, Question 1
A nurse is preparing to administer a medication via a nasogastric tube. Which
action demonstrates the highest level of safety according to current
evidence-based guidelines?
A. Flush with 30 mL of water before and after medication administration.
B. Administer each medication separately and flush between each.
C. Crush all medications together to reduce administration time.
D. Use sterile water for flushing to prevent infection.
Correct Answer: B - Administer each medication separately and
flush between each.
RATIONALE
Administering each medication separately with flushes between
prevents drug interactions and tube occlusion, as recommended by
ISMP guidelines. Flushing with 30 mL is excessive for routine use
and may cause fluid overload; crushing all together risks
incompatibility; sterile water is unnecessary for enteral tubes.
Question 2
A patient with a stage 3 pressure injury has a wound culture positive for
methicillin-resistant Staphylococcus aureus (MRSA). Which type of isolation
precautions should the nurse implement?
A. Standard precautions only
B. Contact precautions
C. Droplet precautions
D. Airborne precautions
Correct Answer: B - Contact precautions
Page 2
, RATIONALE
MRSA is transmitted primarily via direct or indirect contact, requiring
contact precautions (gloves, gown, dedicated equipment). Standard
precautions alone are insufficient; droplet and airborne precautions are
for organisms spread by respiratory droplets or aerosols, respectively.
Question 3
A nurse is assessing a patient receiving furosemide. Which set of laboratory
values most urgently requires intervention?
A. Sodium 138 mEq/L, potassium 3.1 mEq/L
B. Sodium 145 mEq/L, potassium 4.0 mEq/L
C. Sodium 130 mEq/L, potassium 5.2 mEq/L
D. Sodium 135 mEq/L, potassium 3.5 mEq/L
Correct Answer: A - Sodium 138 mEq/L, potassium 3.1 mEq/L
RATIONALE
Furosemide, a loop diuretic, causes potassium loss; a potassium of 3.1
mEq/L indicates hypokalemia, which can precipitate dysrhythmias
and requires immediate intervention. The other options show either
normal values or abnormalities not directly life-threatening in this
context.
Question 4
Which nursing action best demonstrates the ethical principle of veracity?
A. Keeping a patient's diagnosis confidential from family.
B. Telling a patient the truth about a medication error that occurred.
C. Advocating for a patient's right to refuse treatment.
D. Providing equal care to all patients regardless of background.
Correct Answer: B - Telling a patient the truth about a
medication error that occurred.
Page 3
, RATIONALE
Veracity is the duty to tell the truth. Disclosing a medication error
upholds this principle. Confidentiality relates to privacy; advocacy
relates to autonomy; equal care relates to justice.
Question 5
A nurse is teaching a patient about a new prescription for warfarin. Which
statement by the patient indicates a need for further teaching?
A. I will use an electric razor to shave.
B. I will increase my intake of leafy green vegetables.
C. I will report any unusual bleeding or bruising.
D. I will keep my appointments for blood tests.
Correct Answer: B - I will increase my intake of leafy green
vegetables.
RATIONALE
Leafy green vegetables are high in vitamin K, which antagonizes
warfarin and can reduce its effectiveness. Patients should maintain
consistent, not increased, intake. The other statements are correct
safety measures.
Question 6
A patient is admitted with severe dehydration. Which assessment finding
would the nurse expect?
A. Bradycardia and hypertension
B. Tachycardia and hypotension
C. Crackles and jugular venous distention
D. Weight gain and peripheral edema
Correct Answer: B - Tachycardia and hypotension
Page 4
A nurse is preparing to administer a medication via a nasogastric tube. Which
action demonstrates the highest level of safety according to current
evidence-based guidelines?
A. Flush with 30 mL of water before and after medication administration.
B. Administer each medication separately and flush between each.
C. Crush all medications together to reduce administration time.
D. Use sterile water for flushing to prevent infection.
Correct Answer: B - Administer each medication separately and
flush between each.
RATIONALE
Administering each medication separately with flushes between
prevents drug interactions and tube occlusion, as recommended by
ISMP guidelines. Flushing with 30 mL is excessive for routine use
and may cause fluid overload; crushing all together risks
incompatibility; sterile water is unnecessary for enteral tubes.
Question 2
A patient with a stage 3 pressure injury has a wound culture positive for
methicillin-resistant Staphylococcus aureus (MRSA). Which type of isolation
precautions should the nurse implement?
A. Standard precautions only
B. Contact precautions
C. Droplet precautions
D. Airborne precautions
Correct Answer: B - Contact precautions
Page 2
, RATIONALE
MRSA is transmitted primarily via direct or indirect contact, requiring
contact precautions (gloves, gown, dedicated equipment). Standard
precautions alone are insufficient; droplet and airborne precautions are
for organisms spread by respiratory droplets or aerosols, respectively.
Question 3
A nurse is assessing a patient receiving furosemide. Which set of laboratory
values most urgently requires intervention?
A. Sodium 138 mEq/L, potassium 3.1 mEq/L
B. Sodium 145 mEq/L, potassium 4.0 mEq/L
C. Sodium 130 mEq/L, potassium 5.2 mEq/L
D. Sodium 135 mEq/L, potassium 3.5 mEq/L
Correct Answer: A - Sodium 138 mEq/L, potassium 3.1 mEq/L
RATIONALE
Furosemide, a loop diuretic, causes potassium loss; a potassium of 3.1
mEq/L indicates hypokalemia, which can precipitate dysrhythmias
and requires immediate intervention. The other options show either
normal values or abnormalities not directly life-threatening in this
context.
Question 4
Which nursing action best demonstrates the ethical principle of veracity?
A. Keeping a patient's diagnosis confidential from family.
B. Telling a patient the truth about a medication error that occurred.
C. Advocating for a patient's right to refuse treatment.
D. Providing equal care to all patients regardless of background.
Correct Answer: B - Telling a patient the truth about a
medication error that occurred.
Page 3
, RATIONALE
Veracity is the duty to tell the truth. Disclosing a medication error
upholds this principle. Confidentiality relates to privacy; advocacy
relates to autonomy; equal care relates to justice.
Question 5
A nurse is teaching a patient about a new prescription for warfarin. Which
statement by the patient indicates a need for further teaching?
A. I will use an electric razor to shave.
B. I will increase my intake of leafy green vegetables.
C. I will report any unusual bleeding or bruising.
D. I will keep my appointments for blood tests.
Correct Answer: B - I will increase my intake of leafy green
vegetables.
RATIONALE
Leafy green vegetables are high in vitamin K, which antagonizes
warfarin and can reduce its effectiveness. Patients should maintain
consistent, not increased, intake. The other statements are correct
safety measures.
Question 6
A patient is admitted with severe dehydration. Which assessment finding
would the nurse expect?
A. Bradycardia and hypertension
B. Tachycardia and hypotension
C. Crackles and jugular venous distention
D. Weight gain and peripheral edema
Correct Answer: B - Tachycardia and hypotension
Page 4
