Question 1

The nurse is making assignments for the next shift.  Which client should the nurse assign to the new nurse coming out of orientation?

Accepted Answer

A) Client diagnosed with chronic anemia receiving iron via IV route 
B) Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dL (33.3 mmol/L) 
C) Client undergoing ultrafiltration for congestive heart failure 
D) Client with a prescription for routine hemodialysis who has chronic renal failure

Question 2

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen.  How should the nurse respond?

Accepted Answer

A) Ask about liver disease and give acetaminophen from the nurse's personal supply 
B) Assess the employee's blood pressure 
C) Check for allergies to drugs before giving acetaminophen from hospital stock 
D) Refer employee to the employee health provider

Question 3

A nurse is caring for an older client admitted for failure to thrive and a history of recent falls and weight loss.  The client lives in the child's home, but the nurse is questioning the safety of the home.  The nurse needs to assess the appropriateness of the living situation and arrange for an alternate living situation or additional support if needed.  It is most appropriate for the nurse to consult with which interdisciplinary team member during the assessment?

Accepted Answer

A) Adult protective services 
B) Physical therapist 
C) Physician 
D) Social worker

Question 4

The nurse receives report on 4 clients.  Which client should be seen first?

Accepted Answer

A) 10-month-old with audible congestion and mucus-producing cough 
B) 10-year-old with an active nose bleed who is applying pressure 
C) 12-year-old with urinary frequency and burning, and fever 
D) 15-year-old with painful right hip, fever, and limited range of motion

Question 5

A nurse working in the office of a health care provider (HCP) must respond to client telephone messages.  The nurse should return which call first?

Accepted Answer

A) Client with a left shoulder sling due to a fractured clavicle, reports nausea after taking oxycodone 
B) Client with a right leg cast applied yesterday for a fractured ankle, reports tingling in the right foot 
C) Client with diabetes, reports having taken the usual dose of insulin this morning and is now vomiting 
D) Client with fibromyalgia who is prescribed amitriptyline for sleep, reports continued insomnia

Question 6

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period.  Which client would be the priority for the nurse to see first?

Accepted Answer

A) A client post cholecystectomy reporting increased nausea 
B) A client post myomectomy with mild oozing of blood from the surgical site 
C) A client post spinal surgery requesting additional pain medication 
D) A client post transurethral resection of the prostate with reddish-pink drainage

Question 7

Which emergency department client would be allowed to leave against medical advice after the risks are discussed with the primary health care provider?

Accepted Answer

A) 5-year-old client with meningitis whose parent refuses antibiotics 
B) Client who tried to commit suicide by taking a handful of acetaminophen an hour ago 
C) Client with a urinary tract infection who is disoriented to time and place 
D) Client with coffee-ground emesis from chronic use of high-dose aspirin

Question 8

Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care?  Select all that apply.

Accepted Answer

A) Client diagnosed with lumbar spinal cord compression has paraplegia 
B) Client's Glasgow Coma Scale (GCS) score is 3 
C) Client is refusing a life-saving treatment due to religious beliefs 
D) Client with intracerebral hemorrhage has aphasia 
E) Oriented client has cancer and is on a ventilator

Question 9

The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM.  Which assigned client should the nurse see first?

Accepted Answer

A) Client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells 
B) Client with an ulcerative colitis flare-up has temperature 101 F (38.3 
C)  and abdominal cramping 
C) Client with atrial fibrillation, on telemetry, prescribed warfarin, with an International Normalized Ratio (INR) of 3.2 
D) Client with chronic kidney disease scheduled for bedside hemodialysis at 8:00 AM, with a serum creatinine of 8.4 mg/dL (743 µmol/L)

Question 10

The registered nurse (RN) is working with unlicensed assistive personnel (UAP).  Which task can the RN safely delegate to the UAP?

Accepted Answer

A) Assisting a 2-day postoperative hip arthroplasty client with morning care 
B) Collecting a urine specimen for culture and sensitivity from a client with a Foley catheter 
C) Initial change of colostomy bag for a client who is 1-day postoperative colostomy 
D) Refilling the empty enteral feeding container with tube feeding

Question 11

The nurse receives report on 4 clients.  Which client conditions require priority assessment?

Accepted Answer

A) 34-year-old with acute pericarditis reporting left-sided chest pain that is worse with inspirations 
B) 54-year-old post right femoropopliteal bypass surgery reporting sudden-onset severe right foot pain 
C) 64-year-old post hip replacement reporting sudden-onset right-sided chest pain and dyspnea 
D) 70-year-old with pneumonia; rapid, irregular pulse of 140/min; and blood pressure of 130/86 mm Hg

Question 12

The nurse reviews the assigned clients' laboratory results and medication administration records.  Which finding is the highest priority for the nurse to follow-up with the health care provider?

Accepted Answer

A) Gram-negative infection and positive blood cultures in a client prescribed tobramycin 
B) Serum B-type natriuretic peptide (BNP) 650 pg/mL (650 ng/L) in a client prescribed furosemide 
C) Serum potassium 5.7 mEq/L (5.7 mmol/L) in a client prescribed spironolactone 
D) Serum sodium 132 mEq/L (132 mmol/L) in a client prescribed IV normal saline solution at 175 mL/hr

Question 13

The nurse witnessed a signed informed consent for an inguinal hernia repair surgery.  During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair.  Which action should the nurse perform?

Accepted Answer

A) Add the secondary hernia to the consent form that the client signed before the procedure 
B) Call the client's medical power of attorney to provide consent for the additional procedure 
C) Document that an additional hernia was found and that it will require surgery at a later time 
D) Witness an additional consent after both procedures are complete and the client is awake

Question 14

During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent.  What is the best response for the day charge nurse to give?

