North Carolina RN: Safe and Effective Care Environment Practice Test

Practice test questions — RN: Safe and Effective Care Environment

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

   • A client receiving routine IV antibiotics
   • A client who is 1 hour postoperative and reports increasing surgical-site pain rated 6/10
   • A client with new-onset shortness of breath and oxygen saturation of 88% ✓
   • A client requesting pain medication for chronic back pain

   Priority assessment follows the ABCs (Airway, Breathing, Circulation) and Maslow's hierarchy of needs. Physiological needs come first, and within physiological needs, airway and breathing concerns take priority. The client with new-onset shortness of breath and O2 saturation of 88% has an acute resp…

2. Which action by a nurse demonstrates appropriate use of the chain of command?

   • Calling the physician directly with a non-urgent question without notifying the charge nurse
   • Reporting a concern about a physician's order first to the charge nurse, then escalating to the nurse manager and through the medical chain if the concern is not addressed ✓
   • Refusing to speak to the physician at any time
   • Discussing the concern in a public area

   The chain of command is the hierarchical structure used to escalate clinical concerns when standard channels do not resolve them. Proper sequence: bring the concern to the immediate supervisor first (charge nurse), then to the nurse manager, then to higher administrative or medical authorities (nurs…

3. The RN is delegating tasks to a UAP (Unlicensed Assistive Personnel). Which task is appropriate to delegate?

   • Initial assessment of a newly admitted client
   • Teaching a client about a new medication
   • Taking routine vital signs on a stable postoperative client ✓
   • Evaluating the effectiveness of pain medication

   Delegation to UAPs (CNAs, patient care techs) follows the 'Five Rights of Delegation' from the NCSBN: right task, right circumstances, right person, right direction/communication, right supervision. UAPs can perform routine, repetitive tasks for stable clients — bathing, feeding, ambulating, vital s…

4. An RN is supervising an LPN (Licensed Practical Nurse). Which task can the LPN perform?

   • Administer IV push medications to a critically ill client
   • Develop the nursing care plan for a newly admitted client
   • Administer oral medications and reinforce client teaching ✓
   • Perform the initial admission assessment

   LPN scope of practice varies by state but generally includes: administering oral, IM, and subcutaneous medications; reinforcing teaching done by the RN (not initial teaching); performing routine dressing changes; collecting data (but not initial comprehensive assessment in most states); providing ba…

5. A client with a terminal illness has signed a 'Do Not Resuscitate' (DNR) order. What does this order mean?

   • The client refuses all medical treatment
   • The client refuses cardiopulmonary resuscitation (CPR) and related interventions in the event of cardiac or respiratory arrest — other treatments continue as ordered ✓
   • The client's care will be withdrawn entirely
   • The order only applies after the client's death

   A DNR order specifically directs that CPR (chest compressions, defibrillation, intubation, advanced cardiac medications) will not be performed if the client experiences cardiac or respiratory arrest. The order does NOT mean: no treatment at all (the client continues to receive all other ordered trea…

6. What is a 'durable power of attorney for healthcare'?

   • Authority over the client's finances
   • A legal document authorizing a designated person (healthcare proxy) to make healthcare decisions for the client if the client becomes unable to do so ✓
   • A document that takes effect only after death
   • Hospital admission paperwork

   A durable power of attorney for healthcare (also called a healthcare proxy or healthcare surrogate) is a legal document in which a competent adult designates another person to make healthcare decisions if the client becomes incapacitated and unable to make decisions themselves. The 'durable' aspect …

7. What is the most important infection-control measure?

   • Wearing gloves at all times
   • Hand hygiene (washing with soap and water or using alcohol-based hand rub) — performed before and after every patient contact ✓
   • Wearing N95 respirators routinely
   • Isolation of all clients

   Hand hygiene is the single most important intervention to prevent healthcare-associated infections (HAIs). CDC guidelines specify when to perform hand hygiene: before patient contact, before aseptic procedures, after body fluid exposure risk, after patient contact, and after contact with patient sur…

8. A client with active tuberculosis (TB) is admitted. What type of isolation precautions are required?

   • Standard precautions only
   • Airborne precautions: private negative-pressure room, N95 respirator for caregivers, mask for client during transport ✓
   • Contact precautions
   • Droplet precautions

   Airborne precautions are required for diseases transmitted by small droplet nuclei (under 5 microns) that remain suspended in the air for extended periods. Examples: tuberculosis (TB), measles, varicella (chickenpox), disseminated zoster. Requirements: (1) Private negative-pressure room (Airborne In…

9. What are the 'rights' of safe medication administration?

   • Right pharmacy and right insurance
   • Right patient, right medication, right dose, right route, right time, right documentation — with some sources adding right reason, right response, right to refuse ✓
   • Right physician and right diagnosis
   • Just verify the medication name

   The traditional 'Five Rights' of medication administration are right patient, right medication, right dose, right route, right time. Modern practice has added: right documentation (chart immediately after administration, not before), right reason (the medication should be appropriate for the indicat…

