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OBA NCLEX-RN (Part 1) study materials
OBA NCLEX-RN (Part 1) study resources

OBA NCLEX-RN (Part 1) practice questions

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Question 1Safe and Effective Care Environment

A nurse is preparing to administer a medication through a central venous catheter. Which action best reflects the principle of maintaining sterile technique during this procedure?

  1. Perform hand hygiene and don clean gloves before accessing the hub
  2. Scrub the catheter hub with an antiseptic and allow it to dry before access Correct answer.
  3. Flush the line with tap water to confirm patency
  4. Attach tubing without cleaning the connection site to save time

Explanation

Central line care bundles require scrubbing the hub with an antiseptic and allowing full drying time before each access, because contamination at the connection site is a leading source of bloodstream infection. Clean gloves and hand hygiene alone do not sterilize the hub, and skipping disinfection defeats the bundle.

Question 2Safe and Effective Care Environment

A client with a documented allergy to penicillin is prescribed a cephalosporin. What is the nurse's priority action?

  1. Administer the drug and monitor for a reaction
  2. Document the allergy and give the drug as ordered
  3. Give half the dose as a test dose
  4. Withhold the drug and clarify the order with the prescriber Correct answer.

Explanation

Cross-reactivity between penicillins and cephalosporins is possible, so the nurse should withhold the medication and verify the order with the prescriber before administration. Administering a suspected allergen or improvising a test dose without an order is unsafe practice.

Question 3Safe and Effective Care Environment

Which nursing action is most important for preventing falls in an older adult admitted to the hospital?

  1. Applying physical restraints to all older clients
  2. Encouraging the client to walk unassisted to build strength
  3. Keeping the bed in the highest position for easier access
  4. Rounding frequently and keeping call light and personal items within reach Correct answer.

Explanation

Frequent rounding with the call light and belongings within reach addresses the common fall risk of unassisted reaching and toileting. Environmental safety measures are the most effective primary prevention strategy for falls in hospitalized older adults.

Question 4Safe and Effective Care Environment

A nurse receives a verbal order from a prescriber for a high-alert medication. What is the appropriate action?

  1. Refuse to accept any verbal orders under all circumstances
  2. Accept the order and administer the drug immediately
  3. Ask another nurse to transcribe the order later
  4. Write down the order, read it back to the prescriber, and follow facility policy for verification Correct answer.

Explanation

Verbal orders must be documented, read back to the prescriber to confirm accuracy, and verified according to facility policy, especially for high-alert medications. Read-back is a recognized safety practice that reduces transcription errors.

Question 5Safe and Effective Care Environment

Which action demonstrates correct use of standard precautions when caring for a client?

  1. Reusing gloves between two clients after hand sanitizing
  2. Wearing a gown only when the client requests it
  3. Performing hand hygiene before and after client contact Correct answer.
  4. Wearing gloves for all client contact regardless of risk

Explanation

Hand hygiene before and after every client contact is the cornerstone of standard precautions and the single most effective way to prevent transmission of infection. Gloves supplement but never replace hand hygiene.

Question 6Safe and Effective Care Environment

A client is placed on airborne precautions. Which action should the nurse take when entering the room?

  1. Open the door to improve airflow
  2. Wear an N95 respirator and perform hand hygiene Correct answer.
  3. Wear a surgical mask only
  4. Wear gloves but no mask

Explanation

Airborne precautions require an N95 or higher-level respirator, along with standard precautions such as hand hygiene, before entering the room. The door should remain closed to maintain negative pressure.

Question 7Safe and Effective Care Environment

A nurse is documenting care in the electronic health record. Which practice best supports legal and safe documentation?

  1. Recording objective findings and interventions with times Correct answer.
  2. Leaving blanks in the record for later completion
  3. Charting care in advance to save time
  4. Using another nurse's login to complete charting

Explanation

Accurate, timely, objective documentation with times reflects the care provided and supports legal defensibility. Charting in advance or sharing logins compromises record integrity and violates privacy standards.

Question 8Safe and Effective Care Environment

Which client assignment is most appropriate for a nurse who is delegating tasks to unlicensed assistive personnel (UAP)?

