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NCLEX-RN practice questions

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Question 1Safe and Effective Care Environment - Management of Care

A registered nurse is working with an unlicensed assistive personnel (UAP). Which task is appropriate for the nurse to delegate to the UAP?

  1. Teaching a client how to use an incentive spirometer
  2. Administering a scheduled oral pain medication
  3. Completing the admission assessment for a newly admitted client
  4. Ambulating a stable client who is two days postoperative Correct answer.

Explanation

Delegation to UAP is limited to tasks that are routine, predictable, and do not require nursing judgment or teaching. Ambulating a stable postoperative client fits within UAP preparation, and the nurse remains accountable by supervising and evaluating the outcome.

Question 2Safe and Effective Care Environment - Management of Care

A client is scheduled for a cardiac catheterization. Who is responsible for obtaining the client's informed consent?

  1. The nurse manager of the cardiac unit
  2. The registered nurse assigned to the client
  3. The health care provider who will perform the procedure Correct answer.
  4. The unlicensed assistive personnel who prepares the client

Explanation

Obtaining informed consent is the responsibility of the provider performing the procedure, who must explain the risks, benefits, and alternatives. The nurse verifies the client understands, witnesses the signature, and notifies the provider if questions remain unanswered.

Question 3Safe and Effective Care Environment - Management of Care

A client with a terminal illness tells the nurse, "I do not want to be put on a breathing machine." Which document best records this client's specific wishes?

  1. A living will Correct answer.
  2. A do-not-resuscitate order signed by the nurse
  3. An informed consent form for intubation
  4. A durable power of attorney for health care

Explanation

A living will is an advance directive that states the client's preferences for life-sustaining treatment when the client can no longer speak for themselves. A health care proxy names a decision maker rather than listing specific treatments.

Question 4Safe and Effective Care Environment - Management of Care

Which action by a nurse constitutes a breach of client confidentiality?

  1. Reviewing a client's chart to provide care for that client
  2. Discussing a client's plan of care during a unit report with the care team
  3. Reporting a suspected case of tuberculosis to the public health department
  4. Telling a coworker in the hospital cafeteria about a client's HIV status Correct answer.

Explanation

Protected health information may be shared only with those involved in the client's care or as required by law. Discussing a client's HIV status with a coworker who is not involved in care, in a public area, is an unauthorized disclosure.

Question 5Safe and Effective Care Environment - Management of Care

A nurse suspects that a 4-year-old client has been physically abused. Which action should the nurse take?

  1. Ask the family's permission before making a report
  2. Report the suspicion to the state child protective agency Correct answer.
  3. Document the suspicion and monitor the child at the next visit
  4. Confront the parents with the suspicion before discharge

Explanation

Nurses are mandated reporters and must report suspected child abuse or neglect to the state child protective agency. Reporting does not require parental permission or proof, and the nurse does not conduct the investigation.

Question 6Safe and Effective Care Environment - Management of Care

A nurse is using the SBAR format to report a change in a client's condition. Which information belongs in the "R" component?

  1. The client's vital signs and current complaints
  2. The nurse's assessment of the client's lung sounds
  3. A recommendation for the provider's next action Correct answer.
  4. The client's name, room number, and diagnosis

Explanation

SBAR stands for Situation, Background, Assessment, and Recommendation. The recommendation component states what the nurse believes should happen next, such as a request for a specific order or medication.

Question 7Safe and Effective Care Environment - Management of Care

A client refuses a scheduled dose of insulin. What is the nurse's best action?

  1. Tell the client that refusal will result in discharge
  2. Ask the unlicensed assistive personnel to persuade the client
  3. Respect the refusal, document it, and notify the provider Correct answer.
  4. Hold the client's arm and administer the dose

Explanation

A client with decision-making capacity may refuse any treatment, and the nurse must honor that right. The nurse documents the refusal, explores the reason, and notifies the provider of the potential consequences.