Accepted Answer

A) Encourage the night nurse to provide the UAP with additional training 
B) Indicate that it is the night nurse's job to deal with staff problems 
C) Remind the night nurse that the UAP is doing the best job the UAP can 
D) Suggest that the night nurse discuss concerns with the nurse manager

Question 15

A nurse discontinues patient-controlled analgesia per the health care provider's prescription, and notes that there is 10 mL of morphine sulfate left in the cartridge.  All other nurses on the unit appear busy.  What is the most appropriate action by the nurse?

Accepted Answer

A) Ask unlicensed assistive personnel to witness the wasting of the medication 
B) Document that another nurse was not available to waste the medication 
C) Wait until another nurse is available and then witness the waste together 
D) Waste the morphine alone and then show the empty cartridge to the charge nurse

Question 16

The nurse receives handoff of care report on four clients.  Which client should the nurse assess first?

Accepted Answer

A) Client with Graves disease who has a heart rate of 110/min and blood pressure of 122/85 mm Hg 
B) Client with pneumonia and temperature of 101.8 F (38.8 
C)  who is unable to receive antibiotics due to an occluded IV catheter 
C) Client with sickle cell disease whose pain rating has increased from 3 to 9 on a scale of 0-10 over the last hour 
D) Client with type 2 diabetes whose fingerstick glucose level is 220 mg/dL (12.2 mmol/L)

Question 17

Which of the following tasks would the charge nurse on a surgical unit assign to the experienced unlicensed assistive personnel (UAP)?

Accepted Answer

A) Assisting a client in ambulating to the bathroom for the first time following surgery 
B) Explaining why using the incentive spirometer is important to a client with postoperative pneumonia 
C) Feeding a client with dementia who has a blood sugar of 70 mg/dL (3.9 mmol/L) 
D) Taking vital signs every 15 minutes on a client who was just transferred from the post- anesthesia recovery unit

Question 18

Which client does the nurse assess first after receiving the morning report?

Accepted Answer

A) Client has cellulitis from injecting heroin; threatening to leave against medical advice if more morphine is not given right now 
B) Client is 1 day postoperative colectomy; night nurse medicated client with morphine 15 minutes ago 
C) Client is 2 days postoperative open gastric bypass surgery; now reporting nausea and dry heaving 
D) Client is 3 days postoperative total knee replacement; waiting to be discharged

Question 19

The nurse on the neurotrauma unit receives report on 4 clients.  Which client should the nurse assess first?

Accepted Answer

A) Client in neurogenic shock from a spinal cord injury, with pulse of 56/min, blood pressure of 120/60 mm Hg, and warm and pink skin 
B) Client with a concussion from closed-head injury due to a fall, Glasgow Coma Scale score of 15, headache, and memory loss 
C) Client with a subdural hematoma, pulse of 48/min, blood pressure of 190/90 mm Hg, and a pupil that reacts slowly to light 
D) Client with central diabetes insipidus from a head injury, hypernatremia, and urine output of 210 mL/hr

Question 20

The nurse receives the following information in the hand-off report.  Which client should the nurse assess first?

Accepted Answer

A) Client with a paralytic ileus following a colon resection who has abdominal distension, no audible bowel sounds, and nausea 
B) Client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of 90/60 mm Hg, and pulse of 110/min 
C) Client with bacterial peritonitis following surgery for a ruptured appendix who is receiving IV tobramycin and has a temperature of 101 F (38.3 
C)  
D) Client with dysphagia and a sore throat who has a nasogastric tube to administer contrast media for an abdominal CT scan

Exam 5: Leadership & Management

The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation?

A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?

The nurse receives report on 4 clients. Which client should be seen first?

A nurse working in the office of a health care provider (HCP) must respond to client telephone messages. The nurse should return which call first?

The post-anesthesia care unit nurse is caring for 4 clients during the immediate postoperative period. Which client would be the priority for the nurse to see first?

Which emergency department client would be allowed to leave against medical advice after the risks are discussed with the primary health care provider?

Which situations would prompt the health care team to use the client's advance directive to make a decision regarding care? Select all that apply.

The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first?

The registered nurse (RN) is working with unlicensed assistive personnel (UAP) . Which task can the RN safely delegate to the UAP?

The nurse receives report on 4 clients. Which client conditions require priority assessment?

The nurse reviews the assigned clients' laboratory results and medication administration records. Which finding is the highest priority for the nurse to follow-up with the health care provider?

The nurse witnessed a signed informed consent for an inguinal hernia repair surgery. During the procedure, the surgeon discovers a secondary ventral hernia that also requires repair. Which action should the nurse perform?

During the shift report, the night charge nurse tells the day charge nurse that the night unlicensed assistive personnel (UAP) is totally incompetent. What is the best response for the day charge nurse to give?

A nurse discontinues patient-controlled analgesia per the health care provider's prescription, and notes that there is 10 mL of morphine sulfate left in the cartridge. All other nurses on the unit appear busy. What is the most appropriate action by the nurse?

The nurse receives handoff of care report on four clients. Which client should the nurse assess first?

Which of the following tasks would the charge nurse on a surgical unit assign to the experienced unlicensed assistive personnel (UAP) ?

Which client does the nurse assess first after receiving the morning report?

The nurse on the neurotrauma unit receives report on 4 clients. Which client should the nurse assess first?

The nurse receives the following information in the hand-off report. Which client should the nurse assess first?