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1. A nurse enters a client's room and finds the client unresponsive. What is the priority initial action Which response is most
appropriate in this situation?
■ Assess responsiveness and begin the emergency response according to facility protocol
• Document the event before assessing the client
• Leave the room to find the chart
• Offer oral fluids
Answer: Assess responsiveness and begin the emergency response according to facility protocol
2. Which action best demonstrates standard precautions Which response is most appropriate in this situation?
■ Use appropriate hand hygiene and PPE based on anticipated exposure
• Wear sterile gloves for every client interaction
• Use the same gloves between clients
• Skip hand hygiene when gloves are worn
Answer: Use appropriate hand hygiene and PPE based on anticipated exposure
3. A nurse is preparing to administer medication. Which action is most important for preventing an administration error Which
response is most appropriate in this situation?
■ Verify the medication, client, dose, route, time, and relevant safety checks
• Rely only on the client's room number
• Skip allergy verification
• Administer medications prepared by an unidentified person
Answer: Verify the medication, client, dose, route, time, and relevant safety checks
4. Which finding should the nurse report promptly because it may indicate deterioration Which response is most appropriate
in this situation?
■ A new change in level of consciousness
• A client asking for a blanket
• A routine meal preference
• A stable chronic finding already documented
Answer: A new change in level of consciousness
5. A nurse enters a client's room and finds the client unresponsive. What is the priority initial action What is the best next
action?
• Document the event before assessing the client
• Leave the room to find the chart
• Offer oral fluids
■ Assess responsiveness and begin the emergency response according to facility protocol
Answer: Assess responsiveness and begin the emergency response according to facility protocol
6. Which action best demonstrates standard precautions What is the best next action?
• Wear sterile gloves for every client interaction
• Use the same gloves between clients
• Skip hand hygiene when gloves are worn
, ■ Use appropriate hand hygiene and PPE based on anticipated exposure
Answer: Use appropriate hand hygiene and PPE based on anticipated exposure
7. A nurse is preparing to administer medication. Which action is most important for preventing an administration error What
is the best next action?
• Rely only on the client's room number
• Skip allergy verification
• Administer medications prepared by an unidentified person
■ Verify the medication, client, dose, route, time, and relevant safety checks
Answer: Verify the medication, client, dose, route, time, and relevant safety checks
8. Which finding should the nurse report promptly because it may indicate deterioration What is the best next action?
• A client asking for a blanket
• A routine meal preference
• A stable chronic finding already documented
■ A new change in level of consciousness
Answer: A new change in level of consciousness
9. A nurse enters a client's room and finds the client unresponsive. What is the priority initial action Which option best
reflects sound professional judgment?
• Leave the room to find the chart
• Offer oral fluids
■ Assess responsiveness and begin the emergency response according to facility protocol
• Document the event before assessing the client
Answer: Assess responsiveness and begin the emergency response according to facility protocol
10. Which action best demonstrates standard precautions Which option best reflects sound professional judgment?
• Use the same gloves between clients
• Skip hand hygiene when gloves are worn
■ Use appropriate hand hygiene and PPE based on anticipated exposure
• Wear sterile gloves for every client interaction
Answer: Use appropriate hand hygiene and PPE based on anticipated exposure
11. A nurse is preparing to administer medication. Which action is most important for preventing an administration error
Which option best reflects sound professional judgment?
• Skip allergy verification
• Administer medications prepared by an unidentified person
■ Verify the medication, client, dose, route, time, and relevant safety checks
• Rely only on the client's room number
Answer: Verify the medication, client, dose, route, time, and relevant safety checks
12. Which finding should the nurse report promptly because it may indicate deterioration Which option best reflects sound
professional judgment?
• A routine meal preference
• A stable chronic finding already documented
■ A new change in level of consciousness
• A client asking for a blanket
, Answer: A new change in level of consciousness
13. A nurse enters a client's room and finds the client unresponsive. What is the priority initial action Which choice is most
consistent with safe practice?
