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NLN NEX study materials
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NLN NEX practice questions

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Question 1Safe and Effective Care Environment

A nurse is caring for a client with an active Clostridioides difficile infection. Which action is required when leaving the client's room?

  1. Wipe the hands with a sanitizing cloth.
  2. Rub the hands with an alcohol-based product.
  3. Remove gloves and exit the room.
  4. Wash the hands with soap and water. Correct answer.

Explanation

C. difficile is a spore-forming organism, and alcohol-based products do not reliably kill spores. Soap and water handwashing with friction physically removes the spores. Contact precautions with gown and gloves are also used, but gloves alone do not replace hand hygiene.

Question 2Safe and Effective Care Environment

Which method is acceptable for verifying a client's identity before administering a medication?

  1. Reading the name on the door card
  2. Checking the name and date of birth on the arm band Correct answer.
  3. Asking the client to state his full name
  4. Confirming the room and bed number

Explanation

Two identifiers must be used, and the client's arm band with name and date of birth is the reliable source. The client's spoken name alone is not sufficient because of confusion or misidentification. Room and bed numbers are location data, not identifiers.

Question 3Safe and Effective Care Environment

A fire breaks out in a client's room on a medical unit. Which action should the nurse take first?

  1. Move the client out of the room. Correct answer.
  2. Activate the fire alarm pull station.
  3. Close the unit's fire doors.
  4. Extinguish the fire with an extinguisher.

Explanation

The RACE sequence places rescue of anyone in immediate danger first, followed by alarm, containment, and extinguishing. Removing the client from the fire source protects life before other steps are taken. Only after the client is safe does the nurse activate the alarm and contain the fire.

Question 4Safe and Effective Care Environment

A nurse is planning care for an older adult who is at risk for falls. Which intervention should the nurse include?

  1. Keep all four side rails raised at all times.
  2. Keep the bed low with the wheels locked. Correct answer.
  3. Place the call light out of the client's reach.
  4. Encourage the client to walk without assistance.

Explanation

A bed in the lowest position with locked wheels reduces the distance and impact of a fall and prevents the bed from rolling when the client transfers. Side rails are not used as a substitute for supervision. Call lights and assistive devices are placed within reach to prevent unsupervised climbing out of bed.

Question 5Safe and Effective Care Environment

Which instruction should the nurse give a client who uses supplemental oxygen at home?

  1. Increase the flow rate when short of breath.
  2. Store spare oxygen cylinders flat in a closet.
  3. Keep the oxygen source away from open flames. Correct answer.
  4. Apply petroleum jelly to the nares for dryness.

Explanation

Oxygen supports combustion, so it must be kept away from flames, sparks, and heat sources. Cylinders are stored upright and secured, not laid flat. Flow rates are prescribed and are never self-adjusted, and oil-based products such as petroleum jelly are avoided near oxygen equipment.

Question 6Safe and Effective Care Environment

Which communication tool is used to structure handoff reports between caregivers?

  1. START
  2. RACE
  3. SBAR Correct answer.
  4. PASS

Explanation

SBAR organizes handoff into Situation, Background, Assessment, and Recommendation, which improves completeness and reduces omissions. RACE is a fire response sequence, START is a mass-casualty triage method, and PASS is the technique for using a fire extinguisher.

Question 7Safe and Effective Care Environment

A client reports itching and hives after eating bananas and avocados. Which precaution should the nurse plan for?

  1. A gluten-free diet with no wheat products
  2. A shellfish-free diet and no iodine products
  3. Latex-free gloves and equipment Correct answer.
  4. Peanut-free diet and avoidance of nut products

Explanation

Sensitivity to banana, avocado, kiwi, and chestnut is associated with latex-fruit syndrome, so latex-containing products should be avoided. The reaction described is not related to peanuts, gluten, or shellfish. Latex avoidance includes gloves, tourniquets, tape, and catheter ports.

Question 8Safe and Effective Care Environment

A person who identifies himself as the client's employer telephones the unit and asks about the client's condition. Which action by the nurse is appropriate?

  1. Give a brief general update about the client's condition.
  2. Ask the caller to come to the unit in person.
  3. Confirm only whether the client is a patient on the unit.
  4. Decline until the client gives written authorization. Correct answer.

Explanation

Protected health information may be shared only with people the client has authorized in writing, unless the inquiry is for treatment, payment, or operations. Even confirming that someone is a patient can be a disclosure in some circumstances. The nurse should verify authorization through the facility's release-of-information process.

