NP 1 the next RN in charge. This nursing care you any more food and drinks”.

What initial
illustrates of what kind of method? action is best for the nurse to take?
1. The registered nurse is planning to delegate A. primary nursing method A. Take no action because it is the
tasks to unlicensed assistive personnel (UAP). B. case method family member saying that to the
Which of the following task could the C. team method client
registered nurse safely assigned to a UAP? D. functional method B. Talk to the family member and
A. Monitor the I&O of a comatose 7. A newly hired nurse on an adult medicine explain that what she/he has said is
toddler client with salicylate unit with 3 months experience was asked to not appropriate for the client
poisoning float to pediatrics. The nurse hesitates to C. Give the family member the number
B. Perform a complete bed bath on a 2- perform pediatric skills and receive an for an Elder Abuse Hot line
year-old with multiple injuries from interesting assignment that feels D. Document what the family member
a serious fall overwhelming. The nurse should: has said
C. Check the IV of a preschooler with A. resign on the spot from the nursing 13. Which is true about informed consent?
Kawasaki disease position and apply for a position A. A nurse may accept responsibility
D. Give an outmeal bath to an infant that does not require floating signing a consent form if the client is
with eczema B. Inform the nursing supervisor and unable
2. A nurse manager assigned a registered the charge nurse on the pediatric B. Obtaining consent is not the
nurse from telemetry unit to the pediatrics floor about the nurse’s lack of skill responsibility of the physician
unit. There were three patients assigned to and feelings of hesitations and C. A physician will not subject himself
the RN. Which of the following patients should request assistance to liability if he withholds any facts
not be assigned to the floated nurse? C. Ask several other nurses how they that are necessary to form the basis
A. A 9-year-old child diagnosed with feel about pediatrics and find of an intelligent consent
rheumatic fever someone else who is willing to D. If the nurse witnesses a consent for
B. A young infant after pyloromyotomy accept the assignment surgery, the nurse is, in effect,
C. A 4-year-old with VSD following D. Refuse the assignment and leave the indicating that the signature is that
cardiac catheterization unit requesting a vacation a day of the purported person and that
D. A 5-month-old with Kawasaki 8. An experienced nurse who voluntarily the person’s condition is as indicated
disease trained a less experienced nurse with the at the time of signing
3. A nurse in charge in the pediatric unit is intention of enhancing the skills and 14. A mother in labor told the nurse that she
absent. The nurse manager decided to assign knowledge and promoting professional was expecting that her baby has no chance to
the nurse in the obstetrics unit to the advancement to the nurse is called a: survive and expects that the baby will be born
pediatrics unit. Which of the following A. mentor dead. The mother accepts the fate of the baby
patients could the nurse manager safely assign B. team leader and informs the nurse that when the baby is
to the float nurse? C. case manager born and requires resuscitation, the mother
A. A child who had multiple injuries D. change agent refuses any treatment to her baby and
from a serious vehicle accident 9. The pediatrics unit is understaffed and the expresses hostility toward the nurse while the
B. A child diagnosed with Kawasaki nurse manager informs the nurses in the pediatric team is taking care of the baby. The
disease and with cardiac obstetrics unit that she is going to assign one nurse is legally obligated to:
complications nurse to float in the pediatric units. Which A. Notify the pediatric team that the
C. A child who has had a nephrectomy statement by the designated float nurse may mother has refused resuscitation
for Wilm’s tumor put her job at risk? and any treatment for the baby and
D. A child receiving an IV chelating A. “I do not get along with one of the take the baby to the mother
therapy for lead poisoning nurses on the pediatrics unit” B. Get a court order making the baby a
4. The registered nurse is planning to delegate B. “I have a vacation day coming and ward of the court
task to a certified nursing assistant. Which of would like to take that now” C. Record the statement of the mother,
