Question 1

An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss.  The client has been in the hospital 4 times over the last several months and is "tired of being poked and prodded."  Which topic would be most important for the nurse to discuss with this client's health care team?

Accepted Answer

A) Need for discharge to a skilled nursing facility 
B) Nutritional consult with instructions on a high-calorie diet 
C) Option of palliative care 
D) Physical therapy prescription to promote activity

Question 2

A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation.  The nurse walks into the room and finds that the client is not breathing.  What should the nurse do first?

Accepted Answer

A) Activate the code system 
B) Call the health care provider (HCP) stat 
C) Check the apical pulse 
D) Check the blood pressure

Question 3

Which emergency department clients cannot be allowed to sign out against medical advice?  Select all that apply.

Accepted Answer

A) Client in sickle cell crisis receiving oxygen via face mask 
B) Client who drank a 1 L bottle of vodka 2 hours ago 
C) Client who hears voice commands to kill a coworker 
D) Client with mania who has not eaten in 5 days 
E) Client with ST elevation on ECG monitoring

Question 4

Four clients are seen by the emergency department nurse.  Which client is a priority for treatment and definitive care?

Accepted Answer

A) 7-day-old fussy infant with a rectal temperature of 100.6 F (38.1 
C)  and 6 wet diapers today 
B) Client receiving radiation therapy who has 6-in (15.2-cm) arm laceration that is not actively bleeding 
C) Client with purulent drainage and crusting of the eyelid with vision unaffected 
D) New parent who is crying and overwhelmed, and denies suicidal ideation

Question 5

The nurse is planning to assess 4 assigned clients.  Which client situation is of greatest concern and warrants immediate assessment?

Accepted Answer

A) Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications 
B) Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain 
C) Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage 
D) Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting

Question 6

The nurse assistant reports vital signs on 4 clients.  Which client should be a priority for the nurse to assess?

Accepted Answer

A) 28-year-old with infective endocarditis and heart rate of 105/min 
B) 45-year-old with acute pancreatitis and sinus tachycardia of 120/min 
C) 65-year-old with tachycardia of 110/min after liver biopsy 
D) 74-year-old on diltiazem drip with atrial fibrillation and heart rate of 115/min

Question 7

The nurse has received report on 4 clients.  Which client should the nurse see first?

Accepted Answer

A) Client admitted this morning with acute pyelonephritis whose IV line is infiltrated 
B) Client scheduled for surgery in 2 hours who has questions about the procedure 
C) Client who had a colostomy yesterday and now has a leaking colostomy bag 
D) Client with a total hip replacement 3 days ago who reports no bowel movement in 2 days

Question 8

The nurse is caring for clients on a busy medical-surgical unit.  Which client would be priority to assess first?

Accepted Answer

A) A client with an ileostomy bag that has leaked stool all over 
B) A client with chronic obstructive pulmonary disease, diminished breath sounds, and SpO2 of 91% 
C) A client with deep venous thrombosis who missed the last warfarin dose 
D) A client with sepsis who is developing petechiae

Question 9

The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a caustic chemical agent.  A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue.  What is the nurse's priority action?

Accepted Answer

A) Assess skin to determine severity of burns and wounds 
B) Assign client to a cot with other similarly triaged clients 
C) Assist the client to the designated showering area 
D) Prepare supplies to establish intravenous access

Question 10

Which of the following are examples of medical battery?  Select all that apply.

Accepted Answer

A) A child is placed in a papoose restraint for suturing of a facial laceration with the parent present 
B) Application of soft wrist restraints to the arms of a confused, adult client with a nasogastric tube 
C) The nurse administers 2 mg of morphine PRN to a difficult, alert client but tells the client it is saline 
D) The nurse inserts a needed urinary catheter even though a competent client refuses it 
E) The nurse threatens to put a client in restraints if the client does not stay in bed

Question 11

A float nurse from labor and delivery is assigned to the cardiac care unit.  Which client is most appropriate for the charge nurse to assign to the float nurse?

Accepted Answer

A) Client 3 days following a myocardial infarction who is on 6 L of oxygen and reports nausea 
B) Client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO 
C) Client with a demand pacemaker set at 70/min who has a ventricular rate of 65/min 
D) Client with angina at rest who has normal troponin levels and normal sinus rhythm on ECG

Question 12

Which situations require that the registered nurse (RN) report to an appropriate authority?  Select all that apply.

Accepted Answer

A) Client has a row of 3-inch circles down the back from "cupping" 
B) Client is diagnosed with gonorrhea and requests not to report under the Health Insurance Portability and Accountability Act (HIPA
A)  
C) RN thinks a teenage client's signs are from abuse, but the health care provider does not 
D) RN thinks an elderly client's signs are from abuse but the client denies this 
E) Syphilis is diagnosed in an 11-year-old who denies sexual activity

Question 13

The nurse receives report on 4 clients.  Which client should the nurse see first?

Accepted Answer

A) Client 2 hours post foot amputation surgery has a surgical dressing saturated with bright red blood 
B) Client scheduled for whirlpool bath in 20 minutes has the dressing on the infected foot ulcer fall off 
C) Client with arteriovenous graft for hemodialysis access has new-onset pain and redness at graft site 
D) Client with urinary retention and infection receiving antibiotics is confused and trying to pull out Foley catheter

Question 14

An unaccompanied 16-year-old girl comes to the emergency department with severe abdominal pain and vomiting.  The client has a temperature of 102.2 F (39 C) and a pulse of 120/min and is lethargic.  The client's parents are out of town, and no guardians can be reached.  How should this client's care be handled?