Question 9Safe and Effective Care Environment

After providing care to a client on contact precautions, in which order does the nurse remove personal protective equipment?

  1. Gown, mask, gloves, goggles
  2. Mask, gloves, gown, goggles
  3. Gloves, gown, mask, goggles
  4. Gloves, goggles, gown, mask Correct answer.

Explanation

Contaminated items are removed first and the cleanest item last: gloves, then face protection, then gown, then mask or respirator. The mask is removed last because the nurse must untie the gown before reaching the ties behind the head. Hand hygiene follows removal.

Question 10Safe and Effective Care Environment

A nurse sustains a needlestick from a used intravenous catheter. Which action should the nurse take first?

  1. Scrub the site with an alcohol sponge for 5 minutes.
  2. Wash the site with soap and water. Correct answer.
  3. Apply bleach solution to the puncture site.
  4. Cover the site and finish the shift first.

Explanation

Immediate washing with soap and water is recommended after a percutaneous exposure; mucous membranes are flushed with water. Caustic agents and aggressive scrubbing are not used because they can damage tissue. Reporting and post-exposure evaluation follow promptly but do not replace washing.

Question 11Safe and Effective Care Environment

Which precautions are required for a client with active pulmonary tuberculosis who is coughing?

  1. Airborne precautions with an N95 mask Correct answer.
  2. Standard precautions alone
  3. Droplet precautions with a surgical mask
  4. Contact precautions with gown and gloves

Explanation

Tuberculosis spreads through airborne droplet nuclei that remain suspended and travel on air currents, so an airborne infection isolation room and a fit-tested N95 respirator are required. Surgical masks do not filter particles small enough for airborne transmission. Contact and droplet precautions do not address airborne spread.

Question 12Safe and Effective Care Environment

A client with neutropenia is admitted to the oncology unit. Which action should the nurse include in the plan of care?

  1. Place a vase of fresh flowers at the bedside.
  2. Include raw fruits and vegetables with meals.
  3. Use a shared blood pressure cuff for all clients.
  4. Assign staff who have no active infection. Correct answer.

Explanation

A client with a low neutrophil count has limited ability to fight infection, so caregivers with active infection or recent live-vaccine exposure are reassigned. Plants, soil, and standing water harbor organisms and are removed from the room. Raw fruits and vegetables are restricted in many neutropenic protocols because of surface organisms.

Question 13Safe and Effective Care Environment

A client who is agitated and combative is placed in a vest restraint. Which nursing action is required?

  1. Tie the restraint straps to the side rails.
  2. Renew the order every 24 hours.
  3. Remove the restraint only during sleep.
  4. Assess the client every 15 minutes. Correct answer.

Explanation

For violent or self-destructive restraints, the client is assessed at least every 15 minutes for circulation, skin integrity, hydration, and safety. Orders for violent restraints in adults are limited to 4 hours and must be renewed after face-to-face evaluation. Straps are secured to a fixed part of the bed frame, never to side rails.

Question 14Safe and Effective Care Environment

The provider has obtained informed consent for a surgical procedure. What is the nurse's responsibility before the client is transported?

  1. Verify the client's understanding and signature. Correct answer.
  2. Determine whether the client is legally competent.
  3. Obtain the client's signature after sedation is given.
  4. Explain the surgical risks and benefits to the client.

Explanation

Obtaining informed consent is the provider's responsibility, which includes disclosing risks, benefits, and alternatives. The nurse's role is to witness the signature and to confirm that the client understands what was explained and is signing voluntarily. A consent signed after sedation is not valid, and competency determinations rest with the provider or courts.

Question 15Safe and Effective Care Environment

A provider gives a verbal order for a medication change. Which action by the nurse is correct?

  1. Ask the unit secretary to transcribe it later.
  2. Wait for the provider to write it in person.
  3. Accept it only if the provider is the attending.
  4. Write it down and read it back. Correct answer.

Explanation

Verbal and telephone orders are written down and read back to the prescriber to verify accuracy, then countersigned per policy. Any provider with prescriptive authority may give orders within his or her scope. Delaying transcription risks missing a needed therapy.

Question 16Safe and Effective Care Environment

Which task is appropriate for the nurse to delegate to unlicensed assistive personnel?

  1. Teach a client about a new medication.
  2. Assess a client's surgical incision.
  3. Ambulate a stable client after bed rest. Correct answer.
  4. Evaluate a client's pain after analgesia.

