Fire Safety/Sleep
A nurse is teaching a client about good sleep habits. Which recommendation supports healthy sleep?
A. Drink caffeinated beverages before bedtime
B. Keep the bedroom dark and quiet
C. Take long naps late in the afternoon
D. Watch TV in bed until sleepy
What is keep the bedroom dark and quiet?
A dark, quiet, and comfortable environment promotes sleep. Caffeine, late naps, and stimulating activities before bed can disrupt sleep cycles.
A nurse is preparing to move a client from the bed to a stretcher. Which action should the nurse take first to ensure the client’s safety?"
What is lock the stretcher brakes?
Locking the stretcher brakes is the first safety step before transferring a client to prevent falls or injury."
Which nursing intervention is the highest priority to reduce fall risk?
A. Encourage independent ambulation
B. Keep the bed in the lowest position
C. Provide education at discharge
D. Place personal items on the overbed table
What is keeping the bed in the lowest position?
Falls are most likely to occur in bed or during transfers. Keeping the bed in the lowest position immediately reduces the risk of injury if a patient accidentally tries to get up.
A nurse notes crackles in the lungs, oxygen saturation of 88%, and increased work of breathing. This step of the nursing process focuses on collecting this objective data.
What is assessment?
Assessment is the first step of the nursing process and involves collecting subjective and objective data.
Objective data are measurable and observable, such as:
Crackles in the lungs (auscultation)
Oxygen saturation of 88% (vital signs/monitoring)
Increased work of breathing (physical observation)
This step identifies the client’s actual or potential health problems, which then guides diagnosis, planning, implementation, and evaluation.
A registered nurse (RN) is unsure whether performing a newly assigned clinical task is within their legal scope of practice. Which resource should the nurse consult first to determine if the task is permitted?
The Nurse Practice Act
The Nurse Practice Act is a state-specific law that defines:
The legal scope of practice for RNs and LPNs/LVNs
Allowed and prohibited nursing tasks
Requirements for licensure and delegation
After rescuing clients in a fire, the nurse should next:
A. Attempt to fight the fire immediately
B. Pull the fire alarm and notify the fire department
C. Close all windows
D. Call the patient’s family
What is pull the fire alarm and notify the fire department?
The Alarm step ensures that help arrives quickly. Delaying notification can allow the fire to spread, putting patients and staff at risk.
A client with shortness of breath is placed in a position with the head of the bed elevated 30–45 degrees.
What is semi-Fowler’s position?
Semi-Fowler’s improves ventilation, reduces risk of aspiration, and is often used for clients with respiratory or cardiac issues. Pillows may support the head, arms, or knees.
Which environmental modification is essential to reduce fall risk in a client’s hospital room?
A. Keeping the room dimly lit
B. Ensuring pathways are clear of clutter
C. Encouraging the client to walk without assistance
D. Placing frequently used items on a high shelf
What is ensuring pathways are clear of clutter?
Clutter-free pathways reduce tripping hazards and provide safe walking space, which is critical in preventing falls.
After reviewing assessment findings, the nurse identifies Impaired Gas Exchange related to alveolar-capillary membrane changes. This step involves analyzing data to identify client problems.
What is diagnosis?
Nursing Diagnosis is the second step of the nursing process.
It involves interpreting and analyzing assessment data to identify actual or potential health problems that the nurse can address.
Assessment data: Crackles, low oxygen saturation, increased work of breathing
Problem identified: Impaired Gas Exchange
Related factor: Alveolar-capillary membrane changes
A clear nursing diagnosis guides planning, interventions, and evaluation.
Nursing diagnoses focus on patient responses to health conditions, not the medical diagnosis itself.
A nurse is caring for a client with advanced cancer who refuses further chemotherapy after being fully informed of the risks and benefits. The client’s family insists that treatment continue and asks the nurse to convince the client to change their decision.
Which ethical principle from the American Nurses Association (ANA) Code of Ethics should guide the nurse’s response?
What is Autonomy.
refers to the client’s right to make informed decisions about their own care.
According to the ANA Code of Ethics, nurses must respect a competent client’s choices, even when those decisions conflict with the wishes of family members or healthcare providers. The nurse’s role is to support the client’s decision and advocate for their expressed preferences.
A client with a valid DNR order experiences cardiac arrest. The client’s adult child insists the nurse perform CPR. What should the nurse do?
A. Begin CPR to satisfy the family
B. Follow the DNR order and provide comfort measures
C. Call security to remove the family
D. Delay care until the physician arrives
What is follow the DNR order and provide comfort measures?
A valid DNR order is legally binding. Family members cannot override the client’s documented wishes. The nurse must advocate for the client’s rights.
A nurse is caring for a client who has been immobile in bed for several days following a stroke. The client has limited sensation and requires total assistance for repositioning.
Which nursing action is the highest priority to prevent a pressure injury?
