, Question 1
A nurse receives a verbal order for a high-alert medication during an
emergency. Which action best satisfies safe medication practice while enabling
immediate treatment?
A. Administer the medication and document the verbal order after the
emergency resolves.
B. Perform an independent double-check, read back the order, and obtain
provider countersignature within the facility's required timeframe.
C. Ask another nurse to transcribe the order and administer the
medication without a read-back.
D. Refuse to administer until a written order is placed in the chart.
Correct Answer: B - Perform an independent double-check, read
back the order, and obtain provider countersignature within the
facility's required timeframe.
RATIONALE
Verbal orders for high-alert medications require a read-back,
independent double-check when indicated, and timely provider
countersignature to reduce error risk while preserving urgent care.
Delaying documentation or refusing administration can harm the
patient, and omitting read-back or double-check increases the risk of a
serious medication error.
Question 2
Which set of vital signs most urgently warrants escalation using a rapid
response or early warning system?
A. Temperature 37.8°C, HR 92, RR 18, BP 118/72, SpO2 96%
B. Temperature 38.9°C, HR 118, RR 26, BP 88/54, SpO2 89% on room
air
C. Temperature 36.5°C, HR 58, RR 14, BP 138/86, SpO2 98%
D. Temperature 37.2°C, HR 104, RR 20, BP 142/90, SpO2 95%
Page 2
,Correct Answer: B - Temperature 38.9°C, HR 118, RR 26, BP
88/54, SpO2 89% on room air
RATIONALE
Hypotension, tachycardia, tachypnea, fever, and hypoxemia together
indicate physiologic deterioration and possible sepsis or respiratory
failure, meeting escalation criteria. The other sets show isolated or
mild abnormalities that do not meet rapid response thresholds.
Question 3
A provider orders 500 mg of a medication. The pharmacy supplies a 250 mg/5
mL oral suspension. Using dimensional analysis, how many milliliters will the
nurse administer?
A. 2.5 mL
B. 10 mL
C. 5 mL
D. 20 mL
Correct Answer: B - 10 mL
RATIONALE
Using dimensional analysis: 500 mg × (5 mL / 250 mg) = 10 mL. The
other options result from misplacing the ratio or inverting the
concentration.
Question 4
During a sterile dressing change, the nurse notices the sterile field has become
damp where the sterile drape touches the patient's gown. What is the most
appropriate action?
A. Continue the procedure but avoid touching the damp area.
B. Place a new sterile drape over the damp area and proceed.
C. Stop, consider the field contaminated, and obtain new sterile supplies.
D. Apply an impermeable barrier over the damp area and continue.
Page 3
, Correct Answer: C - Stop, consider the field contaminated, and
obtain new sterile supplies.
RATIONALE
Moisture allows capillary action and microbial migration, rendering
the sterile field contaminated; the nurse must stop and replace
supplies. Avoiding or covering the area does not restore sterility.
Question 5
Which documentation entry best reflects legally defensible, objective nursing
charting?
A. Patient appears to be in pain and is probably exaggerating symptoms.
B. Patient reports pain 8/10, grimacing, guarding abdomen; provider
notified at 14:10.
C. Patient is a difficult patient who refuses to cooperate with care.
D. Patient seems okay but may need pain medication later.
Correct Answer: B - Patient reports pain 8/10, grimacing,
guarding abdomen; provider notified at 14:10.
RATIONALE
Objective charting uses measurable, observable data and includes
provider notification, avoiding subjective or judgmental language. The
other entries contain opinions, vague terms, or bias that weaken the
legal record.
Question 6
A patient with Clostridioides difficile diarrhea is on contact precautions. Which
action is most important to prevent transmission?
A. Use an alcohol-based hand rub after removing gloves.
B. Wear gloves and a gown, and perform hand hygiene with soap and
water after care.
C. Place the patient in a negative-pressure room.
Page 4
A nurse receives a verbal order for a high-alert medication during an
emergency. Which action best satisfies safe medication practice while enabling
immediate treatment?
A. Administer the medication and document the verbal order after the
emergency resolves.
B. Perform an independent double-check, read back the order, and obtain
provider countersignature within the facility's required timeframe.
C. Ask another nurse to transcribe the order and administer the
medication without a read-back.
D. Refuse to administer until a written order is placed in the chart.
Correct Answer: B - Perform an independent double-check, read
back the order, and obtain provider countersignature within the
facility's required timeframe.
RATIONALE
Verbal orders for high-alert medications require a read-back,
independent double-check when indicated, and timely provider
countersignature to reduce error risk while preserving urgent care.
Delaying documentation or refusing administration can harm the
patient, and omitting read-back or double-check increases the risk of a
serious medication error.
Question 2
Which set of vital signs most urgently warrants escalation using a rapid
response or early warning system?
A. Temperature 37.8°C, HR 92, RR 18, BP 118/72, SpO2 96%
B. Temperature 38.9°C, HR 118, RR 26, BP 88/54, SpO2 89% on room
air
C. Temperature 36.5°C, HR 58, RR 14, BP 138/86, SpO2 98%
D. Temperature 37.2°C, HR 104, RR 20, BP 142/90, SpO2 95%
Page 2
,Correct Answer: B - Temperature 38.9°C, HR 118, RR 26, BP
88/54, SpO2 89% on room air
RATIONALE
Hypotension, tachycardia, tachypnea, fever, and hypoxemia together
indicate physiologic deterioration and possible sepsis or respiratory
failure, meeting escalation criteria. The other sets show isolated or
mild abnormalities that do not meet rapid response thresholds.
Question 3
A provider orders 500 mg of a medication. The pharmacy supplies a 250 mg/5
mL oral suspension. Using dimensional analysis, how many milliliters will the
nurse administer?
A. 2.5 mL
B. 10 mL
C. 5 mL
D. 20 mL
Correct Answer: B - 10 mL
RATIONALE
Using dimensional analysis: 500 mg × (5 mL / 250 mg) = 10 mL. The
other options result from misplacing the ratio or inverting the
concentration.
Question 4
During a sterile dressing change, the nurse notices the sterile field has become
damp where the sterile drape touches the patient's gown. What is the most
appropriate action?
A. Continue the procedure but avoid touching the damp area.
B. Place a new sterile drape over the damp area and proceed.
C. Stop, consider the field contaminated, and obtain new sterile supplies.
D. Apply an impermeable barrier over the damp area and continue.
Page 3
, Correct Answer: C - Stop, consider the field contaminated, and
obtain new sterile supplies.
RATIONALE
Moisture allows capillary action and microbial migration, rendering
the sterile field contaminated; the nurse must stop and replace
supplies. Avoiding or covering the area does not restore sterility.
Question 5
Which documentation entry best reflects legally defensible, objective nursing
charting?
A. Patient appears to be in pain and is probably exaggerating symptoms.
B. Patient reports pain 8/10, grimacing, guarding abdomen; provider
notified at 14:10.
C. Patient is a difficult patient who refuses to cooperate with care.
D. Patient seems okay but may need pain medication later.
Correct Answer: B - Patient reports pain 8/10, grimacing,
guarding abdomen; provider notified at 14:10.
RATIONALE
Objective charting uses measurable, observable data and includes
provider notification, avoiding subjective or judgmental language. The
other entries contain opinions, vague terms, or bias that weaken the
legal record.
Question 6
A patient with Clostridioides difficile diarrhea is on contact precautions. Which
action is most important to prevent transmission?
A. Use an alcohol-based hand rub after removing gloves.
B. Wear gloves and a gown, and perform hand hygiene with soap and
water after care.
C. Place the patient in a negative-pressure room.
Page 4
