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PN Level 1 study materials
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PN Level 1 practice questions

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Question 1Safe and Effective Care Environment: Coordinated Care

A nurse is preparing to administer a blood transfusion. Which action best reflects the principle of coordinated care immediately before the transfusion begins?

  1. Begin the transfusion and complete the verification paperwork afterward
  2. Verify the client's identity and blood product with a second qualified staff member at the bedside Correct answer.
  3. Ask the client to confirm the unit number on the blood bag matches the chart
  4. Delegate the double-check to a nursing assistant who is available

Explanation

Coordinated care for transfusion requires a two-person bedside verification of client identity, blood type, and unit number before infusion starts. This shared check reduces the risk of a hemolytic reaction and reflects team accountability.

Question 2Safe and Effective Care Environment: Coordinated Care

A nurse is assigning client care to a licensed practical nurse and a nursing assistant. Which task is appropriate to delegate to the nursing assistant?

  1. Reinforcing teaching about a new insulin regimen
  2. Measuring and recording a client's intake and output Correct answer.
  3. Performing the initial assessment on a newly admitted client
  4. Evaluating whether a client's pain goal has been met

Explanation

Intake and output measurement is a routine, standardized task within nursing assistant scope and does not require nursing judgment. Teaching, initial assessment, and evaluation all require a licensed nurse's clinical decision-making.

Question 3Safe and Effective Care Environment: Coordinated Care

During handoff report, which communication approach best supports safe transfer of care between shifts?

  1. Providing a brief summary only if the client is unstable
  2. Reporting verbally to any available staff member in the hallway
  3. Relying on the written chart alone so the report stays brief
  4. Using a structured format covering situation, background, assessment, and recommendation Correct answer.

Explanation

Structured handoff tools such as SBAR ensure critical information is communicated consistently and reduce omissions that lead to adverse events. Coordinated care depends on complete, organized transfer of responsibility.

Question 4Safe and Effective Care Environment: Coordinated Care

A client with limited English proficiency is being admitted. Which action reflects appropriate use of an interpreter?

  1. Speak slowly in English and rely on gestures
  2. Use a qualified medical interpreter and document the interpreter's identity Correct answer.
  3. Ask the client's adult child to interpret the consent discussion
  4. Provide written materials in English and assume comprehension

Explanation

Coordinated, safe care requires qualified medical interpreters for clients with limited English proficiency, and the interpreter's use should be documented. Family members, especially minors, should not interpret clinical discussions because of accuracy and confidentiality concerns.

Question 5Safe and Effective Care Environment: Coordinated Care

A nurse is preparing to discharge a client who will need wound care at home. Which referral best supports continuity of care?

  1. Home health agency for skilled wound care and follow-up Correct answer.
  2. Social work for transportation vouchers
  3. Pharmacy for medication counseling
  4. Physical therapy for gait training

Explanation

A home health agency provides skilled nursing services, including wound care, in the home and coordinates follow-up, which directly supports continuity of care after discharge. Other referrals address different needs.

Question 6Safe and Effective Care Environment: Coordinated Care

A nurse is documenting care in the electronic health record. Which action best supports care coordination among the interdisciplinary team?

  1. Sharing login credentials with a colleague to speed documentation
  2. Waiting until the end of the shift to enter all data
  3. Recording assessments and interventions promptly and accurately Correct answer.
  4. Documenting only significant changes to save time

Explanation

Timely, accurate documentation allows all team members to access current information and make informed decisions. Delayed or incomplete records impair coordination and can compromise client safety.

Question 7Safe and Effective Care Environment: Coordinated Care

A nurse is caring for a client who requires transfer to a higher level of care. Which action is the nurse's priority in coordinating this transfer?

  1. Waiting for the family to arrange transportation
  2. Communicating the client's condition and needs to the receiving facility before transfer Correct answer.
  3. Completing the transfer without notifying the receiving unit
  4. Documenting the transfer after the client has left

Explanation

Safe transfer requires communicating the client's condition, treatments, and needs to the receiving facility so appropriate resources are ready. This handoff between facilities is central to coordinated care.