  1. Teaching a client about a new insulin regimen
  2. Administering oral medications
  3. Performing an initial assessment on a new admission
  4. Assisting a stable client with a bed bath Correct answer.

Explanation

Tasks delegated to UAP must be routine, predictable, and not require nursing judgment, such as bathing a stable client. Assessment, medication administration, and client teaching require the professional nurse's scope of practice.

Question 9Safe and Effective Care Environment

A nurse is caring for a client with a new tracheostomy. Which action is most important to maintain airway safety?

  1. Changing the tracheostomy ties daily regardless of condition
  2. Deflating the cuff every two hours
  3. Keeping emergency airway equipment and a backup tracheostomy tube at the bedside Correct answer.
  4. Suctioning the airway on a fixed schedule every hour

Explanation

A patent airway must be maintained at all times, so emergency equipment and a same-size backup tracheostomy tube must be immediately available at the bedside. Routine scheduled suctioning and arbitrary cuff deflation are not supported practices.

Question 10Safe and Effective Care Environment

A client reports sudden onset of chest pain and shortness of breath two days after surgery. What is the nurse's first action?

  1. Apply supplemental oxygen and notify the provider immediately Correct answer.
  2. Document the findings and continue monitoring
  3. Administer a prescribed analgesic and reassess in one hour
  4. Ambulate the client to assess tolerance

Explanation

Sudden chest pain and dyspnea after surgery suggest a pulmonary embolism, a life-threatening emergency requiring immediate oxygen and provider notification. Delay in treatment can be fatal.

Question 11Safe and Effective Care Environment

A nurse is preparing to administer a blood transfusion. Which action is essential before starting the transfusion?

  1. Administer the blood through a line containing dextrose solution
  2. Warm the blood in a microwave to prevent chills
  3. Verify the client's identity and blood product compatibility with a second nurse Correct answer.
  4. Start the transfusion rapidly to finish quickly

Explanation

Two-person verification of client identity and product compatibility is a critical safety step that prevents transfusion reactions from mismatched blood. Blood must not be warmed in a microwave and should not be given with dextrose-containing solutions.

Question 12Safe and Effective Care Environment

A client with a new colostomy is being taught about care. Which statement by the client indicates understanding?

  1. I will empty the pouch when it is about one-third to one-half full Correct answer.
  2. I can skip hand hygiene since the pouch is sealed
  3. I should change the pouch every day regardless of leakage
  4. I should avoid all activity to prevent leakage

Explanation

Emptying the pouch when it is one-third to one-half full prevents excessive weight and leakage while maintaining a good seal. Pouch changes are based on leakage or schedule, not necessarily daily, and normal activity is encouraged.

Question 13Safe and Effective Care Environment

A nurse is caring for a client receiving intravenous potassium. Which action is most important?

  1. Mixing the potassium with other medications in the same syringe
  2. Administering as a rapid IV push
  3. Verifying that the infusion is diluted and given at a controlled rate Correct answer.
  4. Giving the potassium through a peripheral line without monitoring

Explanation

Potassium must be diluted and infused at a controlled rate because rapid administration can cause fatal cardiac dysrhythmias. It should never be given by IV push.

Question 14Safe and Effective Care Environment

A client is at risk for aspiration after a stroke. Which intervention should the nurse implement?

  1. Thicken liquids as prescribed and monitor swallowing Correct answer.
  2. Provide straws for all fluids
  3. Place the client in a supine position for meals
  4. Encourage large bites to speed eating

Explanation

Thickened liquids and monitored swallowing reduce aspiration risk in clients with dysphagia after a stroke. Positioning should be upright during meals, and straws and large bites increase aspiration risk.

Question 15Safe and Effective Care Environment

A nurse is caring for a client in restraints. Which action is required for safe and ethical care?

  1. Tying restraints to the side rails
  2. Monitoring the client at regular intervals and releasing restraints periodically Correct answer.
  3. Applying restraints without an order for convenience
  4. Leaving the client alone in the room without observation

Explanation

Restraints require a valid order, ongoing monitoring, and periodic release for range of motion and needs such as toileting. They must be tied to a fixed part of the bed frame, not side rails, and the client must never be left unobserved.

