1Question
The nurse is prioritizing care for a group of older adult patients experiencing acute changes in mental status. Which patients require immediate intervention?
Select all that apply.
- A patient with acute agitation and a new unequal pupil size
- A patient with acute confusion and respiratory rate of 30/min
- A patient with new-onset lethargy after a dose of insulin
- A patient with acute confusion who is cooperative and voiding
- A patient with mild disorientation and stable vital signs
Show the answers and explanation
Answers: A, B and C.
- A – A patient with acute agitation and a new unequal pupil size
- B – A patient with acute confusion and respiratory rate of 30/min
- C – A patient with new-onset lethargy after a dose of insulin
The nurse prioritizes patients using the ABCs and identifying life-threatening physiological instability. Lethargy after insulin suggests severe hypoglycemia, tachypnea indicates potential sepsis or hypoxia, and an unequal pupil size points to an acute neurological emergency like increased intracranial pressure. These three patients require immediate assessment and intervention to prevent irreversible injury or death.
Why the others are wrong
- D – A cooperative, hemodynamically stable patient with suspected urinary tract infection is a lower priority than those with unstable vital signs or neurological deficits.
- E – Mild disorientation with stable vital signs represents a lower priority compared to patients with active respiratory, metabolic, or neurological emergencies.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
2Question
A home health nurse suspects that an older adult client is experiencing self-neglect and physical abuse by a caregiver. Which actions by the nurse align with legal and ethical responsibilities?
Select all that apply.
- Delay reporting until absolute proof is obtained.
- Confront the suspected family caregiver immediately.
- Report suspicions to Adult Protective Services immediately.
- Document objective physical findings and client quotes.
- Assess the client's cognitive and functional status.
Show the answers and explanation
Answers: C, D and E.
- C – Report suspicions to Adult Protective Services immediately.
- D – Document objective physical findings and client quotes.
- E – Assess the client's cognitive and functional status.
Nurses are legally mandated reporters who must immediately report any suspected elder abuse or self-neglect to Adult Protective Services without waiting for proof. Accurate, objective documentation of findings and quotes is essential for legal evidence. Assessing cognitive and functional status helps determine the client's vulnerability and capacity to care for themselves safely.
Why the others are wrong
- A – Nurses must report suspected abuse immediately and are not required or permitted to delay reporting to gather absolute proof.
- B – Confronting a suspected abuser can compromise the client's safety and jeopardize the subsequent professional investigation by protective services.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
3Question
An older adult with advanced dementia and no advance directive requires an urgent, non-emergent medical procedure. Which actions should the nurse take to advocate for the patient's decision-making process?
Select all that apply.
- Identify state-specific family hierarchy laws for surrogacy.
- Appoint the patient's closest friend as the default surrogate.
- Consult the facility's ethics committee for guidance.
- Ask the primary provider to sign as the surrogate.
- Assess the patient's capacity to participate in decisions.
Show the answers and explanation
Answers: A, C and E.
- A – Identify state-specific family hierarchy laws for surrogacy.
- C – Consult the facility's ethics committee for guidance.
- E – Assess the patient's capacity to participate in decisions.
To advocate for a cognitively impaired patient without an advance directive, the nurse must first ensure capacity is assessed for the specific decision. If the patient lacks capacity, the nurse must identify the legally recognized surrogate using state-specific family hierarchy laws. Consulting the ethics committee is appropriate if no surrogate is available or if conflicts arise.
Why the others are wrong
- B – The nurse cannot legally appoint a friend as a surrogate, as state laws dictate the specific hierarchy of decision-makers.
- D – The primary care provider cannot act as the patient's surrogate decision-maker due to a conflict of interest.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
4Question
A geriatric patient post-hip fracture repair is transitioning from an acute care hospital to a skilled nursing facility. Which discharge planning actions should the nurse perform?
Select all that apply.
- Providing a verbal handoff to the receiving facility nurse.
- Instructing family to bring home medications to the facility.
- Arranging immediate home health nursing visits.
- Confirming a completed medication reconciliation is sent.