Question 8Safe and Effective Care Environment - Management of Care

A client in an acute care setting requires wrist restraints. Which action must the nurse take?

  1. Tie the restraints to the side rails of the bed
  2. Apply the restraints without an order in an emergency and leave them in place for 24 hours
  3. Obtain a provider's order within the time frame required by facility policy Correct answer.
  4. Remove the restraints only when the client is asleep

Explanation

Restraints require a provider's order that is time limited and renewed per facility policy, along with frequent assessment of the client's needs. In an emergency an order must be obtained promptly, but restraints are never applied as a standing or indefinite measure.

Question 9Safe and Effective Care Environment - Management of Care

A nurse is applying the five rights of delegation. Which action reflects the "right circumstance"?

  1. Giving the UAP clear directions about what findings to report back
  2. Confirming that the client's condition is stable enough for the task Correct answer.
  3. Verifying that the UAP has been trained to perform the task
  4. Confirming the task appears in the UAP's job description

Explanation

The right circumstance means the client's condition and setting are appropriate for delegation at that moment. Even a properly trained delegatee should not perform a task when the client's status makes it unsafe.

Question 10Safe and Effective Care Environment - Management of Care

A client falls while trying to get out of bed and is not injured. After assessing the client, what should the nurse do?

  1. Withhold the incident report unless the client files a complaint
  2. Complete an incident report describing the facts of the event objectively Correct answer.
  3. Write a detailed description of the fall in the client's progress notes only
  4. Ask the UAP who was present to complete the incident report

Explanation

An incident report is an objective, factual account of the event that goes to risk management for quality improvement. It is not copied into the medical record, although the client's assessment and care are documented in the chart.

Question 11Safe and Effective Care Environment - Management of Care

When should discharge planning for a client admitted with a stroke begin?

  1. After the provider writes the discharge order
  2. On the day of admission Correct answer.
  3. When the client's condition becomes stable
  4. On the day before the planned discharge

Explanation

Discharge planning is a continuous process that begins at admission so needs, resources, and referrals can be anticipated. Delaying it until the client is stable or near discharge increases the risk of gaps in care.

Question 12Safe and Effective Care Environment - Management of Care

Which client is most appropriate for the nurse to assign to a licensed practical nurse (LPN)?

  1. A stable client receiving a scheduled oral antibiotic for pneumonia Correct answer.
  2. A client with a new tracheostomy who needs the first suctioning after placement
  3. A client with an unstable blood pressure receiving a new antihypertensive drip
  4. A newly admitted client who requires a comprehensive admission assessment

Explanation

LPN assignments should involve clients whose conditions are stable and whose care is predictable, such as routine medication administration. Unstable clients, new admissions, and complex procedures require RN assessment and judgment.

Question 13Safe and Effective Care Environment - Management of Care

A nurse respects a client's decision to decline a recommended treatment even though the nurse believes the treatment would help. Which ethical principle is the nurse demonstrating?

  1. Beneficence
  2. Fidelity
  3. Justice
  4. Autonomy Correct answer.

Explanation

Autonomy is the client's right to make decisions about their own care, including the right to refuse. The nurse supports the decision even when it conflicts with the nurse's own view of what is beneficial.

Question 14Safe and Effective Care Environment - Management of Care

Under HIPAA, in which situation may the nurse release client information without the client's authorization?

  1. Discussing the client's condition with a curious neighbor who calls the unit
  2. Providing the client's full record to the client's employer
  3. Sharing the client's diagnosis with the nurse's own family
  4. Reporting a positive gonorrhea test to the state health department Correct answer.

Explanation

HIPAA allows disclosure without authorization when another law requires it, such as reporting certain communicable diseases to public health authorities. Disclosures to neighbors, employers, or the nurse's family generally require authorization.

Question 15Safe and Effective Care Environment - Management of Care

A client who speaks only Spanish is admitted and needs to sign a consent form. Which action should the nurse take?

