Exam Review

The LPN in a long-term care facility is considering her tasks for the day. When delegating to the UAP (unlicensed assistive personnel), which of the following statements provide the UAP with the essential goal to communicate the assignment?
(SATA)
A)
The client in bed number 1 is weak, so help her ambulate so she does not fall.
B)
Document vital signs every 4 hours today for your assigned patients who need vital signs.
C)
Encourage frequent position changes to reduce pressure injury.
D)
Please check the blood pressure for Mrs. Brown in room number 2 and report back by 7:30 AM.
A new LPN is assigning tasks to the UAP (unlicensed assistive personnel). Which of the following is appropriate to assign to the UAP?
A)
Assess the IV site of the client in bed number 1 for any signs of redness or swelling.
B)
Give a bed bath to a patient who had a seizure this morning.
C)
Help the client in bed number 2 to ambulate to the bathroom every 2 hours.
D)
Explain to the client in bed number 3 why they can’t eat before surgery.
An LPN caring for a hospitalized client receives a call from someone identifying themselves as the client's adult sibling. The caller states, “I live out of town and can't visit, but I’m very worried. Can you please tell me how my brother is doing?” The nurse checks the chart and sees no documentation of approved family contacts. Which response by the nurse is most appropriate?
A)
I understand your concern, but I cannot confirm or deny any information without the patient’s permission.
B)
Since you're a family member, I can tell you he's doing okay.
C)
Let me transfer you to the charge nurse for an update.
D)
He is stable right now, but I’ll let him know you called.
The graduate nurse is caring for a client that is in droplet isolation precautions. Which question, asked by the graduate nurse, to their mentor indicates that they correctly understand this type of precaution?
A)
Should patients in droplet precautions be placed in a negative pressure room?
B)
Do I need a mask to enter the room?
C)
Should I dispose of the gloves and gown I used after leaving the room?
D)
Where are the extra masks located, the box is empty?

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Exam Review

A client fell out of bed trying to go to the bathroom. The nurse has assessed the patient and no serious injuries were noted. What is the next best action of the nurse?
A)
Document that the client fell.
B)
Fill out an incident report if the client is actually injured.
C)
Notify the healthcare provider.
D)
Assist the client back to bed.
The nurse is caring for an Amish patient. Which of the following is the most appropriate question to assess cultural needs while in the facility?
A)
Do you have any cultural beliefs or food preferences we can help provide while you are here?
B)
Can you tell me any strange beliefs you have?
C)
Why do you not use electricity?
D)
Will your family members be interrupting care while you are here?
The nurse walks in to bring a patient’s medications. She finds the patient unconscious and after a tap and shout realizes the patient is unresponsive. Which intervention has the highest priority?
A)
Check for a carotid pulse for one full minute.
B)
Check for an apical pulse for 30 seconds.
C)
Count the radial pulse for one full minute.
D)
Check for a carotid pulse for no longer than 10 seconds.
A hospital is auditing the number of catheter-associated urinary tract infections (CAUTIs) in the hospital over the last two years. What is the primary reason for the hospital to perform this audit?
A)
CAUTIs increase the patient’s risk of complications and death.
B)
CAUTIs are unable to be prevented by healthcare staff.
C)
CAUTIs decrease the patient’s length of stay in the hospital.
D)
CAUTIs decrease the cost of care to the patient and hospital.

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Exam Review

A nurse who has returned to nursing after a 5-year break applies wrist restraints to a combative patient. Which action indicates that this nurse needs further education?
A)
The nurse checks on the patient every 25 minutes to verify they are safe.
B)
The nurse inserts two fingers underneath the restraint to check for appropriate tightness.
C)
The nurse obtains an order from the provider prior to applying restraints.
D)
The nurse releases the restraints every two hours for range of motion and patient needs.
The nurse is taking care of a non-verbal client. The nurse has been educated on the National Patient Safety Goals (NPSG). What action would be best to verify identification of the client?
A)
Ask the client who they are and have them state their birthday.
B)
Check the client’s name band and compare the MRN (medical record number) and picture in the patient’s chart.
C)
Check their room number and look for their picture in the chart.
D)
Ask the nurse who has been working at the facility for five years to identify the patient.
Which instruction would the nurse give when instructing the UAP (unlicensed assistive personnel) to give a complete bed bath to a patient?
A)
Use 1 washcloth for the whole body.
B)
Do not massage any reddened areas on the patient’s skin.
C)
Disconnect the IV tubing when changing the patient’s gown.
D)
Be sure to wash the patient’s face with soap.
What are possible risks to patient safety while in the healthcare facility? (Select all that apply)
A)
Medication errors
B)
Falling off a ladder
C)
Pressure ulcers
D)
Falling out of bed
E)
Latex reactions

