RNSG 1517 Protection and Regulation
Question Practice Exam with Answers
and Rationales | Latest Update 2026 |
Graded A+
1. A nurse is caring for a client who is post-operative day one following a hip
replacement. Which assessment finding is the earliest indicator of a potential
infection?
A. Elevated white blood cell count
B. Fever of 101.2°F
C. Purulent drainage from the incision site
D. Increased pain at the surgical site not relieved by medication
Answer: D. Increased pain at the surgical site not relieved by medication
Explanation: While fever, elevated WBCs, and purulent drainage are all signs of infection,
increased pain that is unrelieved by medication is often the earliest indicator of a surgical
site infection. It indicates increasing inflammation and tissue damage before other
systemic signs manifest.
2. A client with a history of falls is prescribed a new antihypertensive medication.
Which nursing intervention is most important for the client's safety?
A. Administer the medication with a full glass of water.
B. Instruct the client to change positions slowly.
C. Monitor the client's blood pressure one hour after administration.
D. Keep the client on bed rest for 24 hours.
,Answer: B. Instruct the client to change positions slowly.
Explanation: Antihypertensives can cause orthostatic hypotension, leading to dizziness and
falls. Teaching the client to change positions slowly (e.g., sitting on the edge of the bed for
a minute before standing) is a critical safety intervention to prevent falls.
3. A nurse is preparing to administer a blood transfusion. After obtaining the
blood product from the blood bank, the nurse's priority action is to:
A. Check the client's vital signs.
B. Verify the client's identity with a second licensed nurse.
C. Initiate the transfusion using a 20-gauge IV catheter.
D. Ensure the client has a signed consent form.
Answer: B. Verify the client's identity with a second licensed nurse.
Explanation: The most critical step before starting a blood transfusion is the two-nurse
verification process at the bedside. This ensures the right blood is given to the right
patient, preventing a potentially fatal transfusion reaction. Verification includes checking
the patient's ID band, blood bank number, and ABO/Rh compatibility.
4. Which of the following clients is at the highest risk for developing a pressure
injury?
A. A 45-year-old with a fractured femur in Buck's traction
B. A 70-year-old who is incontinent and has limited mobility
C. A 30-year-old with a spinal cord injury who uses a wheelchair
D. A 60-year-old who is post-operative and has a Braden Score of 22
Answer: B. A 70-year-old who is incontinent and has limited mobility
Explanation: This client has multiple risk factors: advanced age, incontinence (which leads
to moisture and skin breakdown), and limited mobility. While the spinal cord injury
patient is also at risk, the combination of advanced age, incontinence, and immobility
makes this client the highest risk. A Braden Score of 22 indicates low risk.
5. A nurse is caring for a client on contact precautions. Which action is essential
when entering the client's room?
,A. Wear an N95 respirator.
B. Wear a gown and gloves.
C. Wear a surgical mask and eye protection.
D. Ensure the room is at negative pressure.
Answer: B. Wear a gown and gloves.
Explanation: Contact precautions require gown and gloves to prevent the transmission of
organisms spread by direct or indirect contact (e.g., MRSA, VRE). An N95 respirator is for
airborne precautions, a surgical mask is for droplet precautions, and negative pressure is
for airborne isolation rooms.
6. A client is receiving continuous enteral tube feedings. Which intervention is
most effective in preventing aspiration?
A. Check gastric residual volumes every 8 hours.
B. Elevate the head of the bed to 30-45 degrees.
C. Flush the feeding tube with 30 mL of water every 4 hours.
D. Administer the feeding via a pump.
Answer: B. Elevate the head of the bed to 30-45 degrees.
Explanation: Maintaining the head of the bed at 30-45 degrees is the most effective
intervention to prevent aspiration of gastric contents into the lungs. This uses gravity to
keep the stomach contents down.
7. The nurse is educating a client on how to manage their hypertension. Which
statement indicates the client needs further teaching?
