, Question 1
A nurse receives a verbal order for a high-alert medication during a rapid
response event. Which action best reflects the current standard for safe verbal
order management?
A. Transcribe the order and administer the medication immediately, then
have the provider sign within 24 hours.
B. Repeat the order back to the provider, document it as a verbal order,
and obtain a countersignature within the time frame specified by facility
policy.
C. Refuse to accept the verbal order and require the provider to enter it
electronically before any action.
D. Ask a second nurse to listen on the line and co-sign the order before
administration.
Correct Answer: B - Repeat the order back to the provider,
document it as a verbal order, and obtain a countersignature
within the time frame specified by facility policy.
RATIONALE
The Joint Commission and ISMP require read-back verification of
verbal orders, immediate documentation, and provider
countersignature within a facility-defined time frame (typically 24
hours). Immediate administration without read-back (A) bypasses the
safety check; refusing all verbal orders (C) is impractical in
emergencies; and a second-nurse co-sign (D) is not the recognized
standard for verbal order verification.
Question 2
A nurse is evaluating a patient's understanding of a low-sodium diet. Which
patient statement indicates the need for further teaching?
A. I should avoid canned soups and processed deli meats.
B. I can use salt substitutes freely since they contain no sodium.
C. I will read food labels for sodium content per serving.
Page 2
, D. I should limit frozen dinners and restaurant meals.
Correct Answer: B - I can use salt substitutes freely since they
contain no sodium.
RATIONALE
Salt substitutes typically contain potassium chloride, not sodium, but
they are not 'sodium-free' and may be dangerous for patients on
potassium-restricted diets or with renal impairment. The other
statements reflect accurate understanding of low-sodium dietary
principles.
Question 3
Which finding in a patient receiving intravenous furosemide most urgently
requires the nurse's intervention?
A. Serum potassium 3.1 mEq/L with new-onset muscle weakness
B. Urine output of 1,200 mL over 4 hours
C. Blood pressure 118/72 mm Hg
D. Serum sodium 138 mEq/L
Correct Answer: A - Serum potassium 3.1 mEq/L with new-onset
muscle weakness
RATIONALE
Loop diuretics cause potassium loss; a K+ of 3.1 mEq/L with muscle
weakness signals hypokalemia that can progress to dysrhythmias and
requires immediate intervention. The other findings are either
expected diuretic effects or within normal limits.
Question 4
A patient with a new colostomy refuses to look at the stoma and states, 'I can't
deal with this.' Which nursing response is most therapeutic?
A. Reassure the patient that many people feel this way at first.
B. Acknowledge the patient's feelings and offer to stay while the patient
Page 3
, gradually views the stoma.
C. Explain that colostomy care is essential for discharge and must be
learned today.
D. Ask the patient's family to perform all stoma care until the patient is
ready.
Correct Answer: B - Acknowledge the patient's feelings and offer
to stay while the patient gradually views the stoma.
RATIONALE
Therapeutic communication acknowledges the patient's emotional
response and respects readiness while providing gentle support.
Reassurance (A) minimizes feelings; pressuring education (C)
disregards emotional readiness; and delegating all care to family (D)
delays patient self-efficacy.
Question 5
A nurse is preparing to administer packed red blood cells. Which action is
essential before initiation?
A. Prime the tubing with lactated Ringer's solution.
B. Verify the blood product with a second licensed nurse using two
patient identifiers.
C. Administer the transfusion over 6 hours to prevent fluid overload.
D. Add dextrose 5% to the blood to prevent hypoglycemia.
Correct Answer: B - Verify the blood product with a second
licensed nurse using two patient identifiers.
RATIONALE
Blood transfusion requires two-nurse verification with two patient
identifiers per Joint Commission and AABB standards. LR (A)
contains calcium and can clot blood; 6-hour infusion (C) exceeds the
4-hour maximum; and dextrose (D) causes hemolysis.
