si em ayeeee Flashcards
(123 cards)
1
Q
A nurse case manager is coordinating care for a client.History and physical:
Client has terminal lung cancer and is not expected to live more than 6 months.
Select the 3 community resources the nurse should refer the client
A. Hospice care
B. Legal assistance
C. Respite care
D. Adult day care
E. Social worker
A
A. Hospice care
C. Respite care
E. Social worker
2
Q
A nurse suggests respite care for the partner of a client who has mild cognitive impairment.
The client’s partner asks the nurse how that would help. The nurse should explain that respite care would do which of the following?
A. Help her arrange transferring her partner to an assisted living facility.
B. Provide volunteers who will run errands for her.
C. Allow her to take time off from attending to her partner.
D. Send a clinician to assess the safety of leaving her partner alone.
A
C. Allow her to take time off from attending to her partner.
3
Q
A nurse is teaching a newly licensed nurse about telephone prescriptions. Which of the following information should the nurse include?
A. Verify the spelling of the medication with the provider.
B. Transcribe prescriptions received via a voicemail recording.
C. Use standard abbreviations when obtaining a telephone prescription.
D. Request that the provider call prescriptions in to the pharmacy.
A
A. Verify the spelling of the medication with the provider.
4
Q
A charge nurse notices that two staff nurses are not taking meal breaks during their shifts.
Which of the following actions should the nurse take first?
A. Review facility policies for taking scheduled breaks.
B. Discuss time management strategies with the nurses.
C. Determine the reasons the nurses are not taking scheduled breaks.
D. Provide coverage for the nurses’ breaks.
A
C. Determine the reasons the nurses are not taking scheduled breaks.
5
Q
A nurse is assessing a client’s comprehension of a pulmonary function test prior to the procedure. Which of the following client statements indicates to the nurse an understanding of the procedure?
A. “I will be given contrast dye during this test.”
B. “I will run on a treadmill during this test.”
C. “I might have a tube inserted into my airway during this test.”
D. “I might have to wear a nose clip during this test.”
A
D. “I might have to wear a nose clip during this test.”
6
Q
A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following clients should the nurse assign to the newly licensed nurse?
A. A client who sustained a concussion and is being monitored for complications
B. A client who has Guillain-Barré syndrome and a tracheostomy
C. A client who has multiple sclerosis and ataxia
D. A client who has a brain tumor and is admitted for chemotherapy
A
A. A client who sustained a concussion and is being monitored for complications
7
Q
A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which of the following statements demonstrate understanding of the procedure?
A. “HIPAA allows clients to request a review of their own medical records.”
B. “Clients who participate in research studies forfeit their HIPAA right to privacy.”
C. “HIPAA prohibits the uploading of photographs of client’s providers to social media sites.”
D. “HIPAA allows facility-specific coding of client health care information to ensure privacy.”
A
A. “HIPAA allows clients to request a review of their own medical records.”
8
Q
A nurse is teaching a newly licensed nurse about the role of nurses during a facility disaster. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “A nurse can recommend clients who are stable for discharge during a disaster.”
B. “A unit nurse has the authority to prescribe emergency medications during a disaster.”
C. “A nurse should communicate with the performance improvement committee during a disaster to improve client outcomes.”
D. “A unit nurse can provide information to the media during a disaster.”
A
A. “A nurse can recommend clients who are stable for discharge during a disaster.”
9
Q
A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A. A client who has active bleeding from a puncture wound of the left groin area
B. A client who has a raised red skin rash on his arms, neck, and face
C. A client who reports right-sided flank pain and is diaphoretic
D. A client who reports shortness of breath and left neck and shoulder pain
A
D. A client who reports shortness of breath and left neck and shoulder pain
10
Q
A nurse is planning discharge for a client who had a lung resection. The nurse initiates a referral for a social worker. Which of the following assessment data supports this referral?
A. The client needs to have someone come in to help her bathe at home.
B. The client needs to have someone bring oxygen tanks and equipment to her home.
C. The client needs to have range-of-motion exercises to assist with ambulation.
D. The client needs to arrange financial resources to purchase equipment.
A
D. The client needs to arrange financial resources to purchase equipment.
11
Q
A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
A. Notify risk management before initiating treatment.
B. Contact the client’s next of kin to obtain consent for treatment.
C. Proceed with treatment without obtaining written consent.
D. Have the client sign a consent for treatment.
A
C. Proceed with treatment without obtaining written consent.
12
Q
A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full-thickness burns on 72% of his body?
A. Black
B. Yellow
C. Red
D. Green
A
A. Black
13
Q
A nurse on a medical surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
A. Reinforcing dietary teaching with a client who has heart disease
B. Providing postmortem care for a client who has just died
C. Accompanying a client who just had a wound debridement to physical therapy
D. Obtaining a urine specimen from an older adult client
A
A. Reinforcing dietary teaching with a client who has heart disease
14
Q
A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?
A. The client’s preferred time for bathing
B. The time the client received his last dose of pain medication
C. The belief that the client has a difficult relationship with his son
D. The steps to follow when providing wound care
A
B. The time the client received his last dose of pain medication
15
Q
A nurse on an acute mental health unit is assessing four clients. Which of the following clients is the highest priority?
A. A client who has dementia and exhibits aphasia
B. A client who has bipolar disorder and displays constant pacing
C. A client who has schizophrenia and uses neologisms
D. A client who has depressive disorder and has poor personal hygiene
A
B. A client who has bipolar disorder and displays constant pacing
16
Q
A nurse is updating a postoperative client’s plan of care. The nurse should include which of the following as the priority interventions?