  1. Have the client sign the English form without explanation since the provider already explained
  2. Use gestures and pictures to explain since interpreters are not available on weekends
  3. Arrange for a qualified medical interpreter to assist with the discussion Correct answer.
  4. Ask the client's 12-year-old child to interpret the form

Explanation

Clients with limited English proficiency are entitled to a qualified medical interpreter so that consent is truly informed. Using family members, especially children, risks errors, breaches confidentiality, and may not convey the information accurately.

Question 16Safe and Effective Care Environment - Management of Care

A client recovering from hip replacement surgery will return home alone. Which referral is most important for the nurse to make before discharge?

  1. Cardiac rehabilitation
  2. Home health care Correct answer.
  3. Annual eye examination
  4. Smoking cessation

Explanation

The client will recover alone after hip surgery, so assistance with activities of daily living and safety in the home is the most immediate need. Home health care provides skilled assessment, teaching, and support in the home.

Question 17Safe and Effective Care Environment - Management of Care

A client received the wrong unit of blood and experienced a hemolytic reaction. Which action should the nurse manager take as part of the facility's quality improvement process?

  1. Suspend all nurses involved in the event until the investigation is complete
  2. Delay the review until the client's family files a lawsuit
  3. Participate in a root cause analysis to identify system failures Correct answer.
  4. Revise the client's medical record to reflect the correct unit

Explanation

A hemolytic reaction from a wrong unit is a serious event that triggers a root cause analysis, which examines system and process failures rather than blaming individuals. The goal is to redesign processes so the error cannot recur.

Question 18Safe and Effective Care Environment - Management of Care

A nurse is caring for four clients. Which client should the nurse assess first?

  1. A client who needs help ambulating to the bathroom for the first time
  2. A client requesting pain medication for a headache rated 5 out of 10
  3. A client who is waiting for discharge teaching about a new prescription
  4. A client who reports circumoral tingling after a thyroidectomy Correct answer.

Explanation

Circumoral tingling after thyroidectomy suggests hypocalcemia from inadvertent parathyroid injury, which can progress to tetany, seizures, and laryngeal spasm. This physiologic instability takes priority over comfort and discharge needs.

Question 19Safe and Effective Care Environment - Management of Care

A nurse disagrees with a provider's prescription that appears unsafe. After discussing the concern with the provider without resolution, what should the nurse do next?

  1. Refuse to give the medication and document nothing further in the record
  2. Administer the medication as prescribed to avoid conflict
  3. Ask the UAP to administer the medication instead
  4. Follow the facility chain of command and notify the supervisor Correct answer.

Explanation

When a prescription appears unsafe, the nurse must clarify it with the provider and, if unresolved, escalate through the chain of command to a supervisor or the appropriate committee. The nurse remains accountable for protecting the client.

Question 20Safe and Effective Care Environment - Management of Care

A charge nurse is assigning clients for the upcoming shift. Which assignment best reflects appropriate resource management?

  1. Rotate assignments so each nurse receives the same mix of clients
  2. Match complex clients to nurses with strong assessment skills Correct answer.
  3. Give the most complex clients to the nurse who has worked the longest shift
  4. Assign all clients with intravenous lines to the newest nurse

Explanation

Resource management means distributing staff so that client needs match nurse competency, which supports safety and efficiency. Acuity-based assignment is preferred over equal or arbitrary distribution.

Question 21Safe and Effective Care Environment - Management of Care

A nurse delegates vital signs on a stable client to a UAP. The UAP reports a blood pressure of 84/50 mm Hg. What is the nurse's priority action?

  1. Assess the client and notify the provider immediately Correct answer.
  2. Ask the UAP to recheck the blood pressure in about 4 hours
  3. Inform the UAP that reporting values is outside their role
  4. Document the value and continue with the scheduled tasks

Explanation

The nurse retains accountability for the client after delegating and must act on abnormal findings. A blood pressure of 84/50 mm Hg requires immediate nursing assessment and provider notification rather than a delayed recheck.