Explanation

Tasks delegated to unlicensed assistive personnel must be standardized, predictable, and not require nursing judgment. Ambulating a stable client fits these criteria when the client's condition is not changing and the nurse has established the plan. Assessment, teaching, and evaluation of outcomes remain the nurse's responsibility.

Question 17Safe and Effective Care Environment

A client is admitted after a suicide attempt by overdose. Which nursing action is a priority?

  1. Keep the door closed during checks.
  2. Provide one-to-one observation. Correct answer.
  3. Restrict all visitors during the stay.
  4. Allow the client to keep shoelaces.

Explanation

Clients at imminent risk for self-harm require continuous or one-to-one observation with a safe environment. Contraband such as cords, belts, and shoelaces is removed because these are common means of self-harm. Door privacy is balanced against the need for visual monitoring, and visitors are usually permitted after screening.

Question 18Safe and Effective Care Environment

Which item should the nurse keep at the bedside of a client on seizure precautions?

  1. A bed board placed under the mattress
  2. Suction and oxygen equipment Correct answer.
  3. Soft restraints for all extremities
  4. A tongue blade taped to the bed rail

Explanation

Seizure precautions include suction, oxygen, and an airway at the bedside because airway patency and oxygenation can be compromised during and after a seizure. Nothing is forced into the mouth of a seizing client. Restraints are not used because they can cause injury during tonic-clonic movements.

Question 19Safe and Effective Care Environment

A nurse realizes that a client received the wrong dose of a medication. What should the nurse do first?

  1. Assess the client's condition. Correct answer.
  2. Document the error in the progress notes.
  3. Complete an incident report before anything else.
  4. Notify the risk manager before assessing.

Explanation

Client safety comes first, so the nurse assesses for signs of harm and vital sign changes, then notifies the provider as needed. Documentation and an incident report follow the assessment and any interventions. Reporting an incident is never a substitute for assessing the client.

Question 20Safe and Effective Care Environment

Which statement about an incident report is accurate?

  1. It should record the nurse's opinion of who was at fault.
  2. It goes to risk management for quality review. Correct answer.
  3. It is filed in the client's medical record.
  4. It requires the client's signature to be valid.

Explanation

An incident report is an internal quality-improvement document routed to risk management, not part of the permanent medical record. It contains objective facts about the event, not opinions or blame. The client does not sign it, and the medical record contains only the factual description of care and the client's response.

Question 21Safe and Effective Care Environment

Which statement accurately describes root cause analysis after a sentinel event?

  1. It focuses on system flaws rather than individual blame. Correct answer.
  2. It replaces the facility's incident report system.
  3. It identifies the staff member responsible for the error.
  4. It is optional after a sentinel event.

Explanation

Root cause analysis examines underlying processes, communication, staffing, and environmental factors that allowed harm to occur, so system failures are the focus. It is required for sentinel events by accrediting bodies and is conducted by a team. It complements, rather than replaces, incident reporting.

Question 22Safe and Effective Care Environment

A nurse is triaging clients after a mass-casualty event using a color-coded system. Which client should receive the immediate (red) tag?

  1. A client with an open femur fracture and hypotension Correct answer.
  2. A client with a small laceration who is walking and talking
  3. A client with no respirations after the airway is opened
  4. A client with a sprained ankle who can bear weight

Explanation

The immediate category is for clients with life-threatening but treatable injuries, such as hemorrhage or shock from a fracture, who need intervention within minutes. Clients who are walking and talking are delayed or minor. A client who remains apneic after the airway is opened is expected to die and receives the lowest priority category.

Question 23Safe and Effective Care Environment

A charge nurse is assigning clients. Which client is most appropriate to assign to a licensed practical nurse?

  1. A client with new-onset chest pain who is awaiting ICU transfer
  2. A client two days after a craniotomy who needs neuro checks
  3. A client receiving a first dose of intravenous chemotherapy
  4. A stable client whose colostomy pouch needs changing Correct answer.

Explanation

Assignments should match the caregiver's scope and the client's stability; a stable client needing routine colostomy care is appropriate for an LPN. New-onset chest pain, first-time chemotherapy, and post-craniotomy neurologic assessment require the assessment and teaching skills of a registered nurse. Unstable or unpredictable clients stay with the RN.

Question 24Safe and Effective Care Environment

Which situation is an example of a chemical restraint?