A. "I will check my blood pressure daily and record the readings."
B. "I will take my medication at the same time every day."
C. "I will decrease my intake of fresh fruits and vegetables."
D. "I will incorporate a 30-minute walk into my routine most days."
Answer: C. "I will decrease my intake of fresh fruits and vegetables."
Explanation: A key component of managing hypertension (the DASH diet) is increasing the
, intake of fruits and vegetables, which are high in potassium and fiber. Decreasing their
intake is counterproductive and indicates a need for further teaching.
8. A nurse is caring for a client with a chest tube. The collection chamber is
accidentally knocked over and breaks. What is the nurse's priority action?
A. Apply an occlusive dressing over the insertion site.
B. Clamp the chest tube close to the client's chest.
C. Submerge the end of the tube in sterile water.
D. Notify the healthcare provider immediately.
Answer: C. Submerge the end of the tube in sterile water.
Explanation: If the drainage system breaks, the immediate priority is to prevent a
pneumothorax. The end of the tube must be submerged in sterile water to maintain the
water seal and prevent air from entering the pleural space. Placing the tube in sterile
water at the bedside is the fastest intervention until a new system is obtained.
9. A client is on a 24-hour urine collection. The unlicensed assistive personnel
(UAP) empties a small amount of urine from the collection container but fails to
put it in the larger collection jug. What should the nurse do?
A. Discard the urine in the larger jug and restart the test.
B. Document the incident and continue the collection.
C. Instruct the UAP to add the urine to the larger jug.
D. Ask the UAP to note the amount and time in the chart.
Answer: A. Discard the urine in the larger jug and restart the test.
Explanation: For a 24-hour urine collection, all urine must be saved. If any urine is
discarded or lost, the entire test is invalid, and it must be restarted. It is not possible to
accurately account for the "missing" sample.
10. The nurse is preparing a client for surgery. Which statement made by the client
requires immediate follow-up before the procedure?
A. "I am feeling very nervous about the surgery."
B. "I had a glass of water with my morning pills."
Question Practice Exam with Answers
and Rationales | Latest Update 2026 |
Graded A+
1. A nurse is caring for a client who is post-operative day one following a hip
replacement. Which assessment finding is the earliest indicator of a potential
infection?
A. Elevated white blood cell count
B. Fever of 101.2°F
C. Purulent drainage from the incision site
D. Increased pain at the surgical site not relieved by medication
Answer: D. Increased pain at the surgical site not relieved by medication
Explanation: While fever, elevated WBCs, and purulent drainage are all signs of infection,
increased pain that is unrelieved by medication is often the earliest indicator of a surgical
site infection. It indicates increasing inflammation and tissue damage before other
systemic signs manifest.
2. A client with a history of falls is prescribed a new antihypertensive medication.
Which nursing intervention is most important for the client's safety?
A. Administer the medication with a full glass of water.
B. Instruct the client to change positions slowly.
C. Monitor the client's blood pressure one hour after administration.
D. Keep the client on bed rest for 24 hours.
,Answer: B. Instruct the client to change positions slowly.
Explanation: Antihypertensives can cause orthostatic hypotension, leading to dizziness and
falls. Teaching the client to change positions slowly (e.g., sitting on the edge of the bed for
a minute before standing) is a critical safety intervention to prevent falls.
3. A nurse is preparing to administer a blood transfusion. After obtaining the
blood product from the blood bank, the nurse's priority action is to:
A. Check the client's vital signs.
B. Verify the client's identity with a second licensed nurse.
C. Initiate the transfusion using a 20-gauge IV catheter.
D. Ensure the client has a signed consent form.
Answer: B. Verify the client's identity with a second licensed nurse.
Explanation: The most critical step before starting a blood transfusion is the two-nurse
verification process at the bedside. This ensures the right blood is given to the right
patient, preventing a potentially fatal transfusion reaction. Verification includes checking
the patient's ID band, blood bank number, and ABO/Rh compatibility.