Question 8Safe and Effective Care Environment: Coordinated Care

Which member of the interdisciplinary team is best suited to address a client's difficulty affording prescribed medications?

  1. The social worker in collaboration with the care team Correct answer.
  2. The dietitian
  3. The physical therapist
  4. The pharmacist alone

Explanation

Social workers assess financial and social barriers and connect clients with resources such as assistance programs. Coordination with the care team ensures the medication plan remains safe and realistic.

Question 9Safe and Effective Care Environment: Coordinated Care

A nurse receives a telephone order from a provider for a new medication. Which action reflects safe coordinated practice?

  1. Write the order on a scrap of paper for later transcription
  2. Read back the order to the provider and document it per policy Correct answer.
  3. Ask another nurse to call the provider later to confirm
  4. Accept the order and administer the medication immediately

Explanation

Read-back of telephone orders verifies accuracy and is a standard safety practice that reduces medication errors. The order should then be documented according to facility policy.

Question 10Safe and Effective Care Environment: Coordinated Care

A nurse is planning care for a client being discharged to a rehabilitation facility. Which action best demonstrates continuity of care?

  1. Providing only the discharge diagnosis to the receiving facility
  2. Sending a complete summary of the client's medications, treatments, and goals to the facility Correct answer.
  3. Telling the client to explain the plan to the rehabilitation staff
  4. Assuming the rehabilitation facility will obtain records on its own

Explanation

A complete transfer summary ensures the receiving facility has the information needed to continue care safely. Continuity depends on sharing medications, treatments, and goals across settings.

Question 11Safe and Effective Care Environment: Coordinated Care

A nurse is coordinating care for a client with multiple chronic conditions. Which approach best reflects the case management model?

  1. Developing an individualized plan that integrates services across providers Correct answer.
  2. Referring the client to the emergency department for routine follow-up
  3. Limiting communication to the primary care provider only
  4. Treating each condition separately without coordination

Explanation

Case management emphasizes an individualized, integrated plan that coordinates services across providers to meet complex needs. This reduces fragmentation and improves outcomes.

Question 12Safe and Effective Care Environment: Coordinated Care

A nurse is supervising a nursing assistant who reports that a client refused a bath. Which response demonstrates appropriate delegation follow-up?

  1. Instruct the assistant to force the client to bathe
  2. Document the refusal without further assessment
  3. Ask the assistant to describe the client's response and assess the client's needs Correct answer.
  4. Ignore the report because hygiene is nonessential

Explanation

The nurse retains responsibility for assessment and must gather information and evaluate the client's needs when a delegated task is not completed. This maintains accountability within the delegation process.

Question 13Safe and Effective Care Environment: Coordinated Care

A nurse identifies that a client's discharge plan is not feasible because the client lives alone and cannot manage dressing changes. Which action is most appropriate?

  1. Proceed with discharge as planned and document the concern
  2. Request an interdisciplinary team meeting to revise the plan Correct answer.
  3. Delay discharge indefinitely without notifying the team
  4. Tell the client to arrange a friend to provide wound care

Explanation

When a discharge plan is not feasible, the nurse should involve the interdisciplinary team to revise it and arrange appropriate support. This coordinated approach addresses safety before discharge.

Question 14Safe and Effective Care Environment: Coordinated Care

A nurse is participating in a quality improvement initiative to reduce medication errors during care transitions. Which measure best evaluates the effectiveness of the initiative?

  1. Reviewing the number of supplies ordered
  2. Counting the number of staff meetings held
  3. Tracking the rate of medication discrepancies identified at admission and discharge Correct answer.
  4. Surveying staff about their preferred shift schedule

Explanation

Medication discrepancies at transitions are a direct, measurable indicator of the safety problem being addressed. Tracking this rate allows the team to evaluate whether the initiative reduces errors.

Question 15Safe and Effective Care Environment: Coordinated Care

A nurse is caring for a client who wishes to leave against medical advice. Which action best reflects coordinated, safe practice?

  1. Restrain the client until the provider arrives
  2. Discharge the client without any documentation
  3. Notify the provider, explain risks, and document the client's decision Correct answer.
  4. Ask the client to sign a form without discussion

Explanation

When a client leaves against medical advice, the nurse should notify the provider, ensure the client understands the risks, and document the decision. This respects autonomy while maintaining safety and communication.

