ATI Leadership Fundamental Practice Exam With Answers-371 Solved Questions

ATI LEADERSHIP FUNDAMENTAL EXAM TEST BANK ACTUAL EXAM
QUESTIONS WITH DETAILED VERIFIED ANSWERS/A+ GRADE
ASSURED
1. A patient is brought to the emergency department following a motor-vehicle crash. Drug use is
suspected in the crash, and a voided urine specimen is ordered. The patient repeatedly refuses to
provide the specimen. Which of the following is the appropriate action by the nurse?
A. Tell the patient that a catheter will be inserted.
B. Document the client’s refusal in the chart.
C. Assess the patient for urinary retention.
D. Obtain a provider’s prescription for a blood alcohol level.
Answer: B. Document the client’s refusal in the chart.
2. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate
to assign to a licensed practical nurse?
A. Pick up the meal trays after lunch.
B. Administer a nasogastric tube feeding.
C. Plan break times for assistive personnel.
D. Determine adequacy of ventilator settings.
Answer: B. Administer a nasogastric tube feeding.
3. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a sterile
procedure. Which of the following actions indicates the newly licensed nurse is maintaining
sterile technique? (SATA)
A. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field
B. Opens the sterile pack by first unfolding the top flap away from her body
C. Prepares a container of sterile solution on the field after putting on sterile gloves
D. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field
E. Holds the sterile solution bottle with the label facing up
Answer: B. Opens the sterile pack by first unfolding the top flap away from her body
D. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field

4. A nurse enters a client’s room and identifies that the patient is receiving too much IV fluid
because the IV pump is not working properly. Which of the following actions should the nurse
take first?
A. Auscultate the client’s lungs.
B. Notify the provider.
C. Place a faulty equipment tag on the pump.
D. Complete an incident report.
Answer: A. Auscultate the client’s lungs.
5. A nurse is planning care for a group of clients and can delegate care to a licensed practical
nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse assign to
the LPN?
A. Reinforcing teaching with a patient who is learning to self-administer insulin
B. Ambulating a patient who is scheduled for discharge later in the day
C. Administering morphine IV bolus to a patient who is hr postoperative
D. Admitting a new patient who has chronic back pain to the unit
Answer: A. Reinforcing teaching with a patient who is learning to self-administer insulin
6. A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After
donning a sterile gown and gloves, which of the following actions by the newly licensed nurse
demonstrates correct aseptic technique?
A. The nurse applies goggles.
B. The nurse turns her back to the sterile field.
C. The nurse holds her hands above her waist.
D. The nurse puts on a face mask.
Answer: C. The nurse holds her hands above her waist.
7. A nurse who is caring for a group of clients delegates collection of vital signs to an assistive
personnel (AP). Which of the following actions should the nurse take to evaluate the delegated
task?

A. Review vital sign trends at the end of the shift.
B. Recheck vital signs that are outside the expected reference range.
C. Ask the AP to write a summary of the delegated tasks during the shift.
D. Compare the vital signs the AP obtained with those taken by another AP on a previous shift.
Answer: B. Recheck vital signs that are outside the expected reference range.
8. A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive
personnel?
A. Obtaining a stool sample from a patient who has renal failure
B. Monitoring a patient who has a fluid restriction
C. Assessing a patient who just returned from haemodialysis
D. Reviewing dietary instructions for a patient who has kidney stones
Answer: A. Obtaining a stool sample from a patient who has renal failure
9. 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 patient who has a neck injury and is unable to breathe spontaneously
B. A patient who has two open chest wounds with a left tracheal deviation
C. A patient who has major burns over 75% of her body surface area
D. A patient who has bipolar disorder and is exhibiting signs of hallucination (Class 3)
Answer: B. A patient who has two open chest wounds with a left tracheal deviation
10. A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which
of the following statements by a staff nurse indicates that the teaching was effective?
A. “A family member can interpret to obtain informed consent from a patient who is deaf.”
B. “Consent can be given by a durable power of attorney.”
C. “Guardian consent is required for an emancipated minor.”
D. “The nurse can answer any questions the patient has about the procedure.”
Answer: B. “Consent can be given by a durable power of attorney.”

11. A nurse is caring for four clients. For which of the following clients should the nurse
collaborate with the facility ethics committee?
A. A middle adult patient who leaves the facility against medical advice
B. An older adult patient who has advanced directives on file
C. A young adult patient who is participating in a medical research study
D. An adolescent patient whose parents refuse a blood transfusion for religious reasons
Answer: D. An adolescent patient whose parents refuse a blood transfusion for religious reasons
12. A nurse in an ambulatory care setting is orient a newly licensed nurse who is preparing to
return a call to a client. The nurse should explain that which of the following is an objective of
telehealth?
A. Assessing patient needs
B. Developing patient treatment protocols
C. Providing medication reconciliation
D. Establishing communication between providers
Answer: D. Establishing communication between providers
13. A nurse is providing discharge teaching to a patient who has a new diagnosis of diabetes. The
patient expresses concern about the cost of blood-glucose monitoring supplies. Which of the
following actions should the nurse take?
A. Refer the patient to the social services department.
B. Provide the patient with a week’s worth of supplies from the hospital (still needs help paying
after)
C. Ask the provider about the possibility of less frequent monitoring (pt needs to monitor often)
D. Recommend the patient reuse the testing lancets (breaks the safety & infection protocol)
Answer: A. Refer the patient to the social services department.
14. A charge nurse is receiving change-of-shift report. Which of the following situations should
the charge nurse address first?
A. A nurse on the previous shift wrote an incident report about a medication error.
B. Two staff members have called to say they will be absent.

C. Transport assistance is unavailable to take a patient to occupational therapy.
D. The emergency department nurse is waiting to give report on a new admission.
Answer: D. The emergency department nurse is waiting to give report on a new admission.
15. A nurse who is precepting a newly licensed nurse is discussing the patient assignment for the
shift. Which of the following actions should the nurse preceptor take first to demonstrate
appropriate time management?
A. Complete required tasks.
B. Review the client’s new laboratory values.
C. Determine patientcare goals (set/plan goals)
D. Document assessment data.
Answer: C. Determine patientcare goals (set/plan goals)
16. A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which of
the following statements by a staff nurse indicates understanding?
A. “Clients who participate in research studies forfeit their HIPAA right to privacy.”
B. “HIPAA allows facility-specific coding of patient health care information to ensure privacy.”
C. “HIPAA prohibits the uploading of photographs of client’s providers to social media sites.”
D. “HIPAA allows clients to request a review of their own medical records.”
Answer: D. “HIPAA allows clients to request a review of their own medical records.”
17. A nurse is caring for a patient who has a tumor. The provider recommends surgery. The
patient refuses, but the client’s partner wants the surgery performed. Which of the following is
the deciding factor in determining if the surgery will be done?
A. Whether the patient understands the risk of refusing the procedure
B. Whether the facility ethics committee reached a consensus on the case
C. Whether the partner is the client’s durable power of attorney for health care
D. Whether the client’s refusal is based on religious belief
Answer: A. Whether the patient understands the risk of refusing the procedure

18. A charge nurse is planning the care of four newborns. An assistive personnel and licensed
practical nurse are available for staffing. Which of the following tasks should the nurse assign to
a licensed practical nurse?
A. Conduct the newborn hearing screening. (RN assessment)
B. Administer a hepatitis B vaccine.
C. Perform a New Ballard screening. (RN assessment)
D. Obtain vital signs. (CNA)
Answer: B. Administer a hepatitis B vaccine.
19. During a staff meeting a unit manager reviews the results for documenting patient education
and finds that they are below the benchmark. Which of the following strategies should the nurse
manager implement first?
A. Train LPNs to reinforce teaching with clients using a standardized teaching plan.
B. Determine factors that interfere with the documentation of patient education.
C. Include documentation of patient education as part of unit nurses’ annual performance
evaluation.
D. Offer incentives for the staff once the unit’s results are back in adherence with the benchmark.
Answer: B. Determine factors that interfere with the documentation of patient education.
20. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain
that preventing patient injury by removing a fall hazard demonstrates which of the following
ethical principles?
A. Utility
B. Autonomy
C. Nonmaleficence
D. Veracity
Answer: C. Nonmaleficence
21. A nurse is caring for a group of clients. Which of the following clients should the nurse plan
to assess first?

A. A patient who has congestive heart failure and has lost 0.9 kg (2 lb) in the past 24 hr
(improvement)
B. A patient who has diabetes mellitus and reports paraesthesia in his fingers and toes (ABC-circulation)
C. A patient who has a nasogastric tube and has crackles in the lungs (ABC--airway)
D. A patient who has a new diagnosis of Graves’ disease and a TSH level of 0.2 microunits/mL
Answer: C. A patient who has a nasogastric tube and has crackles in the lungs (ABC--airway)
22. A charge nurse is planning to evacuate clients on the unit because there is a fire on another
floor. Which of the following clients should the nurse evacuate first?
A. A patient who is in Buck’s traction for a left hip fracture (can’t necessarily move too much)
B. A patient who is 1 day postoperative following thoracic surgery and has a chest tube (possible
physical instability)
C. A patient who is confused and restrained for safety (still needs continual nursing
care/assessment)
D. A patient who is receiving IV chemotherapy and is ambulatory
Answer: D. A patient who is receiving IV chemotherapy and is ambulatory
23. A nurse enters the room of a patient who is unconscious and finds that the client’s son is
reading her electronic medical records from a monitor located at the bedside. Which of the
following actions should the nurse take first?
A. Recommend the son meet with the provider to get information about his mother’s condition.
B. Report the possible violation of patient confidentiality to the nurse manager.
C. Complete an incident report regarding the breach of the client’s confidentiality.
D. Log out the computer so that the client’s son is unable to view his mother’s information.
Answer: D. Log out the computer so that the client’s son is unable to view his mother’s
information.
24. A nurse is preparing a patient for cardiac catheterization. Just before the procedure, the
patient asks the nurse about the risks of the procedure. Which of the following actions should the
nurse take?

A. Explain the risks of the procedure to the client.
B. Convey the client’s request to the nurse who witnessed the consent.
C. Check to see if the medial record indicates the provider explained the procedure to the client.
D. Notify the provider about the client’s concerns.
Answer: D. Notify the provider about the client’s concerns.
25. A nurse is prioritizing care after receiving change-of-shift report on four clients. Which of the
following clients should the nurse assess first?
A. A patient who reports a headache with sensitivity to light
B. A patient who reports an urge to void but has not urinated during the prior shift
C. A patient who reports indigestion and pain in her jaw
D. A patient who reports feeling lightheaded when he stands up from a lying position
Answer: C. A patient who reports indigestion and pain in her jaw
26. 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. Discuss time management strategies with the nurses.
B. Determine the reasons the nurses are not taking scheduled breaks. Assess first
C. Provide coverage for the nurses’ breaks.
D. Review facility policies for taking scheduled breaks.
Answer: B. Determine the reasons the nurses are not taking scheduled breaks. Assess first
27. A nurse is preparing to delegate bathing and turning of a newly admitted patient who has endstage bone cancer to an experienced assistive personnel (AP). Which of the following
assessments should the nurse make before delegating care?
A. Has the AP checked the client’s pain level prior to turning her? (RN only - do not delegate
what you can EAT = evaluate, assess, teach)
B. Is the client’s family present so the AP can show them how to turn the client? (this is not
necessary)
C. Has data been collected about specific patient needs related to turning? (Assessment of
holistic care r/t pt needs and what the experienced AP can do)

D. Does the AP have the time to change the client’s central IV line dressing after turning her?
(AP cannot change dressings)
Answer: C. Has data been collected about specific patient needs related to turning? (Assessment
of holistic care r/t pt needs and what the experienced AP can do)
28. A nurse is preparing to transfer a patient from the emergency department to a medicalsurgical unit using the SBAR communication tool. Which of the following information should
the nurse include in the background portion of the report?
A. A prescribed consultation -under situation
B. The client’s vital signs
C. The client’s name -under situation
D. The client’s code status -under situation
Answer: B. The client’s vital signs
29. A nurse is planning discharge for a patient who has rheumatoid arthritis. Which of the
following statements by the patient should the nurse identify as an indication that a referral to an
occupation therapist is necessary?
A. “I need some help planning my meals to maintain my weight.”
B. “I am tired of having pain in my joints all the time.”
C. “I’m having difficulty climbing the stairs at my house.”
D. “I will need assistance with bathing.”
Answer: D. “I will need assistance with bathing.”
30. A nurse in the emergency department is caring for a 16-year-old patient who reports
abdominal pain and is accompanied by an adult neighbour. The provider diagnoses a ruptured
appendix and states that the patient requires an emergency appendectomy. Which of the
following actions should the nurse?
A. Ask the adult neighbour to sign the consent form.
B. Obtain consent from the hospital administrator.
C. Witness the patient signing the consent form.
D. Attempt to notify the client’s guardian to obtain consent.

Answer: D. Attempt to notify the client’s guardian to obtain consent.
31. A nurse on a medical-surgical unit is caring for four clients. Which of the following findings
is the highest priority?
A. A patient who had a cardiac catheterization whose capillary refill in the great toe is 4 seconds
B. A patient who has COPD and has an oxygen saturation of 90%
C. A patient who had a cholecystectomy 6 hr ago and is requesting pain medication
D. A patient whose TPN was discontinued 4 hr ago and is requesting clear liquids
Answer: A. A patient who had a cardiac catheterization whose capillary refill in the great toe is 4
seconds
32. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following
actions should the charge nurse take?
A. Assign clients who are not prescribed narcotics to the staff nurse.
B. Collect data about the staff nurse to support further action.
C. Report the staff nurse to the facility ethics committee.
D. Counsel the staff nurse about substance use.
Answer: B. Collect data about the staff nurse to support further action.
33. A nurse is assessing a client’s comprehension of a pulmonary function test prior to the
procedure. Which of the following patient 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 might have a tube inserted into my airway during the test.’
D. “I will run on a treadmill during this test.”
Answer: B. “I might have to wear a nose clip during this test.”
34. A nurse in the emergency department is triaging four clients. Which of the following clients
should the nurse recommend to be examined first?
A. A toddler who has a 2 cm (0.79 in) head laceration oozing dark red blood

B. An adolescent patient who has an injured ankle and reports a pain level of 8 on a scale from 0
to 10
C. An older adult patient who has dyspnea and a respiratory rate of 26/min
D. An adult patient who has large ecchymosis on both legs
Answer: C. An older adult patient who has dyspnea and a respiratory rate of 26/min
35. A home health nurse finds piles of newspapers in the hallway of a client’s home. The nurse
explains the need to discard the newspapers for safety reasons. The patient agrees to move the
newspapers into the living room. Which of the following conflict resolution strategies has the
nurse used?
A. Collaborating
B. Smoothing
C. Accommodating
D. Compromising
Answer: A. Collaborating
36. A nurse is planning to delegate patientcare assignments. Which of the following tasks should
the nurse plan to delegate to an assistive personnel?
A. Advising a patient on self-administration of acetaminophen
B. Informing a family of a client’s progress in physical therapy
C. Teaching a patient to perform a finger-stick for testing blood glucose levels
D. Performing post mortem care prior to transferring the patient to the morgue
Answer: D. Performing post mortem care prior to transferring the patient to the morgue
37. A nurse is providing discharge teaching to a patient following a total knee arthroplasty.
Which of the following information should the nurse include (SATA)
A. Advance directives information
B. Contact information for the physical therapist
C. Medication guidelines information
D. Insurance information
E. Information about follow-up care

Answer: B. Contact information for the physical therapist
C. Medication guidelines information
E. Information about follow-up care
38. A nurse is planning to discharge a patient who has terminal cancer and suggests that the
family might benefit from respite services. When the client’s partner asks how this service can
help, which of the following responses by the nurse is appropriate?
A. “This service offers psychological interventions during and after your wife’s illness.”
B. “The clinicians help reduce the severity of your wife’s physical problems.”
C. “This service delivers meals and supplies to reduce your errands away from home.”
D. “It makes it possible for you to have some time away from caring for your wife.”
Answer: D. “It makes it possible for you to have some time away from caring for your wife.”
39. A nurse is teaching a patient how to use a finger-stick glucometer at home. Which of the
following instructions should the nurse include?
A. Warm the hands prior to piercing the skin.
B. Cap the lancet prior to putting it in the trash.- never recap
C. Elevate the arm for 1 min before taking the blood sample.- has to be down so gravity can
assist to milk the blood out
D. Obtain the blood sample from the finger pads.
Answer: A. Warm the hands prior to piercing the skin.
40. A nurse is assessing a patient who had a recent stroke. Which of the following findings
should indicate the need for referral to an occupational therapist?
A. Receptive aphasia→ unable to understand language in its written or spoken form
B. Facial drooping →speech therapist
C. Memory loss
D. Unilateral neglect –is one of the disabling features of stroke, and is defined as a failure to
attend to the side opposite a brain lesion.
Answer: D. Unilateral neglect –is one of the disabling features of stroke, and is defined as a
failure to attend to the side opposite a brain lesion.

