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    Exam Review

    1. A charge nurse on a medical-surgical unit is reviewing the electronic medical records of a group of clients during a mass casualty event. Select the two clients that the nurse should recommend for discharge to make room for clients injured in the disaster.
      (SATA)
      A)
      Client 4
      B)
      Client 5
      C)
      Client 3
      D)
      Client 1
      E)
      Client 2
    2. A nurse is planning an in-service program about nationally notifiable infectious diseases. Which of the following diseases should the nurse include as reportable to community health officials?
      A)
      Coxsackievirus
      B)
      Endocarditis
      C)
      Respiratory syncytial virus
      D)
      Lyme disease
    3. A nurse is delegating tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?
      A)
      Tag a malfunctioning piece of equipment as broken.
      B)
      Check on a client whose telemetry monitor is continuously beeping.
      C)
      Determine whether an oxygen flow meter is accurately set at 2 L/min via nasal cannula.
      D)
      Instruct a client about the use of an incentive spirometer.
    4. A nurse manager of medical-surgical units observes charge nurses as they handle conflict resolution. Which of the following situations demonstrates the most appropriate conflict resolution technique by the charge nurse?
      A)
      Situation 1
      B)
      Situation 2
      C)
      Situation 3
      D)
      Situation 4
      E)
      Situation 5
    Page 1 of 17

    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 has a raised red skin rash on their arms, neck, and face
      B)
      A client who reports right-sided flank pain and is diaphoretic
      C)
      A client who reports shortness of breath and left neck and shoulder pain
      D)
      A client who has active bleeding from a puncture wound of the left groin area
    2. A nurse is caring for a group of clients prior to discharge. The nurse should identify that which of the following clients might benefit from a case manager to facilitate continuity of care?
      A)
      A client who is requesting a provider’s note to return to work tomorrow
      B)
      A client who is being discharged home following a minor outpatient procedure
      C)
      A client who is transferring from acute care to a rehabilitation facility
      D)
      A client who is requesting a change in pain medication
    3. A nurse is caring for a client who requests a copy of their medical records immediately. Which of the following responses should the nurse make?
      A)
      "What are you planning on doing with your medical record?"
      B)
      "You must submit a written request before you can receive a copy."
      C)
      "The facility is unable to release your records."
      D)
      "I will make a copy of your medical records right away."
    4. 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 be given contrast dye during this test"
      B)
      "I might have to wear a nose clip during this test"
      C)
      "I will run on a treadmill during this test"
      D)
      "I might have a tube inserted into my airway during this test"
    Page 2 of 17

    Exam Review

    1. A charge nurse is assessing the room of a newly admitted client who has dysphagia. Which of the following pieces of equipment should the nurse ensure is available in the client’s room?
      A)
      Large-handled utensils
      B)
      Bite block
      C)
      Yankauer suction device
      D)
      Nasal cannula and oxygen
    2. A nurse is caring for a client who does not share a language with the nurse. Which of the following actions should the nurse take?
      A)
      Speak facing the interpreter when using language services.
      B)
      Speak in the third person when using an interpreter.
      C)
      Tell the client an interpreter telephone service is only available during daytime hours.
      D)
      Notify the client in writing of their rights to receive an interpreter.
      E)
      None
      F)
      None
    3. A nurse is teaching a client about advance directives. Which of the following statements should the nurse include in the teaching?
      A)
      "You should designate a family member to serve as durable power of attorney."
      B)
      "You should indicate what procedures you will allow if you are unable to communicate."
      C)
      "Once you sign the advance directives, your choices cannot be changed."
      D)
      "A lawyer is required to draw up your advance directives documentation."
    4. A nurse is caring for a client who fell and is reporting pain in their left hip. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nurse take?
      A)
      Have a physical therapist evaluate the client.
      B)
      Notify the nursing supervisor.
      C)
      Complete an incident report in the client's medical record.
      D)
      Apply a warm compress to the hip.
    Page 3 of 17

