I85PREP
⌘ K
JNCLEX-RN (Jordan) study materials
JNCLEX-RN (Jordan) study resources

JNCLEX-RN (Jordan) practice questions

One question at a time. Build your JNCLEX-RN (Jordan) understanding.

First 50 of 200 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Safe and Effective Care Environment: Management of Care

A staff nurse on a medical-surgical unit is assigned five patients and must also complete a quality-improvement audit by the end of the shift. Using the principle of prioritization in the management of care, which action should the nurse take first?

  1. Document the audit before providing any patient care
  2. Assess the acuity of all assigned patients before planning the shift Correct answer.
  3. Ask a colleague to administer all scheduled medications
  4. Delegate the audit data collection to the unit secretary

Explanation

Management of care requires the nurse to establish priorities based on patient acuity and the potential for harm, so a rapid assessment of all assigned patients comes before non-clinical tasks. The audit is important but does not outrank direct patient needs. Delegation and task-sharing must follow assessment and scope-of-practice rules.

Question 2Safe and Effective Care Environment: Management of Care

Which task is appropriate for a registered nurse to delegate to an unlicensed assistive personnel (UAP) working on an inpatient ward?

  1. Performing the initial admission assessment on a transfer
  2. Teaching a newly diagnosed patient to self-inject insulin
  3. Measuring and recording a stable patient's blood pressure Correct answer.
  4. Evaluating a patient's understanding of a low-sodium diet

Explanation

Delegation to unlicensed assistive personnel is limited to tasks that are routine, have a predictable outcome, and require no nursing judgment, such as vital signs on a stable patient. Teaching, initial assessment, and evaluation of learning are professional nursing responsibilities that cannot be delegated. The nurse retains accountability for the delegated task.

Question 3Safe and Effective Care Environment: Management of Care

A nurse is caring for a patient who speaks only Arabic and has just signed a surgical consent form. The consent was obtained through the patient's cousin, who interpreted. Which action best reflects the nurse's advocacy role?

  1. Verify understanding through a qualified medical interpreter before surgery Correct answer.
  2. Delay all communication until the patient learns some English
  3. Proceed because the patient signed the form voluntarily
  4. Ask the cousin to sign a statement confirming accurate translation

Explanation

Informed consent requires that the patient understand the procedure, risks, and alternatives, which depends on accurate communication through a qualified medical interpreter. Using a family member risks miscommunication, confidentiality breaches, and undue influence. The nurse advocates by confirming comprehension before the procedure proceeds.

Question 4Safe and Effective Care Environment: Management of Care

A nurse manager is reviewing staffing for the night shift. Which situation most clearly requires escalation to the charge nurse or nursing supervisor?

  1. One nurse requests a preferred break time
  2. A nurse is assigned six patients with two requiring frequent titration Correct answer.
  3. A new graduate asks for help starting an IV
  4. The unit has one unused isolation room

Explanation

Management of care includes monitoring workload and matching staffing to patient acuity; a nurse caring for six patients with two unstable, frequently titrated infusions exceeds a safe assignment. Escalation protects patient safety and supports the nurse. The other situations are routine and do not by themselves create an unsafe assignment.

Question 5Safe and Effective Care Environment: Management of Care

During a shift handover, the outgoing nurse reports that a patient's condition has deteriorated but omits the most recent vital signs. Which element of the handover process does this most directly compromise?

  1. Continuity and safety of care during transfer of responsibility Correct answer.
  2. The confidentiality of the medical record
  3. The patient's right to refuse treatment
  4. The nurse's eligibility for overtime pay

Explanation

Handover is a transfer of responsibility in which essential clinical information must be communicated so the receiving nurse can continue safe care. Omitting current vital signs on a deteriorating patient creates a gap in continuity and increases the risk of harm. Structured handover tools exist precisely to prevent such omissions.

Question 6Safe and Effective Care Environment: Management of Care

A patient with capacity refuses a prescribed blood transfusion after being fully informed of the risks. What is the nurse's most appropriate action?

  1. Obtain a court order before providing any other care
  2. Respect the refusal and document the discussion and notification Correct answer.
  3. Ask the family to persuade the patient to consent
  4. Administer the transfusion because it was prescribed

Explanation

A competent adult has the legal and ethical right to refuse any treatment, even life-sustaining treatment, after informed discussion. The nurse respects the decision, documents the education and refusal, and notifies the provider. Overriding a capable patient's refusal would constitute battery.