• Offer oral fluids
■ Assess responsiveness and begin the emergency response according to facility protocol
• Document the event before assessing the client
• Leave the room to find the chart
Answer: Assess responsiveness and begin the emergency response according to facility protocol
14. Which action best demonstrates standard precautions Which choice is most consistent with safe practice?
• Skip hand hygiene when gloves are worn
■ Use appropriate hand hygiene and PPE based on anticipated exposure
• Wear sterile gloves for every client interaction
• Use the same gloves between clients
Answer: Use appropriate hand hygiene and PPE based on anticipated exposure
15. A nurse is preparing to administer medication. Which action is most important for preventing an administration error
Which choice is most consistent with safe practice?
• Administer medications prepared by an unidentified person
■ Verify the medication, client, dose, route, time, and relevant safety checks
• Rely only on the client's room number
• Skip allergy verification
Answer: Verify the medication, client, dose, route, time, and relevant safety checks
16. Which finding should the nurse report promptly because it may indicate deterioration Which choice is most consistent
with safe practice?
• A stable chronic finding already documented
■ A new change in level of consciousness
• A client asking for a blanket
• A routine meal preference
Answer: A new change in level of consciousness
17. A nurse enters a client's room and finds the client unresponsive. What is the priority initial action Which response is most
appropriate in this situation?
■ Assess responsiveness and begin the emergency response according to facility protocol
• Document the event before assessing the client
• Leave the room to find the chart
• Offer oral fluids
Answer: Assess responsiveness and begin the emergency response according to facility protocol
18. Which action best demonstrates standard precautions Which response is most appropriate in this situation?
■ Use appropriate hand hygiene and PPE based on anticipated exposure
• Wear sterile gloves for every client interaction
• Use the same gloves between clients
• Skip hand hygiene when gloves are worn
Answer: Use appropriate hand hygiene and PPE based on anticipated exposure
, 19. A nurse is preparing to administer medication. Which action is most important for preventing an administration error
Which response is most appropriate in this situation?
■ Verify the medication, client, dose, route, time, and relevant safety checks
• Rely only on the client's room number
• Skip allergy verification
• Administer medications prepared by an unidentified person
Answer: Verify the medication, client, dose, route, time, and relevant safety checks
20. Which finding should the nurse report promptly because it may indicate deterioration Which response is most
appropriate in this situation?
■ A new change in level of consciousness
• A client asking for a blanket
• A routine meal preference
• A stable chronic finding already documented
Answer: A new change in level of consciousness
21. A nurse enters a client's room and finds the client unresponsive. What is the priority initial action What is the best next
action?
• Document the event before assessing the client
• Leave the room to find the chart
• Offer oral fluids
■ Assess responsiveness and begin the emergency response according to facility protocol
Answer: Assess responsiveness and begin the emergency response according to facility protocol
22. Which action best demonstrates standard precautions What is the best next action?
• Wear sterile gloves for every client interaction
• Use the same gloves between clients
• Skip hand hygiene when gloves are worn
■ Use appropriate hand hygiene and PPE based on anticipated exposure
Answer: Use appropriate hand hygiene and PPE based on anticipated exposure
23. A nurse is preparing to administer medication. Which action is most important for preventing an administration error
What is the best next action?
• Rely only on the client's room number
• Skip allergy verification
• Administer medications prepared by an unidentified person
■ Verify the medication, client, dose, route, time, and relevant safety checks
Answer: Verify the medication, client, dose, route, time, and relevant safety checks
24. Which finding should the nurse report promptly because it may indicate deterioration What is the best next action?
• A client asking for a blanket
• A routine meal preference
• A stable chronic finding already documented
■ A new change in level of consciousness
Answer: A new change in level of consciousness
25. A nurse enters a client's room and finds the client unresponsive. What is the priority initial action Which option best
reflects sound professional judgment?