Exam Review

A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain that preventing client injury by removing a fall hazard demonstrates which of the following ethical principles?
A)
Nonmaleficence
B)
Veracity
C)
Utility
D)
Autonomy
A charge nurse is discussing incident reports with a newly licensed nurse. Which of the following situations should the nurse identify as requiring an incident report?
A)
A client refuses to attend physical therapy.
B)
A visitor pinches his finger in the client's bed frame.
C)
A client throws a box of tissues at a nurse.
D)
A nurse administers a medication 30 min after the scheduled time.
A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which of the following tasks should the nurse assign to the AP?
A)
Administer the initial bolus feeding to a client who has an NG tube.
B)
Collect a urine specimen from a newly admitted client.
C)
Check a client's pain level 30 min after receiving acetaminophen.
D)
Instruct a client to splint an abdominal incision.
A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
A)
A client who reports shortness of breath and left neck and shoulder pain
B)
A client who has a raised red skin rash on their arms, neck, and face
C)
A client who reports right-sided flank pain and is diaphoretic
D)
A client who has active bleeding from a puncture wound of the left groin area

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Exam Review

A nurse is caring for a client who has signed consent for the removal of a tumor in the left frontal lobe of the brain. The client states, "The tumor is on the right side of my head." Which of the following actions should the nurse take?
A)
Tell the client to mark the right side of his head with indelible ink.
B)
Contact the surgery department to validate the operative site.
C)
Ask the surgeon to clarify the operative site with the client.
D)
Continue with the surgery because the client already gave informed consent.
A charge nurse is making assignments for a medical-surgical unit. Which of the following clients is appropriate to assign to a licensed practical nurse?
A)
A client who has emphysema and has an oxygen saturation level of 92%
B)
A client who has dehydration and is being admitted from the emergency department
C)
A client who is scheduled to receive 2 units of RBCs following a hip replacement
D)
A client who is scheduled to start oral nutrition 2 days after a cerebrovascular accident
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 primigravida client who is 1 day postoperative following a cesarean birth and has a PCA pump.
B)
A client who is at 32 weeks of gestation and has premature rupture of membranes.
C)
A multigravida client who has preeclampsia and is receiving misoprostol for induction of labor.
D)
A client who has gestational diabetes and is receiving biweekly nonstress tests.
A nurse manager is preparing to discuss incident reporting with nursing staff. Which of the following situations should the nurse manger include as a reason to complete an incident report?
A)
Client concerns regarding meals
B)
Inability to obtain a client's prescribed medication from pharmacy
C)
Client refusal of a medication
D)
Withholding a client's scheduled medication

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Exam Review

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 (30 to 40 seconds).
B)
A client who has type 1 diabetes mellitus and uses an insulin pump.
C)
A client who has orthostatic hypotension and is receiving IV fluids,
D)
A client who is at risk for pressure injuries and has an albumin level of 4.2 g/dL (3.5 to 5 g/dL).
A charge nurse suspects that a staff nurse is chemically impaired. Which of the following actions should the charge nurse take?
A)
Counsel the staff nurse about substance use.
B)
Collect data about the staff nurse to support further action.
C)
Report the staff nurse to the facility ethics committee.
D)
Assign clients who are not prescribed narcotics to the staff nurse.
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 steps to follow when providing wound care
C)
The time the client received their last dose of pain medication
D)
The belief that the client has a difficult relationship with their child
A nurse is assessing an older adult client who was brought to the emergency department by his adult son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?
A)
Ask the client's son to go to the waiting area
B)
File an incident report
C)
Treat and discharge the client
D)
Ask the client about his injuries with the son present

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Exam Review

A nurse is teaching a client about implied consent. Which of the following information should the nurse include in the teaching?
A)
The nurse's signature indicates they witnessed the client's signature.
B)
A client must understand risks and benefits of the proposed treatment.
C)
Nonverbal behavior indicates agreement.
D)
Consent can be verbal or written.
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 run on a treadmill during this test."
B)
"I might have to wear a nose clip during this test."
C)
"I might have a tube inserted into my airway during this test."
D)
"I will be given contrast dye during this test."
A nurse is chairing a committee about preventing infant abduction in a new birth care center. Which of the following quality control tasks should the nurse assign to be completed first?
A)
Identify the industry standards for infant safety.
B)
Establish measurement criteria for infant safety systems.
C)
Evaluate the selected infant safety system.
D)
Choose an infant safety system.
A nurse is receiving change-of-shift report on four clients. Which of the following clients should the nurse plan to see first?
A)
A client who has cirrhosis and severe pruritus
B)
A client who has a femur fracture and reports numbness of the toes
C)
A client who had a renal biopsy 3 hr ago and has pink-tinged urine
D)
A client who had a laparoscopic appendectomy 8 hr ago and is awaiting discharge

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Exam Review

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)
Accompanying a client who just had a wound debridement to physical therapy.
B)
Reinforcing dietary teaching with a client who has heart disease.
C)
Obtaining a urine specimen from an older adult client.
D)
Providing postmortem care for a client who has just died.
A nurse is providing teaching to a client about advance directives. Which of the following client statements indicates to the nurse an understanding of the teaching?
A)
"My health care surrogate should be my oldest living child."
B)
"Once my advance directives are signed, I no longer make my own decisions."
C)
"My living will determine who speaks for me when I am unable to do so."
D)
"I can alter my advance directives later if I change my mind about treatment."
A nurse manager is evaluating the clients on the unit who are assigned isolation precautions. Which of the following client assignments should the nurse manager identify as correct?
A)
Airborne precautions for a client who has respiratory failure.
B)
Protective precautions for a client who has neutropenia.
C)
Contact isolation for a client who has empyema.
D)
Droplet precautions for a client who has COPD.
A nurse is conducting an in-service about the nursing code of ethics with a group of newly licensed nurses. Which of the following information should the nurse include in the teaching as an example of advocacy?
A)
Suggesting a client's partner attend a support group for emotional support
B)
Recommending a referral for a client who requires physical therapy
C)
Evaluating a client's home for safety hazards
D)
Completing an incident report following a medication error

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Exam Review

A nurse is assessing a client who had a recent stroke. Which of the following findings should indicate to the nurse the need for referral to an occupational therapist?
A)
Receptive aphasia.
B)
Unilateral neglect.
C)
Memory loss.
D)
Facial drooping.
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)
Providing written information to a client regarding palliative care.
C)
Implementing a client's plan of care based on nursing goals.
D)
Obtaining an interpreter for a client who speaks a different language than the nurse.
E)
Initiating IV access on a client who has dementia while he is sleeping.
A nurse manager is developing a quality improvement project. The nurse manager should recognize that which of the following tools should be used to measure outcomes?
A)
SBAR Communication tool
B)
Flowcharts
C)
Clinical indicators
D)
Cause-and-effect diagrams
A nurse is caring for a client who is scheduled for surgery. After signing the consent form, the client tells the nurse that she has concerns about the procedure. Which of the following actions should the nurse take?
A)
Discuss the risks of the procedure.
B)
Notify the provider.
C)
Postpone the procedure.
D)
Emphasize the importance of the procedure.

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