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1. A nurse enters a client's room and discovers the client lying unconscious on the
floor. What is the nurse's priority action?
A. Notify the healthcare provider.
B. Assess responsiveness and activate the emergency response system.
C. Complete an incident report.
D. Obtain the client's medical record.
Answer: B. Assess responsiveness and activate the emergency response system.
Rationale: The nurse must first assess the client's responsiveness and call for emergency
assistance if needed. Airway, breathing, and circulation (ABCs) are always the priority
during an emergency. Documentation and provider notification occur after the client is
stabilized.
2. Which client should the emergency department nurse assess first?
A. A client with a minor ankle sprain.
B. A client with chest pain and diaphoresis.
C. A client requesting a prescription refill.
D. A client with a sore throat for three days.
Answer: B. A client with chest pain and diaphoresis.
Rationale: Chest pain accompanied by diaphoresis may indicate an acute myocardial
infarction requiring immediate intervention. Triage prioritizes potentially life-threatening
conditions before non-urgent complaints.
3. Which action best reduces the risk of patient falls in hospitalized adults?
,A. Keep all side rails raised at all times.
B. Encourage patients to walk independently.
C. Assess fall risk routinely and implement individualized precautions.
D. Restrict fluids to reduce bathroom visits.
Answer: C. Assess fall risk routinely and implement individualized precautions.
Rationale: Routine fall-risk assessment allows nurses to implement appropriate
interventions such as bed alarms, non-slip footwear, and scheduled toileting. Universal
precautions without assessment may be ineffective or even harmful.
4. A nurse identifies smoke coming from an electrical outlet. Which action should
occur first?
A. Rescue clients in immediate danger.
B. Call maintenance.
C. Open windows.
D. Document the incident.
Answer: A. Rescue clients in immediate danger.
Rationale: The RACE protocol begins with Rescue. Clients in immediate danger should be
moved to safety before activating the alarm or attempting fire containment.
5. Which finding indicates effective handoff communication?
A. Information is brief and incomplete.
B. The receiving nurse asks questions for clarification.
C. Only abnormal findings are reported.
D. The report is delayed until after medication administration.
Answer: B. The receiving nurse asks questions for clarification.
Rationale: Effective handoff communication is interactive, allowing clarification to reduce
communication errors and improve patient safety.
6. Which client requires airborne precautions?
A. Influenza
B. Tuberculosis
, C. Methicillin-resistant Staphylococcus aureus (MRSA)
D. Clostridioides difficile
Answer: B. Tuberculosis
Rationale: Tuberculosis spreads through airborne droplet nuclei and requires a negative-
pressure room and N95 respirator.
7. A nurse discovers a medication error immediately after administration. What is the
priority action?
A. Notify risk management.
B. Assess the client for adverse effects.
C. Complete an incident report.
D. Inform the family first.
Answer: B. Assess the client for adverse effects.
Rationale: The client's condition always takes priority following a medication error.
Assessment determines whether immediate treatment is needed before reporting and
documentation.
8. Which intervention is appropriate when using restraints?
A. Apply restraints without a provider's order.
B. Remove restraints every 8 hours.
C. Use restraints only after less restrictive measures fail.
D. Tie restraints to movable side rails.
Answer: C. Use restraints only after less restrictive measures fail.
Rationale: Restraints are a last resort after alternatives have been unsuccessful. They
require continuous monitoring and safe application.
9. Which client is at greatest risk for aspiration?
A. Client with hypertension.
B. Client recovering from a stroke with dysphagia.
C. Client with osteoarthritis.
D. Client with eczema.