10. A nurse notices an error in a previously documented medication administration. What is the appropriate action?

    • Erase or white out the entry
    • Draw a single line through the error, write 'error' or 'mistaken entry', initial and date the correction, then make the correct entry — do not obscure the original ✓
    • Tear out the page
    • Leave the error and add a contradicting note elsewhere

    Proper documentation correction maintains the legal integrity of the medical record. The correct procedure: draw a single line through the incorrect entry so it remains readable; write 'error' or 'mistaken entry' near the line; initial and date the correction; make the correct entry. Never erase, wh…

11. What is the proper sequence for donning (putting on) and doffing (removing) personal protective equipment (PPE)?

    • Same sequence for both
    • Donning: gown, mask/respirator, goggles, gloves. Doffing: gloves, goggles, gown, mask/respirator. The principle is to minimize self-contamination during removal ✓
    • Random order is fine
    • Mask first, then everything else simultaneously

    PPE sequence is critical to prevent self-contamination. Donning (clean to contaminated): (1) Perform hand hygiene; (2) Gown — tied at neck and waist; (3) Mask or respirator — secure with ties or elastic; (4) Goggles or face shield — over the eyes; (5) Gloves — extending over gown cuffs. Doffing (con…

12. A nurse finds an unresponsive client without a pulse. What is the first action?

    • Call the physician
    • Activate the emergency response system (code blue) and begin CPR with chest compressions ✓
    • Document the finding
    • Wait for the rapid response team

    Cardiac arrest requires immediate action. The current AHA Basic Life Support sequence (C-A-B): (1) Check for responsiveness; (2) Activate emergency response (call code blue, ask for AED if available); (3) Begin chest compressions immediately — 100-120 per minute, 2-2.4 inches deep on adults, allowin…

13. What is the proper response if a fire is discovered in a healthcare facility?

    • Run to the exit
    • Use the RACE acronym: Rescue clients in danger, Alarm/activate the fire alert, Contain the fire by closing doors, Extinguish or Evacuate as appropriate ✓
    • Call administration first
    • Open windows for ventilation

    The RACE acronym is the standard fire response in healthcare facilities: R — Rescue any client in immediate danger; A — Activate the fire alarm (pull station) or call the emergency code; C — Contain the fire by closing doors and windows to limit oxygen and smoke spread; E — Extinguish the fire if sm…

14. What is the safest method of identifying a client before any procedure or medication administration?

    • Ask the client their room number
    • Use at least two patient identifiers: typically the client's full name and date of birth, verified against the wristband and the chart ✓
    • Look at the chart only
    • Recognize the client by face

    The Joint Commission's National Patient Safety Goals require using at least two patient identifiers before any procedure, medication administration, blood transfusion, specimen collection, or any other patient-specific intervention. Acceptable identifiers: full name (first and last), date of birth, …

15. What is the correct procedure if a client refuses a prescribed medication?

    • Force the client to take it
    • Respect the client's right to refuse, explore the reason for refusal, educate about the medication's purpose, document the refusal, and notify the prescriber ✓
    • Hide it in food
    • Document that it was given

    Competent adults have the right to refuse any medical treatment, including medications. The nurse must respect this right while ensuring informed decision-making. Steps: (1) Acknowledge the refusal calmly; (2) Explore the reason — concerns about side effects, religious beliefs, distrust, misundersta…

16. What is 'informed consent' in healthcare?

    • Any verbal agreement
    • The process of providing the client with information about a proposed treatment (nature, purpose, risks, benefits, alternatives, consequences of refusal) and obtaining their voluntary agreement before proceeding ✓
    • Only signing a form
    • Family agreement

    Informed consent is both an ethical and legal requirement before most medical interventions. Elements that must be communicated: nature of the proposed treatment; purpose and expected benefits; significant risks and complications; reasonable alternatives (including no treatment); consequences of ref…

17. What is the most appropriate action to prevent client falls?

    • Restrain all clients
    • Assess fall risk on admission and at intervals; implement individualized interventions based on risk factors — bed in low position, call light within reach, non-slip footwear, scheduled toileting, environmental safety ✓
    • Keep clients in bed
    • Use side rails only

    Fall prevention is multifactorial and individualized. Standard practice: (1) Assess fall risk on admission and at regular intervals using a validated tool (Morse Fall Scale, STRATIFY, Hendrich II); (2) Identify specific risk factors — age, history of falls, gait/balance issues, vision problems, medi…

18. Which task must be performed by the RN and cannot be delegated?

    • Bathing a stable client
    • Administering a flu vaccine
    • Performing the initial nursing assessment of a newly admitted client ✓
    • Helping a client to the bathroom

    The initial nursing assessment cannot be delegated — it requires the comprehensive judgment and analysis only an RN can provide. The initial assessment establishes the baseline, identifies acute and chronic issues, develops the nursing diagnoses, and is the foundation of the care plan. This is a nur…

19. A client is experiencing an anaphylactic reaction. What is the priority intervention?

    • Document the reaction
    • Stop the precipitating agent (if applicable), maintain the airway, administer epinephrine intramuscularly per protocol, call for help, prepare for possible intubation ✓
    • Give oral antihistamines
    • Place the client in a chair

    Anaphylaxis is a life-threatening systemic allergic reaction requiring immediate action. Signs: hives, urticaria, swelling (face, lips, tongue, throat), wheezing, stridor, hypotension, shock. Priority interventions: (1) Stop the offending agent — discontinue IV infusion, remove contact; (2) Assess a…

20. A nurse is asked to care for clients in a unit where they have no training or experience. What is the most appropriate response?

