, Question 1
A nurse is preparing to administer a scheduled dose of subcutaneous
enoxaparin. Which action demonstrates correct application of the 'rights' of
medication administration and high-alert medication safety?
A. Verify the dose with a second nurse, administer in the abdomen, and
avoid expelling the air bubble from the prefilled syringe.
B. Aspirate for blood return before injecting to ensure the needle is not in
a blood vessel.
C. Massage the injection site vigorously after administration to enhance
absorption.
D. Administer the medication intramuscularly if the patient has minimal
subcutaneous tissue.
Correct Answer: A - Verify the dose with a second nurse,
administer in the abdomen, and avoid expelling the air bubble
from the prefilled syringe.
RATIONALE
Enoxaparin is a high-alert anticoagulant requiring independent
double-check per ISMP guidelines; the air bubble in prefilled syringes
should not be expelled to ensure full dose delivery, and injection into
the abdomen with rotation is standard. Aspiration is not recommended
for subcutaneous heparin/enoxaparin and may increase hematoma risk.
Massaging the site increases bruising and bleeding. IM administration
is contraindicated due to hematoma risk and altered absorption.
Question 2
Which statement best reflects the correct technique for obtaining a blood
pressure measurement using an automated device when the patient has an
irregular heart rhythm?
A. Take a single automated reading and document it as the resting blood
pressure.
B. Obtain a manual auscultatory blood pressure and compare it with the
Page 2
, automated reading.
C. Use a smaller cuff size to improve accuracy of the automated reading.
D. Position the arm below heart level to enhance detection of Korotkoff
sounds.
Correct Answer: B - Obtain a manual auscultatory blood
pressure and compare it with the automated reading.
RATIONALE
Automated devices may be inaccurate with irregular rhythms; manual
auscultation is the gold standard for verification. A single automated
reading may be unreliable. Cuff size must be appropriate for arm
circumference-too small yields falsely high readings. Arm should be at
heart level; below heart level falsely elevates readings.
Question 3
A nurse is calculating the drip rate for an IV infusion. The order is 1,000 mL of
0.9% NaCl over 8 hours. The drop factor is 15 gtt/mL. What is the correct flow
rate in drops per minute?
A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 125 gtt/min
Correct Answer: B - 31 gtt/min
RATIONALE
Formula: (Volume × drop factor) / time in minutes = (1000 × 15) / 480
= 15, = 31.25, rounded to 31 gtt/min. Option A is incorrect
(miscalculation). Option C is incorrect (using 60 min instead of 480).
Option D is the mL/hr rate, not gtt/min.
Page 3
, Question 4
A patient is admitted with a Stage 3 pressure injury on the sacrum. Which
nursing intervention is most appropriate to promote wound healing?
A. Apply a hydrocolloid dressing and change it every 24 hours.
B. Cleanse the wound with hydrogen peroxide and pack it tightly with
gauze.
C. Perform sharp debridement of eschar at the bedside without a provider
order.
D. Maintain a moist wound environment and reposition the patient at
least every 2 hours.
Correct Answer: D - Maintain a moist wound environment and
reposition the patient at least every 2 hours.
RATIONALE
Stage 3 pressure injuries require a moist wound environment and
pressure offloading via repositioning. Hydrocolloid dressings are
typically changed every 3-7 days, not daily, and may not be
appropriate for full-thickness wounds with exudate. Hydrogen
peroxide is cytotoxic and delays healing. Sharp debridement requires a
provider order and specialized training.
Question 5
Which action by the nurse demonstrates correct sterile technique when
preparing a sterile field for a dressing change?
A. Opening the sterile package by lifting the top flap away from the body
first.
B. Placing sterile items on the field by dropping them from a height of 6
inches.
C. Reaching across the sterile field to adjust the position of a sterile
instrument.
D. Considering the outer 1-inch border of the sterile drape as sterile.
Page 4
A nurse is preparing to administer a scheduled dose of subcutaneous
enoxaparin. Which action demonstrates correct application of the 'rights' of
medication administration and high-alert medication safety?
A. Verify the dose with a second nurse, administer in the abdomen, and
avoid expelling the air bubble from the prefilled syringe.
B. Aspirate for blood return before injecting to ensure the needle is not in
a blood vessel.
C. Massage the injection site vigorously after administration to enhance
absorption.
D. Administer the medication intramuscularly if the patient has minimal
subcutaneous tissue.
Correct Answer: A - Verify the dose with a second nurse,
administer in the abdomen, and avoid expelling the air bubble
from the prefilled syringe.
RATIONALE
Enoxaparin is a high-alert anticoagulant requiring independent
double-check per ISMP guidelines; the air bubble in prefilled syringes
should not be expelled to ensure full dose delivery, and injection into
the abdomen with rotation is standard. Aspiration is not recommended
for subcutaneous heparin/enoxaparin and may increase hematoma risk.
Massaging the site increases bruising and bleeding. IM administration
is contraindicated due to hematoma risk and altered absorption.
Question 2
Which statement best reflects the correct technique for obtaining a blood
pressure measurement using an automated device when the patient has an
irregular heart rhythm?
A. Take a single automated reading and document it as the resting blood
pressure.
B. Obtain a manual auscultatory blood pressure and compare it with the
Page 2
, automated reading.
C. Use a smaller cuff size to improve accuracy of the automated reading.
D. Position the arm below heart level to enhance detection of Korotkoff
sounds.
Correct Answer: B - Obtain a manual auscultatory blood
pressure and compare it with the automated reading.
RATIONALE
Automated devices may be inaccurate with irregular rhythms; manual
auscultation is the gold standard for verification. A single automated
reading may be unreliable. Cuff size must be appropriate for arm
circumference-too small yields falsely high readings. Arm should be at
heart level; below heart level falsely elevates readings.
Question 3
A nurse is calculating the drip rate for an IV infusion. The order is 1,000 mL of
0.9% NaCl over 8 hours. The drop factor is 15 gtt/mL. What is the correct flow
rate in drops per minute?
A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 125 gtt/min
Correct Answer: B - 31 gtt/min
RATIONALE
Formula: (Volume × drop factor) / time in minutes = (1000 × 15) / 480
= 15, = 31.25, rounded to 31 gtt/min. Option A is incorrect
(miscalculation). Option C is incorrect (using 60 min instead of 480).
Option D is the mL/hr rate, not gtt/min.
Page 3
, Question 4
A patient is admitted with a Stage 3 pressure injury on the sacrum. Which
nursing intervention is most appropriate to promote wound healing?
A. Apply a hydrocolloid dressing and change it every 24 hours.
B. Cleanse the wound with hydrogen peroxide and pack it tightly with
gauze.
C. Perform sharp debridement of eschar at the bedside without a provider
order.
D. Maintain a moist wound environment and reposition the patient at
least every 2 hours.
Correct Answer: D - Maintain a moist wound environment and
reposition the patient at least every 2 hours.
RATIONALE
Stage 3 pressure injuries require a moist wound environment and
pressure offloading via repositioning. Hydrocolloid dressings are
typically changed every 3-7 days, not daily, and may not be
appropriate for full-thickness wounds with exudate. Hydrogen
peroxide is cytotoxic and delays healing. Sharp debridement requires a
provider order and specialized training.
Question 5
Which action by the nurse demonstrates correct sterile technique when
preparing a sterile field for a dressing change?
A. Opening the sterile package by lifting the top flap away from the body
first.
B. Placing sterile items on the field by dropping them from a height of 6
inches.
C. Reaching across the sterile field to adjust the position of a sterile
instrument.
D. Considering the outer 1-inch border of the sterile drape as sterile.
Page 4