Accepted Answer

A) Administer care until the parents or guardians can be reached 
B) Admit the client but without giving care until the parents or guardians can be reached 
C) Perform a pregnancy test to see if the client qualifies as an emancipated minor 
D) Provide health care and follow-up advice but do not give any direct care

Question 15

The nurse has received report on 4 clients at the start of the shift.  Which client should the nurse assess first?

Accepted Answer

A) Client in body cast who reports abdominal pain and bloating 
B) Client post mastectomy who reports numbness at the surgical site 
C) Client post neck dissection who reports difficulty chewing 
D) Client receiving antibiotics who reports new-onset vaginal itching

Question 16

The charge nurse in the medical-surgical unit is evaluating client safety.  Which actions by unlicensed assistive personnel (UAP) would require the nurse to intervene?  Select all that apply.

Accepted Answer

A) 1 UAP repositioning a client who is 8 hours postoperative total hip replacement 
B) 1 UAP using a gait belt to transfer a partial weight-bearing client from the bed to a chair 
C) 2 UAPs repositioning a client who is sedated and has been on the left side for 2 hours 
D) 2 UAPs using the log-rolling technique to move a client with a cervical collar 
E) 3 UAPs using a draw sheet to move a client who weighs 220 lb (100 kg) up in bed

Question 17

The licensed practical nurse (LPN) with 20 years of experience approaches the new graduate registered nurse (RN) during orientation.  The LPN states, "The only difference between you and me is the size of our paychecks."  What would be the best response for the new graduate RN to make initially?

Accepted Answer

A) Assert being the manager of the client team 
B) Emphasize the additional education received 
C) Explain the legal difference in the scope of practice 
D) Focus on the need to work together for quality client care

Question 18

The nurse prepares a client for scheduled surgery.  Which actions are the nurse's legal responsibility with regard to informed consent?  Select all that apply.

Accepted Answer

A) Acting as a witness that the client signed the consent form voluntarily 
B) Documenting in the medical record the date and time the signature was obtained 
C) Educating the client if there is a misunderstanding about the procedure 
D) Explaining to the client the right to refuse surgery 
E) Verifying that the client is competent to provide informed consent

Question 19

Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine.  When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients."  What is the best response by the nurse?

Accepted Answer

A) "Would you mind answering the lights anyway?" 
B) "I need you to answer the lights because we want to provide good client care." 
C) Say nothing and answer the lights, but write up a disciplinary action 
D) Tell the UAP that this is unacceptable and speak to the nurse manager

Question 20

A large-scale community disaster occurs and clients must share hospital rooms due to the rapid influx of new victims.  Which room assignments are appropriate in this situation?  Select all that apply.

Accepted Answer

A) 2 clients on contact isolation, one with vancomycin-resistant enterococci infection and another with methicillin-resistant Staphylococcus infection 
B) 2 clients with Clostridium difficile infection, one in the stool and the other in a wound 
C) A client in sickle cell disease crisis and a client with streptococcal pneumonia 
D) A client who had abdominal surgery today and a client with universal precautions 
E) A young client in Buck's traction with an elderly client with Parkinson's disease

Exam 5: Leadership & Management

Which emergency department clients cannot be allowed to sign out against medical advice? Select all that apply.

Four clients are seen by the emergency department nurse. Which client is a priority for treatment and definitive care?

The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment?

The nurse assistant reports vital signs on 4 clients. Which client should be a priority for the nurse to assess?

The nurse has received report on 4 clients. Which client should the nurse see first?

The nurse is caring for clients on a busy medical-surgical unit. Which client would be priority to assess first?

The nurse has been assigned to the staging area of a disaster response to an act of terrorism that deployed a caustic chemical agent. A client comes to the triage area with burns to the skin, severe pain, and visible chemical residue. What is the nurse's priority action?

Which of the following are examples of medical battery? Select all that apply.

A float nurse from labor and delivery is assigned to the cardiac care unit. Which client is most appropriate for the charge nurse to assign to the float nurse?

Which situations require that the registered nurse (RN) report to an appropriate authority? Select all that apply.

The nurse receives report on 4 clients. Which client should the nurse see first?

The nurse has received report on 4 clients at the start of the shift. Which client should the nurse assess first?

The charge nurse in the medical-surgical unit is evaluating client safety. Which actions by unlicensed assistive personnel (UAP) would require the nurse to intervene? Select all that apply.

The licensed practical nurse (LPN) with 20 years of experience approaches the new graduate registered nurse (RN) during orientation. The LPN states, "The only difference between you and me is the size of our paychecks." What would be the best response for the new graduate RN to make initially?

The nurse prepares a client for scheduled surgery. Which actions are the nurse's legal responsibility with regard to informed consent? Select all that apply.

Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my clients." What is the best response by the nurse?

A large-scale community disaster occurs and clients must share hospital rooms due to the rapid influx of new victims. Which room assignments are appropriate in this situation? Select all that apply.