, Question 1
A nurse is preparing to administer a high-alert medication via a smart infusion
pump. Which action best exemplifies the use of a forcing function to reduce
medication errors?
A. Double-checking the medication with a second nurse before
administration.
B. Using barcode scanning that requires the patient's ID and medication
to match before infusion.
C. Placing a 'high-alert' sticker on the medication bag.
D. Reviewing the medication order in the electronic health record.
Correct Answer: B - Using barcode scanning that requires the
patient's ID and medication to match before infusion.
RATIONALE
A forcing function physically prevents the user from proceeding until
conditions are met; barcode scanning that blocks infusion unless the
patient and medication match is a forcing function. Double-checking
is a redundancy, stickers are warnings, and order review is a cognitive
check, none of which force compliance.
Question 2
A nurse is assessing a patient who underwent a paracentesis. Which finding
requires immediate follow-up?
A. Serosanguineous drainage on the dressing.
B. Blood pressure 88/50 mm Hg, heart rate 118 bpm, and confusion.
C. Complaint of mild incisional discomfort.
D. Urine output of 40 mL over the past 2 hours.
Correct Answer: B - Blood pressure 88/50 mm Hg, heart rate 118
bpm, and confusion.
Page 2
, RATIONALE
Hypotension, tachycardia, and confusion suggest hypovolemic shock
from fluid shift or bleeding post-paracentesis, requiring immediate
intervention. Serosanguineous drainage is expected, mild discomfort is
common, and urine output of 40 mL/2 hr is borderline but not
immediately life-threatening.
Question 3
Which statement by a nurse indicates correct understanding of the principle of
'sterile field' during a bedside procedure?
A. Sterile gloves can touch non-sterile surfaces as long as the fingertips
remain sterile.
B. A sterile field is considered contaminated if it is below waist level.
C. Sterile items can be placed on a dry surface without a sterile drape.
D. The sterile field remains sterile if the nurse reaches over it with clean
hands.
Correct Answer: B - A sterile field is considered contaminated if
it is below waist level.
RATIONALE
Sterile fields must be kept above waist level and within sight; below
waist is considered contaminated. Gloves touching non-sterile surfaces
contaminates them, sterile items require a sterile barrier, and reaching
over a sterile field contaminates it.
Question 4
A patient with heart failure is prescribed furosemide 40 mg IV push. Which
assessment finding should the nurse report before administration?
A. Serum potassium 3.2 mEq/L.
B. Blood pressure 110/70 mm Hg.
C. Urine output 50 mL/hr.
D. Heart rate 88 bpm.
Page 3
, Correct Answer: A - Serum potassium 3.2 mEq/L.
RATIONALE
Furosemide is a loop diuretic that causes potassium loss;
administering with hypokalemia (3.2 mEq/L) increases risk of
dysrhythmias. The other values are within normal limits and do not
contraindicate administration.
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 greens are high in vitamin K, which antagonizes warfarin;
patients should maintain consistent intake, not increase it. The other
statements reflect correct safety measures and monitoring.
Question 6
A nurse is caring for a patient with a new colostomy. Which stoma assessment
finding should be reported immediately?
A. Stoma is moist and red.
B. Stoma is dusky and cyanotic.
C. Stoma is slightly edematous.
D. Stoma has a small amount of bleeding when touched.
Correct Answer: B - Stoma is dusky and cyanotic.
Page 4
A nurse is preparing to administer a high-alert medication via a smart infusion
pump. Which action best exemplifies the use of a forcing function to reduce
medication errors?
A. Double-checking the medication with a second nurse before
administration.
B. Using barcode scanning that requires the patient's ID and medication
to match before infusion.
C. Placing a 'high-alert' sticker on the medication bag.
D. Reviewing the medication order in the electronic health record.
Correct Answer: B - Using barcode scanning that requires the
patient's ID and medication to match before infusion.
RATIONALE
A forcing function physically prevents the user from proceeding until
conditions are met; barcode scanning that blocks infusion unless the
patient and medication match is a forcing function. Double-checking
is a redundancy, stickers are warnings, and order review is a cognitive
check, none of which force compliance.
Question 2
A nurse is assessing a patient who underwent a paracentesis. Which finding
requires immediate follow-up?
A. Serosanguineous drainage on the dressing.
B. Blood pressure 88/50 mm Hg, heart rate 118 bpm, and confusion.
C. Complaint of mild incisional discomfort.
D. Urine output of 40 mL over the past 2 hours.
Correct Answer: B - Blood pressure 88/50 mm Hg, heart rate 118
bpm, and confusion.
Page 2
, RATIONALE
Hypotension, tachycardia, and confusion suggest hypovolemic shock
from fluid shift or bleeding post-paracentesis, requiring immediate
intervention. Serosanguineous drainage is expected, mild discomfort is
common, and urine output of 40 mL/2 hr is borderline but not
immediately life-threatening.
Question 3
Which statement by a nurse indicates correct understanding of the principle of
'sterile field' during a bedside procedure?
A. Sterile gloves can touch non-sterile surfaces as long as the fingertips
remain sterile.
B. A sterile field is considered contaminated if it is below waist level.
C. Sterile items can be placed on a dry surface without a sterile drape.
D. The sterile field remains sterile if the nurse reaches over it with clean
hands.
Correct Answer: B - A sterile field is considered contaminated if
it is below waist level.
RATIONALE
Sterile fields must be kept above waist level and within sight; below
waist is considered contaminated. Gloves touching non-sterile surfaces
contaminates them, sterile items require a sterile barrier, and reaching
over a sterile field contaminates it.
Question 4
A patient with heart failure is prescribed furosemide 40 mg IV push. Which
assessment finding should the nurse report before administration?
A. Serum potassium 3.2 mEq/L.
B. Blood pressure 110/70 mm Hg.
C. Urine output 50 mL/hr.
D. Heart rate 88 bpm.
Page 3
, Correct Answer: A - Serum potassium 3.2 mEq/L.
RATIONALE
Furosemide is a loop diuretic that causes potassium loss;
administering with hypokalemia (3.2 mEq/L) increases risk of
dysrhythmias. The other values are within normal limits and do not
contraindicate administration.
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 greens are high in vitamin K, which antagonizes warfarin;
patients should maintain consistent intake, not increase it. The other
statements reflect correct safety measures and monitoring.
Question 6
A nurse is caring for a patient with a new colostomy. Which stoma assessment
finding should be reported immediately?
A. Stoma is moist and red.
B. Stoma is dusky and cyanotic.
C. Stoma is slightly edematous.
D. Stoma has a small amount of bleeding when touched.
Correct Answer: B - Stoma is dusky and cyanotic.
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