, Question 1
A patient with a new colostomy has a wound culture positive for
methicillin-resistant Staphylococcus aureus (MRSA). Which action by the
nurse is most important to prevent transmission?
A. Place the patient in a negative-pressure room.
B. Wear a gown and gloves for all contact with the patient.
C. Use a surgical mask when within 3 feet of the patient.
D. Ensure the patient wears a mask during transport.
Correct Answer: B - Wear a gown and gloves for all contact with
the patient.
RATIONALE
MRSA is transmitted via contact, so gown and gloves are required for
all contact. Negative-pressure rooms are for airborne precautions (e.g.,
tuberculosis). Surgical masks are not required for contact precautions
unless splash risk exists. Patient masking is for droplet precautions.
Question 2
A nurse is assessing a patient with a stage 3 pressure injury on the sacrum.
Which finding requires immediate intervention?
A. The wound bed is 100% red granulation tissue.
B. The periwound skin is macerated and pale.
C. The wound has a moderate amount of serosanguineous drainage.
D. The patient reports pain at the wound site.
Correct Answer: B - The periwound skin is macerated and pale.
RATIONALE
Macerated and pale periwound skin indicates moisture-associated skin
damage and possible ischemia, requiring immediate intervention to
prevent further breakdown. Red granulation tissue indicates healing.
Serosanguineous drainage can be normal. Pain is expected but not the
priority over compromised skin integrity.
Page 2
, Question 3
A nurse is preparing to administer a high-alert medication via IV push. Which
action best demonstrates the nurse's understanding of safe medication
administration?
A. Verify the medication with a second nurse before administration.
B. Administer the medication rapidly to ensure therapeutic effect.
C. Document the medication before administration to save time.
D. Use a single nurse verification for all high-alert medications.
Correct Answer: A - Verify the medication with a second nurse
before administration.
RATIONALE
High-alert medications require independent double-check by a second
nurse to prevent errors. Rapid administration can cause harm.
Documentation should occur after administration. Single-nurse
verification is not best practice for high-alert medications.
Question 4
A patient is admitted with a suspected infection. The nurse notes a white blood
cell count of 15,000/mm³, fever of 38.9°C, and a new onset of confusion.
Which action should the nurse take first?
A. Administer the prescribed antipyretic.
B. Obtain blood cultures before starting antibiotics.
C. Apply a cooling blanket.
D. Reorient the patient to time and place.
Correct Answer: B - Obtain blood cultures before starting
antibiotics.
Page 3
A patient with a new colostomy has a wound culture positive for
methicillin-resistant Staphylococcus aureus (MRSA). Which action by the
nurse is most important to prevent transmission?
A. Place the patient in a negative-pressure room.
B. Wear a gown and gloves for all contact with the patient.
C. Use a surgical mask when within 3 feet of the patient.
D. Ensure the patient wears a mask during transport.
Correct Answer: B - Wear a gown and gloves for all contact with
the patient.
RATIONALE
MRSA is transmitted via contact, so gown and gloves are required for
all contact. Negative-pressure rooms are for airborne precautions (e.g.,
tuberculosis). Surgical masks are not required for contact precautions
unless splash risk exists. Patient masking is for droplet precautions.
Question 2
A nurse is assessing a patient with a stage 3 pressure injury on the sacrum.
Which finding requires immediate intervention?
A. The wound bed is 100% red granulation tissue.
B. The periwound skin is macerated and pale.
C. The wound has a moderate amount of serosanguineous drainage.
D. The patient reports pain at the wound site.
Correct Answer: B - The periwound skin is macerated and pale.
RATIONALE
Macerated and pale periwound skin indicates moisture-associated skin
damage and possible ischemia, requiring immediate intervention to
prevent further breakdown. Red granulation tissue indicates healing.
Serosanguineous drainage can be normal. Pain is expected but not the
priority over compromised skin integrity.
Page 2
, Question 3
A nurse is preparing to administer a high-alert medication via IV push. Which
action best demonstrates the nurse's understanding of safe medication
administration?
A. Verify the medication with a second nurse before administration.
B. Administer the medication rapidly to ensure therapeutic effect.
C. Document the medication before administration to save time.
D. Use a single nurse verification for all high-alert medications.
Correct Answer: A - Verify the medication with a second nurse
before administration.
RATIONALE
High-alert medications require independent double-check by a second
nurse to prevent errors. Rapid administration can cause harm.
Documentation should occur after administration. Single-nurse
verification is not best practice for high-alert medications.
Question 4
A patient is admitted with a suspected infection. The nurse notes a white blood
cell count of 15,000/mm³, fever of 38.9°C, and a new onset of confusion.
Which action should the nurse take first?
A. Administer the prescribed antipyretic.
B. Obtain blood cultures before starting antibiotics.
C. Apply a cooling blanket.
D. Reorient the patient to time and place.
Correct Answer: B - Obtain blood cultures before starting
antibiotics.
Page 3
