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1. A nurse enters a client's room and notices smoke coming from an electrical outlet.
What is the nurse's priority action?
A. Call the physician.
B. Extinguish the fire immediately.
C. Remove the client from immediate danger and activate the fire response system.
D. Continue assessing the client.
Answer: C. Remove the client from immediate danger and activate the fire response
system.
Rationale: Client safety is always the highest priority. Following the RACE protocol (Rescue,
Alarm, Contain, Extinguish/Evacuate), the nurse first rescues anyone in immediate danger
before activating the alarm system and containing the fire.
2. Which client is at the greatest risk for falls?
A. A 25-year-old recovering from appendectomy
B. A 42-year-old with controlled hypertension
C. An 81-year-old receiving opioid analgesics after hip surgery
D. A 35-year-old with seasonal allergies
Answer: C. An 81-year-old receiving opioid analgesics after hip surgery
Rationale: Advanced age, recent surgery, impaired mobility, and opioid use significantly
increase fall risk. This client requires comprehensive fall-prevention interventions.
3. Which intervention best prevents medication errors during medication
administration?
,A. Administer medications quickly.
B. Verify two client identifiers before administration.
C. Ask family members to identify the client.
D. Skip barcode scanning if familiar with the client.
Answer: B. Verify two client identifiers before administration.
Rationale: Using two approved client identifiers before medication administration is a
fundamental safety standard that reduces the risk of wrong-patient medication errors.
4. A client suddenly becomes unresponsive and has no pulse. What should the nurse
do first?
A. Notify the physician.
B. Start high-quality CPR.
C. Obtain a blood pressure.
D. Document the event.
Answer: B. Start high-quality CPR.
Rationale: Immediate initiation of high-quality cardiopulmonary resuscitation greatly
improves survival in cardiac arrest. Emergency activation should occur simultaneously or
immediately afterward according to facility protocol.
5. Which action demonstrates proper body mechanics when transferring a client?
A. Twist while lifting.
B. Keep feet together.
C. Bend at the waist.
D. Keep the load close to the body.
Answer: D. Keep the load close to the body.
Rationale: Holding the client close to the body decreases spinal strain, improves balance,
and reduces the risk of musculoskeletal injury.
6. A confused client repeatedly attempts to climb out of bed. What should the nurse
do first?
, A. Apply wrist restraints.
B. Raise all four side rails.
C. Assess the reason for the behavior.
D. Administer a sedative immediately.
Answer: C. Assess the reason for the behavior.
Rationale: Nursing care begins with assessment. Confusion, pain, hypoxia, urinary urgency,
or medication effects may contribute to unsafe behavior and should be addressed before
restrictive interventions.
7. Which oxygen delivery device provides the highest oxygen concentration?
A. Nasal cannula
B. Simple face mask
C. Venturi mask
D. Non-rebreather mask
Answer: D. Non-rebreather mask
Rationale: A non-rebreather mask can deliver approximately 90% to 100% oxygen when
properly fitted with an adequate flow rate.
8. Which client requires immediate assessment?
A. Client with pain rated 3/10
B. Client requesting a blanket
C. Client reporting sudden chest pain and shortness of breath
D. Client waiting for discharge instructions
Answer: C. Client reporting sudden chest pain and shortness of breath
Rationale: Sudden chest pain with dyspnea may indicate a life-threatening condition such
as myocardial infarction or pulmonary embolism and requires immediate evaluation.
9. Which action best prevents healthcare-associated infections?
A. Wearing gloves for every task
B. Performing hand hygiene before and after client contact