Question 7Safe and Effective Care Environment: Management of Care

A nurse is preparing to delegate a bed bath for a stable patient to a UAP who has never performed the task on this unit. What is the nurse's best first action?

  1. Ask another UAP to teach the first UAP during the task
  2. Perform the bath personally and avoid delegation
  3. Provide instruction and confirm the UAP's competence before delegating Correct answer.
  4. Delegate the task and check the result later

Explanation

The delegating nurse must ensure the delegate has the knowledge and skill to perform the task safely, which includes verifying competence and providing clear directions. Delegation without this verification shifts risk to the patient. The nurse remains accountable for the outcome.

Question 8Safe and Effective Care Environment: Management of Care

A nurse is admitting a patient and must decide which information may be shared with the patient's adult child who calls for an update. Which principle should guide the nurse's response?

  1. Information may be shared if the caller is the eldest child
  2. All information may be shared if the caller provides the patient's room number
  3. Any family member may receive clinical information on request
  4. Only information the patient has authorized may be disclosed Correct answer.

Explanation

Confidentiality requires that the nurse disclose only what the patient has authorized or what is permitted by law. Family relationship alone does not confer a right to protected health information. The nurse should verify any authorization before speaking with the caller.

Question 9Safe and Effective Care Environment: Management of Care

A nurse is caring for four patients and must determine who to assess first. Which patient should the nurse see first?

  1. A patient reporting new shortness of breath and chest tightness Correct answer.
  2. A patient who needs a routine blood glucose check before lunch
  3. A patient requesting a scheduled pain tablet
  4. A patient awaiting discharge teaching about wound care

Explanation

Priority-setting in management of care uses the ABC framework and the potential for rapid deterioration; new dyspnea with chest tightness suggests a cardiopulmonary emergency and takes precedence. Scheduled medications and discharge teaching can follow once the unstable patient is stabilized.

Question 10Safe and Effective Care Environment: Management of Care

Which situation constitutes an appropriate use of restraint according to management-of-care standards?

  1. The patient's family requests restraint to prevent wandering
  2. The patient is confused and repeatedly pulling out a central line despite alternatives Correct answer.
  3. The patient refuses to take scheduled oral medications
  4. Staffing is short and the patient keeps leaving the bed

Explanation

Restraints may be used only to protect the immediate physical safety of the patient or others when less restrictive alternatives have failed, such as a confused patient pulling a life-sustaining line. Restraints are never used for convenience, coercion, or discipline, and require a provider order and monitoring.

Question 11Safe and Effective Care Environment: Management of Care

A nurse receives a telephone order for a high-alert medication. Which action best meets safe medication management standards?

  1. Wait until the prescriber arrives to write the order in person
  2. Ask the unit secretary to transcribe the order later
  3. Accept the order and administer the drug immediately
  4. Read back the complete order to the prescriber and document it Correct answer.

Explanation

Telephone orders, especially for high-alert medications, require a read-back of the complete order to the prescriber to verify accuracy, followed by documentation and timely countersignature. This closed-loop communication reduces medication errors. Delaying transcription to unlicensed staff is unsafe.

Question 12Safe and Effective Care Environment: Management of Care

A nurse is assigned to mentor a newly graduated nurse. Which action best demonstrates the mentor's role in maintaining safe care?

  1. Leaving the new nurse alone to promote independence
  2. Reviewing the new nurse's assessments and providing feedback Correct answer.
  3. Completing the new nurse's documentation to save time
  4. Assigning the new nurse the most complex patients to build confidence

Explanation

Mentoring supports safe practice by verifying the new nurse's clinical reasoning and providing constructive feedback while accountability remains with the new nurse. Gradually increasing complexity is appropriate, but assigning the most complex patients without support endangers patients. Completing another nurse's documentation obscures accountability.

Question 13Safe and Effective Care Environment: Management of Care

A patient is being transferred from the emergency department to a medical ward. Which action best ensures continuity of care?