41. A nurse is participating in the development of a disaster management plan for a hospital. The
nurse should recognize that which of the following resources is the highest priority to have
available in response to a bioterrorism event?
A. A network for communication between staff members and families
B. A mental health specialist on the response team
C. A sufficient supply of personal protective equipment
D. A system for tracking patient information
Answer: C. A sufficient supply of personal protective equipment
42. A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the
following diseases should the nurse report to the state health department?
A. Rotavirus
B. Pertussis
C. Respiratory syncytial virus
D. Group B streptococcal disease
Answer: B. Pertussis
43. A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment used
for a patient who has Clostridium difficile. Which of the following solutions should the nurse
recommend to clean the equipment?
A. Chlorine bleach
B. Triclosan
C. Chlorhexidine
D. Isopropyl alcohol
Answer: A. Chlorine bleach
44. A nurse is assessing an older adult patient who was brought to the emergency department by
his adult son, who reports that the patient fell at home. The nurse suspects elder abuse. Which of
the following actions should the nurse take?
A. Treat and discharge the client.

B. Ask the client’s son to go to the waiting area.
C. File an incident report.
D. Ask the patient about his injuries with the son present
Answer: B. Ask the client’s son to go to the waiting area.
45. A nurse is completing discharge teaching with a patient who is being treated for tuberculosis
(TB). Which of the following statements by the patient indicates an understanding of the
teaching?
A. “I need to take my prescribed medication for 3 months.”
B.“I should have a sputum culture done every 2 to 4 weeks.”
C. “I need to have a TB skin test done once per year.”
D. “I should wear a mask while around my family.”
Answer: B.“I should have a sputum culture done every 2 to 4 weeks.”
46. An older adult patient is awaiting surgery for a fractured right hip. The nurse should
recognize that which of the following can be delegated to an assistive personnel?
A. Checking the pulses of the client’s right foot
B. Recording the client’s vital signs
C. Turning the client
D. Determining the client’s pain level
Answer: B. Recording the client’s vital signs
47. A charge nurse in the newborn nursery is delegating tasks to an assistive personnel (AP).
Which of the following is an appropriate task for the AP?
A. Inspect the skin of a newborn who is receiving phototherapy. – Assess
B. Answer the parents’ questions about newborn circumcision. - Teaching
C. Show a new mother how to change the newborn’s diaper. - Teaching
D. Obtain the weight of a newborn that is receiving formula
Answer: D. Obtain the weight of a newborn that is receiving formula

48. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “A provider can write a prescription for restraints ‘as needed’.”
B. “I need to tie the restraint to the part of the bed frame that moves.”
C. “I should tie the restraints using a square knot.”
D. “I will remove a client’s restraints every 4 hours.”
Answer: D. “I will remove a client’s restraints every 4 hours.”
49. An infection control nurse is planning an education program for a group of newly licensed
nurses. Which of the following infections should the nurse include when discussing illnesses
requiring droplet precautions?
A. Mumps
B. Rubeola
C. Varicella
D. Rotavirus
Answer: A. Mumps
50. A nurse is caring for a patient who has cancer. The patient and her partner are asking the
nurse about hospice are. Which of the following statements by the nurse is appropriate?
A. “Hospice care will prolong the life expectancy of clients who are terminally ill.”
B. “Hospice care is a multidisciplinary program for clients who are terminally ill.”
C. “Hospice care is helpful for clients at various stages of chronic illness.”
D. “Hospital access is no longer available for clients who are in hospice care.”
Answer: B. “Hospice care is a multidisciplinary program for clients who are terminally ill.”
51. A nurse is planning care for a patient who has Addison’s disease. Which of the following
tasks should the nurse plan to delegate to an assistive personnel?
A. Decide how often to measure vital signs.
B. Explain to the patient about a 24-hr urine specimen collection.
C. Determine the client’s muscle strength prior to ambulation.
D. Remind the patient to change positions slowly.

Answer: D. Remind the patient to change positions slowly.
52. A charge nurse discovers that a staff nurse on the unit has made repeated medication errors.
Which of the following actions should the charge nurse take first?
A. Notify the risk management department of the situation.
B. Review with the nurse the principles of medication administration.
C. Ask the nurse to describe her medication administration procedure.
D. Identify education opportunities for the nurse regarding safe medication administration.
Answer: C. Ask the nurse to describe her medication administration procedure.
B. Review with the nurse the principles of medication administration.
D. Identify education opportunities for the nurse regarding safe medication administration.
A. Notify the risk management department of the situation.
53. A case manager is reviewing documentation on several clients and notes a progress report
that falsely identifies a patient as HIV-positive due to multiple sexual partners. The nurse
manager should identify that which of the following torts has occurred?
A. Libel : talking bad about someone via writing it in notes
B. Battery : intentional/wrongful physical contact
C. Slander : Defamation with the spoken word
D. Negligence
Answer: A. Libel : talking bad about someone via writing it in notes
54. A nurse is preparing a patient for an elective mastectomy. The patient is wearing a plain gold
wedding band. Which of the following is an appropriate procedure for taking care of this client’s
ring?
A. Place the client’s ring in the facility safe.
B. Tape the ring securely to the client’s finger.
C. Place the ring in the bad with the client’s clothing.
D. Agree to keep the ring for the patient until after surgery.
Answer: A. Place the client’s ring in the facility safe.

55. A nurse is prioritizing postpartum care for four clients. Which of the following actions should
the nurse take first?
A. Assist a patient who requests help breastfeeding her 4-hr-old newborn.
B. Administer RH immune globulin to a patient who is Rh-negative and 6 hr postpartum.
C. Check uterine tone for a patient who received methylergonovine- if the uterine tone is not
D. Instruct a patient who has an episiotomy about a sitz bath.
Answer: C. Check uterine tone for a patient who received methylergonovine- if the uterine tone
is not
56. A hospice nurse is caring for a patient who has a terminal illness and reports severe pain.
After the nurse administers the prescribed opioid and benzodiazepine, the patient becomes
somnolent and difficult to arouse. Which of the following actions should the nurse take?
A. Withhold the benzodiazepine but continue the opioid.
B. Contact the provider about replacing the opioid with an NSAID.
C. Administer the benzodiazepine but withhold the opioid.
D. Continue the medication dosages that relieve the client’s pain.
Answer: D. Continue the medication dosages that relieve the client’s pain.
57. A nurse is observing an assistive personnel (AP) administer 0.9% sodium chloride enema to
an adult client. For which of the following actions by the AP should the nurse intervene?
A. Administers the solution at room temperature
B. Points tubing in the direction of the umbilicus during insertion
C. Position the patient on her left side with knees flexed
D. Inserts the tubing 8 cm (3.1 in) into the rectum
Answer: C. Position the patient on her left side with knees flexed
58. A nurse is providing information to a patient about advance directives. The nurse should
explain that advance directives include which of the following?
A. Instructions regarding treatments the patient desires or does not desire – (livings wills and
durable power of attorney make up AD ).
B. Information regarding the disposition of the client’s body upon death

C. Information regarding organ donation
D. A form with directions for contacting next of kin
Answer: A. Instructions regarding treatments the patient desires or does not desire – (livings
wills and durable power of attorney make up AD ).
59. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that
which of the following clients is the highest priority?
A. A patient who has peripheral vascular disease and has an absent pedal pulse in the right foot
B. A patient who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy.
C. A patient who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38C (101F)
D. A patient who is postoperative following a laminectomy 12 hr ago and is unable to void
Answer: A. A patient who has peripheral vascular disease and has an absent pedal pulse in the
right foot
60. A staff development nurse is giving an in-service presentation about advocacy in nursing.
Which of the following statements by a nurse indicates an understanding of the role of a patient
advocate?
A. “In the role of patient advocate, I should take responsibility for coordinating each client’s
care.”
B. “As a patient advocate, I will suggest the best course of action for clients who are indecisive.”
C. “My role as a patient advocate is to empower the clients to make informed healthcare
decisions.”
D. “As a patient advocate, I will adhere to the provider’s prescribed treatments.”
Answer: C. “My role as a patient advocate is to empower the clients to make informed
healthcare decisions.”
61. A nurse manager observes an assistive personnel (AP) incorrectly transferring a patient to the
bedside commode. Which of the following actions should the nurse take first?
A. Refer the AP to the facility procedure manual.

B. Instruct the AP to request assistance when unsure about a task.
C. Help the AP assist the patient with the transfer.
D. Demonstrate the proper patient transfer technique for the AP.
Answer: A. Refer the AP to the facility procedure manual.
62. A nurse at the local health department is caring for four clients who have communicable
diseases. Which of the following infections should the nurse report to the state health
department?
A. Chlamydia trachomatis
B. Pediculosis capitis
C. Impetigo contagiosa
D. Candida albicans
Answer: A. Chlamydia trachomatis
63. A charge nurse witnesses two nurses having a loud discussion at the nurses’ station about not
wanting to care for a patient who has drug-resistant tuberculosis. Which of the following actions
should the charge nurse take?
A. Escort the nurses to the nurses’ lounge to continue the discussion.
B. Recommend that both nurses be terminated.
C. Make arrangements to take over the client’s care.
D. Contact the house supervisor to mediate the conflict.
Answer: A. Escort the nurses to the nurses’ lounge to continue the discussion.
64. A newly licensed nurse is floating to an unfamiliar unit and determines that he does not have
sufficient experiences to safely care for his assigned clients. Which of the following actions
should the nurse take?
A. Accept the assignment with help from assistive personnel on the unit.
B. Request that the charge nurse modify the assignment.
C. Document the concern in the nurse’s notes.
D. Notify the risk manager.
Answer: B. Request that the charge nurse modify the assignment.

65. 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. Recommending a referral for a patient who requires physical therapy
B. Suggesting a client’s partner attend a support group for emotional support
C. Evaluating a client’s home for safety hazards
D. Completing an incident report following a medication error
Answer: A. Recommending a referral for a patient who requires physical therapy
66. A charge nurse in the emergency department is supervising a nurse who is floating from the
medical- surgical unit. Which of the following assignments is appropriate for the float nurse?
A. Administer IV nitro-glycerine to a patient who is experiencing chest pain.
B. Perform a urinary catheterization for a patient who has experienced a cerebrovascular accident
C. Set up a trauma room for an incoming patient who was in a motor-vehicle crash.
D. Complete a SAD PERSONS assessment scale for a patient who has attempted suicide.
Answer: B. Perform a urinary catheterization for a patient who has experienced a
cerebrovascular accident
67. A home health nurse is assessing the home environment during an initial visit to a patient
who has history of falls. Which of the following findings should the nurse identify as increasing
the client’s risk for falls? (SATA)
A. A folding chair without arm rests
B. A wheeled office chair at the client’s computer desk
C. A throw rug covering some cracked vinyl flooring in the kitchen
D. A two-wheeled walker used to assist the patient with ambulation
E. A raised vinyl seat on the toilet in the bathroom
Answer: A. A folding chair without arm rests
B. A wheeled office chair at the client’s computer desk
C. A throw rug covering some cracked vinyl flooring in the kitchen

68. A nurse in a long-term care facility should identify that which of the following will provide
security for clients who have dementia?
A. Turning off room lights at night
B. Using a facility
C. Restricting space to reduce pacing
D. Setting alarms on exits
Answer: D. Setting alarms on exits
69. A nurse in the emergency department is preparing to care for a patient who arrived via
ambulance. The patient is disoriented and has a cardiac arrhythmia. Which of the following
actions should the nurse take?
A. Have the patient sign a consent for treatment
B. Notify risk management before initiating treatment
C. Proceed with treatment without obtaining written consent (Implied Consent)
D. Contact the client’s next of kin to obtain consent for treatment
Answer: C. Proceed with treatment without obtaining written consent (Implied Consent)
70. A nurse is reviewing the medication administration record of a patient and notices that an
additional dose of medication has been administered. Which of the following actions should the
nurse take first?
A. Inform the nursing supervisor.
B. Notify the provider
C. Observe the client’s condition.
D. Complete an incident report.
Answer: C. Observe the client’s condition.
71. A nurse is assessing pressure ulcers on four clients to evaluate the effectiveness of a change
in the wound care procedure. Which of the following findings indicate wound healing.
A. Erythema on the skin surrounding a client's wound
B. Deep red colour on the centre of the clients wound
C. Inflammation noted on the tissue edges of a client's wound

D. Increase in serosanguineous exudate from the clients wound
Answer: B. Deep red colour on the centre of the clients wound
72. A nurse received change of shift report at 0700 for four clients. Which of the following
actions should the nurse perform first?
A. Obtain a breakfast tray for a patient who received a morning dose of insulin as part
B. Administer pain medication to a patient who has rheumatoid arthritis and received the last
dose at 0400
C. Restart an infiltrated IV for a patient whose IV antibiotic is scheduled for 0900
D. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours.
(To prevent bacterial contamination, fill the bag with only enough formula to last over a 4-8 hour
period, and change the feeding bag every 24 hours)
Answer: D. Replace a client's enteral nutrition feeding solution that has been hanging for 24
hours.
73. A nurse is orienting a newly licensed nurse on the neurological unit. Which of the following
clients should the nurse assign to the newly licensed nurse?
A. A patient who has multiple sclerosis and ataxia
B. A patient who has brain tumor and is admitted for chemotherapy
C. A patient who has Guillain-Barre syndrome and a tracheostomy
D. A patient who sustained a concussion and is being monitored for complication
Answer: B. A patient who has brain tumor and is admitted for chemotherapy
74. A nurse is providing teaching to a patient about advance directives. Which of the following
statements by the patient indicates an understanding of the teaching?
A. “Once I sign my living will, a family member must co sign it”
B. “I will wait until I have a serious health problems to sign my advance directives”
C. “My doctor will need to provide approval for the decisions outlines in my living will
D. “My durable power of attorney for health care is part of my advance directives”
Answer: D. “My durable power of attorney for health care is part of my advance directives”