- Sending physical therapy progress notes to the facility.
Show the answers and explanation
Answers: A, D and E.
- A – Providing a verbal handoff to the receiving facility nurse.
- D – Confirming a completed medication reconciliation is sent.
- E – Sending physical therapy progress notes to the facility.
Safe care transitions require comprehensive communication and documentation. Confirming medication reconciliation, providing a verbal handoff to the receiving nurse, and sending physical therapy progress notes ensure continuity of care, prevent medication errors, and facilitate appropriate rehabilitation planning at the skilled nursing facility.
Why the others are wrong
- B – Patients in skilled nursing facilities receive medications from the facility pharmacy; bringing home medications poses a significant safety and administration risk.
- C – Home health nursing is inappropriate because the patient is transitioning to an inpatient skilled nursing facility, not returning directly to their home.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
5Question
A nurse is preparing a 78-year-old client with moderate dementia for an elective herniorrhaphy. Which actions should the nurse perform when managing the informed consent process?
Select all that apply.
- Use simplified language and visual aids during teaching.
- Delay the elective surgery until the dementia resolves.
- Verify that the surgeon explained the risks and benefits.
- Assess the client's capacity to understand the decision.
- Obtain consent from the surrogate without assessing client.
Show the answers and explanation
Answers: A, C and D.
- A – Use simplified language and visual aids during teaching.
- C – Verify that the surgeon explained the risks and benefits.
- D – Assess the client's capacity to understand the decision.
Nurses must assess the client's decision-making capacity, as cognitive decline does not automatically invalidate consent. The nurse verifies that the provider explained the procedure's risks and benefits, and uses supportive communication strategies, such as simplified language and visual aids, to facilitate the client's understanding and participation in their care.
Why the others are wrong
- B – Dementia is a progressive, irreversible neurocognitive disorder, making it impossible to delay the procedure until the condition resolves.
- E – Dementia does not automatically render a client incapable of consent, so the client must be assessed before deferring to a surrogate.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
6Question
A nurse is coordinating care for an 82-year-old patient with NYHA Class IV heart failure. Which actions should the nurse take to facilitate palliative care and end-of-life decision-making?
Select all that apply.
- Assess the patient's understanding of their prognosis.
- Postpone end-of-life discussions until hospice is active.
- Initiate a referral for a palliative care consultation.
- Clarify the role of a designated healthcare proxy.
- Instruct the patient to stop all heart failure medications.
Show the answers and explanation
Answers: A, C and D.
- A – Assess the patient's understanding of their prognosis.
- C – Initiate a referral for a palliative care consultation.
- D – Clarify the role of a designated healthcare proxy.
The nurse coordinates care by assessing the patient's understanding of their illness, clarifying surrogate decision-making roles, and initiating a palliative care referral. Palliative care can be introduced at any stage of a serious illness to improve quality of life and align treatment with the patient's goals, regardless of ongoing active management.
Why the others are wrong
- B – End-of-life and advance care planning discussions should occur early in the disease trajectory, well before hospice care is initiated.
- E – Palliative care allows patients to continue disease-modifying medications, such as diuretics, to manage symptoms and maintain comfort.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
7Question
An RN is caring for a frail, hospitalized geriatric patient who is at high risk for falls. Which tasks can the RN safely delegate to the licensed practical/vocational nurse (LPN/LVN)?
Select all that apply.
- Setting up the bed alarm and applying non-slip socks.
- Developing the patient's individualized mobility plan.
- Completing the initial admission fall risk assessment.
- Assisting the patient with a scheduled mechanical transfer.
- Reinforcing transfer safety education previously taught.
Show the answers and explanation
Answers: A, D and E.
- A – Setting up the bed alarm and applying non-slip socks.
- D – Assisting the patient with a scheduled mechanical transfer.
- E – Reinforcing transfer safety education previously taught.
The RN can delegate tasks to the LPN/LVN that involve reinforcing previously taught education, assisting with routine transfers, and implementing standard safety interventions like bed alarms and non-slip footwear. These tasks fall within the LPN/LVN scope of practice for stable patients.