Question 16Safe and Effective Care Environment: Coordinated Care

A nurse is coordinating care for a client who needs physical therapy, dietary counseling, and social work services. Which action best facilitates this coordination?

  1. Having the client coordinate all appointments personally
  2. Referring to each service without a shared plan
  3. Convening an interdisciplinary team conference to align goals Correct answer.
  4. Scheduling separate appointments without sharing information

Explanation

An interdisciplinary conference aligns goals and information among team members, reducing duplication and conflicting recommendations. Shared planning is the foundation of coordinated care.

Question 17Safe and Effective Care Environment: Coordinated Care

A nurse is preparing to delegate a task to a nursing assistant. Which factor is most important for the nurse to consider first?

  1. The assistant's years of experience on the unit
  2. The assistant's personal preference for the task
  3. The client's stability and the complexity of the task Correct answer.
  4. The number of tasks already assigned to the assistant

Explanation

The nurse must first consider client stability and task complexity, because these determine whether delegation is safe. Experience and workload are relevant but secondary to client safety.

Question 18Safe and Effective Care Environment: Coordinated Care

A nurse is caring for a client with a new diagnosis of diabetes who will need ongoing education. Which coordination strategy best supports the client after discharge?

  1. Giving the client a pamphlet without discussion
  2. Telling the client to call if problems arise
  3. Arranging follow-up with a diabetes educator and primary care provider Correct answer.
  4. Providing all education on the day of discharge

Explanation

Coordinating follow-up with a diabetes educator and primary care provider ensures ongoing support and reinforces learning after discharge. Spacing education and providing expert follow-up improves self-management.

Question 19Safe and Effective Care Environment: Coordinated Care

A nurse manager is reviewing staffing for a unit with high client acuity. Which action best reflects safe coordination of care?

  1. Assigning the most complex clients to the least experienced nurse
  2. Rotating assignments randomly each shift
  3. Matching staff competency and skill mix to client acuity Correct answer.
  4. Reducing staff to save costs regardless of acuity

Explanation

Safe staffing aligns staff competency and skill mix with client acuity, which supports quality and safety. Random or cost-driven assignments that ignore acuity increase risk.

Question 20Safe and Effective Care Environment: Coordinated Care

A nurse is caring for a client who reports an allergy to penicillin. Which action best prevents a medication error related to this allergy?

  1. Placing the allergy on a note in the nurse's pocket
  2. Verifying the allergy against prescribed medications before administration Correct answer.
  3. Documenting the allergy in the chart only
  4. Asking the client to remind the nurse at each dose

Explanation

Verifying allergies against prescribed medications before administration is a critical safety check. The allergy should also be documented and flagged in the record and on the client's identification band.

Question 21Safe and Effective Care Environment: Coordinated Care

A nurse is transitioning a client from the hospital to a skilled nursing facility. The client's family asks who is responsible for ensuring medications continue without interruption. Which response best reflects coordinated care?

  1. The family must obtain new prescriptions on their own
  2. The discharging and receiving providers coordinate to ensure medication continuity Correct answer.
  3. The client should stop medications until seen by a new provider
  4. The pharmacy is solely responsible for continuity

Explanation

Medication continuity during transitions depends on coordination between discharging and receiving providers, often through reconciliation. This shared responsibility prevents interruptions and errors.

Question 22Safe and Effective Care Environment: Coordinated Care

A nurse is leading a team meeting after a near-miss medication event. Which approach best reflects a culture of safety?

  1. Discouraging staff from reporting near misses
  2. Focusing only on the outcome without reviewing the process
  3. Analyzing system factors that contributed to the near miss Correct answer.
  4. Blaming the individual who made the error

Explanation

A culture of safety focuses on identifying and correcting system factors rather than blaming individuals, which encourages reporting and prevents recurrence. Near misses provide valuable learning opportunities.

Question 23Safe and Effective Care Environment: Coordinated Care

A nurse is coordinating care for a client who is being discharged with home oxygen. Which action is most important to ensure safe coordination?