Question 16Safe and Effective Care Environment

A nurse is reviewing a medication order for a child. Which action best reflects safe pediatric medication administration?

  1. Verifying the dose against the child's weight and the recommended range Correct answer.
  2. Estimating the dose based on appearance
  3. Using adult dosing and halving it
  4. Administering the full adult dose if the child is large

Explanation

Pediatric doses must be calculated and verified based on weight and the recommended therapeutic range to prevent overdose. Estimating by appearance or halving adult doses is unsafe.

Question 17Safe and Effective Care Environment

A nurse is caring for a client with a chest tube. Which finding requires immediate intervention?

  1. Oscillation of the fluid level with respiration
  2. Continuous bubbling in the water-seal chamber Correct answer.
  3. Serosanguineous drainage in the tubing
  4. The drainage system sitting below the level of the chest

Explanation

Continuous bubbling in the water-seal chamber indicates an air leak in the system, which can lead to a pneumothorax and requires immediate assessment and intervention. Oscillation with breathing and drainage are expected findings.

Question 18Safe and Effective Care Environment

A nurse is preparing to administer a high-alert medication. Which action is most consistent with safe practice?

  1. Using an independent double-check with another qualified nurse Correct answer.
  2. Administering alone without a second check
  3. Administering quickly to save time
  4. Relying on memory for dose calculation

Explanation

Independent double-checks by a second qualified nurse reduce errors with high-alert medications. Memory-based calculation and rushing increase the risk of serious harm.

Question 19Safe and Effective Care Environment

A client is admitted with suspected tuberculosis. Which action should the nurse take first?

  1. Have the client wait in the general waiting area
  2. Perform a tuberculin skin test before room assignment
  3. Place the client in a negative-pressure room with airborne precautions Correct answer.
  4. Remove the client's mask and begin routine care

Explanation

Suspected tuberculosis requires immediate airborne precautions in a negative-pressure room to prevent transmission. Delaying isolation while awaiting tests or having the client wait in a common area increases exposure risk.

Question 20Safe and Effective Care Environment

A nurse is caring for a client who has just returned from surgery and is drowsy. Which action is the priority?

  1. Assessing airway, breathing, and circulation Correct answer.
  2. Encouraging the client to drink fluids immediately
  3. Leaving the client alone to rest
  4. Administering pain medication before assessment

Explanation

Using the ABC framework, the priority after surgery is to assess airway, breathing, and circulation before addressing other needs. A drowsy client is at risk for airway obstruction.

Question 21Safe and Effective Care Environment

A nurse is caring for a client with a new diagnosis of Clostridioides difficile infection. Which action is most important?

  1. Washing hands with soap and water and using contact precautions Correct answer.
  2. Sharing equipment among clients without cleaning
  3. Placing the client in a room with another client
  4. Using alcohol-based hand rub as the sole hand hygiene method

Explanation

C. difficile spores are not reliably killed by alcohol, so soap-and-water handwashing plus contact precautions is essential to prevent spread. Dedicated equipment and a private room further reduce transmission.

Question 22Safe and Effective Care Environment

A nurse is caring for a client receiving a blood transfusion who develops fever, chills, and flank pain. What is the priority action?

  1. Restart the transfusion after the symptoms resolve
  2. Continue the transfusion and give an antipyretic
  3. Slow the transfusion and reassess in thirty minutes
  4. Stop the transfusion immediately and maintain IV access with normal saline Correct answer.

Explanation

Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction, which requires stopping the transfusion immediately and maintaining IV access with normal saline for emergency treatment. Continuing or restarting the product can be fatal.

Question 23Safe and Effective Care Environment

A nurse must prioritize care for four clients. Which client should the nurse assess first?

  1. A client with a new onset of confusion and slurred speech Correct answer.
  2. A client requesting a snack before bed
  3. A client awaiting discharge teaching
  4. A client requesting pain medication for chronic back pain

Explanation

New confusion with slurred speech suggests an acute neurologic event such as a stroke and requires immediate assessment. The other clients have stable or non-urgent needs that can wait.

Question 24Safe and Effective Care Environment

A client is receiving heparin by continuous infusion. Which laboratory result requires the most immediate action?