A. Reposition the client frequently.
B. Instruct the client to use the incentive spirometer.
C. Increase the amount of time the client spends out of bed each day.
D. Ensure the client consumes an adequate amount of fluids.
A
B. Instruct the client to use the incentive spirometer.
17
Q
A charge nurse observes a client fall while ambulating with an assistive personnel and notes that the client’s gait belt was not in place. When reviewing the incident report, the charge nurse finds that the report does not mention the gait belt. Which of the following ethical principles should the charge nurse follow?
A. Nonmaleficence
B. Fidelity
C. Veracity
D. Beneficence
A
C. Veracity
18
Q
A nurse is preparing to fax information to a rehabilitative facility prior to transferring a client.
Which of the following actions should the nurse plan to take?
A. Send the facility a copy of the client’s complete medical record.
B. Avoid using a fax cover sheet in order to reduce paper waste.
C. Call the facility to confirm the fax number after sending the client’s information.
D. Shred extra copies of the client’s records when they are no longer needed.
A
D. Shred extra copies of the client’s records when they are no longer needed.
19
Q
A charge nurse is assessing the room of a newly admitted client who has dysphagia. Which of the following pieces of equipment should the nurse ensure is available in the client’s room?
A. Bite block
B. Yankauer suction device
C. Large-handled utensils
D. Nasal cannula and oxygen
A
B. Yankauer suction device
20
Q
A nurse working on a medical-surgical unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
A. A client who is receiving heparin and has an aPTT of 34 seconds
B. A client who has orthostatic hypotension and is receiving IV fluids
C. A client who has Type 1 diabetes and uses an insulin pump
D. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
A
D. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
21
Q
A charge nurse is evaluating a newly licensed nurse and presents a performance improvement plan to the nurse for remediation. Which of the following outcomes should indicate to the charge nurse that the plan has been effective?
A. The nurse shares their performance plan with another nurse.
B. The nurse attends a critical thinking class.
C. The nurse verbalizes their understanding of the plan.
D. The nurse performs all tasks as specified.
A
D. The nurse performs all tasks as specified.
22
Q
A nurse is caring for a client and notices fraying on the electrical cord of the client fall. The charge nurse should identify that which of the following nurse to take?
A. Request a replacement IV pump.
B. Remove the IV pump from the client’s room.
C. Check the expiration date of the inspection sticker.
D. Report the problem to the engineering team.
A
B. Remove the IV pump from the client’s room.
23
Q
A charge nurse is supervising the actions taken by a staff nurse following a client fall. The charge nurse should identify that which of the following actions by the staff nurse indicates an understanding of the procedure?
A. Sends the incident report to the ethics committee
B. Documents in the client’s record that an incident report was filed
C. Includes the client’s account of the fall in the incident report
D. Lists names of witnesses to the fall in the nurses’ notes
A
C. Includes the client’s account of the fall in the incident report
24
Q
A nurse is caring for a client who requests a copy of their medical records immediately.
Which of the following responses should the nurse make?
A. “You must submit a written request before you can receive a copy.”
B. “The facility is unable to release your records.”
C. “I will make a copy of your medical records right away.”
D. “What are you planning on doing with your medical record?”
A
A. “You must submit a written request before you can receive a copy.”
25
A nurse in an emergency department is triaging four clients following a mass casualty event.
To which of the clients should the nurse assign a red tag?
A. A client who has a compromised airway
B. A client who experienced a brief loss of consciousness
C. A client who has fixed pupils
D. A client who has major burns covering 70% of their body
A. A client who has a compromised airway
26
A nurse manager is reviewing the rate of medication errors on a surgical floor and finds that it is 20% above the national average. Which of the following actions should the nurse manager take?
A. Observe staff medication administration procedures.
B. Require staff to complete a medication administration review module.
C. Identify data that should be collected related to medication errors.
D. Re-evaluate staff performance in relation to the established standard.
C. Identify data that should be collected related to medication errors.
27
A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?
A. Pharmacist
B. Child protective services
C. Respiratory therapist
D. Social worker
D. Social worker
28
A nurse administrator is using benchmarking as control criteria while reviewing current policies and procedures. Which of the following actions should the nurse take?
A. Determine how current practice will affect future performance within the facility.
B. Compare practices within the facility against other high-performing facilities.
C. Establish work initiatives to promote a positive environment.
D. Use root cause analysis to identify gaps in meeting standards.
B. Compare practices within the facility against other high-performing facilities.
29
A nurse is caring for a client who has a tumor. The provider recommends surgery. The client refuses, but the client's partner wants the surgery performed. Which of the following is the deciding factor in determining if the surgery will be done?
A. Whether the facility ethics committee reaches a consensus on the case
B. Whether the client's refusal is based on religious belief
C. Whether the partner is the client's durable power of attorney for health care
D. Whether the client understands the risk of refusing the procedure
D. Whether the client understands the risk of refusing the procedure
30
A charge nurse on an obstetrical unit is preparing the shift assignment. Which of the following clients should be assigned to an RN who has floated from a medical-surgical unit?
A. A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor
B. A client who has gestational diabetes and is receiving biweekly nonstress tests
C. A client who is at 32 weeks of gestation and has premature rupture of membranes
D. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump
D. A primigravida client who is 1 day postoperative following a Cesarean section and has a PCA pump
31
A nurse is planning to develop a standard for removal of indwelling urinary catheters from clients following colon resection. Which of the following resources should the nurse use?