  1. Giving a sedative to an agitated client for staff convenience Correct answer.
  2. Administering an antihistamine to a client experiencing an allergic reaction
  3. Administering a prescribed antipsychotic to a client with a diagnosis of schizophrenia
  4. Administering a prescribed preoperative sedative before a surgical procedure

Explanation

A chemical restraint is a drug given to manage behavior or restrict freedom of movement and is not a standard treatment for the client's medical or psychiatric condition. Sedating an agitated client for staff convenience meets that definition and requires strict monitoring and time-limited orders. Drugs given for a diagnosed condition or a standard procedural purpose are not restraints.

Question 25Safe and Effective Care Environment

A nurse receives an assignment that includes more acutely ill clients than can be safely managed. Which action is most appropriate?

  1. Notify the supervisor and file a written protest. Correct answer.
  2. Refuse the assignment and leave the unit immediately.
  3. Accept the assignment and document concerns later.
  4. Ask a nursing assistant to take the extra clients.

Explanation

The nurse should use the chain of command, informing the supervisor of the unsafe staffing and documenting the concern in writing according to facility policy. Abandoning the unit creates client abandonment, which carries legal consequences. Assigning clients to unlicensed staff does not resolve an acuity problem.

Question 26Safe and Effective Care Environment

A client says, "I have a living will." Which statement best describes the purpose of this document?

  1. It names the person who will make decisions for the client.
  2. It allows the family to change the provider's orders.
  3. It gives the hospital consent to treat in an emergency.
  4. It states the client's wishes about life-sustaining treatment. Correct answer.

Explanation

A living will is an advance directive that records a person's preferences about life-sustaining treatments in situations such as a terminal condition or permanent unconsciousness. It takes effect when the client can no longer speak for himself or herself.

Question 27Safe and Effective Care Environment

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

  1. Close all doors along the corridor.
  2. Activate the fire alarm pull station.
  3. Move the client out of the room. Correct answer.
  4. Discharge a fire extinguisher at the source.

Explanation

Fire response follows the sequence rescue, alarm, contain, extinguish. The first priority is removing anyone in immediate danger from the fire, and only then sounding the alarm and containing the fire.

Question 28Safe and Effective Care Environment

Which action is safest when caring for a client receiving oxygen by nasal cannula?

  1. Lay unused cylinders flat on the floor.
  2. Store the cylinder upright in a secured stand. Correct answer.
  3. Keep spare cylinders near a heat register.
  4. Apply petroleum jelly to the nares.

Explanation

Oxygen cylinders must be secured upright to prevent them from falling and rupturing, and oxygen must be kept away from heat and open flames. Oil-based products such as petroleum jelly are avoided near oxygen because they increase fire risk.

Question 29Safe and Effective Care Environment

A nurse finds that the cord of a client's call-light is frayed and the wires are exposed. Which action should the nurse take?

  1. Leave the cord in use and note it in the record.
  2. Unplug the device and finish the shift without replacing it.
  3. Wrap the frayed area with adhesive tape.
  4. Remove the device from use and report it for repair. Correct answer.

Explanation

Frayed cords are a fire and shock hazard and must be taken out of service immediately and reported for repair or replacement. Taping or continuing to use damaged equipment places the client and staff at risk.

Question 30Safe and Effective Care Environment

A nurse must lift a heavy object from the floor. Which action demonstrates correct body mechanics?

  1. Twist the torso while lifting the object.
  2. Bend at the waist to reach the object.
  3. Lift with the arms held away from the body.
  4. Hold the object close to the body while lifting. Correct answer.

Explanation

Holding the load close to the body keeps the center of gravity over the base of support and reduces strain on the spine. The lifter should bend at the knees, keep the back straight, and avoid twisting while bearing weight.

Question 31Safe and Effective Care Environment

A nurse is about to administer a medication. Which action meets the National Patient Safety Goal for client identification?

  1. Ask the client, "Are you Mrs. Jones?"
  2. Check the room number on the medication record.
  3. Use two identifiers, such as name and date of birth. Correct answer.
  4. Verify identity by matching the client's bed label.

Explanation

Two identifiers must be used and must be directly verified with the client or an attached identification band, never with the room or bed. Accepting a yes or no answer is not acceptable verification.

Question 32Safe and Effective Care Environment

A nurse is splashed in the eye with a cleaning chemical. Where should the nurse look first for first-aid instructions?

  1. The facility policy manual.
  2. The safety data sheet for the product. Correct answer.
  3. The manufacturer's advertising insert.
  4. The product's shipping invoice.

Explanation

The safety data sheet is the required reference for a hazardous product's hazards, first-aid measures, and spill response. It should be immediately available wherever the chemical is used.