    • Accept the assignment and do their best
    • Refuse the assignment entirely and leave
    • Discuss the concern with the supervisor, identify which tasks they are competent to perform, and request supervision or training for unfamiliar tasks — document the conversation ✓
    • Wait for orders without acting

    Nurses have an obligation to practice only within their competency. The American Nurses Association Code of Ethics and most state nurse practice acts require this. When faced with an unfamiliar assignment: communicate concerns to the charge nurse or supervisor; identify specific tasks within the nur…

21. Which is the safest action when receiving a verbal medication order from a physician?

    • Write down the order without confirming
    • Write down the order, then read it back to the physician for verification (read-back), and ensure the physician confirms the order is correct ✓
    • Implement the order from memory
    • Refuse all verbal orders

    Verbal and telephone orders are error-prone because of misheard medications, similar-sounding drug names, and number confusion. The safest practice is the 'read-back' procedure: (1) The nurse writes down the order as it is given; (2) The nurse reads back the complete order to the physician — drug na…

22. A client has C. difficile (C. diff). Which precaution is most important for hand hygiene?

    • Alcohol-based hand rub is sufficient
    • Soap and water must be used because alcohol-based products do not kill C. difficile spores ✓
    • Hand hygiene is not required
    • Only at the start and end of the shift

    Clostridioides difficile (C. diff) is unique among healthcare pathogens because it forms spores that are resistant to alcohol-based hand sanitizers. Alcohol does not kill C. diff spores. Hand hygiene after caring for C. diff clients (or any patient with suspected infectious diarrhea) must use soap a…

23. Who has the authority to consent to medical treatment for an unconscious adult client without advance directives?

    • Any family member who arrives first
    • The legal next of kin or designated healthcare proxy, following the state's hierarchy of surrogate decision-makers — typically spouse, adult children, parents, adult siblings — or by court order if no surrogate is available ✓
    • The hospital administrator
    • Anyone present

    When an adult client is unable to consent due to incapacity and has no advance directive identifying a healthcare proxy, state law establishes a hierarchy of surrogate decision-makers. The typical order: spouse, adult children, parents, adult siblings, other relatives, close friends, court-appointed…

24. What is the first action a nurse should take when responding to a disaster or mass casualty event?

    • Begin treating clients immediately based on order of arrival
    • Triage clients using a standard system (e.g., START) to categorize based on severity and survivability, then treat in priority order ✓
    • Wait for all clients to arrive
    • Refer all clients elsewhere

    Mass casualty events overwhelm normal resources and require triage — sorting clients to allocate limited care effectively. The START (Simple Triage and Rapid Treatment) system is widely used: clients are categorized in less than 60 seconds each into four groups identified by colored tags: Red (Immed…

25. What is HIPAA, and what does it require of nurses?

    • A nursing licensing exam
    • Federal law (Health Insurance Portability and Accountability Act) protecting patient health information; nurses must not share protected health information (PHI) without authorization except for treatment, payment, and healthcare operations ✓
    • A type of insurance
    • A workplace safety law

    HIPAA (Health Insurance Portability and Accountability Act of 1996) Privacy Rule protects Protected Health Information (PHI) — any individually identifiable health information. Nurse responsibilities: (1) Access PHI only for legitimate work purposes; (2) Discuss PHI only in private settings with peo…

26. A nurse receives a verbal order from a physician by telephone. What is the correct procedure?

    • Write the order and implement it without reading it back
    • Repeat the order back to the physician completely (read-back), document it as a verbal order with the prescriber's name, date, time, and nurse's signature, then ensure the physician countersigns within the facility's required timeframe ✓
    • Refuse to accept verbal orders under any circumstances
    • Only accept verbal orders from attending physicians, never residents

    VERBAL AND TELEPHONE ORDER SAFETY is a Joint Commission National Patient Safety Goal specifically because miscommunication of verbal orders is a leading cause of medication errors. THE REQUIRED PROCESS: (1) RECEIVE the order; write it down simultaneously; (2) READ BACK the complete order word-for-wo…

27. A nurse is caring for a client who is confused and attempts to climb out of bed. Which restraint alternative should the nurse try FIRST?