A. Surgical record
B. Provider's prescription
C. Critical pathway
D. Maslow's hierarchy of needs
C. Critical pathway
32
A nurse in a rehabilitation facility is administering medications to a client who was admitted earlier that day. The client refuses two of the medications, stating, "I've never taken these before." Which of the following actions should the nurse take first?
A. Consult the pharmacist about the client's prescribed medications.
B. Call the provider to clarify the client's prescribed medications.
C. Compare the client's medication administration record with the prescriptions on the transfer orders.
D. Review the intended purpose of the prescribed medications with the client.
C. Compare the client's medication administration record with the prescriptions on the transfer orders.
33
A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority?
A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
B. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (101°F)
C. A client who is postoperative following a laminectomy 12 hr ago and is unable to void
D. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy
A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
34
A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "I will remove a client's restraints every 4 hours."
B. "A provider can write a prescription for restraints 'as needed'."
C. "I need to tie the restraint to the part of the bed frame that moves."
D. "I should tie the restraints using a square knot."
A. "I will remove a client's restraints every 4 hours."
35
A charge nurse witnesses two nurses having a loud discussion at the nurses' station about not wanting to care for a client who has drug-resistant tuberculosis. Which of the following actions should the charge nurse take?
A. Make arrangements to take over the client's care.
B. Recommend that both nurses be terminated.
C. Escort the nurses to the nurses' lounge to continue the discussion.
D. Contact the house supervisor to mediate the conflict.
C. Escort the nurses to the nurses' lounge to continue the discussion.
36
A nurse is caring for a group of clients on the surgical floor. Which of the following actions should the nurse take to organize their workload and manage time efficiently?
A. Complete similar tasks for all clients before moving on to the next task.
B. Document nursing interventions as they are completed.
C. Skip breaks to complete tasks if short on time.
D. Complete the lowest priority task at the beginning of the shift.
E. None
F. None
B. Document nursing interventions as they are completed.
37
A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?
A. Instruct the AP to request assistance when unsure about a task.
B. Help the AP assist the client with the transfer.
C. Refer the AP to the facility procedure manual.
D. Demonstrate the proper client transfer technique for the AP.
B. Help the AP assist the client with the transfer.
38
A nurse is preparing to discharge a client. Which of the following information should the nurse manager include in the client's discharge documentation?
A. Do-not-resuscitate status
B. Acuity level of client care
C. Laboratory test results
D. Reconciled medication
D. Reconciled medication
39
A charge nurse provides an annual in-service for the nursing staff regarding ethical practice. Which of the following actions include as an example of ethical practice?
A. A nurse withholds nutrition from a client who has a do-not-resuscitate (DNR) order.
B. A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min.
C. A nurse elects not to care for a client who had an abortion.
D. A nurse raises all four side rails on the bed of a client who is confused.
B. A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min.
40
A nurse is attending an interprofessional team conference for a client who experienced a stroke. For which of the following findings should the team request a prescription for a referral to the occupational therapist?
A. The client has extreme difficulty swallowing.
B. The client requires assistance getting dressed.
C. The client is experiencing dysarthria.
D. The client has four new medications.
B. The client requires assistance getting dressed.
41
A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements indicates an understanding of the teaching?
A. "I will place a client who requires protective isolation in a negative airflow room."
B. "I will wear a cover gown when caring for a client who has herpes simplex."
C. "I will use an alcohol-based hand cleanser when caring for a client who has Clostridium difficile."
D. "I will wear an N95 respirator mask when caring for a client who is on contact precautions."
B. "I will wear a cover gown when caring for a client who has herpes simplex."
42
A charge nurse provides an annual in-service for the nursing staff regarding ethical practice.
Which of the following actions include as an example of ethical practice?
A. A nurse withholds nutrition from a client who has a do-not-resuscitate (DNR) order.
B. A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min.
C. A nurse elects not to care for a client who had an abortion.
D. A nurse raises all four side rails on the bed of a client who is confused.
B. A nurse administers prescribed opioids to a client who has a terminal illness and respiratory rate of 8/min.
43
A nurse is evaluating the time management skills of a newly licensed nurse. Which of the following actions by the newly licensed nurse should the nurse identify as an indication of effective time management?
A. Obtains client intake and output instead of delegating the task to an assistive personnel
B. Skips lunch to catch up on client documentation
C. Reviews a client's medical record before performing a prescribed dressing change
D. Documents medications administered throughout the shift at the end of the day
C. Reviews a client's medical record before performing a prescribed dressing change
44
A nurse is preparing a client for a cardiac catheterization. Just before the procedure, which of the following actions should the nurse take?
A. Check to see if the medical record indicates the provider explained the procedure to the client.
B. Explain the risks of the procedure to the client.
C. Convey the client's request to the nurse who witnessed the consent.
D. Notify the provider about the client's concerns.
A. Check to see if the medical record indicates the provider explained the procedure to the client.
45
A charge nurse observes a licensed practical nurse (LPN) tell a client that she will return with a medication to help relieve the client's nausea. The LPN does not return with the medication. The charge nurse should reinforce which of the following ethical principles with the LPN?
A. Nonmaleficence
B. Veracity
C. Fidelity
D. Justice
C. Fidelity
45
charge nurse is observing a newly licensed nurse change a client's wound dressing. Which of the following actions by the newly licensed nurse demonstrates an understanding of safe handling techniques?