the following clients should not be assigned to C. “I do not feel competent to go and notify the pediatric team, and
a CAN? work on that area” observe carefully for signs of
A. A client diagnosed with diabetes and D. “ I am afraid I will get the most impaired bonding and neglect as a
who has an infected toe serious clients in the unit” reasonable suspicion of child abuse
B. A client who had a CVA in the past 10. The newly hired staff nurse has been D. Do nothing except record the
two months working on a medical unit for 3 weeks. The mother’s statement in the medical
C. A client with Chronic renal failure nurse manager has posted the team leader record
D. A client with chronic venous assignments for the following week. The new 15. The hospitalized client with a chronic
insufficiency staff knows that a major responsibility of the cough is scheduled for bronchoscopy. The
5. The nurse in the medication unit passes the team leader is to: nurse is tasks to bring the informed consent
medications for all the clients on the nursing A. Provide care to the most acutely ill document into the client’s room for a
unit. The head nurse is making rounds with client on the team signature. The client asks the nurse for details
the physician and coordinates clients’ B. Know the condition and needs of all of the procedure and demands an explanation
activities with other departments. The nurse the patients on the team why the process of informed consent is
assistant changes the bed lines and answers C. Document the assessments necessary. The nurse responds that informed
call lights. A second nurse is assigned for completed by the team members consent means:
changing wound dressings; a licensed D. Supervise direct care by nursing A. The patient releases the physician
practitioner nurse takes vital signs and bathes assistants from all responsibility for the
theclients. This illustrates of what method of 11. A 15-year-old girl just gave birth to a baby procedure.
nursing care? boy who needs emergency surgery. The nurse B. The immediate family may make
A. Case management method prepared the consent form and it should be decision against the patient’s will.
B. Primary nursing method signed by: C. The physician must give the client or
C. Team method A. The Physician surrogates enough information to
D. Functional method B. The Registered Nurse caring for the make health care judgments
6. A registered nurse has been assigned to six client consistent with their values and
clients on the 12-hour shift. The RN is C. The 15-year-old mother of the baby goals.
responsible for every aspect of care such as boy D. The patient agrees to a procedure
formulating the care of plan, intervention and D. The mother of the girl ordered by the physician even if the
evaluating the care during her shift. At the end 12. A nurse caring to a client with Alzheimer’s client does not understand what the
of her shift, the RN will pass this same task to disease overheard a family member say to the outcome will be.
client, “if you pee one more time, I won’t give
16. A hospitalized client with severe A. Feet and legs elevated 20 degrees, client. How would the nurse document the
necrotizing ulcer of the lower leg is schedule trunk horizontal, head on small finding?
for an amputation. The client tells the nurse pillow A. Facial edema with ecchymosis and
that he will not sign the consent form and he B. Low Fowler’s with knees gatched at handprint mark: crackles and
does not want any surgery or treatment 30 degrees wheezes
because of religious beliefs about C. Supine with the head turned to the B. Facial edema, with red marks;
reincarnation. What is the role of the RN? left crackles in the lung
A. call a family meeting D. Bed sloped at a 45 degree angle C. Facial edema with ecchymosis that
B. discuss the religious beliefs with the with the head lowest and the legs looks like a handprint
physician highest D. Red bruise mark and ecchymosis on
C. encourage the client to have the 23. The client is brought to the emergency face
surgery department after a serious accident. What 30. On the evening shift, the triage nurse
D. inform the client of other options would be the initial nursing action of the nurse evaluates several clients who were brought to
17. While in the hospital lobby, the RN to the client? the emergency department. Which in the
overhears the three staff discussing the health A. assess the level of consciousness following clients should receive highest
condition of her client. What would be the and circulation priority?