Question 22Safe and Effective Care Environment - Management of Care

The provider has obtained informed consent for a colonoscopy, and the nurse is witnessing the signature. The client says, "I don't really understand what they are going to do." What should the nurse do?

  1. Notify the provider so the procedure can be explained again Correct answer.
  2. Explain the procedure in detail and have the client sign the form
  3. Ask the client's spouse to sign the form instead
  4. Have the client sign the form since the provider already obtained consent

Explanation

Informed consent requires that the client understand the procedure, and the provider is responsible for that explanation. When the client expresses a lack of understanding, the nurse stops the process and notifies the provider before the form is signed.

Question 23Safe and Effective Care Environment - Management of Care

A client with terminal cancer has a valid do-not-resuscitate order. The client's adult child arrives and demands that "everything be done." What is the nurse's best response?

  1. Tell the child that the DNR order can be canceled only after the client dies
  2. Explain that the DNR order reflects the client's documented wishes Correct answer.
  3. Promise the child that full resuscitation will be performed anyway
  4. Ask the child to leave the unit until the client is stable

Explanation

A valid DNR order documents the client's own decisions and remains in effect; family members cannot override a capable client's expressed wishes. The nurse acknowledges the child's distress, provides information, and involves the provider and ethics resources as needed.

Question 24Safe and Effective Care Environment - Management of Care

A client with decision-making capacity decides to leave the hospital against medical advice. Which action is the nurse's priority?

  1. Refuse to allow the client to leave the unit
  2. Physically restrain the client until the provider arrives
  3. Explore the client's reasons, notify the provider, and document Correct answer.
  4. Ask the client to sign a waiver before any teaching is provided

Explanation

A client with decision-making capacity may leave against medical advice. The nurse explores the reasons, notifies the provider, teaches about the risks, and documents the discussion and the client's decision.

Question 25Safe and Effective Care Environment - Management of Care

A nurse suspects that a coworker is impaired by alcohol at the start of the shift. Which action should the nurse take?

  1. Report the observation to the nurse manager or supervisor immediately Correct answer.
  2. Confront the coworker in front of other staff members
  3. Ignore the concern unless a client is harmed
  4. Quietly take over the coworker's medication administration for the shift

Explanation

A nurse who suspects a colleague is impaired must report it immediately so that clients are protected and the colleague can receive help. Nurses have a professional and legal duty to report, and most states offer peer assistance programs.

Question 26Safe and Effective Care Environment - Management of Care

An adult client is scheduled for surgery and the provider has explained the procedure. The client asks the nurse to witness the signature on the informed consent form. Which action should the nurse take?

  1. Ask the client's spouse to co-sign the form as a witness.
  2. Confirm the client's understanding and voluntary signature, then witness it. Correct answer.
  3. Re-explain the procedure and answer all of the client's questions before witnessing.
  4. Sign the form as the person who obtained the consent.

Explanation

The nurse's role in informed consent is to witness the client's signature and confirm that the client is informed and acting voluntarily; the provider is responsible for explaining the procedure and obtaining consent. The nurse may clarify information but must not pressure the client or sign as the person obtaining consent.

Question 27Safe and Effective Care Environment - Management of Care

Which statement best describes the primary goal of case management for a client with a chronic illness?

  1. Assume all clinical decision-making for the client and the client's family throughout care.
  2. Coordinate services and resources to promote quality outcomes across the care continuum. Correct answer.
  3. Complete the client's daily care tasks during hospitalization.
  4. Limit the client's access to specialists in order to reduce costs.

Explanation

Case management coordinates care, services, and resources across settings to achieve quality, cost-effective outcomes. It does not take over the client's decision-making or restrict appropriate access to care.

Question 28Safe and Effective Care Environment - Management of Care

A nurse administers a medication to the wrong client but recognizes the error immediately. Which documentation is appropriate in the client's medical record?