  1. Assuming the client will arrange equipment independently
  2. Waiting until the day of discharge to order equipment
  3. Providing verbal instructions only
  4. Verifying that the equipment supplier, home health agency, and provider have a shared plan Correct answer.

Explanation

Safe discharge with home oxygen requires coordination among the supplier, home health agency, and provider to ensure equipment and support are in place. A shared plan prevents delays and unsafe gaps.

Question 24Safe and Effective Care Environment: Coordinated Care

A nurse observes that two team members disagree about a client's pain management plan, delaying care. Which action best demonstrates effective conflict resolution within coordinated care?

  1. Ignoring the disagreement and continuing the current plan
  2. Facilitating a discussion to clarify concerns and reach a shared plan with the provider Correct answer.
  3. Reporting both staff members to administration immediately
  4. Allowing each staff member to follow a separate plan

Explanation

Facilitating open discussion and involving the provider to reach a shared plan resolves conflict while keeping the client's care consistent. Separate or ignored plans lead to fragmented and unsafe care.

Question 25Safe and Effective Care Environment: Coordinated Care

A nurse is reviewing a client's plan of care with the interdisciplinary team. Which finding best indicates that coordination of care has been effective?

  1. The client reports confusion about the plan
  2. Each discipline documents independently without shared goals
  3. The client's goals are met and handoffs occur without duplication or omission Correct answer.
  4. Multiple providers order conflicting interventions

Explanation

Effective coordination is reflected in goal attainment and seamless handoffs without duplication or omission. Conflicting orders and client confusion indicate fragmented care.

Question 26Safe and Effective Care Environment: Coordinated Care

A nurse is assigned to care for a client who speaks limited English and is scheduled for an informed consent discussion about a procedure. Which action best reflects coordinated, safe care for this client?

  1. Arrange for a qualified medical interpreter to be present for the discussion and consent Correct answer.
  2. Use gestures and written diagrams to explain the procedure without an interpreter
  3. Ask the client's adult child to interpret the procedure and sign as a witness
  4. Proceed with the consent using simple English and confirm understanding with a yes answer

Explanation

Informed consent requires that the client understand the procedure, risks, and alternatives, so communication must be accurate and confidential. A qualified medical interpreter preserves accuracy and avoids relying on family members, who may edit information or create conflicts of interest. Coordination means arranging that resource before the provider's discussion rather than improvising.

Question 27Safe and Effective Care Environment: Coordinated Care

A nurse is preparing to hand off care of a postoperative client at change of shift. Which element is essential for the nurse to include to support safe coordinated care?

  1. A structured summary including current status, pending tasks, and anticipated changes Correct answer.
  2. The client's full medical history copied from the admission note
  3. The previous shift's staffing assignments and break schedule
  4. A list of the nurse's personal opinions about the client's family

Explanation

Handoffs must transfer the information the receiving nurse needs to continue care safely, using a structured format such as SBAR. Current condition, recent changes, pending tests, and anticipated risks are the core content. Including unrelated background or opinions obscures the actionable information.

Question 28Safe and Effective Care Environment: Coordinated Care

A nurse is caring for a client whose condition has deteriorated and who now meets criteria for a higher level of monitoring. The provider is unavailable, and the client's oxygen saturation is falling despite increased oxygen. Which action is the nurse's priority in coordinating care?

  1. Wait for the next scheduled vital signs before escalating the concern
  2. Activate the rapid response or emergency support system while continuing interventions Correct answer.
  3. Ask the charge nurse to reassess the client at the end of the shift
  4. Document the change and continue to monitor until the provider returns

Explanation

When a client deteriorates and the usual provider is not available, the nurse must escalate through the rapid response or emergency support system rather than delay. Coordinated escalation protocols exist so that the nurse can obtain timely help without waiting. Continued monitoring and documentation are done alongside, not instead of, escalation.

Question 29Safe and Effective Care Environment: Coordinated Care

A nurse is admitting a client who reports taking several herbal supplements and prescription medications obtained from two different providers. Which action best supports safe coordination of the medication regimen?