A. The soiled dressing is placed on a nearby table.
B. Sterile supplies are opened prior to removing the old dressing.
C. Clean gloves are discarded after removing the old dressing.
D. Gauze is used to clean the wound from the outside to the center.
C. Clean gloves are discarded after removing the old dressing.
46
A nurse is teaching a client about informed consent. Which of the following information should the nurse include in the teaching?
A. The nurse is responsible for disclosing the expected outcomes of the proposed treatment.
B. Consent can be verbal or written.
C. Nurses rely on consent to perform interventions.
D. The nurse's signature indicates they witnessed the client's signature.
D. The nurse's signature indicates they witnessed the client's signature.
47
A charge nurse witnesses an assistive personnel (AP) failing to follow facility protocol when discarding contaminated linens. Which of the following actions should the nurse take first?
A. Discuss the issue with the AP.
B. Reinforce facility protocols at the next staff meeting.
C. Notify the unit manager about the incident.
D. Alert the infection control department.
A. Discuss the issue with the AP.
48
A client who is unconscious and has extensive internal injuries arrives via ambulance to the emergency unit. Which of the following permits the staff to proceed with emergency surgery?
A. Implied consent
B. Good Samaritan Act
C. Nonmaleficence
D. Living will
A. Implied consent
49
A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?
A. Offer to store the purse at the nurses' station.
B. Tell the client to leave her purse in a drawer of the bedside table.
C. Place the purse in the clothing bag with the client's other belongings.
D. Offer to place the purse in the facility safe.
D. Offer to place the purse in the facility safe.
50
While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?
A. Reinforce the potential consequences of not having this information on record to the nursing staff.
B. Ask nurses who are caring for clients without this information in the medical record to obtain it.
C. Meet with nursing staff to review the policy regarding advance directives.
D. Remind nurses to obtain this information during the admission process.
C. Meet with nursing staff to review the policy regarding advance directives.
51
A charge nurse is observing a newly licensed nurse provide care to four clients. Which of the following actions requires intervention by the charge nurse?
A. Elevates the head of the client's bed to 30° before inserting a nasogastric tube
B. Maintains the chest tube collection device below the level of the insertion site when ambulating the client
C. Assists the client into a fetal position on his side in preparation for a lumbar puncture
D. Assesses the client's gag reflex following an esophagogastroduodenoscopy
A. Elevates the head of the client's bed to 30° before inserting a nasogastric tube
52
A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses.Which of the following scenarios should the nurse include as examples of client advocacy? (Select all that apply.)
A. Implementing a client's plan of care based upon nursing goals
B. Obtaining an interpreter for a client who speaks a different language than the nurse
C. Documenting a client's refusal to take a prescribed medication
D. Initiating IV access on a client who has dementia while he is sleeping
E. Providing written information to a client-regarding palliative care
B. Obtaining an interpreter for a client who speaks a different language than the nurse
C. Documenting a client's refusal to take a prescribed medication
E. Providing written information to a client-regarding palliative care
53
A nurse in an emergency department is caring for a client following a motor-vehicle crash.
The client refuses to provide a urine sample to check for substance use. Which of the following actions should the nurse take?
A. Document the client's refusal in their chart.
B. Tell the client that their blood alcohol level will be checked.
C. Assess the client for urinary retention.
D. Inform the client that a catheter will be inserted.
A. Document the client's refusal in their chart.
54
A nurse is reviewing the medication administration record of a client and notices that a client’s condition requires intervention. Which of the following actions should the nurse take first?
A. Observe the client's condition.
B. Complete an incident report.
C. Inform the nursing supervisor.
D. Notify the provider.
D. Notify the provider.
55
A nurse is teaching a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?
A. "I need to have my attorney review my advance directives."
B. "I should choose a family member as my health care proxy."
C. "I will have a nurse witness the signing of my living will."
D. "I can make changes to my living will even after I sign it."
D. "I can make changes to my living will even after I sign it."
56
A nurse in a long-term care facility is assessing a client who has returned from an acute care facility and the client is confused and agitated. Which of the following actions should the nurse take first?
A. Measure the client's vital signs.
B. Offer reassurance to the family.
C. Reorient the client to his surroundings.
D. Medicate the client with alprazolam.
C. Reorient the client to his surroundings.
57
A nurse is observing a newly licensed nurse prepare a medication from an ampule for a client's injection. For which of the following actions by the newly licensed nurse should the nurse intervene?
A. Withdraws the medication from the ampule using a subcutaneous needle
B. Breaks the top of the ampule using an antiseptic wipe
C. Performs 3 checks of the medication before administration
D. Disposes of the ampule by placing it in a sharps container
A. Withdraws the medication from the ampule using a subcutaneous needle
58
A nurse working in an emergency department is caring for a group of clients. Which of the following clients requires intervention by the nurse?
A. An adolescent who was admitted and refuses to speak to their parents
B. A toddler who cries whenever their parent enters the examination room
C. A preschooler who was previously toilet trained and now requires diapers in the hospital
D. A school-age child who has several abrasions on their lower legs
C. A preschooler who was previously toilet trained and now requires diapers in the hospital
59
A nurse is serving on a committee whose task is to plan cost-effective care at the facility.Which of the following client care tasks should the nurse recommend?
