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SECTION 1: Fundamentals & Safe Care
Q1: A nurse enters a client's room and finds the bed alarm sounding, the IV pump
beeping "occlusion," and the client on the floor stating, "I just slipped getting up." What is
the nurse's priority action?
A. Check the client's pupils and grip strength
B. Help the client back into bed and assess for injury
C. Silence the bed alarm and restart the IV pump
D. Document the fall and complete an incident report
Correct Answer: B
Rationale: The nursing process step is Implementation—immediate client safety is the
priority (Maslow's physiologic need). Helping the client back into bed protects the
cervical spine and allows systematic assessment for injury. Option A is premature:
neuro checks come after basic injury screen. Option C ignores the client. Option D is
required but never precedes client care.
Q2: The nurse reviews the chart of a client on contact precautions for VRE. Which action
by the UAP requires immediate correction?
A. Leaving the isolation gown hanging on the IV pole outside the room
B. Wearing gloves while emptying the client's urinal
,C. Washing hands with alcohol-based rub after glove removal
D. Bringing fresh water into the room wearing gloves
Correct Answer: A
Rationale: Leaving contaminated PPE outside the room violates transmission-based
precautions and creates an infection reservoir. The gown must be discarded inside the
room before exiting. Alcohol rub (C) is acceptable if hands are not visibly soiled; gloves
for urinal (B) and wearing gloves for supply transport (D) are appropriate.
Q3: A client is receiving a secondary (piggy-back) antibiotic that is due at 0800. The
primary IV fluid is running at 125 mL/h and the antibiotic bag contains 50 mL to infuse
over 30 min. What rate should the nurse set for the antibiotic infusion?
A. 50 mL/h
B. 100 mL/h
C. 125 mL/h
D. 150 mL/h
Correct Answer: B
Rationale: Dosage calculation: volume (50 mL) ÷ time (0.5 h) = 100 mL/h. Returning to
the primary rate after infusion prevents fluid overload. Option A would infuse the dose
over 1 h (late). Options C and D exceed the prescribed time.
Q4: The nurse discovers that an insulin pen was left in a client room after
administration. The pen was used on only this client. Which action is most appropriate?
A. Return the pen to the medication refrigerator for future use
B. Dispose of the pen in a sharps container and obtain a new one
,C. Wipe the pen with alcohol and return it to the medication cart
D. Label the pen with the client's name and keep it at bedside
Correct Answer: D
Rationale: Insulin pens are patient-specific devices (CDC, 2023). Keeping the labeled
pen at bedside prevents cross-contamination and maintains the prescribed medication
chain. Disposal (B) wastes medication; refrigeration (A) is unnecessary; alcohol (C)
does not sterilize the internal mechanism.
Q5: During hand-off report, the outgoing nurse states, "The client has a stage 2 pressure
injury on the coccyx, 1.5 cm × 1 cm, no drainage, and is turning q2h." Which SBAR
component is missing?
A. Situation
B. Background
C. Assessment
D. Recommendation
Correct Answer: D
Rationale: SBAR requires a recommendation (e.g., "Continue q2h turns, consider barrier
cream, reassess in 24 h"). The nurse provided situation/background/assessment but
left the incoming nurse without an action plan.
Q6: A client refuses a dose of PO metoprolol, stating, "I already took my morning pill at
home." What is the nurse's best response?
A. "I'll document your refusal and inform the provider."
B. "You must take it; your heart rate is 110."
, C. "Let me verify your home medication list and then we'll decide together."
D. "I'll hold it for now, but this could affect your blood pressure."
Correct Answer: C
Rationale: Assessment step: verify home medications to prevent duplication or
omission, uphold client autonomy, and maintain therapeutic trust. Option A is
premature; option B is coercive; option D lacks assessment.
Q7: The nurse notes a fire in a trash can in a client room. Which action is first according
to RACE?
A. Extinguish the fire with the nearest blanket
B. Close the room door
C. Remove the client from the room
D. Pull the fire alarm
Correct Answer: C
Rationale: RACE = Rescue, Alarm, Confine, Extinguish/evacuate. Removing the client
(rescue) is the immediate life-safety priority.
Q8: A client's advance directive states "No CPR," but the family begs the nurse to "do
everything" when the client stops breathing. What is the nurse's ethical obligation?
A. Honor the family's request and begin CPR
B. Honor the advance directive and provide comfort measures
C. Call the ethics committee before acting
D. Ask the provider to change the code status