75. A nurse is chairing a committee about preventing infant abduction in a new birth care centre.
Which of the following quality control tasks should the nurse assign to be completed first?
A. Identify the industry standards for infant safety
B. Evaluate the selected infant safety system
C. Choose an infant safety system
D. Establish measurement criteria for infant safety systems
Answer: A. Identify the industry standards for infant safety
76. A nurse notes that a patient 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. Respiratory therapist
C. Speech therapist
D. Occupational therapist
Answer: C. Speech therapist
77. A home health nurse is assessing the home environment during an initial visit to a patient
who has a history of falls. Which of the following findings should the nurse identify as
increasing the client's risk for falls (SATA)
A. A wheeled office chair at the client's computer desk
B. A raised vinyl seat on the toilet in the bathroom
C. A throw rug covering some cracked floor
D. A folding chair without arm rests
E. A two wheeled walker used to assist the patient with ambulation
Answer: A. A wheeled office chair at the client's computer desk
C. A throw rug covering some cracked floor
D. A folding chair without arm rests
78. A nurse manager is planning to assign care for four clients on a medical surgical unit. Which
of the following clients should the nurse assign to an LPN

A. An older adult who has lung cancer and has periodic episodes of severe dyspnea
B. A middle adult patient who has a below the knee amputation and requires a dressing change
C. A young adult patient who is postoperative, receiving morphine via epidural, and reports
pruritus
D. An adolescent who requires teaching regarding insulin administration
Answer: B. A middle adult patient who has a below the knee amputation and requires a dressing
change
79. While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that six of the 15 records lack documentation regarding advance directives. Which
of the following is the priority for the nurse to take?
A. Remind nurses to obtain this information during the admission process
B. Reinforce the potential consequences of not having his information on record to the nursing
staff
C. Meet with nursing staff to review the policy regarding advance directive
D. Ask nurse who are caring for patient without his information in the medical record to obtain it
Answer: C. Meet with nursing staff to review the policy regarding advance directive
80. A nurse is caring for a group of clients. Which of the following should the nurse see first?
A. A patient who is postoperative and has a fever.
B. A patient whose pressure ulcer has serosanguineous drainage on the dressing
C. A patient who has diabetes mellitus and is diaphoretic
D. A patient who has a fractured hip and reports a pain level of 7 on a scale from 0-10
Answer: C. A patient who has diabetes mellitus and is diaphoretic
81. A nurse is receiving change-of-shift report for four clients. Which of the following clients
should the nurse care for first?
A. A patient who is 4 hr postoperative following a hernia repair and has pitting edema of the
right leg
B. A patient who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhoea
C. A patient who has pneumonia and requires a tracheostomy dressing change

D. A patient who has a new colostomy and requires discharge teaching
Answer: A. A patient who is 4 hr postoperative following a hernia repair and has pitting edema
of the right leg
82. A nurse manager discovers there is a conflict between nurses working the day shift and
nurses working on the night shift. Which of the following actions should the nurse manager take
first?
A. Acknowledge the conflict and encourage the nurses to focus on working as a team
B. Gather information regarding the situation
C. Encourage the nurses to resolve the conflict autonomously
D. Meet with a committee from each shift to discuss issues related to the conflict
Answer: B. Gather information regarding the situation
83. A nurse in an urgent care clinic is admitting a patient who has been exposed to a liquid
chemical in an industrial setting. Which of the following actions should the nurse take first?
A. Don personal protective equipment
B. Irrigate the exposed area with water
C. Remove the client’s clothing
D. Report the incident to OSHA
Answer: A. Don personal protective equipment
84. A newly licensed nurse realizes that she administered metoprolol 25 mg PO to the wrong
client. Which of the following actions should the nurse perform first?
A. Complete an incident report
B. Measure the client’s vital signs
C. Inform the nurse manager
D. Call the provider
Answer: B. Measure the client’s vital signs
85. A nurse is assessing a patient who has meningitis. Which of the following findings should the
nurse report to the provider immediately?

A. Decreased level of consciousness
B. Generalized rash over trunk
C. Increased temperature
D. Report of photophobia
Answer: A. Decreased level of consciousness
86. A patient who is febrile is admitted to the hospital for treatment of pneumonia. In accordance
with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires
the nurse to complete a variance report with regard to the care pathway?
A. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.
B. A blood culture was obtained after antibiotic therapy had been initiated
C. An allergy to penicillin required an alternative antibiotic to be prescribed
D. The route of antibiotic therapy on the care pathway was changed from IV to PO
Answer: B. A blood culture was obtained after antibiotic therapy had been initiated
87. A nurse manager is making staffing assignments for the maternal newborn unit. Which of the
following clients should the nurse manager assign to a float nurse from the medical-surgical
unit?
A. A patient who is post term and is receiving oxytocin for labor induction
B. A patient who gave birth to her first child and requires instruction on breastfeeding techniques
C. A patient who is 2 days post-operative following a caesarean birth and is having difficulty
ambulating
D. A patient who has preeclampsia and is receiving a continuous magnesium sulphate infusion
Answer: C. A patient who is 2 days post-operative following a caesarean birth and is having
difficulty ambulating
88. A nurse is coordinating an interprofessional team to review proposed standards to reduce the
transmission of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following
members of the interprofessional team should the nurse consult?
A. Risk management coordinator
B. Clinical pharmacist

C. Nursing supervisor
D. Infection control nurse
Answer: D. Infection control nurse
89. A nurse is caring for a patient who has uterine prolapse. The provider has recommended a
total abdominal hysterectomy, but the patient tells the nurse that the surgery is not an option.
Which of the following is an appropriate action for the nurse to take?
A. Discuss with the patient her concerns regarding the procedure
B. Provide the patient with information on treatment options and outcomes
C. Inform the patient of the consequences of uterine prolapse and the need for intervention
D. Initiate a mental health consult to determine the client’s reasons for refusing surgery
Answer: A. Discuss with the patient her concerns regarding the procedure
90. A nurse in the emergency department is assessing a patient who is unconscious following a
motor vehicle crash. The patient requires immediate surgery. Which of the following actions
should the nurse take?
A. Delay the surgery until the nurse can obtain informed consent
B. Obtain telephone consent from the facility administrator before the surgery.
C. Ask the anaesthesiologist to sign the consent.
D. Transport the patient to the operating room without verifying informed consent.
Answer: D. Transport the patient to the operating room without verifying informed consent.
91. A nurse is planning to delegate patientcare assignment. Which of the following tasks should
the nurse plan to delegate to an assistive personnel?
A. Performing postmortem care prior to transferring the patient to the morgue
B. Advising a patient on self-administration of acetaminophen
C. Teaching a patient to perform a finger-stick for testing blood glucose levels
D. Informing a family of a client’s progress in physical therapy
Answer: A. Performing postmortem care prior to transferring the patient to the morgue

92. A nurse is working on a quality improvement team that is assessing an increase in patient fall
at the facility. After problem identification, which of the following actions should the nurse plan
to take first as part of the quality improvement process?
A. Notify staff of the increased fall rate
B. Review current literature regarding patient falls
C. Implement a fall prevention plan
D. Identify clients who are at risk of falls
Answer: D. Identify clients who are at risk of falls
93. A nurse is completing performance evaluation for an assistive personnel (AP). Which of the
following actions by the AP requires intervention by the nurse?
A. The AP uses alcohol hand antiseptic after caring for a patient who has Clostridium difficile.
B. The AP closes the door of a patient who is on airborne precautions.
C. The AP Removes cut flowers from the room of a patient who is in protective environment.
D. The AP wears a mask when a caring for a patient who has varicella.
Answer: A. The AP uses alcohol hand antiseptic after caring for a patient who has Clostridium
difficile.
94. A charge nurse notices that the staff nurse are having difficulty using new IV infusion pumps
for medication administration. Which of the following is priority action by the charge nurse?
A. Assess the staff nurse’s knowledge deficit.
B. Pair an inexperienced nurse with an experienced nurse.
C. Demonstrate use of the pump during medication administration.
D. Plan an in-service education program on the unit.
Answer: A. Assess the staff nurse’s knowledge deficit.
95. 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 patient who has NG tube
B. Check a patient pain level 30min after receiving acetaminophen
C. Collect urine specimen for newly admitted client

D. Instruct a patient to splint an abdominal incisions
Answer: C. Collect urine specimen for newly admitted client
96. A nurse is assisting with triage during a mass casualty event. The nurse applies a red tag to a
client. Which of the following actions should the nurse take?
A. Treat the client’s injuries within 30 min
B. Provide treatment for life-threatening injuries
C. Provide treatment for minor injuries
D. Allow the patient to die without further intervention
Answer: B. Provide treatment for life-threatening injuries
97. A home health nurse is performing a safety assessment of a client’s home. Which of the
following findings should the nurse identify as a safety hazard?
A. The patient has used tracks to secure the carpet on the stairs
B. The client’s electrical cord is taped to the floor
C. The client’s bedside lamp is plugged in using an extension cord with two prongs
D. The patient stores cleaning supplies in a locked cabinet above his head
Answer: C. The client’s bedside lamp is plugged in using an extension cord with two prongs
98. A charge nurse is observing a newly licensed nurse provide care for a patient who has
Clostridium difficile infections. Which of the following actions by the newly licensed nurse
indicate an understanding of proper infection control procedures?
A. Applies a mask before entering the client’s room (It’s contact precaution)
B. Removes fresh flowers from the client’s room.
C. Washes her hands with an alcohol-based hand rub after caring for the client.(no, ineffective
and must wash hands with soap/water)
D. Wears gown when caring for client
Answer: D. Wears gown when caring for client

99. A nurse is preparing discharge planning for a patient who has a newly placed tracheostomy
tube. The nurse should assess the client’s need for which of the following supplies to manage
tracheostomy at home? (SATA)
A. Pipe cleaners
B. O2 Tank
C. Cotton balls
D. Petroleum Jelly
E. Obturator
Answer: A. Pipe cleaners
B. O2 Tank
E. Obturator
100. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the
following clients can give informed consent?
A. An adult patient who has alcohol intoxication- not focused
B. An adolescent patient who is legally emancipated
C. An older adult patient who has questions about the procedure= having questions means you
don’t understand,
D. An adult patient who has moderate Alzheimer’s disease.- cant consent if you are not focused
Answer: B. An adolescent patient who is legally emancipated
101. A nurse is discussing the safekeeping of valuables with a patient who is scheduled for
surgery. Which of the following patient statements indicates the need for further teaching?
A. “I can wear my ankle bracelet since I am just having a local anaesthetic:
B. “I can leave my wedding ring on if it is taped in place”
C. “I should remove my dentures before the procedure”
D. “I should leave my valuables with a family member”
Answer: B. “I can leave my wedding ring on if it is taped in place”

102. A nurse is caring for an older adult patient who has Stage III pressure ulcer. The nurse
requests a consultation with the wound care specialist. Which of the following actions by the
nurse is appropriate when working with a consultant?
A. Request the consultation after several wound care treatments are tried
B. Arrange for the wound care nurse specialist to see the patient daily to provide the
recommended treatments
C. Arrange the consultation for a time when the nurse caring for the patient is able to be present
for the consultation
D. Provide the consultant with subjective opinions and beliefs about the client’s wound care
Answer: C. Arrange the consultation for a time when the nurse caring for the patient is able to be
present for the consultation
103. A nurse is observing an AP administer 0.9% sodium chloride enema to an adult client. For
which of the following actions by the AP should the nurse intervene?
A. Positions the patient on her left side with knees flexed
B. Administers the solution at room temp
C. Points tubing in the direction of the umbilicus during insertion
D. Inserts the tubing 8cm (3.1 in) into the rectum
Answer: A. Positions the patient on her left side with knees flexed
104. A nurse is orienting a newly licensed nurse about patient confidentiality. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “I should encrypt personal health information when sending emails.”
B. “I can post the client’s vital signs in the client’s room.”
C. “I can use another nurse’s password as long as I log off after using the computer”
D. “I should discard personal health information documents in the trash before leaving the unit”
Answer: A. “I should encrypt personal health information when sending emails.”
105. A nurse is participating on a committee that is considering the creation of a policy that will
allow the nurses to remove chest tubes. Which of the following is an appropriate resource for the
nurse to consult in planning for this policy?

A. ANA Standards of Practice
B. ANA Code of Ethics
C. State Nurse Practice Act
D. Institute of medicine
Answer: C. State Nurse Practice Act
106. A charge nurse observe a licensed practical nurse tell a patient that she will return with a
medication to help relieve the client’s nausea. The LPN does not return with the medication. The
charge nurse should reinforce which of the following ethical principles with the LPN?
A. Veracity
B. Justice
C. Fidelity
D. Nonmaleficence
Answer: C. Fidelity
107. A nurse administrator is using benchmarking as control criteria while reviewing current
policies and procedures. Which of the following actions should the nurse take?
A. Use root cause analysis to identify gaps in meeting standards- root cause analysis is done if
the benchmark is not met
B. Establish work initiatives to promote a positive environment
C. Compare practices within the facility against other high-performing facilities
D. Determine how current practice will affect future performance within the facility
Answer: C. Compare practices within the facility against other high-performing facilities
108. A nurse enters a client’s room and identifies that the patient is receiving too much IV fluid
because the IV pump is not working properly. Which of the following actions should the nurse
take first?
A. Place a faulty equipment tag on the pump
B. Notify the provider
C. Auscultate the client’s lungs
D. Complete an incident report

Answer: C. Auscultate the client’s lungs
109. A patient scheduled for a tubal ligation procedure starts to cry as she is wheeled into the
surgical suite. Which of the following nursing statements is an appropriate nursing response?
A. “It’s not too late to cancel the surgery if you want to”
B. “Why did you make the decision to have this procedure?”
C. “This won’t take long and it will be over before you know it”
D. “You shouldn’t be worried because the procedure is very safe”
Answer: A. “It’s not too late to cancel the surgery if you want to”
110. A facility infection control nurse is reviewing the reports of a group of clients. Which of the
following infections should the nurse report to the public health department?
A. Lyme disease
B. Bacterial conjunctivitis
C. Health care-acquired pneumonia
D. MRSA
Answer: A. Lyme disease
111. A nurse on a surgical unit is preparing to transfer a patient to a rehabilitation facility. Which
of the following information should the nurse include in the change-of-shift report?
A. The steps to follow when providing wound care
B. The client’s preferred time for bathing
C. The belief that the patient has a difficult relationship with his son
D. The time the patient received his last dose of pain medication
Answer: D. The time the patient received his last dose of pain medication
112. A nurse receives a new prescription over the telephone from a client’s provider. Which of
the following actions should the nurse take first
A. Write down the complete prescription
B. Read back the prescription to the provider
C. Document the prescription as a telephone prescription in the medical record

D. Ensure that the provider signs the prescription
Answer: B. Read back the prescription to the provider
113. A charge nurse witnessed an assistive personnel failing to follow facility protocol when
discarding contaminated linens. Which of the following actions should the nurse take first?
A. Discuss the issue with the AP
B. Notify the unit manager about the incident
C. Reinforce facility protocols at the next staff meeting
D. Alert the infection control department
Answer: A. Discuss the issue with the AP
114. A nurse is planning care for a patient who is disoriented and has a history of wandering.
Which of the following actions should the nurse include in the plan?
A. Raise all four side rails on the client’s bed
B. Remove the clock and calendar from the client’s room
C. Obtain a prescription for a sedative for the client
D. Provide distractions for the patient during the day
Answer: D. Provide distractions for the patient during the day
115. A nurse is caring for a patient who has a new diagnosis of chlamydia. Which of the
following actions should the nurse take?
A. Initiate contact precautions (standard)
B. Report the infection to the local health department
C. Apply an antiviral cream to lesions
D. Instruct the patient to use condoms until the treatment is completed (NO, not 100%
preventable)
Answer: B. Report the infection to the local health department
116. A nurse is teaching a class of newly licensed nurses about evidence-based practices. The
nurse should include which of the following as the first step in evidence-based practice?
A. Apply research to patientcare practice