  1. A factual description of the error, the client's assessment, and provider notification. Correct answer.
  2. A note blaming the pharmacy for the error and requesting a new supply.
  3. A note stating that an incident report was completed and placed in the file.
  4. No documentation unless the client is injured by the medication error.

Explanation

The medical record should contain factual, objective clinical information about the error, the client's condition, and notifications made. Incident reports are risk-management documents and are not referenced or copied into the medical record.

Question 29Safe and Effective Care Environment - Management of Care

Which action by the nurse best demonstrates the ethical principle of beneficence?

  1. Administering a prescribed analgesic to a client in severe pain. Correct answer.
  2. Allowing the client to refuse a prescribed medication after teaching.
  3. Treating all clients fairly regardless of ability to pay.
  4. Keeping a client's diagnosis confidential from unauthorized persons.

Explanation

Beneficence is the duty to act for the client's good, such as relieving pain and promoting well-being. Autonomy, confidentiality, and justice address different ethical obligations.

Question 30Safe and Effective Care Environment - Management of Care

A 16-year-old client arrives at the emergency department with a neighbor because the parents cannot be reached. The client needs elective surgery. Who is legally authorized to provide informed consent?

  1. Any emergency department physician who determines that the elective surgery is necessary.
  2. The parents or legal guardian, unless the client is emancipated. Correct answer.
  3. The client, because adolescents can consent to their own elective surgery.
  4. The neighbor, because the client is accompanied by a responsible adult.

Explanation

Minors generally cannot provide legal consent for elective procedures; consent must come from a parent or legal guardian unless the minor is emancipated or another legal exception applies. A neighbor or physician cannot consent for elective care simply because the parents are unavailable.

Question 31Safe and Effective Care Environment - Management of Care

A client is being transferred from an acute care hospital to a skilled nursing facility. Which action best promotes continuity of care?

  1. Relying on the client's family to communicate the plan of care to the facility.
  2. Telling the client to bring all medication bottles to the facility and give them to staff.
  3. Sending a complete transfer report with medications, allergies, and plan of care. Correct answer.
  4. Sending only the discharge summary after the client arrives at the facility.

Explanation

Continuity depends on a complete, timely transfer of essential clinical information to the receiving facility. Relying on the client or family to convey the plan creates gaps in care.

Question 32Safe and Effective Care Environment - Management of Care

A client who follows a vegetarian diet for religious reasons is prescribed a regular hospital diet. The client refuses most meals. Which action should the nurse take first?

  1. Collaborate with the dietitian to provide foods matching the client's preferences. Correct answer.
  2. Ask the provider to insert a feeding tube because the client is refusing meals.
  3. Tell the client that the prescribed diet must be followed for safety and to promote healing.
  4. Document the refusal and take no further action during this admission.

Explanation

The nurse should first explore the client's cultural and religious needs and collaborate with nutrition services to provide acceptable foods. Coercion, passive documentation, or unnecessary tube feeding does not address the underlying issue.

Question 33Safe and Effective Care Environment - Management of Care

A nurse suspects that a coworker is impaired by alcohol while providing client care. Which action should the nurse take?

  1. Wait until the end of the shift to see whether client care is affected.
  2. Discuss the concern with other staff members to gather opinions before acting.
  3. Confront the coworker privately and ask them to leave the unit immediately.
  4. Report the concern immediately to the charge nurse or supervisor. Correct answer.

Explanation

An impaired coworker poses an immediate risk to client safety and must be reported through the chain of command so supervisors can remove the employee from care and arrange evaluation. Private confrontation, delay, or gossip can increase risk and violate confidentiality.

Question 34Safe and Effective Care Environment - Management of Care

A nurse on a medical-surgical unit is assigned six acutely ill clients without assistive personnel. The nurse is concerned about safe care. Which action is most appropriate?