  1. INR of 1.0
  2. Hemoglobin within normal limits
  3. Platelet count dropping significantly from baseline Correct answer.
  4. aPTT within the therapeutic range

Explanation

A significant drop in platelets during heparin therapy suggests heparin-induced thrombocytopenia, a serious immune-mediated reaction requiring immediate provider notification and discontinuation of heparin. A therapeutic aPTT and normal hemoglobin are reassuring.

Question 25Safe and Effective Care Environment

A nurse is caring for a client with an epidural infusion for pain control. Which assessment is most critical?

  1. Assessing only the pain score every shift
  2. Monitoring respiratory rate and sedation level frequently Correct answer.
  3. Checking the client's hair and nails
  4. Encouraging ambulation without assistance

Explanation

Epidural opioids can cause respiratory depression and excessive sedation, so frequent monitoring of respiratory rate and sedation level is the most critical assessment. Neurologic and motor checks are also performed per protocol.

Question 26Safe and Effective Care Environment

A nurse is preparing to move a client who is unable to assist from the bed to a stretcher. Which action best protects both the client and the nurse from injury?

  1. Ask the client to grip the nurse's neck while the nurse lifts from the bedside.
  2. Keep the bed in the lowest position and pull the client toward the nurse's body.
  3. Raise the bed to waist height and use a friction-reducing slide board with two assistants. Correct answer.
  4. Perform the transfer alone using a draw sheet to save staff time.

Explanation

Safe client handling requires keeping the work at waist height, minimizing friction, and using enough personnel or mechanical lift equipment to match the client's dependency level. Reaching, twisting, and pulling a dependent client increase the risk of musculoskeletal injury to the nurse and shearing injury to the client.

Question 27Safe and Effective Care Environment

A nurse is orienting a newly licensed nurse to fire safety. Which principle should guide the nurse's response when a fire is discovered in a client's room?

  1. Rescue clients in immediate danger, activate the alarm, then contain the fire. Correct answer.
  2. Close all doors on the unit before calling for help or moving anyone.
  3. Extinguish the fire first, then evacuate clients if the extinguisher fails.
  4. Open windows to vent smoke before assisting clients out of the room.

Explanation

The accepted fire response sequence is to rescue anyone in immediate danger, activate the alarm, contain the fire by closing doors, and then extinguish or evacuate as directed. Rescue comes before alarm activation because removing a client from an active fire takes priority over reporting it.

Question 28Safe and Effective Care Environment

A nurse is preparing to apply wrist restraints to a confused client who is pulling at an IV line. Which action should the nurse take?

  1. Obtain an order and assess the client's circulation and skin regularly. Correct answer.
  2. Apply the restraint tightly so the client cannot slip free.
  3. Tie the restraint straps to the side rail of the bed.
  4. Leave the restraint in place until the client is discharged.

Explanation

Restraints require a current order, use of the least restrictive device, and frequent assessment of circulation, skin integrity, and continued need. Tying straps to a side rail is dangerous because the rail can be lowered and the restraint can tighten around the wrist.

Question 29Safe and Effective Care Environment

A nurse is teaching a client about advance directives. Which statement by the client indicates correct understanding of a durable power of attorney for health care?

  1. It is a document that only a physician can complete on my behalf.
  2. It names a person I choose to make health care decisions if I cannot. Correct answer.
  3. It lets my family decide everything after I lose capacity, without any written document.
  4. It takes effect only after my death and distributes my property.

Explanation

A durable power of attorney for health care designates a health care agent chosen by the client to make medical decisions when the client loses decision-making capacity. It is a written document signed while the client is competent and applies during life, not after death.

Question 30Safe and Effective Care Environment

A nurse is caring for a client who speaks limited English and needs to sign a surgical consent. Which action best supports informed consent?

  1. Use a qualified medical interpreter to explain the procedure before signing. Correct answer.
  2. Ask the client's adult child to interpret the consent discussion.
  3. Proceed with the consent because the surgeon already discussed it.
  4. Have the client sign the form and explain the procedure afterward.

Explanation

Informed consent requires that the client understand the procedure, risks, and alternatives in a language the client comprehends, which generally requires a qualified medical interpreter. Using family members as interpreters risks errors, privacy breaches, and undue influence on the client's decision.