A. Change peripheral IV primary tubing every 96 hr.
B. Replace peripheral IV solution bags every 96 hr.
C. Replace total parenteral nutrition solution bags every 48 hr.
D. Change total parenteral nutrition IV tubing every 48 hr.
A. Change peripheral IV primary tubing every 96 hr.
60
A nurse manager is discussing responsibilities of the nurse manager role with a group of newly licensed nurses. Which of the following responsibilities should the nurse include? (Select all that apply.)
A. Make decisions on the unit.
B. Monitor overall functions of the unit.
C. Delegate tasks to assistive personnel.
D. Reward and discipline staff as necessary.
E. Ensure goals of the facility are being met.
B. Monitor overall functions of the unit.
C. Delegate tasks to assistive personnel.
D. Reward and discipline staff as necessary.
E. Ensure goals of the facility are being met.
61
A nurse initiates a referral to an occupational therapist for a client with care at the facility.
Which of the following client care tasks should the nurse support the need for this referral?
A. The client requires assistance with completing oral hygiene.
B. The client expresses the desire to join a support group.
C. The client reports pain when chewing solid foods.
D. The client has difficulty ambulating with a walker.
A. The client requires assistance with completing oral hygiene.
62
A nurse is participating in the development of a disaster management plan for a hospital. For which of the following actions by the resources is the highest priority to have available in response to a bioterrorism event?
A. A system for tracking client information
B. A network for communication between staff members and families
C. A mental health specialist on the response team
D. A sufficient supply of personal protective equipment
D. A sufficient supply of personal protective equipment
63
A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)
A. A nurse and a provider are discussing a client's condition at the nurses' station while a visitor is present.
B. An assistive personnel logs out of the computer prior to responding to a call light.
C. A nurse is reviewing an electronic list of all clients admitted to the unit.
D. A nurse is faxing data about a client to a referred provider.
E. An assistive personnel is informing a friend of the client about their condition.
A. A nurse and a provider are discussing a client's condition at the nurses' station while a visitor is present.
E. An assistive personnel is informing a friend of the client about their condition.
64
A nurse manager is discussing critical pathway use during a staff meeting. Which of the following information should the nurse manager include as an outcome of critical pathway use?
A. Decreased cost-effectiveness
B. Increased variation in clinical interventions
C. Increased length of stay
D. Decreased care delays
D. Decreased care delays
65
A nurse enters a client's room and notices a small fire in the bathroom trash can. The nurse removes the client from the room. Which of the following actions should the nurse take next?
A. Close the fire doors and the doors to the clients' rooms.
B. Extinguish the fire,
C. Activate the fire alarm
D. Remove all clients from the unit.
C. Activate the fire alarm
66
A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? (Select all that apply.)
A. Place a copy of the completed report in the client's medical record.
B. Obtain an order from the client's provider to complete the report.
C. Identify the medication name and dosage administered to the client in the report.
D. Make a copy of the incident report for personal record keeping.
E. Include the time the medication error occurred in the report.
C. Identify the medication name and dosage administered to the client in the report.
E. Include the time the medication error occurred in the report.
67
A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?
A. Reorienting the client several times throughout the day
B. Performing an updated cognitive assessment on the client
C. Requesting a referral for the client to attend reminiscent therapy sessions
D. Providing assistance for the client when ambulating down the hall
C. Requesting a referral for the client to attend reminiscent therapy sessions
68
A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?
A. A nurse explains to a client's family that a DNR order includes withholding comfort measures.
B. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.
C. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min.
D. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better.
A. A nurse explains to a client's family that a DNR order includes withholding comfort measures.
69
A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?
A. Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.
B. Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago.
C. Administer a bronchodilator two times a day for child who has cystic fibrosis.
D. Teach an adolescent who has an exacerbation of ulcerative colitis about a high
-protein, low- fiber diet.
D. Teach an adolescent who has an exacerbation of ulcerative colitis about a high
70
A nurse is teaching a client who speaks a different language than the nurse about medications. Which of the following actions should the nurse take?
A. Speak very slowly during the teaching session.
B. Use medical terminology while explaining the medications.
C. Provide the client with written information in their spoken language.
D. Have the client's family member who is present interpret.
C. Provide the client with written information in their spoken language.
71
A nurse in a clinic is teaching a newly licensed nurse about sexually transmitted infections. The nurse should instruct the newly licensed nurse to report which of the following infections to the health department?
A. Gonorrhea
B. Trichomoniasis
C. Human papillomavirus
D. Candidiasis
A. Gonorrhea
72
A nurse witnesses a coworker not following facility procedure when discarding the unused portion of a controlled substance. Which of the following actions should the nurse take? (Select all that apply.)
A. Submit an incident report to the risk manager.
B. Fife an anonymous report of the incident to the nurse manager.
C. Document a factual account of the incident.
D. Request that the coworker complete an incident report.
E. Identify all witnesses to the incident.
A. Submit an incident report to the risk manager.
C. Document a factual account of the incident.
E. Identify all witnesses to the incident.
73
A nurse in the emergency department admits a client who has been exposed to cutaneous anthrax. Which of the following actions should the nurse take?
A. Plan to administer an antiviral medication to the client.
B. Wear an N95 respirator mask while caring for the client.
C. Prepare to administer antibiotics to the client.
D. Place a surgical mask on the client during transfer to the unit.
C. Prepare to administer antibiotics to the client.
74
A nurse manager is attending a meeting about the cost of health care. Which of the following measures should the nurse implement to reduce the cost of treatment in the acute care setting?