  1. Sending the chart with the patient without verbal communication
  2. Relying on the electronic record alone to convey the plan
  3. Using a structured transfer report covering identifiers, situation, background, assessment, and recommendations Correct answer.
  4. Having the patient explain the plan to the receiving nurse

Explanation

Structured communication during transfer, such as SBAR, ensures that essential clinical information and recommendations reach the receiving nurse, supporting continuity and safety. The record alone may not convey urgency or pending concerns. The transferring nurse remains responsible for a complete handover.

Question 14Safe and Effective Care Environment: Management of Care

A nurse manager notices that medication errors cluster around the 0700 shift change. Which action is the most appropriate quality-improvement response?

  1. Add a note to the policy manual without further action
  2. Analyze the process and test a change such as overlapping handover Correct answer.
  3. Discipline the nurses who made the errors
  4. Restrict medication administration to one nurse per shift

Explanation

Quality improvement addresses system factors rather than blaming individuals; analyzing the process and testing a change such as overlapping shift handover targets the root cause. Punitive responses suppress reporting and hide problems. Policy changes without implementation or evaluation do not improve outcomes.

Question 15Safe and Effective Care Environment: Management of Care

A nurse witnesses a colleague administering a medication without scanning the patient's identification band. What is the nurse's most appropriate initial action?

  1. Ignore the behavior because it does not affect the patient
  2. Report the colleague to the licensing authority immediately
  3. Speak directly with the colleague about the concern and the patient's safety Correct answer.
  4. Document the observation in the patient's chart as an incident

Explanation

The first step in professional accountability is to address the concern directly with the colleague to protect the patient and correct the practice. If the behavior persists or harm occurs, the nurse escalates through the chain of command. Immediate regulatory reporting is reserved for serious, unresolved violations.

Question 16Safe and Effective Care Environment: Management of Care

A nurse is caring for a patient who is terminally ill and whose family disagrees about resuscitation status. Which action best reflects the nurse's role in ethical decision-making?

  1. Follow the family member who speaks most forcefully
  2. Facilitate a meeting to clarify the patient's values and document advance directives Correct answer.
  3. Avoid discussing the topic until the patient becomes unresponsive
  4. Decide the resuscitation status independently to avoid conflict

Explanation

The nurse's role in ethical conflict is to advocate for the patient's expressed wishes and to facilitate communication among the patient, family, and team, often through ethics consultation. The patient's autonomy governs, and advance directives should be documented before a crisis. The nurse does not unilaterally determine code status.

Question 17Safe and Effective Care Environment: Management of Care

Which nursing action best demonstrates appropriate case management for a patient with heart failure being discharged home?

  1. Providing a single discharge pamphlet at the end of the stay
  2. Coordinating follow-up appointments, medication reconciliation, and home support before discharge Correct answer.
  3. Referring the patient to the emergency department for all future concerns
  4. Scheduling a follow-up visit for six months after discharge

Explanation

Case management coordinates services, education, and follow-up to prevent readmission and support continuity across settings. Medication reconciliation and timely follow-up are core transition-of-care interventions. A pamphlet alone or a distant follow-up date does not meet the patient's needs.

Question 18Safe and Effective Care Environment: Management of Care

A nurse is assigned to care for a patient whose cultural beliefs conflict with a prescribed dietary plan. Which action best reflects culturally competent management of care?

  1. Document nonadherence and take no further action
  2. Ask the family to bring whatever food the patient prefers
  3. Enforce the prescribed diet without discussion
  4. Explore the patient's beliefs and collaborate with the dietitian on an acceptable plan Correct answer.

Explanation

Culturally competent care involves assessing the patient's beliefs and negotiating a plan that respects them while meeting clinical goals, often with interdisciplinary collaboration. Ignoring beliefs or simply permitting unrestricted food may compromise treatment. The nurse's role is to facilitate a workable plan.

Question 19Safe and Effective Care Environment: Management of Care

During a mass casualty event, a nurse is triaging patients using color-coded tags. Which patient should receive a red tag?

  1. A patient with an obstructed airway who is breathing after repositioning
  2. A patient with a minor laceration who is walking
  3. A patient with a tension pneumothorax and absent breath sounds Correct answer.
  4. A patient with no pulse and no spontaneous respirations

Explanation

In mass casualty triage, red (immediate) designates life-threatening injuries that are treatable with prompt intervention, such as tension pneumothorax. Airway obstruction corrected by repositioning or minor ambulatory injuries are lower priority, and patients without signs of life are typically categorized as expectant or deceased.

