the correct site with the patient awake and alert, and obtain
a corrected consent form [CORRECT]
C. Cross out "left" on the consent and write "right," then have the surgeon initial the
change
D. Call the patient's family to determine which knee requires surgery
Correct Answer: B
Rationale: The Universal Protocol and Joint Commission NPSG.06.01.01 mandate that
all documentation, site marking, and team confirmation must match before incision. A
discrepancy between consent and site marking is a "hard stop" requiring resolution. The
patient must be involved in verification when possible. Option A violates the time-out
protocol. Option C constitutes alteration of a legal document. Option D is
inappropriate—the patient is the primary source for informed consent verification.
Q4: A nurse is administering heparin 5,000 units subcutaneously. The pharmacy has
sent a vial labeled "heparin 10,000 units/mL." What is the required safety check?
A. Calculate the dose independently and administer 0.5 mL
B. Have a second nurse independently verify the dose calculation, vial concentration,
and patient identity before administration [CORRECT]
C. Call the pharmacy to confirm they sent the correct concentration
D. Administer 1 mL since the dose is within the therapeutic range
Correct Answer: B
, Rationale: Heparin is a high-alert medication per ISMP and HealthStream Medication
Safety Standards. Independent double-check by two nurses is required for high-alert
medications to prevent calculation errors. The calculation is correct (5,000 units ÷
10,000 units/mL = 0.5 mL), but the safety process is paramount. Option A misses the
required double-check. Option C is unnecessary when the vial is correctly labeled.
Option D represents a 100% overdose.
Q5: A patient on a medical-surgical unit becomes agitated and attempts to pull out their
central line. The physician orders wrist restraints. How frequently must the nurse
assess and document?
A. Every 15 minutes for all patients in restraints
B. Every 2 hours for adults over 18 years of age
C. Every 4 hours for adults, every 2 hours for ages 9-17, and every 1 hour for under 9
[CORRECT]
D. Once per shift unless the patient complains of discomfort
Correct Answer: C
Rationale: Per CMS Conditions of Participation and HealthStream Restraint
Competency, assessment frequency varies by age: adults q4h, children 9-17 q2h, under
9 q1h. Assessments must include circulation, range of motion, skin integrity, nutrition,
hydration, and elimination. Option A is incorrect for adult patients. Option B applies only
to pediatric patients ages 9-17. Option D violates federal regulations and places patients
at risk for injury.
Questions and Answers 2026/2027 | Verified Edition | Nursing
Competency | Pass Guaranteed - A+ Graded
Section 1: Patient Safety & Infection Control (Questions 1-15)
Q1: A nurse is preparing to administer a blood transfusion to a patient. The patient
states, "I think that's my name, but I'm not sure." The wristband is smudged but appears
to match. What is the nurse's priority action?
A. Proceed with the transfusion since the wristband appears to match and the patient is
uncertain
B. Ask the patient to state their date of birth and compare it to the medical record while
verifying the wristband
C. Hold the transfusion and obtain a new wristband with the patient's full cooperation
before proceeding [CORRECT]
D. Ask the patient's roommate to confirm the patient's identity
Correct Answer: C
Rationale: Per HealthStream Patient Safety Standards and The Joint Commission
NPSG.01.01.01, two reliable patient identifiers (name, DOB, or MRN) must be used
before any high-risk procedure. A smudged wristband and patient uncertainty constitute
an identification failure requiring immediate correction. Blood transfusions are
high-alert procedures where identification errors can be fatal. Option B is incorrect
because a compromised wristband cannot serve as a valid identifier. Option A violates
safety protocols. Option D breaches HIPAA and is not a valid identifier.
,Q2: A 78-year-old patient with Parkinson's disease and a history of falls is admitted. The
Morse Fall Scale score is 65. Which intervention is most appropriate for this fall risk
level?
A. Place bed alarm and hourly rounding only
B. Bed alarm, non-slip socks, bed in low position, call light within reach, and hourly
rounding addressing the 4 Ps [CORRECT]
C. Apply bilateral soft wrist restraints to prevent unplanned bed exits
D. Move patient to a room closest to the nurses' station and check every 15 minutes
Correct Answer: B
Rationale: A Morse Fall Scale score ≥50 indicates high fall risk per HealthStream
Competency Module. The evidence-based fall bundle includes: bed/chair alarms,
non-slip footwear, bed in lowest position with brakes locked, call light and personal
items within reach, and hourly rounding addressing Pain, Potty, Position, and
Possessions (4 Ps). Option A is insufficient for high-risk patients. Option C is
inappropriate—restraints require a physician order and are last resort. Option D is not a
standard fall prevention intervention.
Q3: During a time-out procedure before a right knee arthroscopy, the circulating nurse
notes the consent form says "left knee" but the site marking and team verbal
confirmation indicate "right knee." What is the correct action?
A. Proceed with the right knee procedure since the site marking matches the team's
verbal confirmation
,B. Stop the procedure, verify the correct site with the patient awake and alert, and obtain
a corrected consent form [CORRECT]
C. Cross out "left" on the consent and write "right," then have the surgeon initial the
change
D. Call the patient's family to determine which knee requires surgery
Correct Answer: B
Rationale: The Universal Protocol and Joint Commission NPSG.06.01.01 mandate that
all documentation, site marking, and team confirmation must match before incision. A
discrepancy between consent and site marking is a "hard stop" requiring resolution. The
patient must be involved in verification when possible. Option A violates the time-out
protocol. Option C constitutes alteration of a legal document. Option D is
inappropriate—the patient is the primary source for informed consent verification.
Q4: A nurse is administering heparin 5,000 units subcutaneously. The pharmacy has
sent a vial labeled "heparin 10,000 units/mL." What is the required safety check?
A. Calculate the dose independently and administer 0.5 mL
B. Have a second nurse independently verify the dose calculation, vial concentration,
and patient identity before administration [CORRECT]
C. Call the pharmacy to confirm they sent the correct concentration
D. Administer 1 mL since the dose is within the therapeutic range
Correct Answer: B
, Rationale: Heparin is a high-alert medication per ISMP and HealthStream Medication
Safety Standards. Independent double-check by two nurses is required for high-alert
medications to prevent calculation errors. The calculation is correct (5,000 units ÷
10,000 units/mL = 0.5 mL), but the safety process is paramount. Option A misses the
required double-check. Option C is unnecessary when the vial is correctly labeled.
Option D represents a 100% overdose.
Q5: A patient on a medical-surgical unit becomes agitated and attempts to pull out their
central line. The physician orders wrist restraints. How frequently must the nurse
assess and document?
A. Every 15 minutes for all patients in restraints
B. Every 2 hours for adults over 18 years of age
C. Every 4 hours for adults, every 2 hours for ages 9-17, and every 1 hour for under 9
[CORRECT]
D. Once per shift unless the patient complains of discomfort
Correct Answer: C
Rationale: Per CMS Conditions of Participation and HealthStream Restraint
Competency, assessment frequency varies by age: adults q4h, children 9-17 q2h, under
9 q1h. Assessments must include circulation, range of motion, skin integrity, nutrition,
hydration, and elimination. Option A is incorrect for adult patients. Option B applies only
to pediatric patients ages 9-17. Option D violates federal regulations and places patients
at risk for injury.