Question 33Safe and Effective Care Environment

A nurse suspects that a child's injuries were inflicted by a caregiver. Which action should the nurse take?

  1. Report the suspicion to the child protective agency. Correct answer.
  2. Wait for the provider to write an order to report.
  3. Question the caregiver before reporting.
  4. Delay reporting until the injuries are confirmed.

Explanation

Nurses are mandated reporters, and the legal duty is to report reasonable suspicion of abuse, not confirmed abuse. A specific provider order is not required and confrontation with the suspected caregiver is avoided.

Question 34Safe and Effective Care Environment

A nurse who is not caring for a client opens that client's electronic health record out of curiosity. Which principle does this action violate?

  1. Beneficence
  2. Fidelity
  3. Confidentiality Correct answer.
  4. Veracity

Explanation

Access to client information is limited to those who need it to provide care. Looking at a record without a care-related reason breaches confidentiality and usually facility policy as well.

Question 35Safe and Effective Care Environment

A client who is confused has a history of falls. Which nursing intervention is most appropriate?

  1. Raise all four side rails while the client is in bed.
  2. Assign a room that is within view of the nurses' station. Correct answer.
  3. Apply a vest restraint whenever the client is alone.
  4. Keep the bed in the highest position for easier transfers.

Explanation

Placing a client who is confused and at risk for falls near staff allows frequent observation, which is a safe, nonrestrictive measure. Restraints are avoided unless less restrictive measures have failed and an order is obtained.

Question 36Safe and Effective Care Environment

A client in the intensive care unit keeps pulling at an arterial line. Which action should the nurse take first?

  1. Cover the site and offer the client a diversion. Correct answer.
  2. Apply soft wrist restraints to both hands.
  3. Obtain an order for a vest restraint.
  4. Document that the client is at risk for injury.

Explanation

Restraints are a last resort, and the nurse must try less restrictive alternatives such as protecting the site and redirecting the client first. Restraints require a provider order and are used only when other measures have failed.

Question 37Safe and Effective Care Environment

A client who is about to sign a surgical consent form asks the nurse, "What are the risks of this operation?" Which response is best?

  1. "The risks are minor, so you can sign now."
  2. "I can describe the risks so you can decide."
  3. "Sign first; your surgeon will answer questions later."
  4. "That question is best answered by your surgeon." Correct answer.

Explanation

Obtaining informed consent requires that the provider performing the procedure disclose its risks, benefits, and alternatives. The nurse's role is to witness the signature, verify understanding, and ensure the client has the chance to speak with the provider, not to supply the disclosure.

Question 38Safe and Effective Care Environment

A client says, "I don't want this surgery, but my daughter insists." Which response by the nurse best supports client rights?

  1. "Tell me more about what you want to do." Correct answer.
  2. "You should sign so your family is not upset."
  3. "Your daughter knows what is best for you."
  4. "I will ask your daughter to sign the consent form."

Explanation

A competent adult has the right to accept or refuse treatment, and the nurse advocates for the client's own decision. Exploring the client's wishes supports autonomy without pressure from family members.

Question 39Safe and Effective Care Environment

A client who speaks little English must sign a consent form. Which action should the nurse take?

  1. Arrange for the facility's trained medical interpreter. Correct answer.
  2. Have the client sign and explain the form afterward.
  3. Ask a bilingual housekeeper to translate the form.
  4. Ask the client's 12-year-old child to interpret.

Explanation

Consent is valid only when the client understands what is being signed, so a trained medical interpreter must convey the information. Using children or untrained staff risks errors and breaches confidentiality.

Question 40Safe and Effective Care Environment

A client recovering from a stroke needs help with bathing and dressing at home. Which referral should the nurse request?

  1. Hospice services for end-of-life care.
  2. Physical therapy for gait training.
  3. Home health aide services for personal care. Correct answer.
  4. Social work for long-term placement.

Explanation

Home health aides provide assistance with activities of daily living such as bathing, dressing, and grooming. Physical therapy addresses mobility and strengthening rather than personal care.

Question 41Safe and Effective Care Environment

A nurse believes a new provider order will harm the client, but the provider refuses to discuss it. Which action should the nurse take next?

  1. Notify the nursing supervisor per the chain of command. Correct answer.
  2. Ask the client to sign a refusal form.
  3. Wait for the next shift to recheck the order.
  4. Carry out the order and document the concern.

Explanation

When a concern about a questionable order is not resolved with the prescriber, the nurse escalates through the chain of command to protect the client. Following an order known to be unsafe is never appropriate.