    • Apply wrist restraints immediately
    • Try non-restraint alternatives first: reorientation, keeping the call light within reach, moving the client closer to the nursing station, asking a family member to stay, providing familiar objects, ensuring the environment is safe (bed in lowest position, side rails up), and addressing unmet needs (pain, need to void, hunger) ✓
    • Sedate the client with a PRN benzodiazepine
    • Restrain only the legs

    RESTRAINT ALTERNATIVES must be exhausted before physical restraints are applied. Restraints are a last resort because they carry significant risks: increased agitation, aspiration, pressure injuries, psychological trauma, and death. JOINT COMMISSION and CMS standards require documentation that alter…

28. Which of the following tasks can an RN appropriately delegate to a licensed practical nurse (LPN)?

    • Performing an initial admission assessment on a newly admitted complex client
    • Administering a scheduled oral medication to a stable client with no known allergies to that medication ✓
    • Developing a nursing care plan for a newly diagnosed client
    • Providing education to a client newly diagnosed with insulin-dependent diabetes

    DELEGATION TO LPN/LVN is governed by the RN's judgment, state practice act, and the 5 Rights of Delegation. Understanding the LPN/LVN SCOPE OF PRACTICE is essential. LPN/LVNs CAN typically do: Administer routine oral, IM, SubQ, and topical medications to stable clients; Perform straightforward asses…

29. A nurse is preparing to administer IV vancomycin to a client. Which laboratory value must be checked BEFORE administration?

    • Serum potassium
    • Serum creatinine and/or BUN — vancomycin is nephrotoxic (kidney-toxic) and is renally cleared; impaired renal function causes drug accumulation and increased toxicity risk; dosing is adjusted based on renal function and monitored via trough serum levels ✓
    • Hemoglobin
    • Serum glucose

    VANCOMYCIN is a glycopeptide antibiotic used primarily for MRSA and other gram-positive organisms. It is one of the most important antibiotics to monitor because of significant toxicity risks. NEPHROTOXICITY — RENAL MONITORING: Vancomycin is eliminated by the kidneys; impaired renal function causes …

30. A client develops a sudden onset of chest pain, shortness of breath, and hypotension after a central line placement. The nurse suspects a pneumothorax. What is the PRIORITY action?

    • Obtain a portable chest X-ray before notifying the physician
    • Stay with the client, call for immediate help (activate rapid response team or code team), administer supplemental oxygen, and notify the physician immediately — this is a life-threatening emergency that cannot wait for X-ray confirmation ✓
    • Have the client take deep breaths to re-expand the lung
    • Increase IV fluid rate

    TENSION PNEUMOTHORAX is a potentially fatal complication of central line placement (and other thoracic procedures). It occurs when air enters the pleural space and cannot escape, progressively compressing the lung and eventually shifting the mediastinum (tension). CLINICAL PRESENTATION: Sudden chest…

31. Which step in hand washing technique is MOST critical for effective reduction of microorganism transmission?

    • Using hot water
    • Mechanical friction for a minimum of 20 seconds covering all surfaces — including between fingers, under nails, and wrists — friction physically removes microorganisms regardless of water temperature ✓
    • Using antibacterial soap exclusively
    • Rinsing before applying soap

    HAND HYGIENE is the single most effective intervention to prevent healthcare-associated infections (HAIs). The 5 MOMENTS FOR HAND HYGIENE (WHO standard): BEFORE touching a patient; BEFORE a clean/aseptic procedure; AFTER body fluid exposure risk; AFTER touching a patient; AFTER touching the patient'…

32. A client who has an advance directive designating 'no heroic measures' is admitted through the ED in cardiac arrest. What should the healthcare team do?

    • Automatically withhold all resuscitation efforts
    • Initiate resuscitation if the advance directive is not immediately available or has not been converted to a current POLST/DNR physician order; verify the advance directive status as quickly as possible and adjust care accordingly ✓
    • Family members have the final say, not the advance directive
    • Only the attending physician decides, ignoring all advance directives

    ADVANCE DIRECTIVES AND EMERGENCY RESUSCITATION create a complex situation when a client arrives in extremis and the advance directive is not immediately available as a formal medical order. KEY PRINCIPLES: AN ADVANCE DIRECTIVE is a legal document expressing the patient's wishes, but it must be CONVE…

33. A nurse suspects a colleague is coming to work under the influence of alcohol. What is the most appropriate action?

    • Say nothing to avoid conflict
    • Report the concern to the charge nurse or nursing supervisor immediately — patient safety is paramount; most states have nurse assistance programs (diversion programs) for nurses with substance use disorders that prioritize recovery over punishment ✓
    • Manage the colleague's patients yourself without reporting
    • Confront the colleague in front of patients

    IMPAIRED HEALTHCARE PROVIDER reporting is both a professional obligation and an ethical duty. The consequences of an impaired nurse providing care can include: medication errors (calculation errors, administering wrong drugs); falls and inadequate supervision; failure to recognize patient deteriorat…

34. Which client is at HIGHEST RISK for developing a healthcare-associated infection (HAI)?

    • A healthy 25-year-old admitted for an elective hernia repair
    • A 68-year-old diabetic client with a Foley catheter, central venous catheter, and mechanical ventilator following major abdominal surgery ✓
    • A 35-year-old with a simple laceration repair
    • A 50-year-old admitted for a colonoscopy

    HAI RISK FACTORS are additive — the more risk factors present, the higher the risk. The 68-year-old in Option B has multiple major risk factors compounding each other. RISK FACTOR ANALYSIS: AGE (>65): Immune senescence — reduced immune response; less reserve to fight infection; thinner, more fragile…

35. A nurse is preparing to administer two different IV medications through the same IV line. Which step must be performed between medications?