Why the others are wrong
- B – Developing and formulating the individualized nursing plan of care is an RN responsibility that cannot be delegated.
- C – The RN must perform all initial assessments, including the baseline fall risk assessment, to establish the patient's safety needs.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
8Question
An 82-year-old client with end-stage heart failure wishes to refuse further life-prolonging treatments. Which actions should the nurse take to advocate for and manage this client's care?
Select all that apply.
- Discontinue all routine nursing care and assessments.
- Obtain consent from the next of kin to validate the choice.
- Advocate for the client's choice during team rounds.
- Assess the client's cognitive decision-making capacity.
- Ensure the advance directive is in the medical record.
Show the answers and explanation
Answers: C, D and E.
- C – Advocate for the client's choice during team rounds.
- D – Assess the client's cognitive decision-making capacity.
- E – Ensure the advance directive is in the medical record.
Nurses must advocate for client autonomy by verifying decision-making capacity, ensuring legal documents like advance directives are accessible, and representing the client's wishes to the interprofessional team.
Why the others are wrong
- A – Refusing life-prolonging treatment does not mean refusing all care; comfort measures, hygiene, and pain management must continue.
- B – Competent adult clients have the legal right to make their own medical decisions without requiring family consent or validation.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
9Question
A nurse is performing medication reconciliation for an 82-year-old client transitioning from the hospital to home. Which actions should the nurse take to prevent polypharmacy-related adverse events?
Select all that apply.
- Screen the final list against the AGS Beers Criteria.
- Identify and flag any duplicate therapeutic classes.
- Compare the discharge list with pre-admission medications.
- Remove all PRN medications from the discharge list.
- Instruct the client to stop all over-the-counter drugs.
Show the answers and explanation
Answers: A, B and C.
- A – Screen the final list against the AGS Beers Criteria.
- B – Identify and flag any duplicate therapeutic classes.
- C – Compare the discharge list with pre-admission medications.
Medication reconciliation requires comparing pre-admission and discharge medications to detect discrepancies. Identifying therapeutic duplications and screening against the AGS Beers Criteria for potentially inappropriate medications in older adults are critical steps to prevent polypharmacy and adverse drug events during care transitions.
Why the others are wrong
- D – PRN medications should be reconciled and kept if clinically indicated, not routinely removed from the discharge list.
- E – Over-the-counter medications should be reviewed and reconciled rather than abruptly stopped without clinical evaluation.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
10Question
A patient with suspected active pulmonary tuberculosis requires emergency intubation in the emergency department. Which action should the nurse prioritize to ensure safety?
- Position a portable fan to blow air toward the door.
- Move the patient to a negative-pressure room.
- Limit personal protective equipment to sterile gloves.
- Wear a standard surgical mask during the procedure.
Show the answer and explanation
Answer: B. Move the patient to a negative-pressure room.
Topic: Tuberculosis Airborne Precautions
Active pulmonary tuberculosis requires airborne precautions to prevent transmission. Moving the patient to a negative-pressure room is the priority, especially during aerosol-generating procedures like intubation, to contain infectious particles.
Why the others are wrong
- A – Fans disperse infectious droplets into surrounding areas, increasing transmission risk.
- C – Intubation requires full airborne PPE, including an N95 respirator, not just gloves.
- D – Standard surgical masks do not filter airborne TB bacilli; an N95 respirator is required.
Remember: TB in the air? Negative pressure is the first care.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
11Question
During the emergency insertion of a central venous catheter for a patient in septic shock, the nurse observes the physician's sterile glove touch the non-sterile bedside table. Which action should the nurse take first?
- Document the breach and monitor the site for infection.
- Assist with completing the insertion to avoid delay.
- Clean the contaminated glove with chlorhexidine wipes.
- Immediately inform the physician and provide a new glove.
Show the answer and explanation
Answer: D. Immediately inform the physician and provide a new glove.
