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    Exam Review

    1. A charge nurse overhears a staff nurse discussing a client's diagnosis in the cafeteria. Which of the following responses should the charge nurse make?
      A)
      "We should discuss your concerns with the client's care team."
      B)
      "Please stop discussing the client in a public area."
      C)
      "Do you understand the HIPAA regulations?"
      D)
      "I will need to notify the client's provider about this breach of confidentiality."
    2. A nurse is caring for a client who is receiving medication via an infusion pump. The nurse notices the pump did not infuse the medication over the programmed amount of time. Which of the following actions should the nurse implement?
      A)
      Report pump malfunction to Clinical Engineering.
      B)
      Closely monitor the pump during next medication administration.
      C)
      Return infusion pump to the equipment storage room.
      D)
      Document incident report in the client's electronic medical record.
    3. A charge nurse is teaching a newly licensed nurse about caring for a client who has COPD. Which of the following instructions should the charge nurse include in the teaching?
      A)
      "Notify me if you observe that the client has distended neck veins."
      B)
      "Call the provider if you note clubbing of the client's fingernails."
      C)
      "Maintain the client's oxygen saturation level above 95 percent."
      D)
      "Have an assistive personnel ambulate the client just before meals."
    4. A nurse notes that a client is eating about half of the food on his plate and coughs frequently during meals. The nurse plans to perform dysphagia screening to determine the client's need for a referral to which of the following providers?
      A)
      Physical therapist
      B)
      Speech therapist
      C)
      Respiratory therapist
      D)
      Occupational therapist
    Page 1 of 18

    Exam Review

    1. A charge nurse is observing a newly licensed nurse provide care for a client who has a Clostridium difficile infection. Which of the following actions by the newly licensed nurse indicates an understanding of proper infection control procedures?
      A)
      Removes fresh flowers from the client's room
      B)
      Wears a gown when caring for the client
      C)
      Applies a mask before entering the client's room
      D)
      Washes her hands with an alcohol-based hand rub after caring for the client
    2. A nurse is tagging a group of clients during triage following an environmental disaster. On which of the following clients should the nurse place a red tag bracelet?
      A)
      A client who has asymmetrical chest wall movement
      B)
      A client who has a large laceration of the forearm
      C)
      A client who has a weeping abrasion over the upper back
      D)
      A client who has a closed fracture of the humerus
    3. A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality (Select all that apply.)
      (SATA)
      A)
      A nurse is reviewing an electronic list of all clients admitted to the unit.
      B)
      An assistive personnel logs out of the computer prior to responding to a call light.
      C)
      A nurse and a provider are discussing a client's condition at the nurses' station while a visitor is present.
      D)
      A nurse is faxing data about a client to a referred provider.
      E)
      An assistive personnel is informing a friend of the client about their condition.
    4. A nurse in a rehabilitation facility is preparing a discharge plan for a client who has paraplegia. Which of the following interventions should the nurse include in the plan?
      A)
      Recommend that the client adhere to a low-fiber diet.
      B)
      Recommend that the client avoid the influenza vaccine.
      C)
      Instruct the client to empty their bladder every 2 hr during the day.
      D)
      Instruct the client to change positions every 3 hr when sitting in a chair.
    Page 2 of 18

    Exam Review

    1. A nurse is caring for a client who has a terminal illness. The client tells the nurse that they want their sibling to make their health care decisions when they are unable to. Which of the following documents should the nurse discuss with the client?
      A)
      Durable power of attorney
      B)
      Living will
      C)
      Informed consent
      D)
      Do-not-resuscitate (DNR) prescription
    2. 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)
      Utility
      B)
      Autonomy
      C)
      Veracity
      D)
      Nonmaleficence
    3. 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 throws a box of tissues at a nurse.
      B)
      A visitor pinches his finger in the client's bed frame.
      C)
      A nurse administers a medication 30 min after the scheduled time.
      D)
      A client refuses to attend physical therapy.
    4. 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.
    Page 3 of 18

    Exam Review

    1. 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 active bleeding from a puncture wound of the left groin area
      C)
      A client who has a raised red skin rash on his arms, neck, and face
      D)
      A client who reports right-sided flank pain and is diaphoretic
    2. 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.
    3. 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 dehydration and is being admitted from the emergency department
      B)
      A client who has emphysema and has an oxygen saturation level of 92%
      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
    4. 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.
    Page 4 of 18

    Exam Review

    1. 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 refusal of a medication
      B)
      Withholding a client's scheduled medication
      C)
      Inability to obtain a client's prescribed medication from pharmacy
      D)
      Client concerns regarding meals
    2. 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 at risk for pressure ulcers and has an albumin level of 4.2 g/dL
      B)
      A client who has Type 1 diabetes and uses an insulin pump
      C)
      A client who is receiving heparin and has an aPTT of 34 seconds
      D)
      A client who has orthostatic hypotension and is receiving IV fluids
    3. 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)
      Assign clients who are not prescribed narcotics to the staff nurse.
      C)
      Report the staff nurse to the facility ethics committee.
      D)
      Collect data about the staff nurse to support further action.
    4. 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
    Page 5 of 18

    Exam Review

    1. 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
    2. 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.
    3. 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."
    4. 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.
    Page 6 of 18