Question 20Safe and Effective Care Environment: Management of Care

A nurse manager is evaluating whether an unlicensed assistive personnel can be assigned to obtain vital signs on a patient receiving a blood transfusion. Which consideration is most important?

  1. The UAP's willingness to accept the assignment
  2. The number of years the UAP has worked on the unit
  3. Whether the patient prefers a UAP to a nurse
  4. Whether the task is within the UAP's training and the nurse can supervise Correct answer.

Explanation

Delegation decisions rest on the delegate's training, the predictability of the task, and the delegating nurse's ability to supervise and evaluate outcomes. Vital signs during transfusion may be delegated in some settings only if the UAP is trained and the nurse retains monitoring responsibility. Personal willingness, seniority, or patient preference do not establish competence.

Question 21Safe and Effective Care Environment: Management of Care

A nurse is planning care for a patient who requires multiple specialists. Which action best demonstrates the nurse's coordinating role?

  1. Scheduling each specialist independently without informing the team
  2. Serving as the central point of communication to align the care plan across disciplines Correct answer.
  3. Referring all questions to the attending physician
  4. Limiting communication to written notes in the chart

Explanation

Care coordination requires the nurse to act as the central communicator, ensuring that the interdisciplinary plan is aligned and that information flows among providers, the patient, and family. Fragmented scheduling or written notes alone can lead to conflicting plans. Delegating all communication to the physician removes nursing continuity.

Question 22Safe and Effective Care Environment: Management of Care

A nurse on an oncology unit has two patients requesting pain medication at the same time. Which principle should guide the nurse's decision about order of care?

  1. The patient whose family is present at the bedside
  2. First-come, first-served regardless of assessment findings
  3. The patient with the longest length of stay
  4. Assessment of pain severity and the potential for harm Correct answer.

Explanation

Priority decisions should be based on clinical assessment and the potential for harm, not on arrival order, length of stay, or family presence. The nurse briefly assesses both patients to determine severity and then acts accordingly. This reflects fair, needs-based management of care.

Question 23Safe and Effective Care Environment: Management of Care

A nurse discovers that a colleague has been documenting assessments that were never performed. What is the nurse's most appropriate action?

  1. Report the concern through the appropriate supervisory and quality channels Correct answer.
  2. Correct the records personally without notifying anyone
  3. Confront the colleague in front of patients
  4. Wait to see whether the pattern continues

Explanation

Falsified documentation is a serious breach of professional integrity and patient safety that must be reported through established supervisory and quality channels. Public confrontation violates privacy, and altering records independently conceals the problem. Delay allows ongoing risk.

Question 24Safe and Effective Care Environment: Management of Care

A nurse is preparing a patient for surgery and notices the consent form lists the wrong procedure. What is the nurse's priority action?

  1. Stop preparation and notify the surgeon and charge nurse to correct the consent Correct answer.
  2. Continue and clarify the discrepancy after surgery
  3. Proceed with preparation because the surgeon signed the form
  4. Ask the patient to initial the correction on the form

Explanation

A discrepancy between the planned procedure and the consent form is a patient safety event that must be resolved before the procedure proceeds. The nurse stops the process and notifies the surgeon and charge nurse so the consent can be corrected and re-verified with the patient. Nurses do not alter consent forms themselves.

Question 25Safe and Effective Care Environment: Management of Care

Which action by a charge nurse best supports a just culture on the unit?

  1. Punishing every error equally to deter mistakes
  2. Assigning blame to the nurse who documented last
  3. Encouraging error reporting and distinguishing system failures from reckless behavior Correct answer.
  4. Suppressing minor incident reports to keep unit statistics favorable

Explanation

A just culture encourages reporting and separates honest human error from at-risk or reckless behavior, focusing on system fixes for the former. Punitive or suppressive responses discourage reporting and hide hazards. Blame assignment does not improve safety.

Question 26Safe and Effective Care Environment: Management of Care

A nurse is caring for an older adult patient who has fallen twice in the past week. Which action best demonstrates the nurse's role in maintaining a safe care environment?