Topic: Sterile Technique Breach
Maintaining strict asepsis during central venous catheter insertion is critical to prevent bloodstream infections. The nurse must immediately advocate for patient safety by pointing out the sterile breach and providing a replacement sterile glove.
Why the others are wrong
- A – Monitoring does not prevent infection; the active breach must be corrected immediately.
- B – Completing the insertion with contaminated gloves risks a life-threatening bloodstream infection.
- C – Chlorhexidine wipes cannot reliably re-sterilize a contaminated glove.
Remember: See a sterile breach, speak up and replace.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
12Question
A nurse is caring for a mechanically ventilated patient receiving continuous enteral feedings. Which action should the nurse prioritize to prevent ventilator-associated pneumonia?
- Elevate the head of the bed to 30 to 45 degrees
- Perform deep tracheal suctioning every two hours
- Change the ventilator circuit tubing every 24 hours
- Instill sterile saline before endotracheal suctioning
Show the answer and explanation
Answer: A. Elevate the head of the bed to 30 to 45 degrees
Topic: Ventilator-Associated Pneumonia Prevention
Elevating the head of the bed to 30 to 45 degrees is the priority intervention to prevent aspiration of gastric contents and enteral formula, which significantly reduces the risk of ventilator-associated pneumonia.
Why the others are wrong
- B – Suctioning should be performed only when clinically indicated, not on a routine schedule.
- C – Routine daily circuit changes increase infection risk; change only when soiled or malfunctioning.
- D – Saline instillation dislodges bacteria into the lower airway, increasing pneumonia risk.
Remember: Keep the head high (30 to 45 degrees) to keep the lungs dry.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
13Question
A 45‑year‑old man with cough and night sweats is brought to the ED for emergency intubation due to respiratory failure. Tuberculosis is suspected. Which actions are appropriate for transmission‑based precautions and PPE during the intubation?
Select all that apply.
- N95 respirator and face shield for all staff.
- Use a closed suction system with an inline viral filter.
- Move patient to negative‑pressure room before intubation.
- Place a surgical mask on the patient during intubation.
- Perform hand hygiene immediately after doffing PPE.
Show the answers and explanation
Answers: A, B, C and E.
- A – N95 respirator and face shield for all staff.
- B – Use a closed suction system with an inline viral filter.
- C – Move patient to negative‑pressure room before intubation.
- E – Perform hand hygiene immediately after doffing PPE.
Staff must wear an N95 respirator and face shield for airborne protection; the patient should be moved to a negative‑pressure isolation room before the aerosol‑generating procedure; a closed suction system with an inline viral filter reduces aerosol spread; hand hygiene after doffing PPE prevents contamination.
Why the others are wrong
- D – A surgical mask does not provide adequate protection during an aerosol‑generating procedure like intubation.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
14Question
A nurse is preparing the bedside for a client undergoing rapid sequence intubation (RSI) in the emergency department. Which actions should the nurse take to prevent bloodborne pathogen exposure and needlestick injuries?
Select all that apply.
- Recap the induction drug needles using a two-handed technique.
- Dispose of the contaminated stylet in a bedside sharps box.
- Activate safety devices on syringes immediately after use.
- Hand unsheathed needles directly to the provider.
- Wear a fluid-resistant gown, mask, and eye protection.
Show the answers and explanation
Answers: B, C and E.
- B – Dispose of the contaminated stylet in a bedside sharps box.
- C – Activate safety devices on syringes immediately after use.
- E – Wear a fluid-resistant gown, mask, and eye protection.
Standard precautions during high-risk airway procedures like rapid sequence intubation require full personal protective equipment to prevent splash exposure. To prevent needlesticks, safety devices must be activated immediately after use, and all sharps, including stylets, must be disposed of in a puncture-resistant container at the point of use.
Why the others are wrong
- A – Recapping needles using a two-handed technique is a major cause of accidental needlesticks and is strictly prohibited by safety guidelines.
- D – Passing unsheathed needles or sharp instruments hand-to-hand increases the risk of accidental injury and should be avoided.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
15Question
A nurse in the intensive care unit is preparing to perform emergency synchronized cardioversion on an unstable patient. Which actions by the nurse ensure staff safety during the procedure?