appropriate nursing action for the RN to take? B. check respirations, circulation, A. an elderly woman complaining of a
A. Tell them it is not appropriate to neurological response loss of appetite and fatigue for the
discuss the condition of the client C. align the spine, check pupils, check past week
B. Ignore them, because it is their right for hemorrhage B. A football player limping and
to discuss anything they want to D. check respiration, stabilize spine, complaining of pain and swelling in
C. Join in the conversation, giving them check circulation the right ankle
supportive input about the case of 24. A nurse is assigned to care to a client with C. A 50-year-old man, diaphoretic and
the client Parkinson’s disease. What interventions are complaining of severe chest pain
D. Report this incident to the nursing important if the nurse wants to improve radiating to his jaw
supervisor nutrition and promote effective swallowing of D. A mother with a 5-year-old boy who
18. A staff nurse has had a serious issue with the client? says her son has been complaining
her colleague. In this situation, it is best to: A. Eat solid food of nausea and vomited once since
A. Discuss this with the supervisor B. Give liquids with meals noon
B. Not discuss the issue with anyone. It C. Feed the client 31. A 80-year-old female client is brought to
will probably resolve itself D. Sit in an upright position to eat the emergency department by her caregiver,
C. Try to discuss with the colleague 25. During tracheal suctioning, the nurse on the nurse’s assessment; the following are
about the issue and resolve it when should implement safety measures. Which of the manifestations of the client: anorexia,
both are calmer the following should the nurse implements? cachexia and multiple bruises. What would be
D. Tell other members of the network A. limit suction pressure to 150-180 the best nursing intervention?
what the team member did mmHg A. check the laboratory data for serum
19. The nurse is caring to a client who just B. suction for 15-20 seconds albumin, hematocrit, and
gave birth to a healthy baby boy. The nurse C. wear eye goggles hemoglobin
may not disclose confidential information D. remove the inner cannula B. talk to the client about the caregiver
when: 26. The nurse is conducting a discharge and support system
A. The nurse discusses the condition of instructions to a client diagnosed with C. complete a police report on elder
the client in a clinical conference diabetes. What sign of hypoglycemia should abuse
with other nurses be taught to a client? D. complete a gastrointestinal and
B. The client asks the nurse to discuss A. warm, flushed skin neurological assessment
the her condition with the family B. hunger and thirst 32. The night shift nurse is making rounds.
C. The father of a woman who just C. increase urinary output When the nurse enters a client’s room, the
delivered a baby is on the phone to D. palpitation and weakness client is on the floor next to the bed. What
find out the sex of the baby 27. A client admitted to the hospital and would be the initial action of the nurse?
D. A researcher from an institutionally diagnosed with Addison’s disease. What A. chart that the patient fell
approved research study reviews the would be the appropriate nursing action to B. call the physician
medical record of a patient the client? C. chart that the client was found on
20. A 17-year-old married client is scheduled A. administering insulin-replacement the floor next to the bed
for surgery. The nurse taking care of the client therapy D. fill out an incident report
realizes that consent has not been signed after B. providing a low-sodium diet 33. The nurse on the night shift is about to
preoperative medications were given. What C. restricting fluids to 1500 ml/day administer medication to a preschooler client
should the nurse do? D. reducing physical and emotional and notes that the child has no ID bracelet.
A. Call the surgeon stress The best way for the nurse to identify the
B. Ask the spouse to sign the consent 28. The nurse is to perform tracheal client is to ask:
C. Obtain a consent from the client as suctioning. During tracheal suctioning, which A. The adult visiting, “The child’s name
soon as possible nursing action is essential to prevent is ____________________?”
D. Get a verbal consent from the hypoxemia? B. The child, “Is your
parents of the client A. aucultating the lungs to determine name____________?”
21. A 12-year-old client is admitted to the the baseline data to assess the C. Another staff nurse to identify this
hospital. The physician ordered Dilantin to the effectiveness of suctioning child
client. In administering IV phenytoin (Dilantin) B. removing oral and nasal secretions D. The other children in the room what
to a child, the nurse would be most correct in C. encouraging the patient to deep the child’s name is
mixing it with: breathe and cough to facilitate 34. The nurse caring to a client has completed
