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    Exam Review

    1. The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next?
      A)
      Direct the nursing assistive personnel to give the acetaminophen.
      B)
      Perform a pain assessment only after administering the acetaminophen.
      C)
      Notify the health care provider to obtain a verbal order.
      D)
      Administer the acetaminophen.
    2. When using the PIE format for documentation, which of the following elements should the nurse include under 'P?
      A)
      Problem identified during assessment
      B)
      Interventions planned for the patient
      C)
      Patient's subjective complaints
      D)
      Evaluation of care provided
    3. Which of the following signs is most indicative of impaired skin integrity?
      A)
      Skin feeling warm to the touch
      B)
      Presence of a wound with partial thickness skin loss
      C)
      Dry skin with no visible lesions
      D)
      Slight redness of the skin after applying pressure
    4. A nursing is preparing to give a handoff report to the oncoming nurse. In which of the following areas should the nurse provide report to the oncoming nurse?
      A)
      Nurse's lounge
      B)
      Conference area
      C)
      Client's bedside
      D)
      Outside client's room
    Page 1 of 9

    Exam Review

    1. A nurse educator is reviewing guidelines for writing an outcome statement. Which examples best indicate a correct outcome statement? (Select All that Apply.)
      (SATA)
      A)
      The patient will be educated about the signs of infection.
      B)
      The patient will know how to manage diabetes effectively.
      C)
      The patient will understand the importance of medication adherence.
      D)
      The patient will walk 50 feet with a walker unassisted by the end of the week.
      E)
      The patient will demonstrate correct use of an inhaler by the end of the teaching session.
      F)
      The patient will report a pain level of less than 4 on a scale of 0 to 10 within 24 hours of receiving pain medication.
    2. A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care?
      A)
      Patient will be offered laxatives or stool softeners this shift.
      B)
      Patient will have one soft, formed bowel movement by end of shift.
      C)
      Patient will not take any pain medications this shift.
      D)
      Patient will walk unassisted to bathroom by the end of shift.
      E)
      Answer: B
    3. Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?
      A)
      The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.
      B)
      The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done.
      C)
      The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps.
      D)
      The nurse elevates a leg cast when the patient reports decreased mobility.
    4. Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?
      A)
      The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.
      B)
      The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done.
      C)
      The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps.
      D)
      The nurse elevates a leg cast when the patient reports decreased mobility
    Page 2 of 9

    Exam Review

    1. A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?
      A)
      Planning
      B)
      Assessment
      C)
      Implementation
      D)
      Evaluation
    2. A nurse receives change of shift report about a group of assigned patients. Which patient should the nurse attend to first?
      A)
      A patient who had surgery two days ago and is learning how to change the dressing
      B)
      A patient who was admitted 30 minutes ago for chest pain
      C)
      A patient who received pain medication 10 minutes ago
      D)
      A patient who is being transferred to a long term care facility this afternoon
    3. When should a nurse perform an ongoing assessment during a patient's hospital stay?
      A)
      Only at the beginning of the hospital stay to establish a baseline.
      B)
      Once a week during routine rounds.
      C)
      At each shift change to identify any changes in the patient's condition.
      D)
      Only when the patient reports new symptoms.
    4. A nurse is assigned to four patients during a morning shift. Which patient should the nurse perform a focused assessment on first?
      A)
      A patient who is scheduled for a routine follow-up visit for hypertension management.
      B)
      A patient who is receiving antibiotics for a urinary tract infection and is requesting assistance with personal hygiene.
      C)
      A patient who is recovering from an appendectomy and is asking about discharge instructions.
      D)
      A patient who is complaining of sudden onset chest pain and shortness of breath.
      E)
      Answer: D
    Page 3 of 9

    Exam Review

    1. Which nursing diagnosis is written in the correct format when using NANDA-I taxonomy?
      A)
      Inability to Ingest Food, related to imbalanced nutrition: less than body requirements, as evidenced by inadequate food intake, weight less than 20% under ideal body weight
      B)
      Caregiver Role Strain, related to depression, as evidenced by constant crying
      C)
      Impaired Skin Integrity, related to physical immobility, as evidenced by a skin tear over sacral area
      D)
      Bowel Obstruction, related to recent abdominal surgery, as evidenced by nausea, vomiting, and abdominal pain
    2. A nurse administers the prescribed inhaled medication then auscultates the patient's lungs after the medication has finished. In what phase of the nursing process would the nurse's action of auscultating the lungs occur?
      A)
      Assessment
      B)
      Evaluation
      C)
      Diagnosis
      D)
      Planning
    3. The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise?
      A)
      Collaborative problem
      B)
      Nursing diagnosis
      C)
      Etiology
      D)
      Defining characteristic
    4. A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.)
      A)
      Teaching about medications
      B)
      Performing resuscitation
      C)
      Inserting a feeding tube
      D)
      Documenting wound care
      E)
      Ambulating a patient
    Page 4 of 9

    Exam Review

    1. Which patient scenario of a surgical patient in pain is most indicative of critical thinking?
      A)
      Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed
      B)
      Administering pain-relief medication according to what was given last shift
      C)
      Offering pain-relief medication based on the health care provider's orders
      D)
      Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past
    2. Which of the following is the most appropriate open-ended question to begin a nursing assessment?
      A)
      "Is this your first time experiencing these symptoms?"
      B)
      "Do you have any allergies?"
      C)
      "Can you describe what brought you to the hospital today?"
      D)
      "Are you feeling any pain right now?"
    3. A nurse reviews a patient's health record and finds the following data. Which example includes only subjective data?
      A)
      Temperature 38 C/100.4F, bowels sounds 15/minute
      B)
      Nausea and stomach cramps.
      C)
      Occasional cough, respiratory rate 18 breaths per minute
      D)
      White blood cell count 14,000/mm3, pain 4/10
    4. The nurse is providing care to a client admitted with pressure injuries. The nurse develops a plan of care focusing on healing measures and prevention of further injury. Which task does the nurse delegate to the nursing assistive personnel (NAP)?
      A)
      Turn and reposition the patient every 2 hours.
      B)
      Assess the patient's skin condition.
      C)
      Apply hydrocolloid dressing to the pressure injury.
      D)
      Change pressure injury dressings every shift.
    Page 5 of 9

    Exam Review

    1. A nurse formulates several nursing diagnoses then prioritizes using Maslow's hierarchy. What nursing diagnosis should have the highest priority?
      A)
      Altered Nutrition: Less Than Body Requirements
      B)
      Ineffective Coping
      C)
      Risk for Falls
      D)
      Impaired Mobility
    2. After receiving change of shift report, the nurse delegates hygiene care for the caseload of patients. Which patient should the nurse delegate to the nursing assistive personnel (NAP)?
      A)
      42 year old who is due to arrive from the emergency room and has experienced a stroke
      B)
      43 year old female who is post operative surgery and is bleeding from their wound
      C)
      82 year old who was admitted several hours ago with pneumonia, is receiving oxygen and needs a complete bath
      D)
      21 year old who had minor hand surgery 24 hours ago needs an assistance to bathe
    3. A nurse takes a health history, measures vital signs and conducts a physical assessment on a new admission. After data analysis, what should the nurse do next?
      A)
      Delegate nursing care to the assistive personnel.
      B)
      Determine the effectiveness of the plan
      C)
      Identify patient centered outcomes and goals
      D)
      Discuss discharge planning with the social worker
    4. A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially?
      A)
      Review the patient's activity orders.
      B)
      Medicate the patient to alleviate discomfort while ambulating.
      C)
      Ask for at least two other assistive personnel to come to the room.
      D)
      Offer the patient a walker.
    Page 6 of 9