Select all that apply.
- Visually confirm that no staff are touching the bed.
- Verbally state "clear" before delivering the shock.
- Move the oxygen source away from the patient's chest.
- Apply conductive gel directly to hands-free pads.
- Hold the hands-free pads in place during the shock.
Show the answers and explanation
Answers: A, B and C.
- A – Visually confirm that no staff are touching the bed.
- B – Verbally state "clear" before delivering the shock.
- C – Move the oxygen source away from the patient's chest.
To ensure staff safety during cardioversion or defibrillation, the nurse must visually confirm that no one is touching the patient, bed, or connected equipment. Verbally warning the team and moving oxygen sources away from the chest prevents electrical transfer and fire hazards.
Why the others are wrong
- D – Hands-free pads are pre-gelled and self-adhesive; adding extra gel can cause electrical arcing and skin burns.
- E – Hands-free pads must never be touched during shock delivery to prevent accidental shock to the nurse.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
16Question
A nurse is preparing to transition a critically ill patient with severe ARDS into the prone position. Which actions should the nurse take to prevent accidental extubation and pressure injuries?
Select all that apply.
- Assign a clinician to solely secure the airway at the head.
- Apply prophylactic foam dressings to the forehead and chin.
- Relocate electrocardiogram electrodes to the patient's back.
- Pull the endotracheal tube taut to eliminate circuit slack.
- Maintain the head in a fixed, hyperextended position.
Show the answers and explanation
Answers: A, B and C.
- A – Assign a clinician to solely secure the airway at the head.
- B – Apply prophylactic foam dressings to the forehead and chin.
- C – Relocate electrocardiogram electrodes to the patient's back.
Safe prone positioning requires a dedicated clinician to secure the airway during the turn. Placing prophylactic foam dressings on facial pressure points and moving electrocardiogram electrodes to the back prevents device-related pressure injuries. Circuits must have adequate slack, and the head must be repositioned regularly to prevent skin breakdown and musculoskeletal injury.
Why the others are wrong
- D – Ventilator circuits must have sufficient slack rather than being taut to prevent tension and accidental extubation during the turn.
- E – The head should be repositioned every 2 hours in a neutral or lateral position, avoiding hyperextension to prevent injury.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
17Question
A patient presents to the emergency department triage desk with a high fever, severe headache, photophobia, and a petechial rash. Which immediate infection control actions should the triage nurse initiate?
Select all that apply.
- Place a surgical mask on the patient immediately.
- Don a surgical mask before caring for the patient.
- Escort the patient to a negative-pressure room.
- Wear an N95 respirator during close contact.
- Assign the patient to a private room.
Show the answers and explanation
Answers: A, B and E.
- A – Place a surgical mask on the patient immediately.
- B – Don a surgical mask before caring for the patient.
- E – Assign the patient to a private room.
Suspected meningococcal meningitis requires droplet precautions. Immediate actions include placing a surgical mask on the patient for source control, isolating the patient in a private room, and having healthcare providers wear a surgical mask when entering the room or providing care.
Why the others are wrong
- C – Negative-pressure isolation rooms are indicated for airborne pathogens, such as tuberculosis, rather than droplet-transmitted pathogens like Neisseria meningitidis.
- D – An N95 respirator is required for airborne precautions, whereas a standard surgical mask is sufficient for droplet precautions.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
18Question
A nurse is assisting a provider with an emergency bedside chest tube insertion for a patient with a tension pneumothorax. Which actions should the nurse perform to maintain surgical asepsis and prevent infection?
Select all that apply.
- Wear a mask, cap, sterile gown, and sterile gloves.
- Shave the insertion site with a razor before draping.
- Apply topical bacitracin ointment around the tube site.
- Prep the insertion site with chlorhexidine-alcohol.
- Apply a large sterile drape over the insertion site.
Show the answers and explanation
Answers: A, D and E.
- A – Wear a mask, cap, sterile gown, and sterile gloves.