B. Develop a clinical question
C. Critically assess the evidence
D. Collect evidence from a variety of sources
Answer: B. Develop a clinical question
117. A nurse assumes the leading role on the hazardous materials team immediately following a
chemical mass casualty incident in the community. As clients arrive at the designed triage area
outside the hospital, which of the following actions should the nurse take?
A. Place shower caps over the client's’ hair
B. Remove contaminated clothing
C. Scrub the client’s skin with betadine solution
D. Admit the injured clients to positive-pressure rooms
Answer: B. Remove contaminated clothing
118. A case manager is reviewing documentation on several clients and notes a progress report
that falsely identifies a patient as HIV-positive due to multiple sexual partners. The nurse
manager should identify that which of the following torts has occurred?
A. Libel
B. Negligence
C. Battery
D. Slander
Answer: A. Libel
119. A nurse is preparing to complete morning assignments on several assigned clients. Which of
the following clients should the nurse plan to assess first?
A. A patient who had a bladder scan that indicated 250 mL of urine in the bladder
B. A patient who is 3 days postoperative and who’s dressing has serosanguinous drainage
C. A patient who has diabetes and an early morning blood glucose of 220 mg/dL
D. A patient who has a nasogastric tube to intermittent suction and reports nausea
Answer: D. A patient who has a nasogastric tube to intermittent suction and reports nausea

120. 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. “Please stop discussing the patient in a public area”
B. “Do you understand the HIPAA regulations?”
C. “We should discuss your concerns with the client’s care team”
D. “I will notify the client’s provider about this breach of confidentiality
Answer: A. “Please stop discussing the patient in a public area”
121. A nurse preceptor is observing a newly hired nurse perform a sterile dressing change. Which
of the following actions should the nurse preceptor identify as maintaining sterile technique?
A. Places sterile gauze 1.3cm (0.5 in) away from the edge of a sterile drape
B. Uses sterile forceps to pack sterile gauze into the wound
C. Sets up the sterile field 30 min prior to performing the dressing change
D. Uses a sterile-gloved hand to adjust the back of the sterile gown.
Answer: B. Uses sterile forceps to pack sterile gauze into the wound
122. A nurse working in a long-term care facility is assessing an older adult patient who has been
receiving antibiotics for 10 days. The patient reports frequent loose stools. Which of the
following actions should the nurse take?
A. Place the patient in a negative-pressure airflow room
B. Perform hand hygiene with alcohol based hand sanitizer.
C. Clean the equipment in the client’s room with bleach.
D. Initiate droplet precautions for the client.
Answer: C. Clean the equipment in the client’s room with bleach.
123. A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse is
having trouble focusing and has difficulty completing care for his assigned clients. Which of the
following interventions is appropriate?
A. Advise him to complete the less time consuming tasks first
B. Recommend that he take time to plan at the beginning of his shifts
C. Offer to provide care for his clients while he take a break

D. Ask other staff members to take over some of his tasks
Answer: B. Recommend that he take time to plan at the beginning of his shifts
124. A nurse is planning discharge for a patient who has lung resection. The nurse initiates a
referral for a social worker. Which of the following assessment data supports this referral?
A. The patient needs to have someone bring O2 tanks and equipment to her home
B. The patient needs to have range-of-motion exercises to assist with ambulation
C. The patient needs to arrange financial resources to purchase equipment
D. The patient needs to have someone come in to help her bathe at home
Answer: C. The patient needs to arrange financial resources to purchase equipment
125. A nurse initiates a referral to an occupation therapist for a patient who has rheumatoid
arthritis. Which of the following assessment findings supports the need for this referral?
A. The patient reports pain when chewing solid foods.
B. The patient expresses the desire to join a support group.
C. The patient requires assistance with completing oral hygiene
D. The patient has difficulty ambulating with a walker
Answer: C. The patient requires assistance with completing oral hygiene
126. A nurse is caring for a patient who has anorexia nervosa. Which of the following
interdisciplinary team members should be consulted in regard to this client’s care? (SATA)
A. Nutritional therapists
B. Case Manager
C. Mental Health counsellor
D. Occupational therapist
E. Physical therapist
Answer: A. Nutritional therapists
B. Case Manager
C. Mental Health counsellor

127. A nurse is prioritizing care after a receiving change-of-shift report on four clients. Which of
the following clients should the nurse assess first?
A. A patient who reports a headache with sensitivity to light.
B. A patient who reports feeling lightheaded when he stands up from a lying position
C. A patient who reports indigestion and pain in her jaw
D. A patient who reports an urge to void but has not urinated during the prior shift
Answer: C. A patient who reports indigestion and pain in her jaw
128. A nurse on an acute mental health unit is assessing four clients. Which of the following
clients is the highest priority?
A. A patient who has depressive disorder and has poor personal hygiene
B. A patient who has dementia and exhibits aphasia
C. A patient who has bipolar disorder and displays constant pacing – (Can lead to physical
exhaustion and death)
D. A patient who has schizophrenia and uses neologisms
Answer: C. A patient who has bipolar disorder and displays constant pacing – (Can lead to
physical exhaustion and death)
129. A nurse is planning care for a group of clients. Which of the following action should the
nurse take first?
A. Obtain a breakfast tray for a patient whose total parenteral nutrition was discontinued 4 hrs
ago.
B. Auscultate the bowel sounds of a patient who has not had bowel movement after taking a
laxative 12hr ago.
C. Provide instruction to the caregiver of a patient who has dementia and new diagnosis of
diabetes mellitus.
D. Check a patient who has a leg cast and reports a new onset of pain.
Answer: D. Check a patient who has a leg cast and reports a new onset of pain.

130. A nurse on a med surg unit is caring for a patient who asks about advance directives and
states that he wants to appoint a health care proxy. Which of the following responses should the
nurse make?
A. “You must choose a member of your family to serve as a your health care proxy.”
B. “A health care proxy can make decisions for you when you are unable to do so.”
C. “You should appoint a health care proxy before undergoing an invasive procedure.”
D. “It is necessary for an attorney to approve your health care proxy.”
Answer: B. “A health care proxy can make decisions for you when you are unable to do so.”
131. A nurse in a rehabilitation facility is administering medications to a patient who was
admitted earlier that day. The patient refuses two of the medications, stating, “I’ve never taken
these before.” Which of the following actions should the nurse take first?
A. Consult the pharmacist about the client’s prescribed medications.
B. Compare the client’s medication administration record with the prescriptions on the transfer
orders.
C. Review the intended purpose of the prescribed medication with the client.
D. Call the provider to clarify the clients prescribed medications.
Answer: B. Compare the client’s medication administration record with the prescriptions on the
transfer orders.
132. A nurse on a med surgical unit is caring for four clients. The nurse should recognize that
which of the following clients is the highest priority?
A. A patient who is postoperative following laminectomy 12hrs ago is unable to void
B. A patient who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy
C. A patient who has peripheral vascular disease and has an absent pedal pulse in the right foot
D. A patient who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38C (101F)
Answer: C. A patient who has peripheral vascular disease and has an absent pedal pulse in the
right foot

133. A nurse in the emergency department admits a patient who has been exposed to cutaneous
anthrax. Which of the following actions should the nurse take?
A. Plan to administer an antiviral medication to the client.
B. Wear an N95 respirator mask while caring for the client.
C. Prepare to administer antibiotics to the client.
D. Place a surgical mask on the patient during transfer to the unit.
Answer: C. Prepare to administer antibiotics to the client.
134. 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. Discuss the time management strategies with the nurses
B. Review facility policies for taking scheduled breaks.
C. Provide coverage for the nurses’ breaks
D. Determine the reasons the nurses are taking scheduled breaks.
Answer: D. Determine the reasons the nurses are taking scheduled breaks.
135. A nurse is caring for a patient who reports acute pain but refuses IM medication. The nurse
distracts the patient and quickly administers the injection. This illustrates which of the
following?
A. False imprisonment
B. Libel
C. Assault
D. Battery
Answer: D. Battery
136. A nurse is speaking with a visitor who asks a questions about the status of a relative who is
a fadov patient on the unit. Which of the following responses by the nurse is appropriate?
A. “I’m not taking care of your relative today, so I don’t have the latest information”
B. “I will have your relative’s nurse come and talk with you about her care.”
C. “Let me check your relative’s medical record to see how she’s doing.”
D. “Please ask your relative about this, because I cannot share information about her.”

Answer: D. “Please ask your relative about this, because I cannot share information about her.”
137. A nurse suggests respite care for the partner of a patient who has mild cognitive impairment.
The client’s partner asks the nurse how that would help. The nurse should explain the respite care
would do which of the following?
A. Allow her to take time off from attending to her partner
B. Provide volunteers who will run errands for her
C. Send a clinician to assess the safety of leaving her partner alone
D. Help her arrange transferring her partner to an assisted living facility
Answer: A. Allow her to take time off from attending to her partner
138. A charge nurse observes a patient fall during ambulation and notes that his gait belt was not
in place. In reviewing the incident report, the nurse finds no mention of a gait belt. Which of the
following ethical principles should guide the nurse’s subsequent actions?
A. Non maleficence - do no harm
B. Veracity - commitment to tell the truth
C. Fidelity - keep promises
D. Beneficence - promote good for others
Answer: B. Veracity - commitment to tell the truth
139. A nurse is caring for a patient who is scheduled for placement of a central venous access
device. Which of the following actions is the nurse’s responsibility in the informed consent
process?
A. Place a photocopy of the signed consent in the client’s medical record
B. Review the risks and benefit of the procedure with the client
C. Discuss alternative treatment options with the client
D. Assess the client’s understanding after the provider has talked with her
Answer: D. Assess the client’s understanding after the provider has talked with her

140. A nurse is providing teaching to an assistive personnel about the application of wrist
restraints to a client. Which of the following instructions should the nurse include in the
teaching?
A. Remove the client’s restraints every 2 hr.
B. Allow 1 fingerbreadth between the restraint and the client’s wrists
C. Attach the restraints to the fixed portion of the frame of the client’s bed
D. Secure the client’s restrains with a square knot
Answer: C. Attach the restraints to the fixed portion of the frame of the client’s bed
141. A nurse is preparing an educational program for staff members 2 a new intravenous pump.
Identify the sequence of actions the nurse should take when developing the program. (Move the
steps into the box on the right, placing them in order of performance).
A. Determine what skills to teach the staff members
B. Develop learning objectives for the program
C. Identify resources available to meet objectives
D. Review the staff member’s evaluation of the program
Answer: A. Determine what skills to teach the staff members
B. Develop learning objectives for the program
C. Identify resources available to meet objectives
D. Review the staff member’s evaluation of the program
142. A nurse suggest respite care for the partner of a patient who has mild impairment. The
client’s partner asks the nurse how that would help. The nurse should explain that respite care
would do which of the following?
A. Offer the opportunity for a healthcare professional to care for the patient in their home.
B. Provide education on caring for her partner with dementia.
C. Help her partner adjust to a short-term stay in a nursing facility.
D. Allow her to take time off attending to her partner
Answer: D. Allow her to take time off attending to her partner

143. A case manager observes a family member of a patient who has Alzheimer’s disease
throwing books on the floor and sobbing while the patient is having a diagnostic test. Which of
the following actions should the case manager take first?
A. Provide information about Alzheimer’s support groups.
B. Suggest the caregiver take some time away from the patient.
C. Ask the caregiver what is upsetting them.
D. Offer to have a brief talk with the caregiver
Answer: D. Offer to have a brief talk with the caregiver
144. A nurse is caring for a patient who has early stage Alzheimer’s disease. In which of the
following actions is the nurse acting as a patient advocate?
A. Educating the patient’s family about disease progression.
B. Assisting the patient in completing an advance directive.
C. Explaining medication side effects to the patient.
D. Requesting a referral for the patient to attend reminiscent therapy sessions
Answer: D. Requesting a referral for the patient to attend reminiscent therapy sessions
145. A nurse manager is reviewing the nursing code of ethics with the staff nurses. Which of the
following statements by a staff nurse indicate understanding of the teaching (SATA).
A. “I will attend continuing education classes for professional growth.”
B. “I can delegate the removal of an IV catheter to an LPN on the unit.”
C. “I administer pain medication to my clients even if they have a history of narcotic addiction.”
Answer: A. “I will attend continuing education classes for professional growth.”
C. “I administer pain medication to my clients even if they have a history of narcotic addiction.”
146. A nurse is discussing advance directives with a client. Which of the following statements by
the patient indicates an understanding of advance directives?
A. “I can designate someone to make healthcare decisions for me if I am unable.”
B. “My family has to follow my wishes as outlined in my living will.”
C. “I can change my advance directive whenever I want.”
D. “I know I have the right to determine if I remain on a breathing machine.”

Answer: D. “I know I have the right to determine if I remain on a breathing machine.”
147. A nurse is caring for a patient who has a pressure ulcer on the coccyx. Which of the
following findings indicated the need for referral to a wound care specialist?
A. The ulcer shows no signs of healing after 2 weeks of treatment.
B. The wound has a foul Odor or purulent drainage.
C. There is an increase in wound size or depth.
D. Presence of slough in the wound bed
Answer: D. Presence of slough in the wound bed
148. A nurse on a medical-surgical unit delegating patientcare. Which of the following tasks
should the nurse delegate to an assistive personnel?
A. Measuring and recording a patient's intake and output.
B. Assisting a patient with ambulation.
C. Reapplying antiembolic stockings.
D. Suctioning a client’s long-term tracheostomy
Answer: D. Suctioning a client’s long-term tracheostomy
149. A nurse is providing teaching about infection control measures to a patient who has an
indwelling urinary catheter. Which of the following instructions should the nurse include in the
teaching?
A. Use sterile technique to collect specimens from the drainage system
B. Keep the drainage bag below the level of the bladder.
C. Perform hand hygiene before and after handling the catheter or drainage system.
D. Change the catheter and drainage bag only as instructed by a healthcare provider.
Answer: A. Use sterile technique to collect specimens from the drainage system
150. A nurse manager is preparing an in-service for a group of staff nurses about organ donation.
Which of the following information should the manager include?
A. Nurses may witness the signing of organ donation consents
B. Organ donation can only occur after brain death is declared.