Question 31Safe and Effective Care Environment

A nurse is reviewing a client's chart and finds a handwritten order that is unclear and appears incomplete. Which action is most appropriate?

  1. Ask another nurse to guess the intended dose.
  2. Read the order as written and administer the medication.
  3. Hold the order and document it as a prescribing error.
  4. Clarify the order with the prescriber before taking action. Correct answer.

Explanation

Unclear or incomplete orders must be clarified with the prescriber before implementation, because guessing creates a serious risk of medication error. The nurse should never administer a medication based on an ambiguous order.

Question 32Safe and Effective Care Environment

A nurse is caring for a client who has just had a seizure and is now confused. Which action should the nurse take to keep the client safe?

  1. Apply soft limb restraints to prevent movement.
  2. Leave the client alone with the call light within reach.
  3. Raise the side rails and place the bed in the lowest position. Correct answer.
  4. Encourage the client to walk to the bathroom unassisted.

Explanation

After a seizure the client is in a postictal state with confusion and a high fall risk, so the nurse should keep the bed low, raise the side rails, and remain nearby. Restraints are avoided because they increase agitation and injury risk.

Question 33Safe and Effective Care Environment

A nurse is preparing to administer a medication through a central venous catheter. Which action best prevents a catheter-related bloodstream infection?

  1. Change the dressing only when the catheter is removed.
  2. Flush the lumen with tap water before each use.
  3. Reuse the same syringe for multiple medication draws.
  4. Scrub the hub with an antiseptic and allow it to dry before access. Correct answer.

Explanation

Disinfecting the catheter hub with an appropriate antiseptic and allowing it to dry before access reduces contamination of the catheter lumen and bloodstream. Scrub-the-hub technique is a core element of central line maintenance bundles.

Question 34Safe and Effective Care Environment

A nurse is planning care for a client who is at risk for falls. Which intervention should the nurse include in the plan?

  1. Dim the hallway lights and keep the door closed at night.
  2. Apply bilateral wrist restraints during the night.
  3. Keep the client's personal items on a table across the room.
  4. Encourage the client to use the call light and keep it within reach. Correct answer.

Explanation

Fall prevention includes teaching the client to call for help and keeping the call light, personal items, and assistive devices within easy reach. Environmental adjustments and client education are preferred over restraints.

Question 35Safe and Effective Care Environment

A nurse is reviewing a client's laboratory results before administering a scheduled dose of digoxin. Which finding should prompt the nurse to withhold the dose and notify the prescriber?

  1. Digoxin level of 0.9 ng/mL
  2. Serum creatinine of 0.8 mg/dL
  3. Heart rate of 58 beats per minute Correct answer.
  4. Potassium of 4.2 mEq/L

Explanation

Digoxin slows conduction through the atrioventricular node, and a heart rate below 60 beats per minute is a reason to hold the dose and notify the prescriber. Potassium, creatinine, and therapeutic drug levels within normal limits do not require withholding.

Question 36Safe and Effective Care Environment

A nurse is caring for a client who is receiving a continuous heparin infusion. Which action is most important when the platelet count drops significantly from baseline?

  1. Stop the infusion and notify the prescriber immediately. Correct answer.
  2. Administer vitamin K and continue the heparin at the same rate.
  3. Continue the infusion and recheck the platelet count in one week.
  4. Increase the infusion rate to maintain anticoagulation.

Explanation

A significant fall in platelets during heparin therapy suggests heparin-induced thrombocytopenia, a prothrombotic disorder that requires stopping heparin and notifying the prescriber promptly. Continuing or increasing heparin can lead to thrombosis and serious harm.

Question 37Safe and Effective Care Environment

A nurse is admitting a client who has active pulmonary tuberculosis. Which type of room should the nurse assign?

  1. A private room with positive-pressure airflow.
  2. A private room with negative-pressure airflow. Correct answer.
  3. A standard room with the curtain drawn.
  4. A semiprivate room with the door kept open.

Explanation

Tuberculosis is transmitted by airborne droplet nuclei, so the client requires an airborne infection isolation room with negative pressure and frequent air exchanges. Positive-pressure rooms are used to protect immunocompromised clients, not to contain airborne pathogens.