  1. Ask the clients' families to help with nonclinical tasks during the shift.
  2. Refuse to provide care to any of the clients until staffing improves.
  3. Notify the charge nurse and, if unresolved, escalate through the chain of command. Correct answer.
  4. Accept the assignment and document the staffing concerns at the end of the shift.

Explanation

The nurse has a professional obligation to advocate for safe staffing and should use the chain of command when concerns are not resolved. Abandoning clients or relying on families for clinical tasks is unsafe.

Question 35Safe and Effective Care Environment - Management of Care

A hospitalized client asks the nurse for a copy of the client's medical record. Which response by the nurse is appropriate?

  1. I will follow facility policy and arrange for you to obtain a copy. Correct answer.
  2. You cannot see your record while you are still hospitalized.
  3. You must ask your insurance company to send it to you.
  4. Your provider must approve every request before you are allowed to see your record.

Explanation

Clients generally have a legal right to access their medical records, and the nurse should follow facility policy to process the request. Provider approval and insurance involvement are not routine prerequisites.

Question 36Safe and Effective Care Environment - Management of Care

To establish a claim of professional negligence against a nurse, which elements must the client prove?

  1. Intent, malice, and physical harm.
  2. Duty, breach of duty, causation, and damages. Correct answer.
  3. A written policy violation and a witness.
  4. An adverse event and an incident report.

Explanation

Professional negligence requires proof of a duty owed to the client, a breach of that duty, causation, and damages. Intent, malice, incident reports, or policy violations alone do not establish negligence.

Question 37Safe and Effective Care Environment - Management of Care

After a sentinel event, a hospital conducts a root cause analysis (RCA). Which statement describes the primary purpose of this process?

  1. To determine which staff member involved in the event should be disciplined.
  2. To prepare a public statement for the media about the event.
  3. To replace the facility's incident reporting system after the event.
  4. To identify system factors that contributed and prevent recurrence. Correct answer.

Explanation

Root cause analysis examines system and process failures to reduce the likelihood of recurrence. It is not a disciplinary or public-relations process.

Question 38Safe and Effective Care Environment - Management of Care

A client's family disagrees with the client's documented wish to decline dialysis. The client is alert and oriented. The nurse has discussed the conflict with the family. Which action is most appropriate next?

  1. Ask the provider to write an order for dialysis despite the client's refusal.
  2. Follow the family's request because they are the client's surrogate decision-makers in all matters.
  3. Transfer the client to another unit to avoid the conflict with the family.
  4. Support the client's decision and request an ethics consultation if conflict persists. Correct answer.

Explanation

An alert, oriented client with decision-making capacity retains the right to accept or refuse treatment, even when family disagrees. Ethics consultation can help resolve persistent conflict while the client's wishes are respected.

Question 39Safe and Effective Care Environment - Management of Care

During discharge, which action by the nurse best supports medication safety for a client transitioning home?

  1. Giving the client a printed list of medications without reviewing them together.
  2. Reconciling home medications with discharge prescriptions and reviewing the list. Correct answer.
  3. Telling the client to stop all previous medications before leaving the hospital.
  4. Providing verbal discharge instructions only, in order to save time during the process.

Explanation

Medication reconciliation compares the client's home medications with new discharge prescriptions to identify duplications, omissions, and interactions. Reviewing the final list with the client supports safe self-administration.

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

A nurse is caring for a client with Clostridioides difficile infection. Which hand hygiene action should the nurse take after removing gloves?

  1. Wash hands with soap and water Correct answer.
  2. Use an antiseptic hand wipe
  3. Rinse hands with sterile water
  4. Use an alcohol-based hand rub

Explanation

Clostridioides difficile spores are not reliably killed by alcohol-based hand rubs. The nurse should wash hands with soap and water using friction to remove spores after glove removal.

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

After providing care to a client on contact precautions, which personal protective equipment should the nurse remove first?