    Exam Review

    1. A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?
      A)
      A client who has bipolar disorder and is exhibiting signs of hallucination
      B)
      A client who has major burns over 75% of their body surface area
      C)
      A client who has two open chest wounds with a left tracheal deviation
      D)
      A client who has a neck injury and is unable to breathe spontaneously
    2. A nurse manager is preparing to discuss incident reporting with nursing staff. Which of the following situations should the nurse manager include as a reason to complete an incident report?
      A)
      Inability to obtain a client’s prescribed medication from pharmacy
      B)
      Client refusal of a medication
      C)
      Client concerns regarding meals
      D)
      Withholding a client's scheduled medication
    3. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?
      A)
      "I will instruct visitors to wear a mask when visiting a client who is on contact precautions."
      B)
      "I will place a client who has compromised immunity in a negative-pressure airflow room."
      C)
      "I will have a client who is on airborne precautions wear a mask when out of their room."
      D)
      "I will wear an N95 respirator mask when caring for a client who is on droplet precautions."
    4. A nurse is providing an in-service about actions to take during a fire on the unit. Which of the following instructions should the nurse include?
      A)
      Move client care equipment into the hallway
      B)
      Use the fire extinguisher by aiming at the top of the flames
      C)
      Close the windows in client rooms
      D)
      Place wet towels at the base of doors
    Page 4 of 17

    Exam Review

    1. A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?
      A)
      “I am not sure how I will pay for all the therapy I will need”
      B)
      “I hope I can adjust to using crutches while I am recovering”
      C)
      “I just don’t think I can handle looking at my leg”
      D)
      “I am worried about taking care of my toddler at home”
    2. A charge nurse is teaching a group of nurses about the purpose of a living will. Which of the following information about living wills should the charge nurse include in the teaching?
      A)
      Addresses resuscitation measures
      B)
      Provides protection against malpractice
      C)
      Documents that the client gave informed consent
      D)
      Designates a health care surrogate to make health care decisions
    3. A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?
      A)
      Determine the reasons the nurses are not taking scheduled breaks
      B)
      Provide coverage for the nurses’ breaks
      C)
      Discuss time management strategies with the nurses
      D)
      Review facility policies for taking scheduled breaks
    4. The nurse is providing care for the client. Which of the following findings should the nurse report to the provider? Select five findings that the nurse should report.
      A)
      Respiratory assessment
      B)
      Temperature
      C)
      Heart rate
      D)
      Neurological status
      E)
      X-ray results
      F)
      Bowel pattern
      G)
      Oxygen saturation
    Page 5 of 17

    Exam Review

    1. A nurse manager is receiving report and is faced with the following situations that require intervention. Which of the following should the nurse manager address first?
      A)
      A client is refusing care from assistive personnel of the opposite gender
      B)
      No transport assistance is available to take a client to physical therapy
      C)
      Two nurses had a heated disagreement about a scheduling issue
      D)
      Three staff members have called to say they will be absent
    2. A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? (Select all that apply.)
      A)
      Place a copy of the completed report in the client's medical record.
      B)
      Obtain an order from the client's provider to complete the report.
      C)
      Include the time the medication error occurred in the report.
      D)
      Identify the medication name and dosage administered to the client in the report
      E)
      Make a copy of the incident report for personal record keeping
    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.)
      A)
      A nurse and a provider are discussing a client's condition at the nurses’ station while a visitor is present
      B)
      A nurse is faxing data about a client to a referred provider
      C)
      An assistive personnel is informing a friend of the client about their condition
      D)
      A nurse is reviewing an electronic list of all clients admitted to the unit
      E)
      An assistive personnel logs out of the computer prior to responding to a call light
    4. A nurse enters a client's room to witness an informed consent for a gastroscopy. The client states he does not understand the procedure. Which of the following actions should the nurse take?
      A)
      Inform the provider that the client requires clarification about the procedure.
      B)
      Educate the client about the risks of refusing the procedure.
      C)
      Complete an incident report.
      D)
      Answer the client's questions concerning the procedure.
    Page 6 of 17