  1. Obtain a complete medication reconciliation including supplements and verify with the providers Correct answer.
  2. Record only the prescription medications the client can name accurately
  3. Tell the client to stop all supplements until a provider reviews them
  4. Ask the client to bring the information at the next outpatient visit

Explanation

Medication reconciliation is a coordinated process that captures all medications, including over-the-counter products and supplements that can interact with prescriptions. Verifying with the prescribing providers resolves discrepancies and duplicate therapy. Recording partial information or deferring the review leaves the client at risk during the current admission.

Question 30Safe and Effective Care Environment: Coordinated Care

A nurse is reviewing a plan of care for a client with a chronic wound who will be discharged home. The plan lists wound care supplies and a home health referral, but the client has no transportation and no caregiver at home. Which analysis best reflects the nurse's responsibility in coordinating this discharge?

  1. The plan should be revised because unmet logistical needs can prevent the client from receiving ordered care Correct answer.
  2. The plan is adequate because home health will manage all needs
  3. The plan is complete because the provider signed the orders
  4. The plan should be delayed until the client arranges transportation independently

Explanation

Effective discharge coordination requires that the plan be realistic for the client's actual resources, not merely ordered. A lack of transportation and caregiver support can prevent wound care from occurring, so the nurse must identify and address these barriers before discharge. Revising the plan links the clinical orders to the client's real circumstances.

Question 31Safe and Effective Care Environment: Safety and Infection Control

A practical nurse is preparing to insert a urinary catheter. Which action best demonstrates surgical asepsis during the procedure?

  1. Keeping the sterile catheter tip below bladder level after insertion
  2. Wearing clean examination gloves while handling the sterile tray
  3. Reusing the same sterile gloves to reposition the drainage tubing
  4. Cleaning the meatus with antiseptic solution using sterile gloves Correct answer.

Explanation

Surgical asepsis requires that sterile items touch only sterile items; cleansing the meatus with sterile gloves and antiseptic maintains the sterile field at the insertion site. Clean gloves are not sterile and contaminate the tray. Gloves that have touched nonsterile tubing are contaminated and cannot return to the sterile field.

Question 32Safe and Effective Care Environment: Safety and Infection Control

A nurse is caring for a client with an active draining wound. Which personal protective equipment is essential before entering the room?

  1. Mask and gown only
  2. Shoe covers and mask
  3. Gown and gloves Correct answer.
  4. Goggles and cap

Explanation

Contact precautions for a draining wound require a gown and gloves for any anticipated contact with the client or contaminated surfaces. Goggles, caps, and shoe covers are not routinely required for wound drainage alone. A mask alone does not prevent contact transmission.

Question 33Safe and Effective Care Environment: Safety and Infection Control

A client is placed on airborne precautions for suspected pulmonary tuberculosis. Which room assignment is appropriate?

  1. A private room with the door open and standard precautions
  2. A semiprivate room with a client who has the same diagnosis
  3. A positive-pressure room with high-efficiency filtration
  4. A negative-pressure room with the door closed Correct answer.

Explanation

Airborne precautions require a private room with negative pressure relative to the corridor and a closed door to prevent escape of droplet nuclei. Positive-pressure rooms push air outward and are used for protective isolation, not airborne infection. Cohorting is not appropriate for a new suspected case before confirmation.

Question 34Safe and Effective Care Environment: Safety and Infection Control

When performing hand hygiene with an alcohol-based rub, which technique is correct?

  1. Rubbing hands together until they are completely dry Correct answer.
  2. Rinsing hands with water after the rub dries
  3. Applying rub to visibly soiled hands before washing
  4. Using a small amount to shorten drying time

Explanation

Alcohol-based hand rub must be rubbed over all surfaces until completely dry so the alcohol can achieve its antimicrobial effect. Visibly soiled hands require soap and water because alcohol does not remove organic material. Rinsing after the rub washes away the product and reduces effectiveness.

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

A nurse finds a client on the floor after a fall. Which action should the nurse take first?