  1. The respirator
  2. The face shield
  3. The gown
  4. The gloves Correct answer.

Explanation

Gloves are the most contaminated item and are removed first. Eye protection, gown, and mask or respirator follow, with hand hygiene after all PPE is removed.

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

A client with suspected pulmonary tuberculosis is admitted. Which precaution should the nurse initiate?

  1. Standard precautions with gloves for care
  2. Contact precautions with gown and gloves
  3. Airborne precautions with an N95 respirator Correct answer.
  4. Droplet precautions with a surgical mask and private room

Explanation

Pulmonary tuberculosis is transmitted by airborne droplet nuclei, so an airborne infection isolation room with negative pressure and a fit-tested N95 respirator is required. The door should remain closed.

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

A client has influenza. Which precaution is appropriate?

  1. Contact precautions only
  2. Standard precautions only
  3. Airborne precautions with an N95 respirator
  4. Droplet precautions with a surgical mask Correct answer.

Explanation

Influenza is transmitted by large respiratory droplets, so droplet precautions plus standard precautions are used. A surgical mask is worn when within 3 feet of the client.

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

A nurse is caring for a client colonized with MRSA in a wound. Which action is most appropriate?

  1. Wear a surgical mask when entering the room
  2. Wear gloves and a gown for all client contact Correct answer.
  3. Place the client in a negative-pressure room
  4. Use alcohol-based hand rub instead of soap and water

Explanation

MRSA is spread by direct and indirect contact. Gown and gloves for all contact, dedicated equipment, and hand hygiene are required.

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

A nurse sustains a needlestick from a contaminated needle. What should the nurse do first?

  1. Squeeze the site to express blood
  2. Request HIV post-exposure prophylaxis
  3. Wash the site with soap and water Correct answer.
  4. Apply an alcohol-based antiseptic without washing

Explanation

The site should be washed immediately with soap and water; do not squeeze or use caustic agents. The nurse then reports the exposure and seeks post-exposure evaluation.

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

Which action by the nurse is correct when disposing of a used lancet?

  1. Wrap it in a paper towel and discard
  2. Recap the needle before disposal
  3. Place it in the regular trash
  4. Place it in a sharps container Correct answer.

Explanation

Used sharps must be placed immediately in a puncture-resistant, leak-proof sharps container. Recapping is avoided because it increases needlestick risk.

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

A nurse discovers a fire in a client's room. Which action should the nurse take first?

  1. Activate the fire alarm
  2. Close the client's door
  3. Extinguish the fire with a fire extinguisher
  4. Rescue clients in immediate danger Correct answer.

Explanation

RACE stands for Rescue, Alarm, Confine, and Extinguish or Evacuate. The first priority is removing clients from immediate danger.

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

A client is receiving oxygen by nasal cannula. Which instruction should the nurse give?

  1. Smoke only when the oxygen flow rate is turned low
  2. Use a wool blanket while oxygen is in use
  3. Avoid petroleum-based ointments on the nose Correct answer.
  4. Store the oxygen cylinder lying flat

Explanation

Oxygen supports combustion, so petroleum-based products, smoking, and flammable materials must be avoided. Cylinders should be secured upright.

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

A nurse is caring for a client at risk for seizures. Which item should be kept at the bedside?

  1. A wheelchair
  2. A padded tongue blade
  3. A syringe of flumazenil
  4. Suction equipment Correct answer.

Explanation

Seizure precautions include suction and oxygen at the bedside, a low bed with padded side rails, and no oral objects during a seizure. A tongue blade should never be forced into the mouth.

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

Which action best prevents falls in an older adult client?

  1. Keep the call light within reach Correct answer.
  2. Use a bed height that is above waist level
  3. Keep all four side rails raised at all times
  4. Apply wrist restraints at night

Explanation

Fall prevention includes keeping the bed low, call light and personal items within reach, non-skid footwear, and an uncluttered room. Restraints and raised side rails can increase injury risk.