A. Apply lotion to bony prominences
B. Reposition the client at least every 2 hours
C. Keep the head of the bed elevated at all times
D. Massage areas of redness
What is reposition the client at least every 2 hours?
Immobility leads to prolonged pressure over bony prominences, decreasing blood flow and increasing the risk for pressure injuries. Frequent repositioning is the most effective and evidence-based prevention strategy. Massage and constant head-of-bed elevation can increase shear and tissue damage.
A nurse enters a client’s room and finds the client attempting to get out of bed without assistance.
What is the best immediate action by the nurse?
A. Document the behavior in the medical record
B. Call the provider
C. Assist the client back to bed safely
D. Apply restraints
What is C What is assisting the client back to bed safely?
The highest priority is client safety (preventing falls) → always follow ABCs + Maslow’s safety principle.
After interventions, the nurse reassesses the client and notes improved oxygen saturation and decreased dyspnea. This step determines whether goals have been met and if the plan needs revision.
What is Evaluation?
Evaluation is the final step of the nursing process.
It involves reassessing the client after interventions to determine if:
Nursing goals were achieved
Interventions were effective
The plan of care needs modification
This professional behavior requires nurses to keep client information private and share it only with authorized members of the healthcare team.
What is confidentiality?
Confidentiality is a core principle of nursing ethics and professionalism.
It means protecting the client’s personal and health information from unauthorized disclosure.
HIPAA
A client reports difficulty falling asleep and staying asleep at least 3 nights per week for several months.
What is insomnia?
Insomnia is characterized by difficulty initiating or maintaining sleep and can lead to daytime fatigue and impaired functioning.
A nurse assesses a wound on a client’s sacrum and notes full-thickness skin loss with visible subcutaneous fat, but no exposed bone, tendon, or muscle.
How should the nurse document this wound?
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Stage 3 pressure injury
D. Stage 4 pressure injury
What is Stage 3 pressure injury?
A Stage 3 pressure injury involves:
Full-thickness skin loss
Visible adipose (fat) tissue
Possible slough
No exposed bone, tendon, or muscle
A client has fallen in the hospital. What is the nurse’s first priority?
A. Notify the provider
B. Assess the client for injury
C. Document the incident
D. Complete an incident report
What is B. Assess the client for injury?
Immediate assessment of the client’s condition is the top priority because safety and ABCs (Airway, Breathing, Circulation) must be addressed first.
The nurse sets a goal that the client’s oxygen saturation will remain above 94% within 24 hours. This nursing process step involves setting measurable, client-centered outcomes.
What is planning?
Planning is the third step of the nursing process.
Identifying goals and desired outcomes for the client
Making outcomes specific, measurable, achievable, relevant, and time-bound (SMART)
Guiding the selection of nursing interventions
This ethical principle requires the nurse to be truthful when communicating with clients and families.
What is veracity?
Veracity is the ethical principle of truthfulness in all professional interactions.
Why are sedative-hypnotics used cautiously in older adults?
A. They increase appetite
B. They cause urinary frequency
C. They increase the risk for falls and confusion
D. They improve balance
What is increased risk for falls and confusion?
Sedative-hypnotics are used cautiously in older adults because age-related changes make them more sensitive, increasing the risk of falls, confusion, and respiratory depression.
Which factor is considered a modifiable health risk that a nurse can address through education and lifestyle changes?
A. Age
B. Family history of heart disease
C. Cigarette smoking
D. Genetic predisposition
What is cigarette smoking?
Modifiable health risks are factors that can be changed or controlled through lifestyle modifications, education, or interventions. Smoking is a major modifiable risk factor linked to cardiovascular disease, cancer, and respiratory illness. Age, genetics, and family history are nonmodifiable.
An 85-year-old client is hospitalized for pneumonia. The nurse notes the client has muscle weakness, poor vision, and a history of urinary urgency at night.
Which intervention is the most important to prevent falls for this client?
A. Encourage the client to walk independently at night
B. Keep the client’s bed in the lowest position and place a night-light in the room
C. Place the call light out of reach to encourage the client to get up
D. Avoid using assistive devices to promote independenceB, What is keeping the bed in the lowest position and placing a night-light in the room?
B. What is keeping the bed in the lowest position and placing a night-light in the room?
Lowest bed position reduces the distance a client could fall, minimizing injury if they attempt to get up unassisted.
A nurse assesses a client and identifies airway obstruction. What is the next step in the nursing process?
A. Evaluation
B. Diagnosis
C. Implementation
D. Documentation
What is implementation?
Once a life-threatening problem is identified, the nurse must act immediately—implementation comes before completing other steps.
A nurse notices that a client is hesitant to undergo a procedure after receiving conflicting information from the healthcare team. The nurse provides clarification, supports the client’s questions, and ensures the client’s preferences are respected.
This professional action is an example of:
A. Confidentiality
B. Advocacy
C. Whistleblowing
D. Veracity
What is Advocacy?
Advocacy involves supporting and promoting the client’s rights, choices, and best interests.
protect autonomy