A. Normal Saline removal of upper-airway secretions the assessment. Which of the following will be
B. Heparinized normal saline D. administering 100% oxygen to considered to be the most accurate charting
C. 5% dextrose in water reduce the effects of airway of a lump felt in the right breast?
D. Lactated Ringer’s solution obstruction during suctioning. A. “abnormally felt area in the right
22. The nurse is caring to a client who is 29. An infant is admitted and diagnosed with breast, drainage noted”
hypotensive. Following a large hematemesis, pneumonia and suspicious-looking red marks B. “hard nodular mass in right breast
how should the nurse position the client? on the swollen face resembling a handprint. nipple”
The nurse does further assessment to the C. “firm mass at five ‘ clock, outer
quadrant, 1cm from right nipple’
 D. “mass in the right breast 4cmx1cm 41. A community health nurse is schedule to B. Hexachlorophene (Phisohex)
35. The physician instructed the nurse that do home visit. She visits to an elderly person C. Soap and water
intravenous pyelogram will be done to the living alone. Which of the following D. Chlorhexidine gluconate (CHG)
client. The client asks the nurse what is the observation would be a concern? (Hibiclens)
purpose of the procedure. The appropriate A. Picture windows 49. The mother of the client tells the nurse, “
nursing response is to: B. Unwashed dishes in the sink I’m not going to have my baby get any
A. outline the kidney vasculature C. Clear and shiny floors immunization”. What would be the best
B. determine the size, shape, and D. Brightly lit rooms nursing response to the mother?
placement of the kidneys 42. After a birth, the physician cut the cord of A. “You and I need to review your
C. test renal tubular function and the the baby, and before the baby is given to the rationale for this decision”
patency of the urinary tract mother, what would be the initial nursing B. “Your baby will not be able to attend
D. measure renal blood flow action of the nurse? day care without immunizations”
36. A client visits the clinic for screening of A. examine the infant for any C. “Your decision can be viewed as a
scoliosis. The nurse should ask the client to: observable abnormalities form of child abuse and neglect”
A. bend all the way over and touch the B. confirm identification of the infant D. “You are needlessly placing other
toes and apply bracelet to mother and people at risk for communicable
B. stand up as straight and tall as infant diseases”
possible C. instill prophylactic medication in the 50. The nurse is teaching the client about
C. bend over at a 90-degree angle from infant’s eyes breast self-examination. Which observation
the waist D. wrap the infant in a prewarmed should the client be taught to recognize when
D. bend over at a 45-degree angle from blanket and cover the head doing the examination for detection of breast
the waist 43. A 2-year-old client is admitted to the cancer?
37. A client with tuberculosis is admitted in hospital with severe eczema lesions on the A. tender, movable lump
the hospital for 2 weeks. When a client’s scalp, face, neck and arms. The client is B. pain on breast self-examination
family members come to visit, they would be scratching the affected areas. What would be C. round, well-defined lump
adhering to respiratory isolation precautions the best nursing intervention to prevent the D. dimpling of the breast tissue
when they: client from scratching the affected areas? Answers and Rationales
A. wash their hands when leaving A. elbow restraints to the arms 1. D. Bathing an infant with eczema
B. put on gowns, gloves and masks B. Mittens to the hands can be safely delegated to an aide;
C. avoid contact with the client’s C. Clove-hitch restraints to the hands this task is basic and can
roommate D. A posey jacket to the torso competently performed by an aid.
D. keep the client’s room door open 44. The parents of the hospitalized client ask 2. B. The RN floated from the
38. An infant is brought to the emergency the nurse how their baby might have gotten telemetry unit would be least
department and diagnosed with pyloric pyloric stenosis. The appropriate nursing prepared to care for a young infant
stenosis. The parents of the client ask the response would be: who has just had GI surgery and
nurse, “Why does my baby continue to A. There is no way to determine this requires a specific feeding regimen.
