NURS 121L-A: Patient Safety & Emergency Response (2026 Update)
WCU
1. A nurse enters a patient room and observes smoke coming from a
wastebasket. Which action should the nurse take first according to the RACE
protocol?
A. Rescue and remove any clients in immediate danger.
B. Activate the fire alarm system.
C. Confine the fire by closing the door.
D. Extinguish the fire using a fire extinguisher.
Answer: A
Rationale: According to the RACE acronym (Rescue, Alarm, Confine, Extinguish), the
priority is always the safety of the patient. The nurse must first rescue anyone in
immediate danger.
2. When using a fire extinguisher (PASS), what is the correct sequence of
actions?
A. Push the lever, Aim at the top of flames, Squeeze, Sweep.
B. Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep side to side.
C. Pull the pin, Aim at the top of flames, Spray, Sweep.
D. Point the nozzle, Activate, Squeeze, Spray.
Answer: B
Rationale: PASS stands for Pull the pin, Aim at the base of the fire, Squeeze the handle, and
Sweep from side to side.
,3. Which clinical finding would most likely trigger a nurse to activate the Rapid
Response Team (RRT) for a post-operative patient?
A. A heart rate increase from 72 to 88 beats per minute.
B. Pain level reported as 8/10.
C. Serosanguinous drainage on the surgical dressing.
D. A sudden change in the level of consciousness.
Answer: D
Rationale: RRT is activated for acute clinical deterioration. A sudden change in mental
status is a critical indicator of neurological or respiratory decline.
4. The nurse is caring for an older adult with a Braden Scale score of 12. What is
the nurse’s priority interpretation of this score?
A. The patient is at low risk for pressure injuries.
B. The score is within the normal range for this age group.
C. The patient has a localized pressure injury already.
D. The patient is at high risk for pressure injuries.
Answer: D
Rationale: On the Braden Scale, lower scores indicate higher risk. A score of 12 indicates
‘High Risk’ (Scores 10-12 are high risk; 13-14 are moderate risk).
5. In the SBAR communication tool, which information belongs in the ‘B’
(Background) section?
A. The patient’s current blood pressure and heart rate.
B. The patient’s admitting diagnosis and medical history.
C. The nurse’s suggestion for a specific lab test.
D. The reason the nurse is calling the physician right now.
Answer: B
Rationale: Background includes clinical context such as admitting diagnosis, medical
history, and relevant past interventions.
, 6. A nurse is preparing to administer a high-alert medication. Which action is
essential for patient safety?
A. Administering the medication as quickly as possible.
B. Having another registered nurse perform an independent double-check.
C. Asking the patient if they recognize the pill.
D. Documenting the administration before giving it to the patient.
Answer: B
Rationale: High-alert medications (e.g., Insulin, Heparin) require an independent double-
check by another RN to prevent catastrophic errors.
7. A patient is placed in four-point soft wrist restraints. How often must the
nurse assess the patient’s skin integrity and neurovascular status?
A. Every 4 hours.
B. Every 2 hours.
C. Once per shift.
D. Every 15 minutes.
Answer: D
Rationale: Patients in physical restraints require observation/monitoring every 15
minutes for safety and neurovascular checks.
8. What is the most effective way to prevent the spread of Clostridioides difficile
(C. diff) in the hospital setting?
A. Using alcohol-based hand sanitizer after every contact.
B. Washing hands with soap and water.
C. Wearing a surgical mask when entering the room.
D. Maintaining a distance of 3 feet from the patient.
Answer: B
Rationale: C. diff spores are resistant to alcohol-based sanitizers; physical friction with
soap and water is required to remove them.
WCU
1. A nurse enters a patient room and observes smoke coming from a
wastebasket. Which action should the nurse take first according to the RACE
protocol?
A. Rescue and remove any clients in immediate danger.
B. Activate the fire alarm system.
C. Confine the fire by closing the door.
D. Extinguish the fire using a fire extinguisher.
Answer: A
Rationale: According to the RACE acronym (Rescue, Alarm, Confine, Extinguish), the
priority is always the safety of the patient. The nurse must first rescue anyone in
immediate danger.
2. When using a fire extinguisher (PASS), what is the correct sequence of
actions?
A. Push the lever, Aim at the top of flames, Squeeze, Sweep.
B. Pull the pin, Aim at the base of the fire, Squeeze the handle, Sweep side to side.
C. Pull the pin, Aim at the top of flames, Spray, Sweep.
D. Point the nozzle, Activate, Squeeze, Spray.
Answer: B
Rationale: PASS stands for Pull the pin, Aim at the base of the fire, Squeeze the handle, and
Sweep from side to side.
,3. Which clinical finding would most likely trigger a nurse to activate the Rapid
Response Team (RRT) for a post-operative patient?
A. A heart rate increase from 72 to 88 beats per minute.
B. Pain level reported as 8/10.
C. Serosanguinous drainage on the surgical dressing.
D. A sudden change in the level of consciousness.
Answer: D
Rationale: RRT is activated for acute clinical deterioration. A sudden change in mental
status is a critical indicator of neurological or respiratory decline.
4. The nurse is caring for an older adult with a Braden Scale score of 12. What is
the nurse’s priority interpretation of this score?
A. The patient is at low risk for pressure injuries.
B. The score is within the normal range for this age group.
C. The patient has a localized pressure injury already.
D. The patient is at high risk for pressure injuries.
Answer: D
Rationale: On the Braden Scale, lower scores indicate higher risk. A score of 12 indicates
‘High Risk’ (Scores 10-12 are high risk; 13-14 are moderate risk).
5. In the SBAR communication tool, which information belongs in the ‘B’
(Background) section?
A. The patient’s current blood pressure and heart rate.
B. The patient’s admitting diagnosis and medical history.
C. The nurse’s suggestion for a specific lab test.
D. The reason the nurse is calling the physician right now.
Answer: B
Rationale: Background includes clinical context such as admitting diagnosis, medical
history, and relevant past interventions.
, 6. A nurse is preparing to administer a high-alert medication. Which action is
essential for patient safety?
A. Administering the medication as quickly as possible.
B. Having another registered nurse perform an independent double-check.
C. Asking the patient if they recognize the pill.
D. Documenting the administration before giving it to the patient.
Answer: B
Rationale: High-alert medications (e.g., Insulin, Heparin) require an independent double-
check by another RN to prevent catastrophic errors.
7. A patient is placed in four-point soft wrist restraints. How often must the
nurse assess the patient’s skin integrity and neurovascular status?
A. Every 4 hours.
B. Every 2 hours.
C. Once per shift.
D. Every 15 minutes.
Answer: D
Rationale: Patients in physical restraints require observation/monitoring every 15
minutes for safety and neurovascular checks.
8. What is the most effective way to prevent the spread of Clostridioides difficile
(C. diff) in the hospital setting?
A. Using alcohol-based hand sanitizer after every contact.
B. Washing hands with soap and water.
C. Wearing a surgical mask when entering the room.
D. Maintaining a distance of 3 feet from the patient.
Answer: B
Rationale: C. diff spores are resistant to alcohol-based sanitizers; physical friction with
soap and water is required to remove them.