A. Reserve budgetary planning for senior management.
B. Encourage staff to participate in quality improvement projects.
C. Staff an additional assistive personnel each shift.
D. Plan budget needs based on average client stay over 6 months
B. Encourage staff to participate in quality improvement projects.
75
A nurse tells the unit manager, "I am tired of all the changes on the unit. If things don't get better. I'm going to quit." Which of the following responses by the unit manager is appropriate?
A. "You should file a written complaint with hospital administration."
B. “I think you have a right to be upset. I am tired of the changes, too."
C. "Just stick with it a little longer. Things will get better soon."
D. "So you are upset about all the changes on the unit?"
D. "So you are upset about all the changes on the unit?"
76
A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?
A. Unilateral ptosis
B. Altered level of consciousness
C. Diminished hand-to-mouth coordination
D. Impaired voluntary cough
D. Impaired voluntary cough
77
A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique?
A. The nurse turns her back to the sterile field.
B. The nurse holds her hands above her waist.
C. The nurse applies goggles.
D. The nurse puts on a face mask.
B. The nurse holds her hands above her waist.
78
A charge nurse is teaching a newly licensed nurse about caring for a client who has COPD. Which of the following instructions should the charge nurse include in the teaching?
A. "Notify me if you observe that the client has distended neck veins."
B. "Maintain the client's oxygen saturation level above 95 percent."
C. "Call the provider if you note clubbing of the client's fingernails"
D. "Have an assistive personnel ambulate the client just before meals."
A. "Notify me if you observe that the client has distended neck veins."
79
A nurse manager notes that the number of medication administration errors has increased on the unit. Which of the following actions should the nurse take first?
A. Serve on a quality improvement committee.
B. Conduct a root cause analysis.
C. Develop preventative measures.
D. Review current evidence-based practice.
B. Conduct a root cause analysis.
80
A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?
A. Withhold the benzodiazepine but continue the opioid.
B. Continue the medication dosages that relieve the client's pain.
C. Contact the provider about replacing the opioid with an NSAID.
D. Administer the benzodiazepine but withhold the opioid.
B. Continue the medication dosages that relieve the client's pain.
81
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
A. Report of photophobia
B. Increased temperature
C. Decreased level of consciousness
D. Generalized rash over trunk
C. Decreased level of consciousness
82
A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?
A. Demonstrate use of the pump during medication administration.
B. Assess the staff nurses' knowledge deficit.
C. Pair an inexperienced nurse with an experienced nurse.
D. Plan an in-service education program on the unit
B. Assess the staff nurses' knowledge deficit.
83
A nurse is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?
A. Tell the client to leave her purse in a drawer of the bedside table.
B. Offer to store the purse at the nurses' station.
C. Offer to place the purse in the facility safe.
D. Place the purse in the clothing bag with the client's other belongings.
C. Offer to place the purse in the facility safe.
84
A nurse is conducting an in-service on client advocacy with a group of newly licensed nurses. Which of the following scenarios should the nurse include as examples
of client advocacy? (Select all that apply.)
A. Documenting a client's refusal to take a prescribed medication
B. Obtaining an interpreter for a client who speaks a different language than the nurse
C. Providing written information to a client regarding palliative care
D. Implementing a client's plan of care based upon nursing goals
E. Initiating IV access on a client who has dementia while he is sleeping
A. Documenting a client's refusal to take a prescribed medication
B. Obtaining an interpreter for a client who speaks a different language than the nurse
C. Providing written information to a client regarding palliative care
85
A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?
A. A client who has bipolar disorder and is exhibiting signs of hallucination
B. A client who has two open chest wounds with a left tracheal deviation
C. A client who has a neck injury and is unable to breathe spontaneously
D. A client who has major burns over 75% of her body surface area
C. A client who has a neck injury and is unable to breathe spontaneously
86
A nurse manager is evaluating a nursing unit for cost effectiveness. Which of the following activities demonstrates effective cost containment?
A. Implementing rigid yearly budget planning
B. Maintaining budget planning between senior leadership
C. Ensuring proper documentation of client services
D. increasing the unit budget above expected needs
C. Ensuring proper documentation of client services
87
A nurse is reviewing the plan of care for a child who has oppositional defiant disorder. Which of the following members of the interprofessional health care team should the nurse plan to consult?
A. Social worker
B. Physical therapist
C. Occupational therapist
D. Speech pathologist
A. Social worker
88
A nurse is caring for four clients. For which of the following clients should the nurse collaborate with the facility ethics committee?
A. A middle adult client who leaves the facility against medical advice
B. An older adult client who has advance directives on file
C. A young adult client who is participating in a medical research study
D. An adolescent client whose parents refuse a blood transfusion for religious reasons
D. An adolescent client whose parents refuse a blood transfusion for religious reasons
89
A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the following clients should the nurse assign a red tag?
A. A client who has fixed pupils
B. A client who experienced a brief loss of consciousness
C. A client who has a compromised airway
D. A client who has major burns covering 70% of their body
C. A client who has a compromised airway
90
A nurse is participating on a committee that is considering the creation of a policy that will allow nurses to remove chest tubes. Which of the following is an appropriate resource for the nurse to consult in planning for this policy?
A. Institute of Medicine
B. State nurse practice act
C. ANA Standards of Practice
D. ANA Code of Ethics
B. State nurse practice act
91
The family members of an older adult client are expressing conflict over whether the client should have surgery that is recommended by the provider. The oldest adult child has durable power of attorney for health care for the client. The client is oriented to person, place, and time. Which of the following people has the legal authority to make this health care decision?