vomit?” Which of the following would be the preoperatively 3. C. RN floated from the obstetrics
best nursing response of the nurse? B. Their baby was born with this unit should be able to care for a
A. “Your baby eats too rapidly and condition client with major abdominal surgery,
overfills the stomach, which causes C. Their baby developed this condition because this nurse has experienced
vomiting during the first few weeks of life caring for clients with cesarean
B. “Your baby can’t empty the formula D. Their baby acquired it due to a births.
that is in the stomach into the formula allergy 4. A. The patient is experiencing a
bowel” 45. A male client comes to the clinic for check- potentially serious complication
C. “The vomiting is due to the nausea up. In doing a physical assessment, the nurse related to diabetes and needs
that accompanies pyloric stenosis” should report to the physician the most ongoing assessment by an RN
D. “Your baby needs to be burped common symptom of gonorrhea, which is: 5. D. It describes functional nursing.
more thoroughly after feeding” A. pruritus Staff is assigned to specific task
39. A 70-year-old client with suspected B. pus in the urine rather than specific clients.
tuberculosis is brought to the geriatric care C. WBC in the urine 6. B. Case management. The nurse
facilities. An intradermal tuberculosis test is D. Dysuria assumes total responsibility for
schedule to be done. The client asks the nurse 46. Which of the following would be the most meeting the needs of the client
what is the purpose of the test. Which of the important goal in the nursing care of an infant during her entire duty.
following would be the best rationale for this? client with eczema? 7. B. The nurse is ethically obligated to
A. reactivation of an old tuberculosis A. preventing infection inform the person responsible for
infection B. maintaining the comfort level the assignment and the person
B. increased incidence of new cases of C. providing for adequate nutrition responsible for the unit about the
tuberculosis in persons over 65 D. decreasing the itching nurse’s skill level. The nurse
years old 47. The nurse is making a discharge instruction therefore avoids a situation of
C. greater exposure to diverse health to a client receiving chemotherapy. The client abandoningclients and exposing
care workers is at risk for bone marrow depression. The them to greater risks
D. respiratory problems are nurse gives instructions to the client about 8. A. This describes a mentor
characteristic in this population how to prevent infection at home. Which of 9. B. This action demonstrates a lack of
40. The nurse is making a health teaching to the following health teaching would be responsibility and the nurse should
the parents of the client. In teaching parents included? attempt negotiation with the nurse
how to measure the area of induration in A. “Get a weekly WBC count” manager.
response to a PPD test, the nurse would be B. “Do not share a bathroom with 10. B. The team leader is responsible for
most accurate in advising the parents to children or pregnant woman” the overall management of all
measure: C. “Avoid contact with others while clients and staff on the team, and
A. both the areas that look red and feel receiving chemotherapy” this information is essential in order
raised D. “Do frequent hand washing and to accomplish this
B. The entire area that feels itchy to maintain good hygiene” 11. C. Even though the mother is a
the child 48. The nurse is assigned to care the client minor, she is legally able to sign
C. Only the area that looks reddened with infectious disease. The best antimicrobial consent for her own child.
D. Only the area that feels raised agent for the nurse to use in handwashing is: 12. B. This response is the most direct
A. Isopropyl alcohol and immediate. This is a case of
 potential need for advocacy and in the airway is obstructed by the 40. D. Parents should be taught to feel
patient’s rights. suctioning catheter. the area that is raised and measure
13. D. The nurse who witness a consent 29. B. This is an example of objective only that.
for treatment or surgery is data of both pulmonary status and 41. C. It is a safety hazard to have shiny
witnessing only that the client direct observation on the skin by the floors because they can cause falls.
signed the form and that the client’s nurse. 42. D. The first priority, beside
condition is as indicated at the time 30. C. These are likely signs of an acute maintaining a newborn’s patent
of signing. The nurse is not myocardial infarction (MI). An acute airway, is body temperature.
witnessing that the client is MI is a cardiovascular emergency 43. B. The purpose of restraints for this
“informed”. requiring immediate attention. child is to keep the child from
14. C. Although the statements by the Acute MI is potentially fatal if not scratching the affected areas.
mother may not create a suspicion treated immediately. Mittens restraint would prevent
of neglect, when they are coupled 31. D. Assessment and more data scratching, while allowing the most
with observations about impaired collection are needed. The client movement permissible.
bonding and maternal attachment, may have gastrointestinal or 44. C. Pyloric stenosis is not a congenital
they may impose the obligation to neurological problems that account anatomical defect, but the precise
report child neglect. The nurse is for the symptoms. The anorexia etiology is unknown. It develops
further obligated to notify caregivers could result from medications, poor during the first few weeks of life.