C. Nurses should discuss organ donation with the family immediately after the patient's death.
D. The organ procurement organization will coordinate the donation process.
Answer: A. Nurses may witness the signing of organ donation consents
151. A patient scheduled for a tubal ligation procedure starts to cry as she is wheeled into the
surgical suite. Which of the following nursing statements is an appropriate nursing response?
A. “It’s not too late to cancel the surgery if you want to.”
B. “Can you tell me what’s making you feel upset right now?”
C. “It’s normal to feel anxious before surgery. Would you like to talk about it?”
D. “I’m here for you. It’s okay to express your feelings.”
Answer: A. “It’s not too late to cancel the surgery if you want to.”
152. A charge nurse is observing a newly licensed nurse insert an NG tube and connect it to a
suction source. Which of the following actions by the newly licensed nurse demonstrates an
understanding of the process?
A. Clamps the air vent tubing
B. Checks the placement of the NG tube by aspirating gastric contents.
C. Ensures the suction source is set to continuous suction at the highest level.
D. Maintains the patient in a supine position during the procedure.
Answer: B. Checks the placement of the NG tube by aspirating gastric contents.
153. A nurse working in an emergency department is performing triage. To which of the
following clients should the nurse assign priority?
A. A patient who has soot markings around each naris following a house fire
B. A patient with a sprained ankle who is in moderate pain.
C. A patient with a minor laceration on the arm that is not actively bleeding.
D. A patient who reports a headache and dizziness but is otherwise stable.
Answer: A. A patient who has soot markings around each naris following a house fire
154. A nurse receives change-of-shift report for the following four clients. Which of the
following clients should the nurse assess first?

A. An older adult patient who has bacterial pneumonia and a new onset of restlessness
B. A young adult with a fractured wrist who is in moderate pain.
C. A middle-aged patient with stable angina who is awaiting a stress test.
D. An older adult patient with chronic obstructive pulmonary disease (COPD) who has an
oxygen saturation of 92%.
Answer: A. An older adult patient who has bacterial pneumonia and a new onset of restlessness
155. 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 patient who has emphysema and has oxygen saturation of 92%
B. A patient who is postoperative following a total hip replacement and requires frequent vital
sign monitoring.
C. A patient with newly diagnosed diabetes who needs education on insulin administration.
D. A patient with congestive heart failure who is experiencing shortness of breath and needs
assessment.
Answer: A. A patient who has emphysema and has oxygen saturation of 92%
156. A nurse is admitting a patient who is scheduled for cholecystectomy. The patient does not
speak English and is accompanied by her adult daughter. Which of the following actions should
the nurse take?
A. Access a language line to interpret what is being said
B. Ask the daughter to interpret for the patient.
C. Use hand gestures and pictures to communicate.
D. Provide written materials about the procedure in English.
Answer: A. Access a language line to interpret what is being said
157. A nurse is caring for a patient who has an MI. The client’s daughter ask the nurse to review
her father’s medical with her. Which of the following responses should the nurse make?
A. “Your father will have to give permission for you to review the record.”
B. “I can’t share any information without your father’s consent.”
C. “Let me check with your father and see if he’s comfortable with this.”

D. “I can discuss general information about your father’s condition, but specific details are
confidential.”
Answer: A. “Your father will have to give permission for you to review the record.”
158. A nurse is teaching a patient who requires protective isolation due to immune system
compromise. Which of the following instructions should the nurse include to protect the client?
A. “Make sure your visitors wear a gown when they are in your room.”
B. “Wear gloves and a gown whenever you need to leave your room.”
C. “Be sure to eat plenty of fresh fruit and vegetables.”
D. “Limit the number of visitors you have to reduce the risk of infection.”
Answer: A. “Make sure your visitors wear a gown when they are in your room.”
D. “Limit the number of visitors you have to reduce the risk of infection.”
159. A nurse in the emergency department is preparing a married 17-year-old patient for an
appendectomy. The client’s parents are en route to the facility but have not spoken with the
surgeon. Which of the following actions should the nurse take?
A. Have the patient sign the consent form after the surgeon explains the procedure
B. Wait for the parents to arrive before proceeding with the consent process.
C. Obtain verbal consent from the parents over the phone.
D. Explain the procedure to the patient and allow her to make an informed decision.
Answer: A. Have the patient sign the consent form after the surgeon explains the procedure
160. A nurse is preparing a patient for surgery. The patient has signed the consent form but tells
the nurse that she has reconsidered because she is worried about the pain. Which of the following
responses by the nurse is appropriate?
A. “I understand, and it’s not too late to change your mind.”
B. “You’ll be given pain medication after the surgery to help manage your discomfort.”
C. “It’s important to proceed with the surgery as planned.”
D. “Have you discussed your concerns about pain with your surgeon?”
Answer: D. “Have you discussed your concerns about pain with your surgeon?”

161. A nurse is completing discharge teaching with a patient who is being treated with
tuberculosis (TB). Which of the following statements by the patient indicates an understanding
of the teaching?
A. “I should have a sputum culture done every 2-4 weeks”
B. “I can stop taking my medication once I start feeling better.”
C. “I need to avoid contact with other people while I'm on treatment.”
D. “I will need to wear a mask only when I feel sick.”
Answer: A. “I should have a sputum culture done every 2-4 weeks”
162. A nurse is preparing discharge planning for a patient who has a newly placed tracheostomy
tube. The nurse should assess the client’s need for which of the following to manage the
tracheostomy at home? (SATA)
A. Obturator
B. Oxygen tank
C. Suction machine
D. Tracheostomy tube spare
Answer: A. Obturator
C. Suction machine
163. A nurse is completing discharge teaching about dietary supplements for nitrogen loss with a
patient who has cancer. Which of the following nutrients should the nurse recommend the patient
increase?
A. Protein
B. Carbohydrates
C. Fats
D. Vitamins
Answer: A. Protein
164. A case manager is preparing a patient who has a spinal cord injury for discharge from the
rehabilitation setting to home. Which of the following actions is the case manager’s priority
when creating the discharge plan?

A. Facilitate patient referrals for community resources
B. Assess the patient's home environment for safety and accessibility.
C. Provide education to the patient about managing their condition.
D. Arrange follow-up appointments with healthcare providers.
Answer: A. Facilitate patient referrals for community resources
165. A nurse is chairing a committee about preventing infant abduction in a new birth care
centre. Which of the following quality control tasks should the nurse assign to be completed
first?
A. Establish measurement criteria for infant safety systems.
B. Evaluate the selected infant safety system.
C. Choose an infant safety system.
D. Identify the industry standards for infant safety.
Answer: D. Identify the industry standards for infant safety.
166. A nurse at a local health department is caring for four clients who have communicable
diseases. Which of the following infections should the nurse report to the state health
department?
A. Chlamydia trachomatis
B. Pediculosis capitis
C. Impetigo contagiosa
D. Candida albicans
Answer: A. Chlamydia trachomatis
167. A nurse at a clinic is teaching a newly licensed nurse about sexually transmitted infections.
The nurse should instruct the newly licensed nurse to report which of the following infections to
the health department.
A. Candidiasis
B. Gonorrhoea
C. Trichomoniasis
D. Human papillomavirus

Answer: B. Gonorrhoea
168. A charge nurse discovers that a staff nurse on the unit has made repeated medication errors.
Which of the following actions should the charge nurse take first?
A. Review with the nurse principles of medication administration.
B. Ask the nurse to describe the medication administration procedure.
C. Identify education opportunities for the nurse regarding safe medication administration.
D. Notify the risk management department of the situation.
Answer: C. Identify education opportunities for the nurse regarding safe medication
administration.
169. The family members of an older adult patient are expressing conflict over whether the
patient should have surgery that is recommended by the provider. The oldest adult child has
durable power of attorney for health care for the client. The patient is oriented to person, place,
and time. Which of the following people has the legal authority to make the health care decision?
A. The provider
B. The oldest adult child
C. The partner
D. The client
Answer: D. The client
170. A nurse is working with a committee that is performing an annual review of policies and
procedures. After gathering data, identify the sequence the committee should follow when using
the stages of change. (put in order)
A. Determine goals
B. Create a revised protocol
C. Implement the revised protocol
D. Review the results of the provisions.
Answer: A. Determine goals
B. Create a revised protocol
C. Implement the revised protocol

D. Review the results of the provisions.
171. A nurse is providing a change of shift report for the oncoming nurse. Which of the
following information should the nurse include in the report?
A. “ The client’s partner came to visit him 2 hours ago and smelled of alcohol.”
B. “ The patient is the president of a local bank.”
C. “ The patient will need vital signs checked every 4 hours.”
D. “ The patient is currently in the radiology department for a chest x-ray.”
Answer: D. “ The patient is currently in the radiology department for a chest x-ray.”
172. A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis
of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which
of the following referrals should the nurse recommend?
A. Child protective services
B. Pharmacist
C. Social worker
D. Respiratory therapist
Answer: C. Social worker
173. A nurse is preparing a shift assignment for an assistive personnel on the unit. Which of the
following tasks should the nurse assign to the AP?
A. Check a client’s pain level 30 min after receiving acetaminophen
B. Administer the initial bolus feeding to a patient who has an NG tube
C. Collect a urine specimen from a newly admitted client
D. Instruct a patient to splint an abdominal incision
Answer: C. Collect a urine specimen from a newly admitted client
174. A nurse is teaching a class of newly licensed nurses about evidence- based practice. The
nurse should include which of the following as a first step in evidence-based practice.
A. Collect evidence from a variety of sources
B. Develop a clinical question

C. Apply research to patientcare practice
D. Critically assess the evidence
Answer: B. Develop a clinical question

175. A nurse is inspecting a clients IV pump prior to use. The nurse should tag and report which
of the following safety hazards?
A. The electrical cord is taped to the floor
B. The IV pump is plugged into an outlet close to the bed
C. The IV pump has a free-flow protective device
D. The electric plug has two short prongs – (Must be 3 prongs)
Answer: D. The electric plug has two short prongs – (Must be 3 prongs)
176. A nurse who is caring for a group of clients, delegates collection of vital signs to an assistive
personnel. Which of the following actions should the nurse take to evaluate the delegated task?
A. Recheck vital signs that are outside the expected reference range
B. Review the vital sign trends at the end of the shift.
C. Ask the AP to write a summary of the delegated tasks during the shift.
D. Compare the vital signs the AP obtained with those taken by another AP on a previous shift.
Answer: A. Recheck vital signs that are outside the expected reference range
177. A nurse is caring for a patient who has signed consent for the removal of the tumor in the
left frontal lobe of the brain. The patient states, “The tumor is on the right side of my head.”
Which of the following actions should the nurse take?

A. Continue with the surgery because the patient already gave informed consent.
B. Ask the surgeon to clarify the operative site with the client
C. Contact the surgery department to validate the operative site
D. Tell the patient to mark the right side of his head with indelible ink
Answer: B. Ask the surgeon to clarify the operative site with the client
178. A nurse is preparing to witness a client’s signature on an informed consent for a surgical
procedure. Which of the following actions is the nurse’s responsibility?
A. Ensuring the patient appears competent to consent to the procedure
B. Discussing options for the alternative therapies with the client.
C. Providing the patient with a complete description of the procedure
D. Explaining the risks associated with the procedure to the client
Answer: A. Ensuring the patient appears competent to consent to the procedure
179. A charge nurse witnesses two nurses having a loud discussion at the nurses’ station about
not wanting to care for a patient who has drug-resistant tuberculosis. Which of the following
actions should the charge nurse take?
A. Make arrangements to take over the clients care.
B. Contact the house supervisor to mediate the conflict
C. Escort the nurses to the nurses lounge to continue the discussion
D. Recommend that both nurses are terminated
Answer: C. Escort the nurses to the nurses lounge to continue the discussion
180. A nurse is observing an assistive personnel administer 0.9% sodium chloride enema to an
adult client. For which of the following actions by the AP should the nurse intervene?
A. Inserts the tubing 8 cm (3.1 in) into the rectum
B. Positions the patient on her left side with knees flexed
C. Points tubing in the direction of the umbilicus during insertion
D. Administers the solution at room temperature
Answer: B. Positions the patient on her left side with knees flexed

Rationale: Prepare and warm the enema solution. Position the patient on the left side with the
right leg flexed forward. Slowly insert the rectal tube 7.5 to 10 cm (3 to 4 in).
181. A nurse is prioritizing care after receiving report on four clients. Which of the following
clients should the nurse assess first?
A. A patient who reports feeling lightheaded when he stands up from a lying position
B. A patient who reports an urge to void but has not urinated during the shift prior
C. A patient who reports indigestion and pain in her jaw
D. A patient who reports a headache with sensitivity to light
Answer: C. A patient who reports indigestion and pain in her jaw
182. A charge nurse is directing the unit nurses to implement the emergency response plan for a
fire on the unit. Which of the following instructions should the charge nurse give to the unit
nurses?
A. Ask ambulatory clients to help move clients in wheelchairs to safety
B. Continue therapy for clients who are receiving oxygen
C. Close the doors of the unit before moving clients to a safe place
D. Maintain mechanical ventilation for clients who are on life support.
Answer: B. Continue therapy for clients who are receiving oxygen
183. A nurse is providing teaching to an older adult patient regarding home safety. Which of the
following instructions should the nurse include in the teaching?
A. Cover chords with the carpet to prevent falls
B. Unplug humidifier before cleaning it
C. Change batteries in the smoke alarm every 2 years
D. Set the water heater to 60 degrees C (140 F)
Answer: B. Unplug humidifier before cleaning it
184. A nurse is using the SBAR communication tool while giving report on a client. The nurse
should include the client’s pain level after receiving a PRN dose of morphine 1 hr ago during
which part of the report?

A. A-assessment
B. B-background
C. R-recommendation
D. S-situation
Answer: A. A-assessment
185. A nurse is comparing the rate of medication errors on the medical unit to the rate from a
medical unit in a magnet hospital. Which of the following quality improvement methods is the
nurse using?
A. Benchmarking
B. Structure audit
C. Risk benefit analysis
D. Root cause analysis
Answer: A. Benchmarking
186. A nurse is planning a discharge for a patient who has a new diagnosis of COPD and lives
alone. Which of the following actions is the nurse’s priority?
A. Provide printed materials for new prescriptions
B. Set up appointments in in-home physical therapy
C. Request a referral for a home safety assessment
D. Suggest participating in a community group
Answer: C. Request a referral for a home safety assessment
187. A nurse is caring for a group of clients. Which of the following clients should the nurse see
first?
A. A patient who is postoperative and has a fever (nonurgent)
B. A patient who has a fractured hip and reports a pain level of 7 on a scale of 0 to10
C. A patient who has pressure ulcer has serosanguineous drainage on the dressing
D. A patient who has diabetes mellitus and is diaphoretic
Answer: D. A patient who has diabetes mellitus and is diaphoretic

188. A nurse manager is reviewing documentation on several clients and notes a progress report
that falsely identifies a patient as an HIV-positive due to multiple sexual partners. The nurse
manager should identify that which of the following torts has occurred?
A. Negligence
B. Battery
C. Libel
D. Slander
Answer: C. Libel
189. A nurse initiates a referral to an occupational therapist for a patient who has rheumatoid
arthritis. Which of the following assessment findings supports the need for the referral?
A. The patient has difficulty ambulating with a walker
B. The patient requires assistance with completing oral hygiene
C. The patient reports pain when chewing on solid foods
D. The patient expresses desire to join a support group
Answer: B. The patient requires assistance with completing oral hygiene
190. A home health nurse finds piles of newspaper in the hallway of a client’s home. The nurse
explains the need to discard the newspapers for safety reasons. The patient agrees to move the
newspapers into the living room. Which of the following conflict resolution strategies has the
nurse used?
A. Compromising
B. Smoothing
C. Collaborating
D. Accommodating
Answer: C. Collaborating
191. A nurse reports to a charge nurse that a client’s visitor slipped and fell. The visitor denies
any injury and is walking around. Which of the following instructions should the charge nurse
give the nurse?
A. “ Have the visitor sign a waiver”

