,Q1 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
A nurse is assessing a patient who has just received a blood transfusion. Which
finding indicates an acute hemolytic reaction, requiring immediate action?
A. Generalized urticaria and pruritus
B. Sudden onset of chills, fever, and lower back pain CORRECT
C. Mild dyspnea and wheezing
D. Elevated blood pressure and headache
RATIONALE: Acute hemolytic reactions occur within minutes and present with fever, chills, lower
back pain, and hemoglobinuria due to intravascular hemolysis. Urticaria and wheezing are more
typical of allergic reactions, while hypertension and headache are not classic signs of a hemolytic
reaction.
Q2 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
According to the hospital's fire response plan, if a fire occurs in a patient's room,
which is the FIRST action the nurse should take?
A. Attempt to extinguish the fire with a fire extinguisher
B. Confine the fire by closing doors and windows
C. Remove the patient from the immediate area CORRECT
D. Activate the fire alarm and call the fire department
RATIONALE: The RACE acronym guides fire response: Rescue, Alarm, Confine, Extinguish. The
first step is to rescue patients in immediate danger by moving them to a safe location.
Extinguishing, confining, and alarming follow, but patient safety is the priority.
Page 2
,Q3 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
A nurse is preparing to administer a continuous tube feeding. Which action is
essential to prevent aspiration?
A. Verify tube placement by aspirating stomach contents and checking pH
B. Elevate the head of the bed to at least 30 to 45 degrees CORRECT
C. Flush the tube with 30 mL of water before and after feeding
D. Administer the feeding at room temperature
RATIONALE: Elevating the head of the bed to 30-45 degrees is the primary prevention for
aspiration during tube feeding. While verifying placement and flushing are important, they do not
directly prevent aspiration. Temperature of feeding is not a key factor.
Q4 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
A nurse is calculating the intake for a patient who consumed 6 oz of coffee, 4 oz of
juice, and 8 oz of water. How many mL should the nurse record?
A. 480 mL
B. 540 mL CORRECT
C. 600 mL
D. 660 mL
RATIONALE: Convert ounces to mL: 1 oz = 30 mL. Total fluid = (6+4+8) oz = 18 oz. 18 oz × 30
mL/oz = 540 mL. The other options represent incorrect conversions or arithmetic.
Page 3
, Q5 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
A nurse is caring for a patient who is at risk for pressure injuries. Which
intervention is most important to include in the plan of care?
A. Massage bony prominences to improve circulation
B. Reposition the patient every 2 hours while in bed CORRECT
C. Use a donut-shaped cushion to relieve sacral pressure
D. Keep the head of the bed elevated at 45 degrees continuously
RATIONALE: Regular repositioning every 2 hours is the cornerstone of pressure injury
prevention. Massaging bony prominences can damage capillaries; donut cushions increase
pressure and are not recommended; continuous HOB elevation increases shear and sacral
pressure.
Q6 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
A nurse is preparing to administer an IM injection to a patient with a small muscle
mass. Which needle size and injection site are most appropriate?
A. 22-gauge, 1-inch needle into the deltoid CORRECT
B. 25-gauge, 5/8-inch needle into the deltoid
C. 21-gauge, 1.5-inch needle into the ventrogluteal
D. 23-gauge, 1-inch needle into the vastus lateralis
RATIONALE: For IM injections, a 22-gauge, 1-inch needle is typically used for the deltoid in
adults with small muscle mass. The 5/8-inch needle is too short for IM; the ventrogluteal may be
too large for small patients; the vastus lateralis is used more in infants, but the needle size is
acceptable, yet the deltoid is preferred for small muscle mass.
Page 4
PATIENT-CENTERED CARE
A nurse is assessing a patient who has just received a blood transfusion. Which
finding indicates an acute hemolytic reaction, requiring immediate action?
A. Generalized urticaria and pruritus
B. Sudden onset of chills, fever, and lower back pain CORRECT
C. Mild dyspnea and wheezing
D. Elevated blood pressure and headache
RATIONALE: Acute hemolytic reactions occur within minutes and present with fever, chills, lower
back pain, and hemoglobinuria due to intravascular hemolysis. Urticaria and wheezing are more
typical of allergic reactions, while hypertension and headache are not classic signs of a hemolytic
reaction.
Q2 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
According to the hospital's fire response plan, if a fire occurs in a patient's room,
which is the FIRST action the nurse should take?
A. Attempt to extinguish the fire with a fire extinguisher
B. Confine the fire by closing doors and windows
C. Remove the patient from the immediate area CORRECT
D. Activate the fire alarm and call the fire department
RATIONALE: The RACE acronym guides fire response: Rescue, Alarm, Confine, Extinguish. The
first step is to rescue patients in immediate danger by moving them to a safe location.
Extinguishing, confining, and alarming follow, but patient safety is the priority.
Page 2
,Q3 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
A nurse is preparing to administer a continuous tube feeding. Which action is
essential to prevent aspiration?
A. Verify tube placement by aspirating stomach contents and checking pH
B. Elevate the head of the bed to at least 30 to 45 degrees CORRECT
C. Flush the tube with 30 mL of water before and after feeding
D. Administer the feeding at room temperature
RATIONALE: Elevating the head of the bed to 30-45 degrees is the primary prevention for
aspiration during tube feeding. While verifying placement and flushing are important, they do not
directly prevent aspiration. Temperature of feeding is not a key factor.
Q4 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
A nurse is calculating the intake for a patient who consumed 6 oz of coffee, 4 oz of
juice, and 8 oz of water. How many mL should the nurse record?
A. 480 mL
B. 540 mL CORRECT
C. 600 mL
D. 660 mL
RATIONALE: Convert ounces to mL: 1 oz = 30 mL. Total fluid = (6+4+8) oz = 18 oz. 18 oz × 30
mL/oz = 540 mL. The other options represent incorrect conversions or arithmetic.
Page 3
, Q5 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
A nurse is caring for a patient who is at risk for pressure injuries. Which
intervention is most important to include in the plan of care?
A. Massage bony prominences to improve circulation
B. Reposition the patient every 2 hours while in bed CORRECT
C. Use a donut-shaped cushion to relieve sacral pressure
D. Keep the head of the bed elevated at 45 degrees continuously
RATIONALE: Regular repositioning every 2 hours is the cornerstone of pressure injury
prevention. Massaging bony prominences can damage capillaries; donut cushions increase
pressure and are not recommended; continuous HOB elevation increases shear and sacral
pressure.
Q6 APPLY THE NURSING PROCESS TO PRIORITIZE AND IMPLEMENT SAFE,
PATIENT-CENTERED CARE
A nurse is preparing to administer an IM injection to a patient with a small muscle
mass. Which needle size and injection site are most appropriate?
A. 22-gauge, 1-inch needle into the deltoid CORRECT
B. 25-gauge, 5/8-inch needle into the deltoid
C. 21-gauge, 1.5-inch needle into the ventrogluteal
D. 23-gauge, 1-inch needle into the vastus lateralis
RATIONALE: For IM injections, a 22-gauge, 1-inch needle is typically used for the deltoid in
adults with small muscle mass. The 5/8-inch needle is too short for IM; the ventrogluteal may be
too large for small patients; the vastus lateralis is used more in infants, but the needle size is
acceptable, yet the deltoid is preferred for small muscle mass.
Page 4