Question 42Safe and Effective Care Environment

Which observation indicates that a sterile field has been contaminated?

  1. Sterile solution is poured into a sterile basin.
  2. Sterile items are held above waist level.
  3. The nurse's gown touches the sterile drape. Correct answer.
  4. The nurse keeps the field in view at all times.

Explanation

Anything that is not sterile, including the nurse's gown, contaminates the field on contact. Sterile objects must remain above waist level and within the nurse's view to be considered sterile.

Question 43Safe and Effective Care Environment

Which action should the nurse take before administering a high-alert medication such as intravenous insulin?

  1. Have a second nurse independently verify dose and pump settings. Correct answer.
  2. Document the dose before administration to save time.
  3. Ask a second nurse to watch the injection.
  4. Check the dose alone and have the second nurse sign later.

Explanation

High-alert medications carry a heightened risk of serious harm, so an independent double check by a second nurse is required before administration. Each nurse calculates and verifies separately rather than one confirming the other's conclusion.

Question 44Safe and Effective Care Environment

A nurse tells a client, "If you refuse this injection, I will hold you down and give it anyway." The client becomes frightened. Which tort has occurred?

  1. Defamation
  2. Assault Correct answer.
  3. Negligence
  4. Battery

Explanation

Assault is a threat that causes a reasonable fear of imminent harmful or offensive contact, and no physical contact is required. Battery requires actual unauthorized touching of the client.

Question 45Safe and Effective Care Environment

Nurses notice that pharmacy deliveries arrive late every evening, delaying medication administration. Which action best reflects participation in quality improvement?

  1. Document the delays only when a client complains.
  2. Collect data on the delays and bring them to the quality committee. Correct answer.
  3. Report individual pharmacy staff to the manager.
  4. Work around the problem by borrowing doses from other units.

Explanation

Quality improvement uses systematic data about processes, not individual blame, to identify causes and design solutions. Bringing measured data to the quality committee addresses the system problem.

Question 46Safe and Effective Care Environment

A competent adult client who has not been legally detained states an intention to leave the hospital. Which action by the nurse constitutes false imprisonment?

  1. Asking the client to sign an against-medical-advice form
  2. Locking the unit door to keep the client inside Correct answer.
  3. Notifying the provider that the client wishes to leave
  4. Telling the client about the risks of leaving

Explanation

False imprisonment is the intentional confinement of a person within a fixed area without legal justification. A competent client who has not been legally detained may leave, and physical barriers or threats cannot be used to prevent it.

Question 47Safe and Effective Care Environment

A suspicious unattended package is found in the hospital lobby. Which action should the nurse take?

  1. Avoid touching the package and notify security. Correct answer.
  2. Carry the package to the security office.
  3. Place the package in a nearby trash receptacle.
  4. Open the package to identify the contents.

Explanation

An unattended package is treated as potentially dangerous until security assesses it, and no one should touch, move, or open it. The area is cleared and security is notified so the item can be evaluated safely.

Question 48Safe and Effective Care Environment

The family of a client with a severe brain injury asks about organ donation. Which statement about donation is accurate?

  1. Only people who carry a donor card may donate.
  2. A person who is younger than 18 can never donate.
  3. Donation always prevents an open-casket funeral.
  4. The donation decision is separate from decisions about treatment. Correct answer.

Explanation

The decision to donate is considered separately from decisions about the client's care so that it never influences treatment or the determination of death. Donation is also possible without a donor card when the family or legally authorized person consents.

Question 49Safe and Effective Care Environment

A client becomes agitated and raises a fist toward the nurse. Which action should the nurse take first?

  1. Turn and run quickly from the client's room.
  2. Step back to a safe distance and call for help. Correct answer.
  3. Threaten the client with restraints.
  4. Stand close to the client and speak loudly.

Explanation

The nurse first creates safety by increasing distance, keeping an exit route open, and summoning assistance. Calm communication and a show of support follow once the immediate threat is reduced.

Question 50Safe and Effective Care Environment

A nurse is caring for a client receiving internal radiation with a sealed implant. Which action protects the nurse from exposure?

  1. Place the client's used linens in the regular laundry.
  2. Limit the time spent in the client's room. Correct answer.
  3. Wear a lead apron at all times.
  4. Stay at the bedside while the client eats meals.

Explanation

Protection from internal radiation relies on the three principles of time, distance, and shielding, so shortening the time near the source reduces dose. A lead apron does not adequately shield against the high-energy gamma rays emitted by most implants.