Question 38Safe and Effective Care Environment

A nurse is preparing to administer an intramuscular injection to an adult client. Which site and technique best reduce the risk of injury?

  1. Use the dorsogluteal site and aspirate before injecting.
  2. Use the deltoid site for volumes up to 3 mL in adults.
  3. Use the ventrogluteal site and inject at a 90-degree angle. Correct answer.
  4. Use the vastus lateralis site with a 45-degree angle.

Explanation

The ventrogluteal site is preferred for adult intramuscular injections because it is free of major nerves and blood vessels, and intramuscular injections are given at a 90-degree angle. The dorsogluteal site carries risk of sciatic nerve injury and is generally avoided.

Question 39Safe and Effective Care Environment

A nurse is caring for a client who has an order for nasogastric tube feedings. Which action best reduces the risk of aspiration?

  1. Administer the feeding rapidly to shorten the feeding time.
  2. Keep the head of the bed flat during and after feedings.
  3. Check residual volume only once every 24 hours.
  4. Verify tube placement and elevate the head of the bed 30 to 45 degrees. Correct answer.

Explanation

Aspiration prevention during enteral feeding includes confirming tube position and keeping the head of the bed elevated at least 30 to 45 degrees during and after feedings. Rapid administration and a flat position increase the risk of regurgitation and aspiration.

Question 40Safe and Effective Care Environment

A nurse is caring for a client who has an order for a new medication and is reviewing the client's allergy history. The client reports a previous reaction to a related drug. Which action should the nurse take?

  1. Give half the ordered dose to test for tolerance.
  2. Administer the medication and monitor closely for a reaction.
  3. Hold the medication and contact the prescriber about the allergy. Correct answer.
  4. Administer an antihistamine first, then give the full dose.

Explanation

A reported allergy to a related drug requires the nurse to hold the medication and clarify the order with the prescriber before administration. Administering a known allergen, even with monitoring or premedication, exposes the client to preventable anaphylaxis.

Question 41Safe and Effective Care Environment

A nurse is caring for a client who has a new ileostomy. Which finding should the nurse report to the prescriber immediately?

  1. Output that is liquid and green
  2. Small amount of bleeding at the stoma edge
  3. Stoma that is dark purple and dry Correct answer.
  4. Stoma that is pink and moist

Explanation

A stoma should be pink to red and moist; a dark purple, dusky, or dry stoma suggests ischemia and requires immediate notification of the prescriber. Liquid green output and minor edge bleeding are common after ileostomy creation.

Question 42Safe and Effective Care Environment

A nurse is caring for a client who is receiving intravenous morphine for pain. Which assessment finding is most important to report?

  1. Respiratory rate of 8 breaths per minute Correct answer.
  2. Drowsiness relieved by a short nap
  3. Pain rating that decreased from 7 to 3
  4. Blood pressure of 118/72 mm Hg

Explanation

Opioids depress the central respiratory drive, and a respiratory rate of 8 breaths per minute signals respiratory depression that requires immediate intervention. Effective pain relief and stable vital signs indicate a therapeutic response.

Question 43Safe and Effective Care Environment

A nurse is caring for a client who has just returned from surgery with a drain in place. Which action best promotes safe management of the drain?

  1. Clamp the drain tubing to prevent fluid loss.
  2. Irrigate the drain every shift with sterile saline.
  3. Secure the tubing and keep the drainage system below the insertion site. Correct answer.
  4. Milk the tubing vigorously to increase suction.

Explanation

Drain tubing should be secured to prevent tension and dislodgement, and the collection device is kept below the insertion site so fluid flows by gravity and does not back up. Clamping, routine irrigation, and vigorous milking are not standard and can cause injury or infection.

Question 44Safe and Effective Care Environment

A nurse is reviewing a client's medication administration record and notices that a long-acting insulin is scheduled at the same time as a short-acting insulin. Which action is most consistent with safe medication practice?

  1. Administer the short-acting insulin before meals and the long-acting insulin at its scheduled time, verifying each dose independently. Correct answer.
  2. Ask the unlicensed assistive personnel to administer the insulin.
  3. Administer the long-acting insulin only and skip the short-acting dose.
  4. Draw both insulins into one syringe after verifying the doses.