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Exam Review

The student nurse is caring for a patient newly diagnosed with Clostridium Difficile (C-Diff). The student requires more education when they make which statement?
A)
Place the patient in contact isolation.
B)
Personal protective equipment (PPE) should be discarded inside the room after providing care.
C)
Use alcohol-based hand sanitizer instead of soap and water.
D)
Wear gloves and gown when providing care.
A nurse is caring for a client who just had knee surgery 2 days ago and is scheduled for physical therapy (PT) now. The patient is nervous and crying. She does not want to get out of bed this morning. Which action by the nurse is most likely to be helpful in reducing the patient’s concerns?
A)
Telling the patient, “We will talk more about this after you have had medications.”
B)
Standing at the side of the bed saying, “Come on, you got to do this, everyone gets nervous.”
C)
Sitting beside the patient and stating, “You seem distressed today, tell me a little about what has you upset, I have some time.”
D)
Ignoring the patient’s distress and continuing with the scheduled therapy.
The nurse needs to verify the apical pulse rate of his patient who takes Digoxin (cardiac medication). Which of the following is the best way to find an apical heart rate?
A)
By placing the stethoscope over the chest and moving it until the heartbeat is detected.
B)
By locating the 5th intercostal space, mid-clavicular line then auscultating for 60 seconds.
C)
By placing the stethoscope directly on the center of the chest and auscultating for 30 seconds and multiply × 2.
D)
By locating the 3rd intercostal space, mid-axillary line then auscultating for 60 seconds.
The LPN is caring for a client who recently had knee surgery. The client is ready to get out of bed and would like to eat after ambulating. The LPN mentions calling PT (physical therapy) and dietary to consult. She explains to the patient the priority reason for collaboration is which of the following?
A)
Collaboration is only necessary for patients with a chronic illness due to complications.
B)
Collaboration is the main cause of billing errors for a hospital stay.
C)
Communication decreases the need for nursing interventions.
D)
Collaboration decreases the risk for patient injury and may decrease length of hospital stay.

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Exam Review

The LPN is educating a patient newly diagnosed with diabetes about proper foot care. Which of the following, if said by the patient, requires further education on diabetic foot care?
A)
It is ok to walk barefoot outside for a few minutes each day.
B)
I should report any changes, bumps or red spots on my feet.
C)
I should examine my feet daily, including the bottom of the foot.
D)
I should wash my feet daily and dry thoroughly.
A nurse is explaining contact isolation to a patient with C-Diff and the patient’s spouse. What explanation best describes the reasoning for using contact isolation?
A)
It is needed to break the chain of infection.
B)
It is needed to protect the patient from infection.
C)
It decreases the amount of time needed for patient care.
D)
It requires a nurse, not a nursing assistant, to provide patient care.
What is the primary reason for performing perineal care on a male patient with incontinence?
A)
To reduce the risk of skin breakdown in the patient’s genital area.
B)
To promote personal hygiene while minimizing perineal odor.
C)
To remove all microorganisms from the patient’s perineal area.
D)
To provide comfort and a relaxed, refreshed feeling.
A Foley catheter has been ordered for a patient with a hip fracture. Which action will the nurse take to prevent a catheter-associated urinary tract infection (CAUTI)?
A)
Remove the catheter when it is no longer needed.
B)
Perform catheter care only one time during the 12-hour shift.
C)
Keep the catheter drainage bag on the bed, under the blanket.
D)
Insert the catheter using gloves out of the box on the wall.

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Exam Review

Which pulse site will the nurse palpate immediately distal to the antecubital space?
A)
Radial
B)
Apical
C)
Femoral
D)
Carotid
The nurse is aware that the first “R” in I-SBAR reflects which statement best?
A)
I observed the patient fall on the floor.
B)
Vital signs are BP 120/80, pulse 72, respirations 16.
C)
The patient is a 70-year-old male, diagnosed with dementia.
D)
I recommend an order for a culture and sensitivity (C&S) to confirm an infection.
When transferring a patient from the bed to the wheelchair, the nurse will do which of the following?
A)
Ensure that the wheelchair is unlocked and can easily move.
B)
Keep a narrow base of support when assisting the patient.
C)
Position the bed so the patient’s feet are flat on the floor.
D)
Limit the patient’s movement during the transfer.
An alert and oriented 70-year-old patient has been admitted to the long-term care facility from home seven days ago and has refused to take a bath since admission. What action will the nurse take initially?
A)
Contact the family to assist the patient with bathing; only family can make the patient bathe.
B)
Notify the physician of the patient’s situation and ask for a sedative.
C)
Assess the reasons the patient does not want to bathe and inform him of the risks.
D)
Explain to the patient he is at high risk for infection and he does not have a choice; it must be done today.

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