  1. Ask the family to remain at the bedside at all times
  2. Apply a vest restraint during the night to keep the patient in bed
  3. Complete a fall-risk assessment and initiate the unit's fall-prevention protocol Correct answer.
  4. Request that the patient be moved to a room closer to the nurses' station

Explanation

Management of care requires the nurse to identify risk and implement evidence-based preventive interventions, which begins with a validated fall-risk assessment and a matching prevention protocol. This addresses the actual cause of risk rather than restricting the patient. Moving the room or asking family to stay may be adjuncts but do not substitute for assessment and protocol-driven prevention.

Question 27Safe and Effective Care Environment: Management of Care

A nurse is preparing to administer a medication and realizes the dose written on the order is ten times the usual range. Which action should the nurse take first?

  1. Ask a colleague to administer the medication instead
  2. Reduce the dose to the usual range and give it
  3. Hold the medication and clarify the order with the prescriber Correct answer.
  4. Administer the dose as written and document the prescriber's order

Explanation

The nurse is accountable for safe medication administration and must withhold any medication that appears unsafe until the order is clarified with the prescriber. Administering, altering the dose independently, or delegating the questionable order all bypass the verification step and create patient harm. Clarification protects the patient and preserves the legal record.

Question 28Safe and Effective Care Environment: Management of Care

A patient tells a nurse that she does not want her roommate informed about her diagnosis. Which action by the nurse best reflects the principle of confidentiality?

  1. Limit discussion of the patient's information to those directly involved in her care Correct answer.
  2. Share the diagnosis only with the roommate, since they share a room
  3. Post the diagnosis on the patient's door so staff can identify precautions
  4. Discuss the case in the staff break room to seek advice

Explanation

Confidentiality in management of care means protected health information is shared only with caregivers who need it to provide treatment. Discussing the case in public or semipublic areas, or disclosing to the roommate, breaches that duty. Posting diagnoses on doors is also a disclosure unless a specific precaution sign is required by policy.

Question 29Safe and Effective Care Environment: Management of Care

A nurse is caring for four patients on a medical unit. Which patient should the nurse assess first?

  1. A patient with chronic obstructive pulmonary disease requesting a breathing treatment
  2. A patient who reports new chest pain and is diaphoretic Correct answer.
  3. A patient with a stable gastrointestinal bleed awaiting a repeat hemoglobin
  4. A patient with a scheduled dressing change who is asking for pain medication

Explanation

Triage by acuity directs the nurse to the patient with the most immediately life-threatening problem, and new chest pain with diaphoresis suggests acute coronary syndrome. This patient requires immediate assessment and intervention. The others have needs that are important but not immediately unstable.

Question 30Safe and Effective Care Environment: Management of Care

A nurse is delegating tasks to unlicensed assistive personnel. Which task is appropriate for the nurse to delegate?

  1. Teaching a patient how to use an incentive spirometer
  2. Obtaining vital signs on a stable postoperative patient Correct answer.
  3. Performing the initial assessment of a newly admitted patient
  4. Evaluating whether a patient's pain medication was effective

Explanation

Delegation rules reserve assessment, teaching, evaluation, and clinical judgment for the licensed nurse, while routine data collection on stable patients can be delegated. Vital signs on a stable patient fit within unlicensed assistive personnel scope when the nurse retains responsibility for interpretation. The other tasks require nursing judgment or education.

Question 31Safe and Effective Care Environment: Management of Care

A nurse is caring for a patient who speaks limited English and needs to give informed consent for a procedure. Which action by the nurse best supports the patient's rights?

  1. Proceed with the consent because the physician already explained it
  2. Use a qualified medical interpreter to explain the procedure and consent Correct answer.
  3. Have the patient sign the form and explain details afterward
  4. Ask the patient's adult child to interpret the consent discussion

Explanation

Informed consent requires that the patient understand the procedure, risks, and alternatives, so a qualified medical interpreter must be used when language is a barrier. Relying on a family member risks errors and coercion, and signing before understanding invalidates consent. The nurse advocates for the patient's right to comprehend the information.

Question 32Safe and Effective Care Environment: Management of Care

A nurse manager is reviewing an incident in which a nurse made a medication error. Which action best reflects the principles of a just culture?