Explanation

Insulin requires independent verification of each dose and type, with short-acting insulin timed to meals and long-acting insulin given at its scheduled time. Insulin is a high-alert medication, so administration must follow the rights of medication administration and independent double-checks.

Question 45Safe and Effective Care Environment

A nurse is caring for a client who is confused and repeatedly tries to get out of bed. Which action should the nurse take first?

  1. Move the client to a room near the nurses' station and increase observation. Correct answer.
  2. Ask the prescriber for a sedative.
  3. Apply a vest restraint immediately.
  4. Raise all four side rails and leave the room.

Explanation

The least restrictive measures should be tried first, such as closer observation, environmental modification, and frequent checks. Restraints and sedatives are reserved for situations in which less restrictive interventions have failed and a specific order is obtained.

Question 46Safe and Effective Care Environment

A nurse is caring for a client who has a chest tube connected to a water-seal drainage system. Which action is correct when the drainage tubing becomes disconnected from the system?

  1. Clamp the tubing and wait for the next shift to reconnect it.
  2. Reconnect the tubing with tape and continue monitoring.
  3. Place the end of the tubing in sterile water and obtain a new system. Correct answer.
  4. Lower the drainage system to the floor to improve flow.

Explanation

If chest tube tubing disconnects from the drainage system, the end is placed in sterile water to create a temporary water seal and a new system is obtained promptly. Clamping the tube can cause tension pneumothorax, and taping a contaminated connection risks infection.

Question 47Safe and Effective Care Environment

A nurse is caring for a client who has been prescribed a new antibiotic and develops hives, wheezing, and a blood pressure of 82/50 mm Hg. Which action should the nurse take first?

  1. Stop the infusion and call for emergency help. Correct answer.
  2. Give the next scheduled dose and reassess in one hour.
  3. Document the reaction and continue to monitor.
  4. Administer the oral antibiotic with food to reduce the reaction.

Explanation

Hives, wheezing, and hypotension indicate anaphylaxis, which requires immediately stopping the offending agent and activating emergency response. The nurse should then prepare for epinephrine and airway support per protocol.

Question 48Safe and Effective Care Environment

A nurse is reviewing the plan of care for a client who is receiving total parenteral nutrition. Which action is most important to prevent a serious complication?

  1. Flush the line with sterile water before each use.
  2. Increase the infusion rate rapidly if the client reports hunger.
  3. Change the central line dressing every day with clean gloves.
  4. Monitor blood glucose and taper the infusion gradually when discontinuing. Correct answer.

Explanation

Total parenteral nutrition contains high concentrations of glucose, so blood glucose must be monitored and the infusion tapered gradually to prevent rebound hypoglycemia when it is stopped abruptly. Aseptic technique and appropriate flush solutions are also essential.

Question 49Safe and Effective Care Environment

A nurse is caring for a client who is receiving mechanical ventilation. Which finding is most concerning and requires immediate action?

  1. Mild anxiety relieved by reassurance
  2. Suctioning needed once per shift
  3. Peak airway pressure that is rising and absent breath sounds on the right Correct answer.
  4. Oxygen saturation of 95% on the current settings

Explanation

Rising peak airway pressures with absent breath sounds on one side suggest a pneumothorax or mucus plug and require immediate assessment and intervention. Stable oxygenation, routine suctioning, and mild anxiety are expected findings in a ventilated client.

Question 50Safe and Effective Care Environment

A nurse is caring for a client who has been receiving a continuous infusion of norepinephrine. Which action is most important when discontinuing the infusion?

  1. Taper the infusion gradually while monitoring blood pressure. Correct answer.
  2. Flush the line rapidly with saline to clear the medication.
  3. Stop the infusion abruptly and remove the IV catheter.
  4. Place the client in a flat position and stop the infusion at once.

Explanation

Vasopressors such as norepinephrine maintain vascular tone, and abrupt discontinuation can cause severe hypotension, so the infusion is tapered while blood pressure is monitored closely. The IV site is also assessed for extravasation before discontinuation.