- D – Prep the insertion site with chlorhexidine-alcohol.
- E – Apply a large sterile drape over the insertion site.
To prevent pleural space infections during chest tube insertion, maximal sterile barrier precautions must be maintained. This includes preparing the skin with chlorhexidine-alcohol, wearing full sterile personal protective equipment, and draping the patient with a large sterile drape to establish a proper sterile field.
Why the others are wrong
- B – Shaving with a razor creates micro-abrasions that increase infection risk; clippers should be used if hair removal is necessary.
- C – Topical antibiotic ointments are not recommended for chest tube sites because they do not prevent infection and can promote fungal growth.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
19Question
An emergency department nurse is preparing to initiate a temporary peripheral norepinephrine infusion for a patient in septic shock. Which safety interventions should the nurse implement?
Select all that apply.
- Apply a tight pressure dressing over the insertion site.
- Select a large vein proximal to the wrist or hand.
- Assess the site for blood return and patency hourly.
- Administer the infusion using an electronic infusion pump.
- Insert the catheter into a dorsal hand vein.
Show the answers and explanation
Answers: B, C and D.
- B – Select a large vein proximal to the wrist or hand.
- C – Assess the site for blood return and patency hourly.
- D – Administer the infusion using an electronic infusion pump.
Vasoactive infusions administered peripherally require strict safety measures to prevent extravasation. The nurse must use an electronic infusion pump to ensure precise dosing, select a large vein proximal to the hand or wrist to reduce extravasation risk, and assess the site hourly for patency and blood return to detect early signs of infiltration.
Why the others are wrong
- A – Tight pressure dressings can obscure direct visualization of the insertion site and increase localized pressure, potentially promoting extravasation.
- E – Dorsal hand veins should be avoided for vasoactive infusions due to the high risk of extravasation and subsequent localized tissue necrosis.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
20Question
A multi-trauma patient in the resuscitation bay requires emergency urinary catheterization. Which action by the nurse best maintains infection control and sterile technique during this urgent procedure?
- Obtain a new sterile kit if contamination occurs.
- Cleanse the perineal area using a back-to-front motion.
- Use clean utility gloves to expedite the insertion.
- Pre-test the balloon by inflating it prior to insertion.
Show the answer and explanation
Answer: A. Obtain a new sterile kit if contamination occurs.
Topic: Urinary Catheter Sterile Technique
Strict sterile technique is vital to prevent catheter-associated urinary tract infections. If any contamination of the sterile field or equipment occurs, the nurse must immediately discard the contaminated items and obtain a new sterile kit.
Why the others are wrong
- B – Cleansing must be front-to-back to prevent introducing rectal bacteria into the urethra.
- C – Sterile gloves, not clean utility gloves, are required to maintain asepsis during insertion.
- D – Pre-testing the balloon is no longer recommended as it can damage the catheter.
Remember: Contaminated kit? Start fresh to prevent CAUTI.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
21Question
During a code blue, a nurse sustains a high‑risk needle stick from an unknown source. What is the nurse’s first action to reduce infection risk?
- Apply a sterile dressing and wait for lab results.
- Wash the puncture site with soap and water immediately.
- Start antiretroviral therapy without reporting.
- Continue caring for the patient and document later.
Show the answer and explanation
Answer: B. Wash the puncture site with soap and water immediately.
Topic: Needle Stick Protocol
Immediately washing the puncture site with soap and water is the critical first step after a needle stick. This physical decontamination helps flush out pathogens and significantly reduces the risk of bloodborne pathogen transmission before seeking medical evaluation.
Why the others are wrong
- A – Delays essential immediate decontamination and increases the risk of pathogen absorption.
- C – Requires formal medical evaluation, prescription, and mandatory occupational exposure reporting.
- D – Prioritizes non-urgent tasks over immediate self-care, increasing infection risk.
Remember: Wash first, report second, treat third.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
22Question
A nurse sustains a high-risk needlestick injury while administering emergency medications during a cardiac arrest. Which immediate actions and post-exposure prophylaxis (PEP) protocols should the nurse follow?