A. The oldest adult child
B. The partner
C. The provider
D. The client
D. The client
92
A nurse is teaching a group of assistive personnel about airborne precautions. Which of the following statements should the nurse make?
A. "Masks are not required when more than 3 ft from a client who requires airborne precautions."
B. "A client who has influenza requires airborne precautions."
C. "An N95 respirator mask is required when caring for a client who has the measles!"
D. "Clients who have varicella should be placed in a positive pressure room."
C. "An N95 respirator mask is required when caring for a client who has the measles!"
93
A nurse is caring for a client who communicates with sign language. The provider needs to obtain informed consent from the client. Which of the following actions should the nurse take?
A. Contact a medical translator to serve as an interpreter.
B. Have the provider speak loudly when communicating with the client.
C. Request the client's family member to assist with translation.
D. Ask the provider to sit to the side of the client.
A. Contact a medical translator to serve as an interpreter.
94
A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?
A. Two staff members have called to say they will be absent.
B. Transport assistance is unavailable to take a client to occupational therapy.
C. The emergency department nurse is waiting to give report on a new admission
D. A nurse on the previous shift wrote an incident report about a medication error.
C. The emergency department nurse is waiting to give report on a new admission
95
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
A. "Why did you make the decision to have this procedure?"
B. "It's not too late to cancel the surgery if you want to."
C. "This won't take long and it will be over before you know it."
D. "You shouldn't be worried because the procedure is very safe."
B. "It's not too late to cancel the surgery if you want to."
96
A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client's need for which of the following supplies to manage the tracheostomy at home? (Select all that apply.)
A. Oxygen tank
B. Pipe cleaners
C. Obturator
D. Cotton balls
E. Petroleum jelly
A. Oxygen tank
C. Obturator
97
A nurse is caring for client who is having difficulty walking following a stroke. For which of the following members of the interprofessional team should the nurse request a referral?
A. Dietitian
B. Social worker
C. Occupational therapist
D. Physical therapist
D. Physical therapist
98
A nurse is caring for a client who is experiencing cardiac arrest and has a do-not-resuscitate (DNR) prescription. The client's partner requests medical intervention. Which of the following actions should the nurse take?
A. Have the client's partner sign a consent form to reverse the DNR prescription.
B. Begin chest compressions on the client.
C. Contact social services to confer with the client's partner.
D. Adhere to the client's treatment decision.
D. Adhere to the client's treatment decision.
99
A nurse witnesses a newly licensed nurse take a client's prescribed pain medication instead of administering it to the client. Which of the following actions should the nurse take?
A. Instruct the newly licensed nurse to complete an incident report.
B. Document the incident in the client's medical record.
C. Provide the client with information about the incident.
D. Communicate the incident to the nurse manager.
D. Communicate the incident to the nurse manager.
100
A nurse is teaching a newly licensed nurse about the role of nurses during a facility disaster. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "A nurse can recommend clients who are stable for discharge during a disaster."
B. "A unit nurse has the authority to prescribe emergency medications during a disaster."
C. "A unit nurse can provide information to the media during a disaster."
D. "A nurse should communicate with the performance improvement committee during a disaster to improve client outcomes."
A. "A nurse can recommend clients who are stable for discharge during a disaster."
101
A nurse on a medical-surgical unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?
A. Instructing a client on self-administration of a tap water enema
B. Suctioning a client's long-term tracheostomy
C. Performing a dressing change on a client's peripherally inserted central catheter
D. Using a pain rating scale to monitor a client's pain level
D. Using a pain rating scale to monitor a client's pain level
102
A nurse is caring for a client who has a new diagnosis of Crohn's disease and is interested in learning more about their condition. Which of the following actions should the nurse take?
A. Recommend podcasts that discuss Crohn's disease to the client.
B. Encourage the client to research Crohn's disease on websites that have a "gov" address.
C. Ask a licensed practical nurse to explain Crohn's disease to the client.
D. Suggest that the client read articles that recommend specific treatments for Crohn's disease.
B. Encourage the client to research Crohn's disease on websites that have a "gov" address.
103
Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost- containment plan?
A. Use clean gloves rather than sterile gloves for colostomy care
B. Wait to dispose of sharps containers until they are completely full.
C. Return unused supplies from the bedside to the unit's supply stock.
D. Store opened bottles of normal saline in a refrigerator for up to 48 hr
C. Return unused supplies from the bedside to the unit's supply stock.
104
A nurse is providing teaching to an assistive personnel about the application of wrist restraints to a client. Which of the following instructions should the nurse include in
the teaching?
A. Attach the restraints to the fixed portions of the frame of the client's bed.
B. Remove the client's restraints every 2 hr
C. Secure the client's restraints with a square knot.
D. Allow 1 fingerbreadth between the restraint and the client's wrists.
A. Attach the restraints to the fixed portions of the frame of the client's bed.
105
A charge nurse is educating a group of newly licensed nurses about the case management approach to client care. Which of the following statements by a newly licensed nurse indicates an understanding of the responsibilities of a nurse in case management?
A. "Each nurse completes one specific task for a group of clients."
B. "Nurses use critical pathways when caring for clients."
C. "Nurses delegate and supervise assigned tasks."
D. "Nurses who have advanced training provide direct care for select clients."
B. "Nurses use critical pathways when caring for clients."
106
A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?
A. Request another family member assist the client's partner with care.
B. Contact the case manager to discuss discharge options.
C. Ask the provider to delay the client's discharge home for a few more days.
D. Recommend the partner place the client in a long-term care facility.
B. Contact the case manager to discuss discharge options.
107
A nurse is delegating oral care for a client who is unconscious to an assistive personnel (AP). The AP tells the nurse that APs are not allowed to perform the delegated task. Which of the following actions should the nurse take?