    • Nothing — IV drugs in the same line mix harmlessly
    • Flush the IV line with compatible flush solution (usually normal saline) between medications to prevent drug incompatibilities in the line that could cause precipitation, altered drug activity, or patient harm ✓
    • Change the entire IV tubing set
    • Only flush if the drugs are antibiotics

    IV DRUG COMPATIBILITY and proper flushing between medications is a patient safety requirement, not an optional step. WHY FLUSHING MATTERS: Many IV drugs are INCOMPATIBLE with each other — when they mix in the IV tubing, they can: precipitate (form a solid that can cause emboli); inactivate each othe…

36. A nurse discloses a client's HIV status to the client's employer without the client's consent. What is this an example of?

    • Normal information sharing between healthcare and community
    • A HIPAA violation — unauthorized disclosure of protected health information (PHI) to a non-authorized party; the client did not consent and the employer has no legal right to this information ✓
    • Acceptable if the nurse believed it was for public health
    • Only a problem if the client finds out

    THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) PRIVACY RULE protects all individually identifiable health information (Protected Health Information, PHI). An employer is NOT an authorized recipient of health information without specific patient authorization or a legally defined exc…

37. When activating a rapid response team (RRT), which clinical changes most justify calling?

    • Only changes visible on the ECG monitor
    • Acute changes in mental status, respiratory rate outside 8-30 breaths/min, heart rate outside 40-130 bpm, systolic BP below 90 mmHg, oxygen saturation below 90%, or a nurse's 'gut feeling' that something is wrong — early activation saves lives ✓
    • Vital sign changes only if outside normal range for 4+ hours
    • Only after the attending physician is notified and unavailable

    RAPID RESPONSE TEAMS (RRTs) exist to bring critical care expertise to deteriorating patients on general wards BEFORE they progress to cardiac arrest. Research consistently shows that most in-hospital cardiac arrests are preceded by 6-8 hours of deteriorating vital signs and clinical condition that w…

38. When delegating care to a UAP for an unstable client whose condition has been changing, which action is MOST important?

    • Delegate the task and check back only at the end of the shift
    • Clearly specify what changes or findings to report immediately, give specific parameters (e.g., 'call me right away if heart rate is above 110 or blood pressure drops below 90/60'), and check back frequently — the nurse retains full responsibility for the unstable client ✓
    • Delegate completely and trust the UAP's judgment
    • Avoid delegating anything to any UAP for any reason

    DELEGATION FOR UNSTABLE CLIENTS requires heightened communication and supervision because the stakes of missed information are high. While some tasks may be appropriately delegated even for unstable clients (basic hygiene, feeding), the nurse must maintain very close oversight. THE MOST IMPORTANT EL…

39. A nurse discovers they administered a medication to the wrong patient. After taking immediate steps to assess the patient and notify the provider, what must the nurse do?

    • Document only if the patient has an adverse reaction
    • Complete a medication error report (incident/occurrence report) per facility policy, document the error in the medical record factually, and notify the charge nurse — transparency and reporting prevent future errors and protect the patient ✓
    • Discuss it only with a trusted colleague
    • Document it as 'medication given as ordered' to avoid consequences

    MEDICATION ERROR REPORTING is mandatory for patient safety, quality improvement, and legal protection. It is also an ethical obligation. IMMEDIATE ACTIONS AFTER A MED ERROR: (1) ASSESS the patient for harm — vital signs, symptoms, allergic reactions; (2) NOTIFY the prescriber immediately — they need…

40. Which statement accurately describes the nurse's accountability when tasks are delegated to assistive personnel?

    • Once delegated, accountability transfers completely to the UAP
    • The RN retains accountability for the outcome of delegated tasks — delegation transfers RESPONSIBILITY for the task to the delegate, but the RN's accountability for overall care management, supervision, and outcome remains ✓
    • The RN is only accountable for tasks personally performed
    • Accountability transfers to the charge nurse once any task is delegated

    DELEGATION AND ACCOUNTABILITY is a critically tested NCLEX concept that many candidates confuse. THE CORE PRINCIPLE: Delegation transfers the RESPONSIBILITY for performing the specific task to the delegatee. Delegation does NOT transfer the RN's ACCOUNTABILITY for the overall care outcomes, supervis…

41. A nurse is caring for a client with active tuberculosis (TB). Which type of precaution and personal protective equipment is required?