Page 4
A nurse receives a verbal order for a high-alert medication during a rapid
response event. Which action best reflects the current standard for safe verbal
order management?
A. Transcribe the order and administer the medication immediately, then
have the provider sign within 24 hours.
B. Repeat the order back to the provider, document it as a verbal order,
and obtain a countersignature within the time frame specified by facility
policy.
C. Refuse to accept the verbal order and require the provider to enter it
electronically before any action.
D. Ask a second nurse to listen on the line and co-sign the order before
administration.
Correct Answer: B - Repeat the order back to the provider,
document it as a verbal order, and obtain a countersignature
within the time frame specified by facility policy.
RATIONALE
The Joint Commission and ISMP require read-back verification of
verbal orders, immediate documentation, and provider
countersignature within a facility-defined time frame (typically 24
hours). Immediate administration without read-back (A) bypasses the
safety check; refusing all verbal orders (C) is impractical in
emergencies; and a second-nurse co-sign (D) is not the recognized
standard for verbal order verification.
Question 2
A nurse is evaluating a patient's understanding of a low-sodium diet. Which
patient statement indicates the need for further teaching?
A. I should avoid canned soups and processed deli meats.
B. I can use salt substitutes freely since they contain no sodium.
C. I will read food labels for sodium content per serving.
Page 2
, D. I should limit frozen dinners and restaurant meals.
Correct Answer: B - I can use salt substitutes freely since they
contain no sodium.
RATIONALE
Salt substitutes typically contain potassium chloride, not sodium, but
they are not 'sodium-free' and may be dangerous for patients on
potassium-restricted diets or with renal impairment. The other
statements reflect accurate understanding of low-sodium dietary
principles.
Question 3
Which finding in a patient receiving intravenous furosemide most urgently
requires the nurse's intervention?
A. Serum potassium 3.1 mEq/L with new-onset muscle weakness
B. Urine output of 1,200 mL over 4 hours
C. Blood pressure 118/72 mm Hg
D. Serum sodium 138 mEq/L
Correct Answer: A - Serum potassium 3.1 mEq/L with new-onset
muscle weakness
RATIONALE
Loop diuretics cause potassium loss; a K+ of 3.1 mEq/L with muscle
weakness signals hypokalemia that can progress to dysrhythmias and
requires immediate intervention. The other findings are either
expected diuretic effects or within normal limits.
Question 4
A patient with a new colostomy refuses to look at the stoma and states, 'I can't
deal with this.' Which nursing response is most therapeutic?
A. Reassure the patient that many people feel this way at first.
B. Acknowledge the patient's feelings and offer to stay while the patient
Page 3
, gradually views the stoma.
C. Explain that colostomy care is essential for discharge and must be
learned today.
D. Ask the patient's family to perform all stoma care until the patient is
ready.
Correct Answer: B - Acknowledge the patient's feelings and offer
to stay while the patient gradually views the stoma.
RATIONALE
Therapeutic communication acknowledges the patient's emotional
response and respects readiness while providing gentle support.
Reassurance (A) minimizes feelings; pressuring education (C)
disregards emotional readiness; and delegating all care to family (D)
delays patient self-efficacy.
Question 5
A nurse is preparing to administer packed red blood cells. Which action is
essential before initiation?
A. Prime the tubing with lactated Ringer's solution.
B. Verify the blood product with a second licensed nurse using two
patient identifiers.
C. Administer the transfusion over 6 hours to prevent fluid overload.
D. Add dextrose 5% to the blood to prevent hypoglycemia.
Correct Answer: B - Verify the blood product with a second
licensed nurse using two patient identifiers.
RATIONALE
Blood transfusion requires two-nurse verification with two patient
identifiers per Joint Commission and AABB standards. LR (A)
contains calcium and can clot blood; 6-hour infusion (C) exceeds the
4-hour maximum; and dextrose (D) causes hemolysis.
Page 4
