Safe and Effective Care Environment

Question 1

A nurse is receiving a client from the emergency department who has a history of MRSA. Which transmission-based precaution is required?

Accepted Answer

Contact precautions with gloves and gown for all client contact

Answer

MRSA (methicillin-resistant Staphylococcus aureus) is transmitted by direct and indirect contact with infected surfaces, wounds, and skin. Contact precautions — including gloves and gown worn upon entry to the room — are required. Airborne and droplet precautions are used for respiratory pathogens.

Question 2

A nurse discovers a fire in a client's room. Using the RACE protocol, which action should be taken first?

Accepted Answer

Rescue clients in immediate danger by moving them away from the fire

Answer

The RACE acronym stands for Rescue, Alarm, Confine, Extinguish. Rescue (moving clients in immediate danger) is always the first priority. After all persons are safe, the alarm is activated, the fire is confined by closing doors, and extinguishment is attempted only if the fire is small and the exit is clear.

Question 3

A nurse is administering medications using the rights of medication administration. A client's medication administration record lists 'metoprolol 50 mg PO daily.' The pill available is labeled 'metoprolol succinate 100 mg.' The nurse should:

Accepted Answer

Clarify the order with the pharmacist before administering, as the tablet may be extended-release

Answer

Metoprolol succinate is an extended-release formulation that must never be split, crushed, or chewed, as this releases the entire dose at once. The nurse must clarify with pharmacy whether a non-scored tablet can be halved and confirm the correct formulation was dispensed before proceeding.

Question 4

A nurse is caring for a client who is confused and has been attempting to get out of bed unassisted. The call light is within reach and a bed alarm is in place. The family asks why the nurse is not using a restraint. The nurse explains that physical restraints:

Accepted Answer

Can increase agitation, cause injury, and worsen confusion without improving safety

Answer

Evidence shows that physical restraints do not prevent falls and can cause significant harm, including skin breakdown, aspiration, worsened agitation, and psychological trauma. They are a last resort after all alternatives have been tried. The Joint Commission discourages their use as a routine fall prevention measure.

Question 5

A nurse is preparing to administer a high-alert medication. Which safety strategy is most important before administration?

Accepted Answer

Perform an independent double-check with a second nurse to verify drug, dose, route, and rate

Answer

High-alert medications (such as insulin, heparin, concentrated electrolytes, and chemotherapy) have a high risk of causing significant patient harm if used in error. An independent double-check by a second nurse is a mandatory safety process to verify all critical parameters before administration.

NCLEX Practice Test

NCLEX Practice Test

Safe and Effective Care Environment