    • Standard precautions only
    • Airborne precautions with a fit-tested N95 respirator and a negative-pressure room ✓
    • Contact precautions with gown and gloves
    • Droplet precautions with a surgical mask

    AIRBORNE PRECAUTIONS are required for tuberculosis. TB spreads via small airborne droplet nuclei that remain suspended in air, so the nurse needs: a fit-tested N95 RESPIRATOR (or higher); a NEGATIVE-PRESSURE (airborne infection isolation) room with the door closed; the client wears a surgical mask i…

42. Before administering a medication, the nurse should verify the 'rights' of medication administration. Which of the following is one of these rights?

    • Right color
    • Right client (verified using two identifiers) ✓
    • Right brand name only
    • Right nurse

    The RIGHTS OF MEDICATION ADMINISTRATION include: RIGHT CLIENT (verified using TWO identifiers, such as name and date of birth — never the room number alone); RIGHT MEDICATION; RIGHT DOSE; RIGHT ROUTE; RIGHT TIME; plus often Right Documentation, Right Reason, Right Response. NCLEX safe care/medicatio…

43. According to the principles of delegation, which task is MOST appropriate for a registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)?

    • Developing the nursing care plan
    • Assisting a stable client with bathing and ambulation ✓
    • Administering IV medications
    • Performing the admission assessment

    Appropriate tasks to delegate to UAP (unlicensed assistive personnel) are ROUTINE, STANDARDIZED tasks for STABLE clients with PREDICTABLE outcomes — such as assisting a stable client with BATHING, AMBULATION, feeding, vital signs, and hygiene (activities of daily living). NCLEX safe care/delegation.…

44. A nurse is implementing fall precautions for an older adult client at high risk for falls. Which intervention is appropriate?

    • Keep all four side rails up at all times
    • Keep the bed in the lowest position, ensure the call light is within reach, and provide nonskid footwear ✓
    • Keep the room dark to encourage rest
    • Leave the client unattended in the bathroom

    FALL PRECAUTIONS for a high-risk client include: keeping the BED in the LOWEST position with wheels locked; CALL LIGHT and personal items within REACH; NONSKID footwear; adequate LIGHTING (including night lights); clear pathways (remove clutter); assist with ambulation/toileting; frequent rounding; …

45. What is the single most effective method for preventing the spread of infection in healthcare settings?

    • Wearing gloves at all times
    • Proper hand hygiene (handwashing or alcohol-based hand rub) ✓
    • Administering antibiotics
    • Isolating all clients

    PROPER HAND HYGIENE — handwashing with soap and water OR using an alcohol-based hand rub — is the SINGLE MOST EFFECTIVE method for preventing the spread of infection. NCLEX safe care/infection control. Perform hand hygiene: before and after client contact, before aseptic procedures, after exposure t…

46. A nurse receives a verbal order from a physician during an emergency. What is the correct procedure for safety?

    • Carry it out from memory without documentation
    • Write down the order, read it back to the physician for confirmation, and ensure it is signed within the required timeframe ✓
    • Ask another nurse to remember it
    • Ignore the order until it is written

    For VERBAL/TELEPHONE ORDERS, the safe procedure is: WRITE DOWN the order (or enter it), then READ IT BACK to the prescriber for verification (read-back/'repeat-back'), and confirm it is correct; the prescriber must SIGN/authenticate the order within the facility's required timeframe (often 24 hours)…

47. A nurse discovers a fire in a client's room. Using the RACE protocol, what is the FIRST action?

    • Extinguish the fire
    • Rescue/remove the client from immediate danger ✓
    • Call the fire department
    • Open the windows

    The RACE fire protocol prioritizes actions in order: R — RESCUE (remove anyone in immediate danger FIRST); A — ALARM (activate the fire alarm/call for help); C — CONTAIN (close doors and windows to contain the fire/smoke); E — EXTINGUISH (use a fire extinguisher if safe) or EVACUATE. NCLEX safe care…

48. A nurse is preparing to administer a 'high-alert' medication such as heparin or insulin. What additional safety measure is recommended?

    • No special measures are needed
    • Have a second nurse independently verify the medication and dose before administration ✓
    • Administer it faster to save time
    • Skip the usual checks since it is urgent

    HIGH-ALERT medications (those with a heightened risk of causing significant harm if used in error) — such as HEPARIN, INSULIN, opioids, chemotherapy, and concentrated electrolytes (e.g., potassium chloride) — require additional safeguards, including an INDEPENDENT DOUBLE-CHECK by a SECOND NURSE who …

49. When using restraints on a client (as a last resort), which nursing action is essential for safe care?

    • Apply them and check once per shift
    • Obtain a provider's order, use the least restrictive type, and frequently monitor the client (circulation, skin, needs) per policy, releasing/repositioning regularly ✓
    • Tie restraints to the side rails
    • Use restraints for staff convenience

    RESTRAINTS are a LAST RESORT after less restrictive measures fail, used only to protect the client or others. SAFE USE requires: a PROVIDER'S ORDER (time-limited; cannot be PRN/standing; emergency application requires an order ASAP); the LEAST RESTRICTIVE type effective; FREQUENT MONITORING per poli…

50. A charge nurse is making client assignments. Which client should be assigned to the most experienced registered nurse?