A. Ask the nurse manager who should perform the task.
B. Perform the oral care.
C. Ask a licensed practical nurse to perform the task.
D. Check the AP job description.
D. Check the AP job description.
108
A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have sufficient experience to safely care for his assigned clients. Which of the following actions should the nurse take?
A. Notify the risk manager.
B. Request that the charge nurse modify the assignment.
C. Document the concern in the nurse's notes.
D. Accept the assignment with help from assistive personnel on the unit.
B. Request that the charge nurse modify the assignment.
109
A nurse is providing care for a client who has terminal cancer and is refusing chemotherapy. Which of the following actions should the nurse take?
A. Provide care for the client using a sympathetic approach.
B. Request the client sign an informed consent.
C. Communicate the client's decision to the provider.
D. Encourage the client to reconsider their decision.
C. Communicate the client's decision to the provider.
110
A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?
A. "I will need assistance with bathing."
B. "I am tired of having pain in my joints all the time."
C. "I need some help planning my meals to maintain my weight”.
D. "I'm having difficulty climbing the stairs at my house."
A. "I will need assistance with bathing."
111
A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?
A. "My doctor will need to provide approval for the decisions outlined in my living will."
B. "I will wait until I have a serious health problem to sign my advance directives."
C. "My durable power of attorney for health care is part of my advance directives."
D. "Once I sign my living will, a family member must co-sign it”.
C. "My durable power of attorney for health care is part of my advance directives."
112
A nurse overhears two assistive personnel (AP) discussing a client's care in the cafeteria. Which of the following actions should the nurse take?
A. Instruct the AP to discontinue the conversation.
B. Notify the client's provider about the incident.
C. Reassign the AP to other clients on the unit.
D. Complete an incident report about the breach of client confidentiality
D. Complete an incident report about the breach of client confidentiality
113
A nurse is providing teaching to a client about advance directives. Which of the following statements by the client indicates an understanding of the teaching?
A. "My doctor will need to provide approval for the decisions outlined in my living will."
B. "I will wait until I have a serious health problem to sign my advance directives."
C. "My durable power of attorney for health care is part of my advance directives.
D. "Once I sign my living will, a family member must co-sign it."
C. "My durable power of attorney for health care is part of my advance directives.
114
A nurse is assessing a client who is 1 day postoperative following a total knee arthroplasty. The client is scheduled for physical therapy in 45 min. Which of the following questions should the nurse ask first?
A. “Have you used an incentive spirometer today?"
B. "What is your current pain level on a scale of 0 to 10?"
C. "Have you informed your family of your physical therapy schedule?"
D. "Would you like to bathe before or after physical therapy?"
B. "What is your current pain level on a scale of 0 to 10?"
115
A nurse overhears two staff members talking in the cafeteria about a client's scheduled surgery. Which of the following actions should the nurse take?
A. File a grievance report about the breach of confidentiality.
B. Discuss the incident with another staff nurse.
C. Counsel the staff members about the breach of confidentiality.
D. Report the staff members actions to the state board of nursing.
C. Counsel the staff members about the breach of confidentiality.
116
A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change in wound care procedure. Which of the following findings indicates wound healing?
A. Increased sangueous exudate from a client's wound
B. Inflammation noted on the tissue edges of a client's wound
C. Erythema on the skin surrounding a client's wound
D. Deep red color on the center of a client's wound
D. Deep red color on the center of a client's wound
117
A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take?
A. Initiate a mental health consult to determine the client's reasons for refusing surgery.
B. Provide the client with information on treatment options and outcomes.
C. Discuss with the client her concerns regarding the procedure.
D. Inform the client of the consequences of uterine prolapse and the need for intervention.
C. Discuss with the client her concerns regarding the procedure.
118
A nurse is assisting a provider with obtaining informed consent from a client who is scheduled for surgery. Which of the following actions should the nurse take?
A. Witness the client's signature on the form
B. Teach the client about the risks involved with the procedure.
C. Explain the procedure to be performed
D. Provide the client with alternative procedure options.
A. Witness the client's signature on the form
119
A nurse is caring for a client who refuses to take their prescribed medication. Which of the following actions should the nurse take first?
A. Document the client's refusal in the medical record.
B. Ensure the client understands the risks of not taking the medication.
C. Dispose of the medication according to facility policy.
D. Inform the provider of the client's refusal.
B. Ensure the client understands the risks of not taking the medication.
120
A nurse is teaching a class of newly licensed nurses about evidence-based practice. The nurse should include which of the following as the first step in evidence-based practice?
A. Critically assess the evidence.
B. Collect evidence from a variety of sources.
C. Apply research to client care practice.
D. Develop a clinical question
D. Develop a clinical question
121
A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?
A. The client's code status
B. The client's name
C. A prescribed consultation
D. The client's vital signs
C. A prescribed consultation
122
A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which of the following actions should the nurse preceptor identify as maintaining sterile technique?
A. Uses sterile forceps to pack sterile gauze into the wound
B. Uses a sterile-gloved hand to adjust the back of the sterile gown
C. Sets up the sterile field 30 min prior to performing the dressing change
D. Places sterile gauze 1.3 cm (0.5 in) away from the edge of a sterile drape
A. Uses sterile forceps to pack sterile gauze into the wound