  1. Move the client back into bed immediately
  2. Notify the family of the fall
  3. Check the client for injury and level of consciousness Correct answer.
  4. Complete an incident report before assisting the client

Explanation

After a fall, the nurse first assesses the client for injury and level of consciousness before moving the client, since movement could worsen a fracture or head injury. Incident reports are completed after care is provided and are not part of the immediate response. Family notification follows clinical assessment.

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

Which action best prevents a needlestick injury when a nurse disposes of a used syringe?

  1. Breaking the needle off before disposal
  2. Recapping the needle using one hand
  3. Placing the syringe in a biohazard bag
  4. Placing the needle in the sharps container without recapping Correct answer.

Explanation

Needles should never be recapped, bent, or broken; the safest practice is to activate the safety device if present and place the needle directly into a puncture-resistant sharps container. Recapping and breaking the needle both increase the risk of a needlestick. Biohazard bags are not puncture resistant.

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

A client with a history of falls is being admitted. Which nursing measure most directly reduces fall risk?

  1. Placing the call light out of reach to discourage movement
  2. Applying a vest restraint to prevent standing
  3. Keeping the bed in the lowest position with side rails up as needed Correct answer.
  4. Dimming all lights in the room at night

Explanation

Keeping the bed low and using side rails appropriately reduces the distance and impact of a fall and is a core fall-prevention measure. Restraints are used only as a last resort and are not a substitute for environmental safety. Removing the call light and dimming lights increase fall risk.

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

A nurse is reinforcing standard precautions. Which body fluid requires the use of gloves when contact is anticipated?

  1. Unbroken skin
  2. Tears
  3. Blood Correct answer.
  4. Sweat

Explanation

Standard precautions apply to blood, all body fluids, secretions, excretions, and nonintact skin. Blood is a primary vehicle for bloodborne pathogens, so gloves are required when contact is anticipated. Sweat, tears, and intact skin are not considered infectious under standard precautions.

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

A nurse is preparing to administer a medication to a client. Which action best demonstrates the right client according to the rights of medication administration?

  1. Using two identifiers such as name and date of birth Correct answer.
  2. Checking the room number on the medication record
  3. Asking the client to confirm the medication name
  4. Verifying the client's diagnosis in the chart

Explanation

The right client is verified using two independent identifiers, such as the client's full name and date of birth, checked against the identification band. Room number alone is unreliable because clients may be moved. Asking the client to confirm a medication name does not verify identity.

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

A client is receiving oxygen therapy. Which safety measure should the nurse teach the client and family?

  1. Place the tank near a heat source to prevent freezing
  2. Use petroleum-based ointment on the nares
  3. Keep the oxygen running during smoking breaks
  4. Store the oxygen tank upright and secure Correct answer.

Explanation

Oxygen cylinders must be stored upright and secured to prevent tipping and injury. Oxygen supports combustion, so smoking, heat sources, and petroleum-based products near the oxygen must be avoided. Petroleum products also increase the risk of fire and skin irritation.

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

A nurse suspects a client is being physically abused by a caregiver. Which action is the priority?

  1. Document the suspicion and revisit it at discharge
  2. Wait for the client to bring up the abuse voluntarily
  3. Ensure the client's immediate safety and follow reporting policy Correct answer.
  4. Confront the suspected abuser in the client's room

Explanation

When abuse is suspected, the priority is the client's immediate safety, followed by reporting according to facility policy and state law. Confronting the suspected abuser could escalate danger and is not the nurse's role. Waiting or delaying until discharge leaves the client at ongoing risk.

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

A nurse is caring for a client with Clostridioides difficile infection. Which action is most important to prevent transmission?

  1. Using an alcohol-based hand rub after client contact
  2. Placing the client in a positive-pressure room
  3. Wearing gloves only when handling stool
  4. Washing hands with soap and water after contact Correct answer.

Explanation

C. difficile spores are resistant to alcohol, so soap and water handwashing is required after contact to mechanically remove spores. Alcohol-based rub does not reliably kill spores. Contact precautions and a private room are appropriate, but positive-pressure rooms are not used for this organism.

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

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

  1. Warm the blood in a microwave
  2. Obtain vital signs 30 minutes after starting
  3. Prime the tubing with dextrose solution
  4. Verify the unit with a second nurse at the bedside Correct answer.