    • A stable client awaiting discharge
    • An unstable client requiring frequent assessment and complex care ✓
    • A client needing assistance with morning hygiene
    • A client with stable chronic conditions

    The MOST EXPERIENCED/skilled RN should be assigned the UNSTABLE client requiring frequent assessment, complex care, and clinical judgment — because this client has the greatest risk and the most unpredictable needs. NCLEX safe care/management of care. PRINCIPLE: match the acuity and complexity of th…

51. A nurse is prioritizing care for four clients. Using the ABC framework, which client should be assessed first?

    • A client requesting pain medication
    • A client with an oxygen saturation of 84% and labored breathing ✓
    • A client who needs help to the bathroom
    • A client asking about discharge

    Using the ABC framework (AIRWAY, BREATHING, CIRCULATION), the client with an OXYGEN SATURATION of 84% and LABORED BREATHING is the priority — this is a BREATHING/airway problem that is immediately life-threatening. NCLEX safe care/prioritization. PRIORITIZATION FRAMEWORKS: ABCs (airway and breathing…

52. A client asks to see their own medical record. What is the nurse's best response?

    • Refuse, as records belong only to the facility
    • Recognize the client's right to access their medical record, and follow facility policy/procedure to facilitate the request ✓
    • Tell the client records are confidential from them
    • Give a copy without any documentation

    Clients have a RIGHT to ACCESS their own medical records (under HIPAA and patient rights). The nurse should recognize this right and FOLLOW FACILITY POLICY/PROCEDURE to facilitate the request (which may involve a formal request, a designated process, and the provider/medical records department). NCL…

53. A nurse is caring for a client with Clostridioides difficile (C. diff). Which infection control measure is essential?

    • Use alcohol-based hand sanitizer only
    • Use contact precautions and wash hands with soap and water (alcohol-based sanitizer does not kill C. diff spores) ✓
    • No special precautions needed
    • Use airborne precautions

    For C. DIFFICILE (C. diff — causes severe diarrhea, spread by spores): use CONTACT PRECAUTIONS (gown and gloves) AND wash hands with SOAP AND WATER — because alcohol-based hand sanitizer does NOT kill C. diff SPORES (the mechanical action of soap and water physically removes them). NCLEX safe care/i…

54. A registered nurse is supervising a licensed practical nurse (LPN/LVN). Which task is appropriate to assign to the LPN?

    • Developing the initial plan of care
    • Administering oral and certain other medications to a stable client and reinforcing teaching ✓
    • Performing the initial admission assessment
    • Administering IV push medications (in most facilities)

    Appropriate tasks for an LPN/LVN (within their scope, varies by state/facility): administering ORAL and many other MEDICATIONS to STABLE clients; performing routine, stable procedures; REINFORCING teaching the RN initiated; monitoring stable clients; wound care; collecting data (contributing to asse…

55. A nurse is preparing to administer a blood transfusion. What is an essential safety step before starting the transfusion?

    • Start it quickly without checks
    • Verify the blood product and client identity with a second qualified person (two-person verification of the right blood for the right client), and obtain baseline vital signs ✓
    • Skip vital signs
    • Use the fastest infusion rate possible from the start

    Before a BLOOD TRANSFUSION, essential safety steps include: TWO-PERSON VERIFICATION (two qualified staff independently check) of the client's identity (two identifiers), the blood product (type, Rh, unit number), the order, and the crossmatch — matching the RIGHT blood to the RIGHT client (a mismatc…

56. A nurse receives a client returning from surgery. What is the priority assessment?

    • The client's dietary preferences
    • Airway, breathing, and circulation (ABCs) — including respiratory status, vital signs, and level of consciousness ✓
    • The client's insurance information
    • The client's visiting schedule

    For a POST-OPERATIVE client, the priority assessment follows the ABCs: AIRWAY (patent? — risk of obstruction from sedation/anesthesia), BREATHING (respiratory rate, depth, oxygen saturation — anesthesia depresses respiration), CIRCULATION (vital signs, bleeding, perfusion), and level of consciousnes…

57. Which situation is an example of a nurse obtaining 'informed consent' correctly?

    • The nurse explains the surgery and risks and obtains the signature
    • The provider explains the procedure, risks, benefits, and alternatives to the client, and the nurse witnesses the client's voluntary signature and verifies understanding ✓
    • The nurse signs for the client
    • Consent is assumed without discussion

    INFORMED CONSENT is the responsibility of the PROVIDER performing the procedure (physician/surgeon), who must explain: the PROCEDURE, its RISKS, BENEFITS, and ALTERNATIVES (including the option of no treatment), in terms the client understands. The NURSE'S ROLE: WITNESS the client's VOLUNTARY signat…