of refusal to consent to treatment dentition, or indigestion, and the 45. B. Pus is usually the first symptom,
15. C. It best explains what informed bruises may be attributed to ataxia, because the bacteria reproduce in
consent is and provides for legal frequent falls, vertigo or medication. the bladder.
rights of the patient 32. B. This is closest to suggesting 46. A. Preventing infection in the infant
16. B. The physician may not be aware action-assessment, rather than with eczema is the nurse’s most
of the role that religious beliefs play paperwork- and is therefore the best important goal. The infant with
in making a decision about surgery. of the four. eczema is at high risk for infection
17. A. The behavior should be stopped. 33. C. The only acceptable way to due to numerous breaks in the skin’s
The first step is to remind the staff identify a preschooler client is to integrity. Intact skin is always the
that confidentiality may be violated have a parent or another staff infant’s first line of defense against
18. C. Waiting for emotions to dissipate member identify the client. infection.
and sitting down with the colleague 34. C. It describes the mass in the 47. D. Frequent hand washing and good
is the first rule of conflict resolution. greatest detail. hygiene are the best means of
19. C. The nurse has no idea who the 35. C. Intravenous pyelogram tests both preventing infection.
person is on the phone and the function and patency of the 48. D. CHG is a highly effective
therefore may not share the kidneys. After the intravenous antimicrobial ingredient, especially
information even if the patient gives injection of a radiopaque contrast when it is used consistently over
permission medium, the size, location, and time.
20. A. The priority is to let the surgeon patency of the kidneys can be 49. A. The mother may have many
know, who in turn may ask the observed by roentgenogram, as well reasons for such a decision. It is the
husband to sign the consent. as the patency of the urethra and nurse’s responsibility to review this
21. A. Phenytoin (Dilantin) can cause bladder as the kidneys function to decision with the mother and clarify
venous irritation due to its alkalinity, excrete the contrast medium. any misconceptions regarding
therefore it should be mixed with 36. C. This is the recommended position immunizations that may exist.
normal saline. for screening for scoliosis. It allows 50. D. The tumor infiltrates nearby
22. A. This position increases venous the nurse to inspect the alignment tissue, it can cause retraction of the
return, improves cardiac volume, of the spine, as well as to compare overlying skin and create a dimpling
and promotes adequate ventilation both shoulders and both hips. appearance.
and cerebral perfusion 37. A. Handwashing is the best method
23. D. Checking the airway would be a for reducing cross-contamination.
priority, and a neck injury should be Gowns and gloves are not always
suspected required when entering a client’s
24. D. Client with Parkinson’s disease room.
are at a high risk for aspiration and 38. B. Pyloric stenosis is an anomaly of
undernutrition. Sitting upright the upper gastrointestinal tract. The
promotes more effective condition involves a thickening, or
swallowing. hypertrophy, of the pyloric sphincter
25. C. It is important to protect the RN’s located at the distal end of the
eyes from the possible stomach. This causes a mechanical
contamination of coughed-up intestinal obstruction, which leads
secretions to vomiting after feeding the infant.
26. D. There has been too little food or The vomiting associated with pyloric
too much insulin. Glucose levels can stenosis is described as being
be markedly decreased (less than 50 projectile in nature. This is due to
mg/dl). Severe hypoglycemia may the increasing amounts of formula
be fatal if not detected the infant begins to consume
27. D. Because the client’s ability to coupled with the increasing
react to stress is decreased, thickening of the pyloric sphincter.
maintaining a quiet environment 39. B. Increased incidence of TB has
becomes a nursing priority. been seen in the general population
Dehydration is a common problem with a high incidence reported in
in Addison’s disease, so close hospitalized elderly clients.
observation of the client’s hydration Immunosuppression and lack of
level is crucial. classic manifestations because of
28. D. Presuctioning and postsuctioning the aging process are just two of the
ventilation with 100% oxygen is contributing factors of tuberculosis
important in reducing hypoxemia in the elderly.
which occurs when the flow of gases