B. “ Document the incident report in the client’s medical record”
C. “Offer the visitor an analgesic”
D. “ Record the event on an occurrence report”
Answer: D. “ Record the event on an occurrence report”
192. A nurse is preparing an education program about professional codes of ethics for nurses.
Which of the following information should the nurse plan to include?
A. A code of ethics is a step-by-step approach to decision making
B. A code of ethics is legally binding
C. A code of ethics outlines the nurses scope of practice
D. A code of ethics is a set of principles for nursing practice
Answer: C. A code of ethics outlines the nurses scope of practice
193. An infection control nurse is planning an education program for a group of newly licensed
nurses. Which of the following infections should the nurse include when discussing illnesses
requiring droplet precautions?
A. Rotavirus
B. Rubeola
C. Varicella
D. Mumps
Answer: D. Mumps
194. A nurse manager discovers there is a conflict between nurses working day shift and working
night shift. Which of the following actions should the nurse take?
A. Gather information regarding the situation
B. Acknowledge the conflict and encourage the nurses to focus on working as a team
C. Encourage the nurses to resolve the conflict autonomously
D. Meet with the a committee of nurses from each shift to discuss issues related to the conflict
Answer: A. Gather information regarding the situation

195. A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After
donning a sterile gown and gloves, which of the following actions by the newly licensed nurse
demonstrates correct aseptic technique?
A. The nurse puts on a face mask
B. The nurse applies goggles
C. The nurse holds her hands above her waist
D. The nurse turns her back to the sterile field
Answer: C. The nurse holds her hands above her waist
196. A nurse in an emergency department is triaging four clients. Which of the following clients
should the nurse recommend to be examined first?
A. An adolescent who has an injured ankle and reports a pain level of 8 on a scale of 0-10
B. A toddler who has a 2cm (0.79 in) head laceration oozing dark red blood
C. An older adult patient who has dyspnea and a respiratory rate of 26min
D. An adult patient who has large ecchymoses on both legs
Answer: C. An older adult patient who has dyspnea and a respiratory rate of 26min
197. A nurse is caring for a patient who has a prescription for transcutaneous electrical nerve
stimulation (TENS). Which of the following members of the interdisciplinary team should the
nurse contact for assistance?
A. Pharmacist
B. Occupational therapist
C. Respiratory therapist
D. Physical therapist
Answer: D. Physical therapist
198. A nurse in a long-term care facility is planning a fall prevention program for the residents.
Which of the following interventions should the nurse include?
A. Accompany residents older than 85 years of age during ambulation
B. Institute rounds every 2 hr during the day to offer toileting
C. Keep the four side rails up on beds at night

D. Apply vest restraints on residents who are confused
Answer: B. Institute rounds every 2 hr during the day to offer toileting
199. A nurse on a surgical unit is preparing to transfer a patient to a rehabilitation facility. Which
of the following information should the nurse include in the change of shift report?
A. The time the patient received his last dose of pain medication
B. The clients preferred bath time
C. The belief that the patient has a difficult relationship with his son
D. The steps to follow when providing wound care
Answer: A. The time the patient received his last dose of pain medication
200. A nurse is caring for four clients who are scheduled to undergo surgery. Which of the
following clients can give informed consent?
A. An adult patient who has moderate Alzheimer’s disease
B. An older adult patient who has questions about the procedure
C. An adult patient who has alcohol intoxication
D. An adolescent patient who is legally emancipated
Answer: D. An adolescent patient who is legally emancipated
201. A nurse is completing a performance evaluation for an assistive personnel. Which of the
following actions by the AP requires intervention by the nurse?
A. The AP wears a mask when caring for a patient who has varicella
B. The AP removes cut flowers from the room of a patient who is in a protective environment
C. The AP closes the door of a patient who is on airborne precaution
D. The AP uses alcohol hand antiseptic after caring for a patient who has C-Diff
Answer: D. The AP uses alcohol hand antiseptic after caring for a patient who has C-Diff
202. A nurse is caring for four clients. For which of the following clients should the nurse
collaborate with the facility ethics committee?
A. A young adult patient who is participating in a medical research study
B. An older adult patient who has advance directives on file

C. An adolescent patient whose parents refuse a blood transfusion for religious reasons
D. A middle adult patient who leaves the facility against medical advice
Answer: C. An adolescent patient whose parents refuse a blood transfusion for religious reasons
203. A nurse is working with a licensed practical nurse (LPN) to care for a group of clients.
Which of the following clients should the nurse delegate to the LPN?
A. A patient who has leukaemia and requires an updated plan of care
B. A patient who is transferring from the PACU following abdominal hernia repair
C. A patient who has type 1 diabetes mellitus and receives insulin before meals
D. A patient who requires discharge teaching about a newly described medication
Answer: C. A patient who has type 1 diabetes mellitus and receives insulin before meals
204. A nurse is coordinating an interprofessional team to review proposed standards to reduce the
transmission of MRSA. Which of the following members of the interprofessional team should
the nurse consult?
A. Infection control nurse
B. Nursing supervisor
C. Risk management coordinator
D. Clinical pharmacist
Answer: A. Infection control nurse
205. A charge nurse provides an annual in-service for the nursing staff regarding ethical practice.
Which of the following actions should the nurse include as an example of ethical practice?
A. A nurse raises all four side rails on the bed of a patient who is confused
B. A nurse refuses to care for a patient who has had an abortion
C. A nurse withholds nutrition from a patient who has DNR order - don’t do this
D. A nurse administers prescribed opioids to a patient who has a terminal illness and respiratory
rate of 8/min
Answer: D. A nurse administers prescribed opioids to a patient who has a terminal illness and
respiratory rate of 8/min

206. 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. Evaluating a client’s home for safety hazards
B. Recommending a referral for a patient who requires physical therapy
C. Completing an incident report following a medication error
D. Suggesting a client’s partner attend a support group for emotional support
Answer: B. Recommending a referral for a patient who requires physical therapy
207. A nurse enters a client’s room and identifies that the patient is receiving too much IV fluid
because the IV pump is not working properly. Which of the following actions should the nurse
take first?
A. Notify the provider
B. Place a faulty equipment tag on the pump
C. Auscultate the client’s lungs
D. Complete and incident report
Answer: C. Auscultate the client’s lungs
208. A nurse is documenting and completing an incident report after a patient falls out of bed.
Which of the following actions should the nurse take when completing the documentation?
A. Document in the incident report, ‘ Entered room and discovered patient lying prone on the
floor’
B. Document in the nurses report, ‘Photocopy of incident report sent to risk management’
C. Document in incident report, ‘patient found lying on the floor after falling out of bed’
D. Document in nurses notes, ‘Incident report completed and filed’
Answer: C. Document in incident report, ‘patient found lying on the floor after falling out of
bed’
209. A nurse is planning discharge teaching for a patient who has a newly placed tracheostomy
tube. The nurse should assess the client’s need for which of the following supplies to manage
tracheostomy at home? (SATA)

A. Cotton-twill tracheostomy ties
B. Suction machine
C. Povidone – iodine swabs
D. Petroleum jelly lubricated gauze
E. Oxygen tank
Answer: B. Suction machine
E. Oxygen tank
210. A nurse is providing discharge teaching to a patient following total knee arthroplasty. Which
of the following information should the nurse include? (SATA)
A. Information about follow up care
B. Medication guideline information
C. Advance directives information
D. Contact information for the physical therapist
E. Insurance information
Answer: A. Information about follow up care
B. Medication guideline information
D. Contact information for the physical therapist
211. 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. “ I will need to notify the client’s provider about the breach of confidentiality”
C. “ Please stop discussing the patient in a public area”
D. “ Do you understand HIPAA regulations?”
Answer: C. “ Please stop discussing the patient in a public area”
212. A nurse is caring for a patient who reports taking a new herbal supplement after reading
about it on the Internet. Which of the following instructions should the nurse provide the client?
A. Compare website’s information with a variety of sources
B. Look for medical information on network (. Net) websites

C. Ensure the website is sponsored by a pharmaceutical company
D. Consider the Internet information reliable if it is written by a doctor
Answer: D. Consider the Internet information reliable if it is written by a doctor
213. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain
that preventing patient injury by removing a fall hazard demonstrates which of the following
ethical principles?
A. Veracity – nurse’s duty to tell the truth
B. Nonmaleficence – nurse’s obligation to avoid causing harm to the client
C. Utility
D. Autonomy – the ability of the patient to make personal decisions
Answer: B. Nonmaleficence – nurse’s obligation to avoid causing harm to the client
214. A nurse is preparing a patient for surgery. The patient expresses concern that someone might
steal her purse during the procedure. Which of the following actions should the nurse take?
A. Tell the patient to leave her purse in a drawer of the bedside table
B. Place the purse in the clothing bag with the clients belongings
C. Offer to place the purse in the facility’s safe
D. Offer to store the purse in the nurses station
Answer: C. Offer to place the purse in the facility’s safe
215. A staff nurse is supervising a newly licensed nurse who is preparing to administer an
intermittent tube feeding to a client. Which of the following actions by the newly licensed nurse
is appropriate?
A. Elevating the head of the bed 20 degree angle
B. Check residual volume before each feeding
C. Flushing The tube with 15 mL of water
D. Adding coloured food dye to the formula
Answer: B. Check residual volume before each feeding

216. A home health nurse is assessing the home environment during an initial visit to a patient
who has a history of falls. Which of the following findings should the nurse identify as
increasing the client’s risk of falls? (SATA)
A. A throw rug covering some cracked vinyl flooring in the kitchen
B. A folding chair without arm rests
C. A two- wheeled walker used to assist the patient with ambulation
D. A raised vinyl seat on the toilet in the client’s bathroom
E. A wheeled office chair at the client’s computer desk
Answer: A. A throw rug covering some cracked vinyl flooring in the kitchen
B. A folding chair without arm rests
E. A wheeled office chair at the client’s computer desk
217. A nurse on a medical- surgical unit is caring for a patient who asks about advance directives
and states the he wants to appoint a health care proxy. Which of the following responses should
the nurse make?
A. “ It is necessary for an attorney to approve your health care proxy”
B. “ A health care proxy can make decisions for you when you are unable to do so”
C. “ You must choose a member of your family to serve as your health care proxy”
D. “ You should appoint a health care proxy before undergoing an invasive procedure”
Answer: B. “ A health care proxy can make decisions for you when you are unable to do so”
218. A nurse is preparing to transfer a patient to the radiology department using the wheelchair.
Which of the following actions should the nurse take?
A. Push the wheelchair into the elevator, large wheels last
B. Leave a transfer belt in place until the patient returns from radiology
C. Keep the footplates lowered throughout the transfer process.
D. Test the locks on both wheels of the chair prior to transfer.
Answer: D. Test the locks on both wheels of the chair prior to transfer.
219. A nurse is providing an in-service about patient rights for a group of nurses. Which of the
following statements should the nurse include in the in-service?

A. “A nurse can apply restraints on a PRN basis”
B. “A nurse can administer medications without consent to a patient as part of a research study”
Patients have right to refuse
C. “A nurse can disclose information to a family member with the client’s permission.”
D. “A nurse is responsible for informing clients about treatment options”
Answer: C. “A nurse can disclose information to a family member with the client’s permission.”
220. A charge nurse suspects that a staff nurse is chemically impaired. Which of the following
actions should the charge nurse take?
A. Assign clients who are not prescribed narcotics to the staff nurse
B. Counsel the staff nurse about substance abuse use
C. Collect data about the staff nurse to support further action Always assess first
D. Report the staff nurse to the facility ethics committee
Answer: C. Collect data about the staff nurse to support further action Always assess first
221. A charge nurse is admitting a patient who speaks a different language than the nurse and
will require and interpreter. Which of the following actions should the nurse plan to take?
A. Limit interpreter services to daytime hours
B. Repeat the same words to the interpreter if the patient does not understand
C. Assign a bilingual staff member to be the interpreter when caring for the client
D. Pause in the middle of the sentence when using an interpreter
Answer: C. Assign a bilingual staff member to be the interpreter when caring for the client
222. A nurse is caring for a patient who has Addison’s disease. Which of the following tasks
should the nurse plan to delegate to an assistive personnel?
A. Explain to the patient about a 24hr urine specimen collection RN
B. Determine the client’s muscle strength prior to ambulation RN
C. Decide how often to measure vital signs RN
D. Remind the patient to change positions slowly within AP scope
Answer: D. Remind the patient to change positions slowly within AP scope

223. A nurse is caring for a patient who had a stroke and is experiencing difficulty swallowing.
The nurse should arrange a referral to which of the following members of the interprofessional
team regarding the client’s condition?
A. Speech pathologist – Evaluates and makes recommendations regarding the impact of
disorders or injuries on speech, language, and swallowing
B. Occupational therapist
C. Physical therapist
D. Social worker
Answer: A. Speech pathologist – Evaluates and makes recommendations regarding the impact of
disorders or injuries on speech, language, and swallowing
224. A nurse is planning care for four clients who were classified using a disaster triage tag team
system following a mass casualty event. Which of the following clients should the nurse identify
as priority?
A. A patient who has a red tag
B. A patient who has a yellow tag (delayed – serious but not life threatening)
C. A patient who has a green tag (minor, walking wounded)
D. A patient who has a black tag
Answer: A. A patient who has a red tag
225. A nurse is assessing an older adult patient who was brought to the emergency department by
his adult son, who reports that the patient fell at home. The nurse suspects elder abuse. Which of
the following actions should the nurse take?
A. File an incident report
B. Ask the patient about his injuries with the son present
C. Treat and discharge the client
D. Ask the client’s son to wait in the waiting room
Answer: D. Ask the client’s son to wait in the waiting room
226. A charge nurse is reviewing the actions by a nurse following a patient fall. Which of the
following actions by the nurse requires intervention by the charge nurse?