  1. Suspend the nurse pending investigation of the error
  2. Focus the review on system factors and the nurse's accountability for following policy Correct answer.
  3. Keep the incident confidential from the quality improvement team
  4. Report the nurse to the licensing board before reviewing the event

Explanation

A just culture separates honest human error from reckless behavior and examines system failures while holding staff accountable for following policy. The goal is learning and prevention, not punishment of an individual for a systemic problem. Immediate discipline, board referral without review, or hiding the event from quality improvement undermines safety reporting.

Question 33Safe and Effective Care Environment: Management of Care

A nurse is caring for a patient who is scheduled for surgery in two hours and has just eaten a full breakfast. Which action should the nurse take?

  1. Ask the patient to drink water to help digestion
  2. Document the meal and continue preoperative preparation
  3. Notify the surgeon and anesthesia provider immediately Correct answer.
  4. Proceed with the surgery because the patient is already admitted

Explanation

Preoperative fasting is a patient safety requirement because food in the stomach increases aspiration risk during anesthesia. The nurse must immediately notify the surgeon and anesthesia provider so the case can be rescheduled or reassessed. Proceeding, merely documenting, or encouraging more intake would expose the patient to serious harm.

Question 34Safe and Effective Care Environment: Management of Care

A charge nurse is preparing assignments for the shift. Which assignment best reflects appropriate matching of patient needs to staff competency?

  1. Assign a nurse returning from extended leave to the unit's most complex patient
  2. Assign an experienced critical care nurse to a patient with an unstable airway Correct answer.
  3. Assign a new graduate to a patient with a new tracheostomy and complex ventilator settings
  4. Assign a nurse floated from a clinic to a patient requiring continuous cardiac monitoring

Explanation

Management of care requires matching patient acuity and complexity to the competency of the assigned nurse, so the most unstable airway patient should go to a nurse with critical care experience. Assigning less experienced or unfamiliar staff to high-complexity patients creates avoidable risk. The charge nurse retains responsibility for safe assignment decisions.

Question 35Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to insert a peripheral IV catheter. Which action best prevents a needlestick injury during the procedure?

  1. Asking a colleague to hold the sharps container during insertion
  2. Placing the used catheter on the bedside table until the procedure ends
  3. Recapping the needle with one hand before disposal
  4. Activating the safety device immediately after withdrawing the stylet Correct answer.

Explanation

Needlestick prevention relies on activating the engineered safety device at the point of use, immediately after the sharp is withdrawn and before any further handling. Recapping, even with one hand, reintroduces a hand-to-needle exposure and is discouraged. Leaving a sharp uncapped on a surface creates a downstream injury risk for anyone clearing the area.

Question 36Safe and Effective Care Environment: Safety and Infection Control

A client with active pulmonary tuberculosis is admitted to a general medical unit. Which room assignment and staff protection measure should the nurse anticipate?

  1. A private room with negative-pressure airflow and an N95 respirator Correct answer.
  2. A private room with positive-pressure airflow and a surgical mask
  3. A semiprivate room with the curtain drawn and a surgical mask
  4. A semiprivate room with a dedicated bathroom and gloves only

Explanation

Tuberculosis spreads by airborne droplet nuclei that remain suspended and travel on air currents, so airborne precautions require a private airborne infection isolation room with negative pressure and staff respiratory protection at least as protective as an N95. Surgical masks do not seal and do not filter droplet nuclei reliably. Positive-pressure rooms are used to protect immunocompromised clients, not to contain a source.

Question 37Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client with Clostridioides difficile diarrhea. Which combination of precautions is correct?

  1. Airborne precautions with an N95 respirator during room entry
  2. Contact precautions with soap-and-water handwashing after contact Correct answer.
  3. Droplet precautions with a surgical mask during direct care
  4. Standard precautions with an alcohol-based hand rub after contact

Explanation

C. difficile spores are not killed by alcohol, so contact precautions are combined with thorough soap-and-water handwashing, which physically removes spores. Gowns and gloves are used for all room entry. Droplet and airborne precautions address respiratory transmission and are not indicated here.

Question 38Safe and Effective Care Environment: Safety and Infection Control

A client is placed on seizure precautions. Which item should the nurse ensure is at the bedside?