Select all that apply.
- Wash the needle stick site immediately with soap and water.
- Forcefully squeeze the wound to express blood.
- Apply concentrated bleach to disinfect the wound.
- Report the exposure to secure a safe handoff of care.
- Initiate PEP medications within 72 hours of exposure.
Show the answers and explanation
Answers: A, D and E.
- A – Wash the needle stick site immediately with soap and water.
- D – Report the exposure to secure a safe handoff of care.
- E – Initiate PEP medications within 72 hours of exposure.
Immediate first aid for a needlestick injury requires washing the area with soap and water. In an emergency code blue, the nurse must report the exposure to secure a safe handoff of care. Post-exposure prophylaxis must be initiated within 72 hours of the exposure to be effective in preventing viral replication.
Why the others are wrong
- B – Squeezing or milking the wound is not recommended because it can cause tissue trauma and potentially promote pathogen entry.
- C – Applying caustic agents like bleach is contraindicated because it damages tissue and does not reduce transmission risk.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
23Question
The nurse is triaging victims from a building collapse using the START system. Which clients should the nurse categorize as Red (Immediate)?
Select all that apply.
- A client with a femur fracture who obeys simple commands
- An apneic client who remains apneic after airway opening
- An apneic client who begins breathing after airway opening
- A client with respirations of 32/min and a weak pulse
- A client with a radial pulse who cannot follow commands
Show the answers and explanation
Answers: C, D and E.
- C – An apneic client who begins breathing after airway opening
- D – A client with respirations of 32/min and a weak pulse
- E – A client with a radial pulse who cannot follow commands
Under the START triage system, clients categorized as Red (Immediate) require urgent life-saving care. This includes clients who begin breathing only after manual airway opening, those with a respiratory rate greater than 30 breaths per minute, and those who have adequate perfusion but are unable to follow simple commands.
Why the others are wrong
- A – This client is categorized as Yellow (Delayed) because they can follow simple commands and do not have immediate life-threatening airway or perfusion compromise.
- B – This client is categorized as Black (Deceased/Expectant) because they remain apneic even after simple airway alignment maneuvers.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
24Question
An intensive care unit patient with a severe traumatic brain injury meets clinical criteria for brain death. Which action should the nurse take first?
- Discuss organ donation options with the family.
- Contact the organ procurement organization.
- Discontinue the mechanical ventilator.
- Obtain written consent from the next of kin.
Show the answer and explanation
Answer: B. Contact the organ procurement organization.
Topic: Brain Death and Organ Donation
Federal regulations require the nurse to notify the organ procurement organization (OPO) immediately when a patient meets brain death criteria. The OPO must evaluate eligibility before any discussion about donation occurs with the family.
Why the others are wrong
- A – Approaching the family about donation is the role of trained OPO staff, not the nurse.
- C – Ventilatory support must be maintained to preserve organ perfusion until donation decisions are finalized.
- D – The OPO representative, not the nurse, obtains written consent from the next of kin.
Remember: Call the OPO first; let them handle the family and consent.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
25Question
An unconscious, unaccompanied trauma patient with severe internal bleeding requires immediate emergency surgery. No family members are present. Which action should the nurse take regarding informed consent?
- Request a court order to proceed with the procedure.
- Delay the surgery until a family member is located.
- Prepare the patient for surgery under implied consent.
- Obtain consent from the on-duty hospital administrator.
Show the answer and explanation
Answer: C. Prepare the patient for surgery under implied consent.
Topic: Emergency Implied Consent
In a life-threatening emergency involving an unconscious patient with no available family, consent is legally implied to prevent death or serious harm. The nurse must prioritize immediate life-saving interventions and prepare the patient for surgery.
Why the others are wrong
- A – Seeking a court order causes dangerous delays in a life-threatening emergency.
- B – Delaying emergency surgery to locate family threatens the patient's survival.
- D – Administrators do not grant consent; the emergency itself legally establishes implied consent.
Remember: Life-threatening emergency + unconscious patient = implied consent.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
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