A. Lists names of witnesses to the fall in the incident report
B. Documents in the client’s record, “Incident report was filed”
C. Sends the incident report to risk management
D. Includes the client’s account of the fall in the incident report
Answer: B. Documents in the client’s record, “Incident report was filed”
227. A nurse on a medical-surgical unit is making staff assignments. Which of the following
tasks should the nurse delegate to an assistive personnel?
A. Pouching a client’s established ostomy
B. Reinforcing teaching with a patient about low-sodium diet
C. Demonstrating the use of an incentive spirometer to a client
D. Updating a family member about a client’s condition
Answer: A. Pouching a client’s established ostomy
228. A nurse is caring for a patient who is scheduled for placement of central venous access
device. Which of the following actions is the nurse’s responsibility in the informed consent
process?
A. Discuss alternative treatment options with the client
B. Place a photocopy of the signed informed consent in the client’s medical record
C. Assess the client’s understanding after the provider has talked to her
D. Review the risks and benefits of the procedure with the client
Answer: C. Assess the client’s understanding after the provider has talked to her
229. A nurse is orienting a newly licensed nurse about the use of restraints. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. “ A provider can write a prescription for restraints ‘as needed’
B. “ I should tie the restraints using a square knot”
C. “ I need to tie the restraint to the part of the bed frame that moves”
D. “ I will remove the client’s restraints every 4 hours”
Answer: D. “ I will remove the client’s restraints every 4 hours”

230. A nurse is receiving change of shift report for four clients. Which of the following clients
should the nurse care for first?
A. A patient has pneumonia and requires a tracheostomy dressing change
B. A patient has a new colostomy and requires discharge teaching
C. A patient who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhoea
D. A patient who is 4 hours postoperative following a hernia repair and has pitting edema of the
right leg – (Compartment syndrome)
Answer: D. A patient who is 4 hours postoperative following a hernia repair and has pitting
edema of the right leg – (Compartment syndrome)
231. A charge nurse is receiving change of shift report. Which of the following situations should
the charge nurse report address first?
A. Transport assistance is unavailable to take a patient to occupational therapy
B. The emergency department nurse is waiting to give report on a new admission
C. A nurse on the previous shift wrote an incident report on a medication error
D. Two staff members have called to say there were absent
Answer: D. Two staff members have called to say there were absent
232. A nurse is providing information to a patient about advance directives. The nurse should
explain that advance directions include which of the following?
A. Instructions regarding treatments the patient desires or does not desire
B. Information regarding organ donation
C. Information regarding the disposition of the client’s body upon death
D. A form with directions for contacting next of kin
Answer: A. Instructions regarding treatments the patient desires or does not desire
233. A nurse is reviewing medication administration record of a patient and notices that an
additional dose of medication has been administered. Which of the following actions should the
nurse make first?
A. Inform the nursing supervisor
B. Notify the provider

C. Complete an incident report
D. Observe the client’s condition
Answer: D. Observe the client’s condition
234. A nurse is assessing a patient who has meningitis. Which of the following finding should the
nurse report to the provider immediately?
A. Increased temperature
B. Report of photophobia
C. Decreased level of consciousness
D. Generalized rash over trunk
Answer: C. Decreased level of consciousness
235. A nurse is evaluating a newly licensed nurse who is administering a vitamin K injection to a
newborn. Which of the following actions by the newly licensed nurse indicates understanding of
the teaching? (SATA)
A. Applies gentle pressure at the site after injection
B. Aspirates the syringe for blood return after needle insertion
C. Selects the dorsogluteal site to administer the injection
D. Inserts the needle at a 45° angle - IM should be 90
E. Cleans the injection site with alcohol
Answer: A. Applies gentle pressure at the site after injection
B. Aspirates the syringe for blood return after needle insertion
E. Cleans the injection site with alcohol
236. A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which
of the following statements by a staff nurse indicates that the teaching was effective?
A. “Guardian consent is required for an emancipated minor.”
B. “Consent can be given by a durable power of attorney.”
C. “The nurse can answer any questions the patient has about the procedure.”
D. “A family member can interpret to obtain informed consent from a patient who is deaf.”
Answer: B. “Consent can be given by a durable power of attorney.”

237. A nurse is teaching a patient how to use a finger-stick glucometer at home. Which of the
following instructions should the nurse include?
A. Obtain the blood sample from the finger pads.
B. Elevate the arm for 1 min before taking the blood sample.
C. Cap the lancet prior to putting it in the trash.
D. Warm the hands prior to piercing the skin
Answer: D. Warm the hands prior to piercing the skin
238. A patient is admitted with COPD. Which of the following findings should the nurse report
to the provider?
A. Report of dyspnea on exertion
B. Oxygen saturation 89% on room air
C. White blood cell count 9,000/mm3
D. Bilateral crackles on auscultation of lungs
Answer: D. Bilateral crackles on auscultation of lungs
239. A patient schedule for a tubal ligation procedure starts to cry as she is wheeled into the
surgical suite. Which of the following nursing statements is an appropriate nursing response?
A. “You shouldn’t be worried because the procedure is very safe.”
B. “This won’t take long and it will be over before you know it.”
C. “Why did you make the decision to have this procedure?”
D. “It’s not too late to cancel the surgery if you want to.”
Answer: D. “It’s not too late to cancel the surgery if you want to.”
240. A nurse is caring for a patient who reports acute pain but refuses IM medication. The nurse
distracts the patient and quickly administers the injection. This illustrates which of the
following?
A. Libel
B. False imprisonment
C. Battery

D. Assault
Answer: C. Battery
241. A nurse manager overhears a provider and a staff nurse talking about a client’s diagnosis in
the cafeteria. Which of the following actions should the nurse take first?
A. Provide a staff in service about patient confidentiality.
B. Fill out an incident report regarding the situation.
C. Remind them that patient information is confidential.
D. Report the incident to the nursing supervisor.
Answer: C. Remind them that patient information is confidential.
242. A nurse is serving on a committee that is revising the protocol for discharging clients. After
developing an initial plan, in which order should the nurse take the following steps?
A. Determine goals
B. Implement recommended strategies
C. Revise the plan.
D. Evaluate the results
Answer: A. Determine goals
B. Implement recommended strategies
D. Evaluate the results
C. Revise the plan.
243. A nurse is orienting to an emergency department. The nurse is asked to assist with suturing
of a laceration on a client’s hand. Which of the following is the best resource for this nurse?
A. The preceptor on the clinical unit
B. The provider suturing the client’s injury
C. The nursing supervisor
D. The information on the suture package
Answer: B. The provider suturing the client’s injury

244. A patient is brought to the emergency department (ED) following a motor-vehicle crash.
Drug use is suspected in the crash, and a voided urine specimen is ordered. The patient
repeatedly refuses to provide the specimen. Which of the following is the appropriate action by
the nurse?
A. Assess the patient for urinary retention.
B. Obtain a provider’s prescription for a blood alcohol level.
C. Tell the patient that a catheter will be inserted.
D. Document the client’s refusal in the chart.
Answer: D. Document the client’s refusal in the chart.
245. While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that six of the 15 records lack documentation regarding advance directives. Which
of the following is the priority action for the nurse to take?
A. Ask nurses who are caring for clients without this information in the medical record to obtain
it.
B. Remind nurses to obtain this information during the admission process.
C. Meet with nursing staff to review the policy regarding advance directives.
D. Reinforce the potential consequences of not having this information on record to the nursing
staff.
Answer: C. Meet with nursing staff to review the policy regarding advance directives.
246. A nurse who is precepting a newly licensed nurse is discussing the patient assignment for
the shift. Which of the following actions should the nurse preceptor take first to demonstrate
appropriate time management?
A. Determine patientcare goals.
B. Review the client’s new laboratory values.
C. Complete required tasks.
D. Document assessment data.
Answer: A. Determine patientcare goals.

247. A facility provides annual staff education regarding ethical practice. A charge nurse
recognizes a need for further education when which of the following behaviors is observed?
A. A nurse gives prescribed opioids to a patient who has a terminal illness and respirations of
8/min.
B. A nurse refuses to actively participate during an elective abortion procedure scheduled for her
client.
C. A nurse informs a confused patient who wants to go home that he is going to stay at the
facility until he is better.
D. A nurse explains to a client’s family that a DNR includes withholding comfort measures.
Answer: D. A nurse explains to a client’s family that a DNR includes withholding comfort
measures.
248. A nurse is caring for a patient who is unconscious and whose partner is his health care
proxy. The partner has spoken with the provider and wishes to discontinue the client’s feeding
tube. The provider states to the nurse, “I will not discontinue this client’s treatment. His partner
has no right to make decisions regarding the client’s care.” Which of the following responses by
the nurse is appropriate?
A. “We’ll need to have the nursing supervisor review the client’s advance directives.”
B. “You should consider speaking with the facility’s ethics committee before making your
decision.”
C. “You have the right to make that decision, even if the partner is the client’s health care proxy.”
D. “The patient has designated his partner as health care proxy in his advance directives.”
Answer: D. “The patient has designated his partner as health care proxy in his advance
directives.”
249. A parish nurse is making a referral to a community meal delivery program for a member of
the congregation. This is an example of which of the following functions of the parish nurse?
A. Health educator
B. Liaison
C. Pastoral care provider
D. Personal health counsellor

Answer: B. Liaison
250. A nurse is preparing to discharge a patient back to a long-term care facility after he was
admitted to an acute care facility 2 days ago for pneumonia. Which of the following information
should the nurse include in the verbal transfer report?
A. Laboratory results within the expected reference range
B. Level of consciousness
C. List of regularly prescribed medications
D. Date of last bowel movement
Answer: B. Level of consciousness
251. A charge nurse on a postpartum unit is teaching a patient who gave birth 2 hr ago about the
facility’s protocols for preventing newborn abduction. Which of the following instructions
should the nurse include?
A. “Carry your baby snugly in your arms whenever you leave your room.”
B. “Make sure to leave your baby in the bassinet by your bed when you use the bathroom.”
C. “Keep your baby next to you in your bed if you think you might fall asleep.”
D. “Check the photo identification badge of staff members who care for you and your baby.”
Answer: D. “Check the photo identification badge of staff members who care for you and your
baby.”
252. A nurse is assigned the following four clients for the current shift. Which of the following
clients should the nurse assess first?
A. A patient who has diabetes mellitus and a stage 2 pressure ulcer on his foot
B. A patient who has a hip fracture and is in Buck’s traction
C. A patient who has aspiration pneumonia and a respiratory rate 28/min ABC
D. A patient who has a Clostridium difficile infection and needs a stool specimen collected
Answer: C. A patient who has aspiration pneumonia and a respiratory rate 28/min ABC
253. A nurse should recognize that an incident report is required when
A. A visitor pinches his finger in the client’s bed frame.

B. A nurse gives a medication 30 min late.
C. A patient throws a box of tissues at a nurse.
D. A patient refuses to attend physical therapy.
Answer: A. A visitor pinches his finger in the client’s bed frame.
254. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is
appropriate to delegate to a licensed practical nurse?
A. Referring a patient to social services for assistance with transportation
B. Providing the first oral feeding to a patient following a stroke
C. Instructing a patient who is obese about a low-fat diet
D. Changing the dressing on a postoperative wound
Answer: D. Changing the dressing on a postoperative wound
255. A nurse is precepting a newly licensed nurse who is caring for a patient who is confused and
has an IV infusion. The newly licensed nurse has placed the patient in wrist restraints to prevent
dislodging the IV catheter. Which of the following questions should the precepting nurse ask?
A. “Are you removing the client’s restraints every 4 hours?”
B. “Are you able to insert two fingers between the restraints and the client’s skin?”
C. “Did you tie the restraints using a double knot?”
D. “Did you secure the restraints to the side rails of the bed?”
Answer: B. “Are you able to insert two fingers between the restraints and the client’s skin?”
256. A nurse observes a paper bag at the bedside of a client. This finding suggests that the patient
is receiving treatment for which of the following respiratory disorders?
A. Stridor
B. Asthma
C. Hyperventilation
D. Atelectasis
Answer: C. Hyperventilation

257. Which of the following observations requires a charge nurse to intervene and demonstrate
safe handling techniques?
A. A nurse uses goggles to perform tracheostomy suctioning.
B. A nurse places a mask on a patient with tuberculosis before transport to the radiology
department.
C. A nurse cleans up a blood spill with a 1:10 bleach solution.
D. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a
specimen.
Answer: D. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a
specimen.
258. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a
sterile procedure. Which of the following actions indicates the nurse is maintain sterile
technique? (SATA)
A. Opens the sterile pack by first unfolding the flap farthest from her body
B. Holds a bottle of sterile solution 15 cm (6 inches) above the sterile field
C. Places sterile items within a 1.25-cm (0.5-inch) border around the edges of the sterile field
D. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field
E. Rests the cap of a solution container upside down on the sterile field
Answer: A. Opens the sterile pack by first unfolding the flap farthest from her body
B. Holds a bottle of sterile solution 15 cm (6 inches) above the sterile field
D. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field
259. A nurse working on a medical-surgical unit is receiving shift report regarding four clients.
Which of the following patient should the nurse see first?
A. A 75-year-old man who has pneumonia and has a O2 saturation of 92%
B. A 80-year-old woman who has a urinary tract infection and a temperature of 38.2°C (100.8°F)
C. A 45-year-old man who has new onset of confusion 24 hr after a total hip arthroplasty
D. A 50-year-old woman reporting abdominal pain of 7 on a scale of 0 to 10
Answer: C. A 45-year-old man who has new onset of confusion 24 hr after a total hip
arthroplasty

260. An RN is planning patient assignments for a licensed practical nurse (LPN) and three
assistive personnel. The RN should assign the LPN to the patient who requires
A. Recording of daily intake and output
B. Assistance with meals
C. A complete bed bath
D. Frequent dressing changes
Answer: D. Frequent dressing changes
261. A patient has a new permanent pacemaker inserted. Which of the following home care
instructions should the nurse include?
A. Swimming could cause the unit to have an electrical short.
B. The patient should avoid using remote control devices to prevent dysrhythmias.
C. Regular programming evaluations can be conducted by telephone.
D. The patient should avoid using a microwave oven to heat food.
Answer: C. Regular programming evaluations can be conducted by telephone.
262. According to HIPAA regulations, which of the following is a violation of patient
confidentiality?
A. Reporting a client’s disposition to the referring provider
B. Informing housekeeping staff that the patient is in the dialysis unit
C. Providing a copy of the record to the transporting paramedic
D. Telephoning the pharmacy with a prescription for the spouse to pick up
Answer: B. Informing housekeeping staff that the patient is in the dialysis unit
263. A nurse is preparing discharge planning for a patient who has a newly placed tracheostomy
tube. The nurse should assess the client’s need for which of the following to manage the
tracheostomy at home?(SATA)
A. Pipe cleaners
B. Cotton balls
C. Petroleum jelly

D. Oxygen tank
E. Obturator
Answer: A. Pipe cleaners
D. Oxygen tank
E. Obturator
264. A nurse manager is preparing to institute a new system for scheduling staff. Several nurses
have verbalized their concern over the possible changes that will occur. Which of the following
is an appropriate method to facilitate the adoption of the new scheduling system?
A. Provide a brief overview of the new scheduling system immediately before its
implementation.
B. Offer to reassign staff who do not support the change to another unit.
C. Identify nurses who accept the change to help influence other staff nurses.
D. Introduce the new scheduling system by describing how it will save the institution money.
Answer: A. Provide a brief overview of the new scheduling system immediately before its
implementation.
265. A nurse enters a client’s room and observes a fire in the trash can. Identify the sequence of
actions the nurse should take.
A. Remove the patient from the area.
B. Activate the first alarm system.
C. Confine the fire by closing doors and windows.
D. Extinguish the fire if possible.
Answer: A. Remove the patient from the area.
B. Activate the first alarm system.
C. Confine the fire by closing doors and windows.
D. Extinguish the fire if possible.
266. A nurse enters the room of a patient who is unconscious and finds that the client’s son is
reading her electronic medical records from a monitor located at the bedside. Which of the
following actions should the nurse take first?

A. Complete an incident report regarding the breach of the client’s confidentiality.
B. Report the possible violation of patient confidentiality to the nurse manager.
C. Log out the computer so that the client’s son is unable to view his mother’s information.
D. Recommend the son meet with the provider to get information about his mother’s condition.
Answer: C. Log out the computer so that the client’s son is unable to view his mother’s
information.
267. Nurses on an inpatient care unit are working to help reduce unit costs. Which of the
following is appropriate to include in the cost-containment plan?
A. Return unused supplies from the bedside to the unit’s supply stock.
B. Use clean gloves rather than sterile gloves for colostomy care.
C. Wait to dispose of sharps containers until they are completely full.
D. Store opened bottles of normal saline in a refrigerator for up to 48 hr.
Answer: B. Use clean gloves rather than sterile gloves for colostomy care.
268. Which of the following puts a hospital at the highest risk for infringement of patient record
confidentiality?
A. Paper-based charts are stored at the nurses’’ station.
B. A provider and nurse access patient information using once access code.
C. A nurse performs electronic documentation outside a client’s room.
D. A nurse clusters documentation of care for multiple clients.
Answer: B. A provider and nurse access patient information using once access code.
269. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist
restraints to a patient who is agitated and does not have a prescription for restraints. Which of the
following actions should the nurse take first?
A. Review the chart for non-restrain alternatives for agitation.
B. Speak with the AP about the incident.
C. Remove the restraints from the client’s wrists.
D. Inform the unit manager of the incident.
Answer: C. Remove the restraints from the client’s wrists.