Explanation

Two licensed personnel must verify the client identity, blood type, unit number, and expiration at the bedside before transfusion to prevent a hemolytic reaction. Blood must be primed with normal saline, not dextrose, because dextrose causes hemolysis. Vital signs are obtained before starting and monitored after, and blood is never warmed in a microwave.

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

A nurse is teaching a client about home safety after hip replacement surgery. Which instruction best reduces the risk of dislocation?

  1. Sleep on the operative side without a pillow
  2. Twist the torso to reach items behind the chair
  3. Use an elevated toilet seat and avoid bending past 90 degrees Correct answer.
  4. Cross the legs at the knees when sitting

Explanation

After hip replacement, clients should avoid hip flexion beyond 90 degrees, crossing the legs, and twisting to prevent dislocation. Using an elevated toilet seat and avoiding deep bending maintain safe hip alignment. Sleeping on the operative side and twisting the torso increase dislocation risk.

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

A client has a new prescription for warfarin. Which client statement indicates the need for further teaching about bleeding precautions?

  1. I will use a soft toothbrush when brushing my teeth.
  2. I will take aspirin for headaches without checking with my provider. Correct answer.
  3. I will report any black or tarry stools to my provider.
  4. I will wear gloves when gardening.

Explanation

Aspirin and other NSAIDs increase bleeding risk and interact with warfarin, so clients should not take them without consulting the provider. Soft toothbrushes, reporting dark stools, and wearing gloves reduce injury and bleeding risk. Taking aspirin independently is the unsafe statement.

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

A nurse is caring for a client who is confused and repeatedly tries to climb out of bed. Which action is the most appropriate first intervention?

  1. Raise all side rails and leave the room
  2. Increase supervision and use bed alarms and low bed position Correct answer.
  3. Administer a sedative without a prescription
  4. Apply wrist restraints immediately

Explanation

The least restrictive interventions should be tried first, including increased supervision, bed alarms, and a low bed. Restraints require a provider order and are used only when less restrictive measures fail. Sedatives require a prescription and are not a first-line safety measure. Raising all rails and leaving the room does not protect the client.

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

A client is on droplet precautions for influenza. Which action is correct when transporting the client to radiology?

  1. Remove all precautions during transport
  2. Have the client wear a surgical mask during transport Correct answer.
  3. Have the client wear a high-efficiency particulate respirator
  4. Transport the client without notifying radiology

Explanation

When a client on droplet precautions must leave the room, the client should wear a surgical mask to contain respiratory secretions during transport. Precautions are not removed during transport. A high-efficiency respirator is used by staff for airborne precautions, not routinely by the client.

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

A nurse is assessing a client for risk of falls. Which factor most increases the client's risk?

  1. Taking a diuretic and a sedative at bedtime Correct answer.
  2. Wearing nonskid slippers
  3. Using a walker for ambulation
  4. Having a family member present in the room

Explanation

Diuretics increase the need to urinate, especially at night, and sedatives impair balance and alertness, so the combination strongly increases fall risk. A family member present, use of a walker, and nonskid slippers are protective factors.

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

A nurse receives a verbal order from a provider for a new medication. Which action is appropriate?

  1. Write down the order, read it back to the provider, and follow policy Correct answer.
  2. Wait until the provider writes the order at the end of the shift
  3. Accept the order and administer the medication immediately
  4. Ask another nurse to transcribe the order from memory

Explanation

Verbal orders must be written down and read back to the provider to verify accuracy, then documented and countersigned according to facility policy. Administering immediately without verification risks error. Transcribing from memory and delaying until the end of the shift create safety risks.

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

A nurse is preparing to suction a client with a new tracheostomy. Which action maintains infection control?

  1. Applying suction while inserting the catheter
  2. Suctioning for longer than 15 seconds each pass
  3. Reusing the same catheter for 24 hours without cleaning
  4. Using sterile technique for open suctioning Correct answer.

Explanation

Open tracheal suctioning requires sterile technique to prevent introducing pathogens into the airway. Suction should be applied only during withdrawal, and each pass should be limited to about 10 to 15 seconds. Reusing an uncleaned catheter introduces infection.