58. A nurse notes that a medication order reads 'give 10U insulin.' Why is this order potentially unsafe?

    • It is perfectly clear
    • The abbreviation 'U' for units can be misread (e.g., as a zero, making it '100'); 'units' should be written out to prevent dosing errors ✓
    • Insulin is never given
    • The dose is too low to matter

    The abbreviation 'U' for UNITS is on the 'DO NOT USE' list because it can be MISREAD — 'U' can look like a 0 (making '10U' read as '100') or a 4, leading to dangerous dosing errors. The word 'UNITS' should be written out in full. NCLEX safe care/medication safety. OTHER ERROR-PRONE ABBREVIATIONS to …

59. When should a nurse perform hand hygiene according to the principles of standard precautions?

    • Only after caring for a client
    • Before and after client contact, before aseptic procedures, after exposure to body fluids, and after touching the client's environment ✓
    • Only when hands look dirty
    • Only once per shift

    Hand hygiene should be performed at the WHO 'FIVE MOMENTS': (1) BEFORE touching a client; (2) BEFORE an aseptic/clean procedure; (3) AFTER body fluid exposure risk; (4) AFTER touching a client; (5) AFTER touching the client's SURROUNDINGS/environment. NCLEX safe care/infection control. Also: before …

60. A nurse is caring for a client on seizure precautions. Which intervention is appropriate?

    • Restrain the client during a seizure
    • Pad the side rails, keep the bed in low position, have suction and oxygen available, and during a seizure protect the head and turn the client to the side — do not restrain or put anything in the mouth ✓
    • Insert a tongue blade during a seizure
    • Hold the client down firmly

    SEIZURE PRECAUTIONS and care: PREPARE the environment — pad side rails, keep the bed in LOW position, have SUCTION and OXYGEN available, remove hazards. DURING a seizure: PROTECT the client (cushion/protect the head, turn the client to the SIDE to maintain the airway and prevent aspiration, loosen t…

61. Using Maslow's hierarchy of needs to prioritize, which client need would generally be addressed first?

    • A client's need for social interaction
    • A client's physiological need such as oxygen, food, or fluids ✓
    • A client's need for self-esteem
    • A client's need for spiritual fulfillment

    Using MASLOW'S HIERARCHY OF NEEDS to prioritize, PHYSIOLOGICAL needs (oxygen, food, water, elimination, sleep, shelter) are addressed FIRST — they are the most basic and essential for survival. NCLEX safe care/prioritization. MASLOW'S HIERARCHY (bottom to top): (1) PHYSIOLOGICAL (most basic — air, w…

62. A nurse is administering a medication through a feeding tube. What is an important safety practice?

    • Crush all medications together and give enteric-coated tablets crushed
    • Verify each medication can be crushed/given via tube (do not crush enteric-coated or extended-release forms), flush the tube before, between, and after medications, and check tube placement ✓
    • Never flush the tube
    • Give all medications at maximum speed

    Administering medications via FEEDING TUBE safety practices: VERIFY each medication is appropriate for tube administration — do NOT crush ENTERIC-COATED or EXTENDED-RELEASE (sustained-release) medications (crushing destroys the protective coating/timing, risking overdose or stomach irritation — use …

63. A nurse witnesses another nurse diverting (stealing) controlled substances. What is the nurse's ethical and legal obligation?

    • Ignore it to avoid conflict
    • Report the suspected diversion through the proper channels (supervisor/manager) per facility policy and legal requirements ✓
    • Confront the nurse and handle it privately only
    • Take the medications to investigate

    A nurse who witnesses or suspects drug DIVERSION (theft of controlled substances) by a coworker has an ETHICAL and LEGAL obligation to REPORT it through proper channels (supervisor/manager, per facility policy; reporting to the board of nursing/authorities may be required). NCLEX safe care/legal-eth…

64. A nurse is caring for a client with a new prescription. The dose seems unusually high. What should the nurse do?

    • Administer it as written since the provider ordered it
    • Question/clarify the order with the prescriber before administering — the nurse is responsible for safe administration and should not give a dose that appears unsafe ✓
    • Administer half the dose
    • Ask another nurse to give it instead

    If a medication dose appears UNUSUALLY HIGH or unsafe, the nurse must QUESTION/CLARIFY the order with the PRESCRIBER before administering. NCLEX safe care/medication safety. THE NURSE'S RESPONSIBILITY: nurses are legally and ethically responsible for SAFE medication administration — 'the provider or…

65. A nurse is putting on personal protective equipment (PPE) for a client on contact and droplet precautions. What is the correct order for DONNING (putting on) PPE?

    • Gloves, gown, mask, goggles
    • Gown, mask/respirator, goggles/face shield, then gloves ✓
    • Mask, gloves, gown, goggles
    • There is no correct order

    The correct order for DONNING (putting on) PPE is: (1) GOWN; (2) MASK or respirator; (3) GOGGLES or face shield; (4) GLOVES (last, pulled over the gown cuffs). NCLEX safe care/infection control. Memory: 'gown, mask, goggles, gloves.' For DOFFING (removing) PPE, the order is essentially reversed and …