4. Which of the following clients is at the highest risk for developing a pressure
injury?
A. A 45-year-old with a fractured femur in Buck's traction
B. A 70-year-old who is incontinent and has limited mobility
C. A 30-year-old with a spinal cord injury who uses a wheelchair
D. A 60-year-old who is post-operative and has a Braden Score of 22
Answer: B. A 70-year-old who is incontinent and has limited mobility
Explanation: This client has multiple risk factors: advanced age, incontinence (which leads
to moisture and skin breakdown), and limited mobility. While the spinal cord injury
patient is also at risk, the combination of advanced age, incontinence, and immobility
makes this client the highest risk. A Braden Score of 22 indicates low risk.
5. A nurse is caring for a client on contact precautions. Which action is essential
when entering the client's room?
,A. Wear an N95 respirator.
B. Wear a gown and gloves.
C. Wear a surgical mask and eye protection.
D. Ensure the room is at negative pressure.
Answer: B. Wear a gown and gloves.
Explanation: Contact precautions require gown and gloves to prevent the transmission of
organisms spread by direct or indirect contact (e.g., MRSA, VRE). An N95 respirator is for
airborne precautions, a surgical mask is for droplet precautions, and negative pressure is
for airborne isolation rooms.
6. A client is receiving continuous enteral tube feedings. Which intervention is
most effective in preventing aspiration?
A. Check gastric residual volumes every 8 hours.
B. Elevate the head of the bed to 30-45 degrees.
C. Flush the feeding tube with 30 mL of water every 4 hours.
D. Administer the feeding via a pump.
Answer: B. Elevate the head of the bed to 30-45 degrees.
Explanation: Maintaining the head of the bed at 30-45 degrees is the most effective
intervention to prevent aspiration of gastric contents into the lungs. This uses gravity to
keep the stomach contents down.
7. The nurse is educating a client on how to manage their hypertension. Which
statement indicates the client needs further teaching?
A. "I will check my blood pressure daily and record the readings."
B. "I will take my medication at the same time every day."
C. "I will decrease my intake of fresh fruits and vegetables."
D. "I will incorporate a 30-minute walk into my routine most days."
Answer: C. "I will decrease my intake of fresh fruits and vegetables."
Explanation: A key component of managing hypertension (the DASH diet) is increasing the
, intake of fruits and vegetables, which are high in potassium and fiber. Decreasing their
intake is counterproductive and indicates a need for further teaching.
8. A nurse is caring for a client with a chest tube. The collection chamber is
accidentally knocked over and breaks. What is the nurse's priority action?
A. Apply an occlusive dressing over the insertion site.
B. Clamp the chest tube close to the client's chest.
C. Submerge the end of the tube in sterile water.
D. Notify the healthcare provider immediately.
Answer: C. Submerge the end of the tube in sterile water.
Explanation: If the drainage system breaks, the immediate priority is to prevent a
pneumothorax. The end of the tube must be submerged in sterile water to maintain the
water seal and prevent air from entering the pleural space. Placing the tube in sterile
water at the bedside is the fastest intervention until a new system is obtained.
9. A client is on a 24-hour urine collection. The unlicensed assistive personnel
(UAP) empties a small amount of urine from the collection container but fails to
put it in the larger collection jug. What should the nurse do?
A. Discard the urine in the larger jug and restart the test.
B. Document the incident and continue the collection.
C. Instruct the UAP to add the urine to the larger jug.
D. Ask the UAP to note the amount and time in the chart.
Answer: A. Discard the urine in the larger jug and restart the test.
Explanation: For a 24-hour urine collection, all urine must be saved. If any urine is
discarded or lost, the entire test is invalid, and it must be restarted. It is not possible to
accurately account for the "missing" sample.
10. The nurse is preparing a client for surgery. Which statement made by the client
requires immediate follow-up before the procedure?
A. "I am feeling very nervous about the surgery."
B. "I had a glass of water with my morning pills."