  1. A padded tongue blade
  2. Suction equipment and oxygen Correct answer.
  3. Soft wrist restraints applied prophylactically
  4. An indwelling urinary catheter

Explanation

Seizure precautions focus on maintaining a patent airway and supporting oxygenation during and after a seizure, so suction and oxygen must be immediately available. Nothing should be forced into the mouth during a seizure; padded tongue blades are an outdated and dangerous practice. Restraints applied in advance increase injury risk rather than prevent it.

Question 39Safe and Effective Care Environment: Safety and Infection Control

A nurse receives a prescription to apply wrist restraints to a confused client who keeps climbing out of bed. Which action is required before applying the restraints?

  1. Attempt less restrictive measures and document them Correct answer.
  2. Obtain a verbal order from the charge nurse
  3. Apply the restraints and notify the provider within 24 hours
  4. Ask the family to sign a consent form

Explanation

Restraints are a last resort, so the nurse must first try and document less restrictive alternatives such as frequent rounding, bed alarms, and involving family. A licensed provider must order restraints, and orders are time-limited with frequent reassessment and release. Family consent is not the legal requirement that governs restraint use.

Question 40Safe and Effective Care Environment: Safety and Infection Control

During a blood transfusion, a client develops chills, fever, and flank pain within the first 15 minutes. What is the nurse's first action?

  1. Obtain a urine sample and continue at the current rate
  2. Slow the transfusion rate and reassess in 15 minutes
  3. Administer the prescribed antipyretic and continue the transfusion
  4. Stop the transfusion and maintain IV access with normal saline Correct answer.

Explanation

Fever, chills, and flank pain suggest an acute hemolytic transfusion reaction, which can be life-threatening. The priority is to stop the transfusion immediately and keep the line patent with normal saline through new tubing, then notify the provider and blood bank. Slowing or continuing the infusion allows further hemolysis.

Question 41Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to administer a medication through a central venous catheter. Which action reflects correct infection prevention for central line care?

  1. Change the dressing only when it appears soiled
  2. Flush the lumen with tap water before use
  3. Scrub the hub with alcohol for 5 seconds before access
  4. Scrub the needleless connector with chlorhexidine-alcohol and allow it to dry Correct answer.

Explanation

Central line-associated bloodstream infection prevention includes disinfecting the needleless connector with an appropriate antiseptic and allowing full drying time before access. A brief alcohol wipe of a few seconds does not provide adequate disinfection. Dressings are changed on a scheduled basis, and only sterile solutions are used to flush lumens.

Question 42Safe and Effective Care Environment: Safety and Infection Control

A nurse is teaching a client how to care for a new colostomy. Which statement by the client indicates correct understanding of infection prevention?

  1. I will apply alcohol to the stoma to keep it clean
  2. I will wash the skin around the stoma with mild soap and water and pat it dry Correct answer.
  3. I will use a tight belt over the stoma to hold the pouch
  4. I will change the pouch only when it leaks

Explanation

The peristomal skin is cleansed with mild soap and water and gently dried, which removes effluent without damaging skin integrity. Alcohol dries and irritates the stoma mucosa. The pouch is changed on a regular schedule and whenever leakage occurs, since stool left against skin causes breakdown that invites infection.

Question 43Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for several clients. Which situation requires the nurse to perform hand hygiene with soap and water rather than an alcohol-based rub?

  1. Before touching a client's intact skin
  2. Before preparing a sterile dressing tray
  3. After contact with a client's blood-soiled linen Correct answer.
  4. After removing gloves following a dressing change

Explanation

Visible soiling and exposure to spore-forming organisms such as C. difficile require soap and water because alcohol rubs do not remove organic material or inactivate spores. Alcohol-based rub is acceptable for routine decontamination of hands that are not visibly soiled. Sterile preparation and intact-skin contact are not indications for soap and water specifically.

Question 44Safe and Effective Care Environment: Safety and Infection Control

A client with a new tracheostomy is being suctioned. Which action protects the client from infection and injury?

  1. Instill normal saline routinely before each suction pass
  2. Use sterile technique and limit each suction pass to 10 to 15 seconds Correct answer.
  3. Reuse the same catheter for the entire shift
  4. Suction for 30 seconds on each pass

Explanation

Tracheal suctioning is a sterile procedure because the catheter enters the lower airway; passes are kept short, generally 10 to 15 seconds, to limit hypoxemia and mucosal trauma. Routine saline instillation is no longer recommended because it disperses bacteria and causes hypoxia. Catheters are single-use and are not reused across a shift.

