QUESTIONS AND CORRECT ANSWERS WITH
DETAILED RATIONALES
Safety & Infection Control (Questions 1-30)
1. A nurse is preparing to administer a blood transfusion to a client. Which of
the following actions should the nurse take first?
A. Verify the client's identity with a second nurse.
B. Prime the IV tubing with 0.9% normal saline.
C. Check the expiration date on the blood product.
D. Obtain the client's baseline vital signs.
Correct Answer: A
Rationale: Patient safety is the priority. The first and most critical step in
blood administration is the two-nurse verification of the client's identity,
blood product, and compatibility. All other steps are important but occur after
verification.
2. A client is on strict isolation for an infection caused by methicillin-
resistant Staphylococcus aureus (MRSA). Which of the following actions by the
nurse demonstrates an understanding of transmission-based precautions?
A. Wearing a sterile gown and gloves for all client interactions.
B. Placing the client in a negative-pressure room.
C. Wearing an N95 respirator when entering the room.
D. Using dedicated equipment for the client, such as a stethoscope and blood
pressure cuff.
Correct Answer: D
Rationale: MRSA requires contact precautions. Using dedicated, non-critical
equipment for the client prevents the transmission of organisms to other
clients. Gowns and gloves are required for all contact but are not sterile (A). A
negative-pressure room is for airborne precautions (B). An N95 respirator is
for airborne precautions, not contact (C).
,3. A nurse is caring for a client who has a new prescription for a nasogastric
(NG) tube for gastric decompression. To prevent aspiration, which of the
following is the most important nursing action before initiating tube feeding?
A. Flush the tube with 30 mL of air.
B. Check the pH of the gastric aspirate.
C. Verify the position of the tube by x-ray.
D. Place the client in a supine position.
Correct Answer: C
Rationale: An x-ray is the only definitive method to confirm NG tube
placement before initiating feedings. While pH testing (B) is a useful bedside
method, it is not as definitive as an x-ray, especially if the client is on acid-
suppressing medications. Aspiration risk is minimized by positioning the
client with the head of the bed elevated to 30-45 degrees, not supine (D).
4. A nurse is preparing to administer a subcutaneous injection of heparin.
Which of the following actions is correct?
A. Aspirate for a blood return before injecting.
B. Massage the site after the injection to promote absorption.
C. Administer the injection in the client's abdomen.
D. Use a 22-gauge, 1.5-inch needle.
Correct Answer: C
Rationale: The abdomen is the preferred site for subcutaneous heparin due to
its large subcutaneous layer and consistent absorption. Aspiration is not
recommended (A) as it can cause tissue damage and hematoma formation.
The site should not be massaged (B) as it can cause bruising. A 22-gauge, 1.5-
inch needle (D) is too large and long for a subcutaneous injection; a 25-27
gauge, ⅜ to ⅝ inch needle is used.
5. A client is being discharged with a prescription for a cane. The nurse should
instruct the client to hold the cane on which side?
A. The side of the stronger leg.
B. The side of the weaker leg.
C. The side of the dominant hand.
D. The side that is most comfortable.
Correct Answer: A
Rationale: The cane should be held on the stronger side. This allows the cane
,to move with the weaker leg, providing support and reducing the weight-
bearing load on the weaker side.
6. A nurse is preparing a client for a procedure that requires informed
consent. The client states, "I don't understand what the doctor is going to do."
What is the nurse's best action?
A. Explain the procedure to the client in simple terms.
B. Ask the client to sign the consent form and assure them it's a standard
procedure.
C. Notify the healthcare provider and ask them to clarify the information for
the client.
D. Document the client's statement and proceed with the procedure.
Correct Answer: C
Rationale: The nurse's role is to witness the signature and ensure the client
has been adequately informed. If the client does not understand, the nurse
must contact the healthcare provider who is responsible for obtaining
informed consent to provide further explanation.
7. A client is receiving a continuous intravenous (IV) infusion of normal saline.
The nurse notes that the IV site is swollen, cool to the touch, and pale. What is
the priority nursing action?
A. Apply a warm compress to the site.
B. Elevate the client's arm.
C. Stop the infusion and discontinue the IV.
D. Slow the infusion rate and monitor the site closely.
Correct Answer: C
Rationale: The signs and symptoms indicate infiltration (IV fluid leaking into
the subcutaneous tissue). The priority is to stop the infusion and remove the
IV catheter to prevent further damage, such as compartment syndrome.
8. A client with a history of falls is prescribed a new antihypertensive
medication. Which nursing intervention is most important to include in the
client's plan of care to reduce the risk of injury?
A. Keep the bed in the lowest position.
B. Instruct the client to request assistance before getting out of bed.
C. Place a fall risk bracelet on the client.
D. Ensure the call light is within reach.
Correct Answer: B
, Rationale: While all options are important fall prevention strategies, the most
critical intervention is instructing the client to ask for help before getting out
of bed. This directly addresses the risk of orthostatic hypotension from the
new medication. The other actions are supportive but rely on the client's
ability to remember and use them.
9. A nurse is caring for a client with a tracheostomy. Which of the following
actions is essential to prevent a nosocomial infection?
A. Change the tracheostomy tube weekly.
B. Use sterile technique when suctioning.
C. Apply a gauze dressing over the stoma.
D. Administer prophylactic antibiotics.
Correct Answer: B
Rationale: Suctioning is an invasive procedure that can introduce pathogens
into the lower respiratory tract. Using sterile technique is crucial to prevent
hospital-acquired (nosocomial) pneumonia. Tracheostomy tubes are not
changed weekly (A) unless specified. Gauze dressings (C) are changed when
soiled but do not prevent infection as effectively as sterile suctioning.
10. A nurse is preparing to administer an enema to an adult client. In which
position should the nurse place the client?
A. Prone.
B. Supine.
C. Dorsal recumbent.
D. Left lateral Sims' position.
Correct Answer: D
Rationale: The left lateral Sims' position (lying on the left side with the right
knee flexed) allows the enema solution to flow by gravity along the natural
curve of the sigmoid colon and rectum, which promotes comfort and effective
instillation.
11. A nurse is teaching a client about the correct use of a metered-dose inhaler
(MDI). Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will shake the inhaler well before each use."
B. "I will inhale quickly and deeply when I press the canister."
C. "I will hold my breath for about 5 seconds after inhaling."
D. "I will exhale completely before placing the inhaler in my mouth."