Question 45Safe and Effective Care Environment: Safety and Infection Control

A nurse is preparing to insert an indwelling urinary catheter. Which action best reduces the risk of catheter-associated urinary tract infection?

  1. Use a larger catheter to ensure complete drainage
  2. Irrigate the catheter routinely every shift
  3. Cleanse the perineum with an antiseptic solution and use sterile technique
  4. Keep the drainage bag below the level of the bladder and off the floor Correct answer.

Explanation

Maintaining a closed system with the drainage bag below bladder level and off the floor prevents backflow of contaminated urine. Routine irrigation and larger catheters increase mucosal trauma and infection risk. Antiseptic perineal cleansing is not required for catheter insertion; sterile technique with standard cleansing is sufficient.

Question 46Safe and Effective Care Environment: Safety and Infection Control

A client with a known latex allergy is scheduled for surgery. Which action is most important for the nurse to take?

  1. Administer a prophylactic antihistamine before transport
  2. Ensure a latex-free environment and latex-free supplies for the case Correct answer.
  3. Place the client in the room closest to the nurses' station
  4. Ask the client to remove all jewelry before transfer

Explanation

For a known latex allergy, the priority is preventing exposure by creating a latex-free environment and using latex-free gloves, tubing, and equipment. Removing jewelry and room placement do not address the allergen. Prophylactic antihistamines do not prevent a severe reaction and are not a substitute for avoidance.

Question 47Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client receiving a new intravenous antibiotic. Ten minutes into the infusion, the client reports itching and has audible 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 assistance Correct answer.
  2. Document the findings and reassess in 30 minutes
  3. Administer the next scheduled dose of the antibiotic
  4. Elevate the head of the bed and apply cool compresses

Explanation

Itching, wheezing, and hypotension during an infusion indicate anaphylaxis, a life-threatening emergency. The immediate action is to stop the offending infusion and summon emergency help, then follow with epinephrine and airway support as prescribed. Continuing the drug or delaying reassessment allows progression to cardiovascular collapse.

Question 48Safe and Effective Care Environment: Safety and Infection Control

A nurse is planning care for an older adult client who is confused and at risk for falls. Which intervention is most effective for preventing falls?

  1. Place the client in a room farthest from the nurses' station
  2. Use a vest restraint during sleep hours
  3. Apply a bed alarm and round hourly to meet needs Correct answer.
  4. Keep all four side rails raised at all times

Explanation

Hourly rounding that anticipates needs such as toileting, pain, and positioning, combined with a bed alarm, addresses the causes of falls without restricting the client. Raising all side rails is considered a form of restraint and increases injury risk when clients climb over them. Restraints are not a fall prevention measure.

Question 49Safe and Effective Care Environment: Safety and Infection Control

A nurse is reviewing fire safety in the unit. According to the RACE response, which action follows rescuing clients in immediate danger?

  1. Evacuate the entire unit
  2. Close all doors and windows
  3. Extinguish the fire with the nearest extinguisher
  4. Activate the fire alarm and notify staff Correct answer.

Explanation

RACE stands for rescue, alarm, contain, and extinguish or evacuate. After removing anyone in immediate danger, the next step is to activate the alarm so the response system and others are notified. Attempting to extinguish the fire comes after the alarm, and closing doors contains smoke rather than being the second step.

Question 50Safe and Effective Care Environment: Safety and Infection Control

A nurse is teaching a client with a new prescription for warfarin about home safety. Which instruction is most important?

  1. Take aspirin for minor headaches
  2. Use a soft toothbrush and an electric razor Correct answer.
  3. Stop the medication if bruising occurs
  4. Increase intake of green leafy vegetables

Explanation

Warfarin reduces clotting, so measures that prevent bleeding from minor trauma, such as a soft toothbrush and electric razor, are essential safety teaching. Green leafy vegetables contain vitamin K and should be kept consistent rather than increased. Aspirin adds antiplatelet effect and bleeding risk, and bruising alone does not justify stopping therapy without provider guidance.