270. A nurse is providing change-of-shift report for an oncoming nurse. Which of the following
information should the nurse include in the report?
A. “The client’s partner came to visit him 2 hours ago and smelled of alcohol.”
B. “The patient is currently in the radiology department for a chest x-ray.”
C. “The patient will need vital signs every 4 hours.”
D. “The patient is the president of a local bank.”
Answer: B. “The patient is currently in the radiology department for a chest x-ray.”
271. A patient who has substance use disorder is admitted to the mental health unit and reports
that he has been depressed lately. When preparing for discharge the next day, the patient states,
“It’s okay. Soon everything will be just fine.” Which of the following is the nurse’s priority
action?
A. Ask the patient if he has considered hurting himself.
B. Provide the patient with information about Alcoholics Anonymous.
C. Encourage the patient to participate in physical activities.
D. Reinforce the need to follow up with discharge referral.
Answer: A. Ask the patient if he has considered hurting himself.
272. A charge nurse is addressing conflict between two nurses who are having a disagreement at
the nurses’ station. Which of the following strategies should the charge nurse use to assist with
negotiations? (SATA)
A. Continue negotiations until a resolution is made.
B. Have the nurses move the discussion to a private location.
C. Begin negotiations with minimal demands from each nurse.
D. Address the nurses using assertive communication techniques.
E. Use active listening when obtaining each nurse’s perception of the situation.
Answer: B. Have the nurses move the discussion to a private location.
D. Address the nurses using assertive communication techniques.
E. Use active listening when obtaining each nurse’s perception of the situation.

273. A nurse is providing care for four postoperative clients. The nurse should first assess the
client
A. Who is reporting nausea after the prescribed antiemetic was administered.
B. Whose pulse has been steadily increasing during the past shift.
C. Whose urine output has averaged 32 mL/hr for the past 24 hr.
D. Who is reporting a pain level of 8 on a scale of 0 to 10.
Answer: B. Whose pulse has been steadily increasing during the past shift.
274. A nurse finds a patient sitting on the floor holding her right forearm. She tells the nurse that
she slipped and hit her arm. Which of the following actions should the nurse take first?
A. Submit an incident report.
B. Alert the client’s provider of the incident.
C. Reposition the patient to prevent further injury.
D. Check the patient for injuries.
Answer: D. Check the patient for injuries.
275. A nurse in an acute care unit is assessing a group of clients. Which of the following clients
is the nurse’s priority?
A. A patient who has pneumonia and has an oxygen saturation of 95%
B. A patient who has atrial fibrillation and reports chest pain of 5 on a scale from 0 to 10
C. A patient who has peripheral vascular disease and has +1 pedal pulses bilaterally
D. A patient who has inflammatory bowel syndrome and reports two loose stools
Answer: B. A patient who has atrial fibrillation and reports chest pain of 5 on a scale from 0 to
10
276. A nurse is caring for a patient who fell and is reporting pain in the left hip with external
rotation of the left leg. 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. Reposition the patient for comfort.
B. Notify the nursing supervisor about the issue.
C. Contact the client’s physical therapist.

D. Apply a warm compress to the hip.
Answer: B. Notify the nursing supervisor about the issue.
277. Which of the following should lead a nurse to suspect abuse that must be reported?
A. A school-age child has several bruises on her lower legs.
B. A preschool child who was previously trained now requires diapers in the hospital.
C. A toddler cries whenever his parent enters the hospital room.
D. An adolescent admitted to the emergency department won’t speak to his parents.
Answer: C. A toddler cries whenever his parent enters the hospital room.
278. A home health nurse is assessing the home environment of a patient who is on continuous
oxygen therapy. Which of the following findings requires the nurse to intervene?
A. The patient is covered with a woollen blanket.
B. The oxygen machine has a grounded plug.
C. The family keeps a spare oxygen tank in the room.
D. The windows of the client’s room are open.
Answer: A. The patient is covered with a woollen blanket.
279. A nurse is caring for a patient who has increased intracranial pressure and is receiving IV
corticosteroids. Which of the following information is most important for the nurse to report at
shift change?
A. Reddened area on the coccyx
B. Most recent blood glucose reading
C. Glasgow Coma Scale score
D. Laboratory tests scheduled for next shift
Answer: C. Glasgow Coma Scale score
280. A nurse in the emergency department is caring for a group of four clients. Which of the
following clients should the nurse recommend for transfer to the ICU?
A. A patient who has chronic atrial fibrillation and a digoxin level of 0.3 ng/mL
B. A patient who has bleeding esophageal varices and a blood pressure of 90/50 mm Hg

C. A patient who has a head injury and Glasgow Coma Scale score of 10
D. A patient who has chronic kidney disease and a creatinine level of 15 mg/dL
Answer: C. A patient who has a head injury and Glasgow Coma Scale score of 10
281. A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t get
better, I’m going to quit.” Which of the following responses by the unit manager is appropriate?
A. “Just stick with it a little longer. Things will get better soon.”
B. “So you are upset about all the changes on the unit?”
C. “You should file a written complaint with hospital administration.”
D. “I think you have a right to be upset. I am tired of the changes, too.”
Answer: B. “So you are upset about all the changes on the unit?”
282. An older adult patient is awaiting surgery for a fractured right hip. The nurse should
recognize that which of the following can be delegated to assistive personnel?
A. Recording the client’s vital signs
B. Determining the client’s pain level
C. Checking the pulses of the client’s right foot
D. Turning the client
Answer: A. Recording the client’s vital signs
283. A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?
A. Assessing a patient who just returned from haemodialysis
B. Reviewing dietary instructions for a patient with kidney stones
C. Monitoring a patient with a fluid restriction
D. Obtaining a stool sample from a patient with renal failure
Answer: D. Obtaining a stool sample from a patient with renal failure
284. A nurse is providing teaching to a patient who has a new diagnosis of diabetes mellitus. The
patient expresses concern about the cost of blood glucose monitoring supplies. Which of the
following referrals should the nurse make to address the client’s concern?

A. Case manager
B. Dietitian
C. Chaplain
D. House supervisor
Answer: A. Case manager
285. A nurse manager is providing orientation to a group of newly licensed nurses. The nurse
manager should communicate that which of the following actions is the responsibility of the
nurse when responding to a disaster?
A. Assume leadership for directing the emergency plan.
B. Use the chain-of-command for communication.
C. Act as a spokesperson between the facility and the community.
D. Coordinate the activities of emergency medical services.
Answer: A. Assume leadership for directing the emergency plan.
286. A patient who is febrile is admitted to the hospital for treatment of pneumonia. In
accordance with the care pathway, antibiotic therapy is prescribed. Which of the following
situations requires the nurse to complete a variance report with regard to the care pathway?
A. A blood culture was obtained after antibiotic therapy had been initiated.
B. The route of antibiotic therapy on the care pathway was changed from IV to PO.
C. An allergy to penicillin required an alternative antibiotic to be prescribed.
D. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.
Answer: A. A blood culture was obtained after antibiotic therapy had been initiated.
287. A nurse is working on a quality improvement team that is assessing an increase in patient
falls at a facility. After problem identification, which of the following actions should the nurse
plan to take first as part of the quality improvement process?
A. Review current literature regarding patient falls.
B. Identify clients who are at risk for falls.
C. Notify staff of the increased fall rate.
D. Implement a fall prevention plan.

Answer: B. Identify clients who are at risk for falls.
288. To receive a conflict between staff members regarding potential changes in policy, a nurse
manager decides to implement the changes she prefers regardless of the feelings of those who
oppose those changes. Which of the following conflict-resolution strategies is the nurse manager
using?
A. Compromising
B. Cooperating
C. Competing
D. Collaborating
Answer: C. Competing
289. A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse
is having trouble focusing and has difficulty completing care for his assigned clients. Which of
the following interventions is appropriate?
A. Ask other staff members to take over some of his tasks.
B. Advise him to complete less time-consuming tasks first.
C. Recommend that he take time to plan at the beginning of his shift.
D. Offer to provide care for his clients while he takes a break.
Answer: C. Recommend that he take time to plan at the beginning of his shift.
290. Patient satisfaction surveys from a surgical unit indicate that pain is not being adequately
relieved during the first 12 hr postoperatively. The unit manager decides to identify postoperative
pain as a quality indicator. Which of the following data sources will be helpful in determining the
reason why clients are not receiving adequate pain management after surgery?
A. Prospective chart audit
B. Pain assessment policy
C. Postoperative care policy
D. Retrospective chart audit
Answer: C. Postoperative care policy

291. The mother of a patient with breast cancer states, “It’s been hard for her, especially after
losing her hair. And it has been difficult to pay for all the treatments.” Which of the following
actions is appropriate patient advocacy?
A. The nurse suggests counseling for the client’s body image issues.
B. The nurse investigates potential resources to help the patient purchase a wig.
C. The nurse informs the next shift nurse regarding the mother’s concerns.
D. The nurse explains to the mother that most clients with cancer lose their hair.
Answer: B. The nurse investigates potential resources to help the patient purchase a wig.
292. A nurse performing triage during a mass casualty incident should recognize that which of
the following clients should be transported to the hospital first?
A. A patient who has a 4-inch laceration on the forearm
B. A patient who has an open fracture of the femur
C. A patient who reports substernal chest pain radiating to the neck
D. A patient who has a penetrating head injury and fixed and dilated pupils
Answer: C. A patient who reports substernal chest pain radiating to the neck
293. A nurse is caring for an older adult patient who has a Stage III pressure ulcer. The nurse
requests a consultation with the wound care specialist. Which of the following actions by the
nurse is appropriate when working with a consultant?
A. Request the consultation after several wound care treatments are tried.
B. Arrange the consultation for a time when the nurse caring for the patient is able to be present
for the consultation.
C. Provide the consultant with subjective opinions and beliefs about the client’s wound care.
D. Arrange for the wound care nurse specialist to see the patient daily to provide the
recommended treatment.
Answer: B. Arrange the consultation for a time when the nurse caring for the patient is able to be
present for the consultation.
294. Which of the following items must be discarded in a biohazard waste receptacle?
A. A bedsheet from a patient with bacterial pneumonia

B. An empty IV bag removed from a patient who has HIV
C. A urinary catheter drainage bag from a patient who is postoperative
D. A peripheral pad from a patient who is 24-hr post-vaginal delivery
Answer: D. A peripheral pad from a patient who is 24-hr post-vaginal delivery
295. A patient is admitted with tuberculosis and placed in a negative pressure room. Which of the
following nursing actions is appropriate?
A. Notify the local health department of the admission.
B. Ensure that admitting staff undergo PPD skin tests.
C. Place a sign on the client’s door with the diagnosis.
D. Determine who had contact with the patient in the last 48 hr.
Answer: D. Determine who had contact with the patient in the last 48 hr.
296. A nurse is preparing to transcribe a client’s medication prescription in the medical record.
Which of the following should the nurse recognize as containing the essential components of a
medication order?
A. Haloperidol 1 mg by mouth
B. Multivitamin every morning by mouth
C. Aspirin 650 mg by mouth every 4 hr
D. NPH insulin 10 units before meals and at bedtime
Answer: C. Aspirin 650 mg by mouth every 4 hr
297. A nurse is caring for a patient who has anorexia nervosa. Which of the following
interdisciplinary team members should be consulted in regard to this client’s care? (SATA)
A. Case manager
B. Mental health counsellor
C. Physical therapist
D. Nutritional therapist
E. Occupational therapist
Answer: A. Case manager
B. Mental health counsellor

D. Nutritional therapist
298. A charge nurse is assessing staff knowledge about safety procedures regarding needlestick
injuries. Which of the following statements by a nurse indicates appropriate understanding of
these safety procedures?
A. “An incident report should be completed if a patient receives a stick from her own used
needle.”
B. “I should stop the bleeding as soon as possible following a needlestick injury.”
C. “Prophylactic treatment should be initiated after a needlestick during preparation of an
injection.”
D. “The needle should be recapped to prevent injury during transport to the biohazard container.”
Answer: C. “Prophylactic treatment should be initiated after a needlestick during preparation of
an injection.”
299. Which of the following actions taken by a nurse constitutes battery?
A. Failing to put up side rails on a confused client’s bed
B. Threatening to apply wrist restraints to control a patient who is agitated
C. Inserting a feeding tube against the wishes of a patient who refuses to eat
D. Telling a patient who refused his oral medication that he will be given an injection
Answer: C. Inserting a feeding tube against the wishes of a patient who refuses to eat
300. A charge nurse notices that two staff nurses are not taking meal breaks during their regular
8-hr shifts. Which of the following actions should the nurse take first?
A. Provide coverage for the nurses’ breaks.
B. Discuss time management strategies with the nurses.
C. Determine the reasons the nurses are not taking scheduled breaks.
D. Review facility policies for taking scheduled breaks.
Answer: B. Discuss time management strategies with the nurses.
301. A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?

A. Determine adequacy of ventilator settings.
B. Plan break times for assistive personnel.
C. Administer a nasogastric tube feeding.
D. Pick up the meal trays after lunch.
Answer: C. Administer a nasogastric tube feeding.
302. A nurse is an ambulatory care setting is orienting a newly licensed nurse who is preparing to
return a call to a client. The nurse should explain that which of the following is an objective of
telehealth?
A. Assessing patient needs
B. Providing medication reconciliation
C. Developing patient treatment protocols
D. Establishing communication between providers
Answer: D. Establishing communication between providers
303. A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of the
following actions should the nurse manager take first?
A. Remove the nurse from the unit.
B. Have a blood alcohol level drawn from the nurse.
C. Report the situation to the director of nursing.
D. Document a factual description of the situation.
Answer: A. Remove the nurse from the unit.
304. A case manager working in a rehabilitation unit is discharging to home a patient who has a
spinal cord injury at vertebral level C-7. Which of the following is the priority action when
creating the discharge plan?
A. Select strategies for cost-effective home care.
B. Provide educational handouts related to care requirements.
C. Identify the client’s ability to perform activities of daily living.
D. Recommend community resources available to assist with patientcare.
Answer: C. Identify the client’s ability to perform activities of daily living.

305. A nurse manager is preparing to institute a new system for scheduling staff. Several nurses
have verbalized their concern over the possible changes that will occur. Which of the following
is an appropriate method to facilitate the adoption of the new scheduling system?
A. Identify nurses who accept the change to help influence other staff nurses.
B. Provide a brief overview of the scheduling system immediately before its implementation.
C. Introduce the new scheduling system by describing how it will save the institution money.
D. Offer to reassign staff who do not support the change to another unit.
Answer: C. Introduce the new scheduling system by describing how it will save the institution
money.
306. A patient who is febrile is admitted to the hospital for treatment of pneumonia. In
accordance with the care pathway, antibiotic therapy is prescribed. Which of the following
situations requires the nurse to complete a variance report with regard to the care pathway?
A. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.
B. A blood culture was obtained after antibiotic therapy had been initiated.
C. The route of antibiotic therapy on the care pathway was changed from IV to PO.
D. An allergy to penicillin required an alternative antibiotic to be prescribed.
Answer: B. A blood culture was obtained after antibiotic therapy had been initiated.
307. A nurse should recognize that an incident report is required when
A. A patient refuses to attend physical therapy.
B. A visitor pinches his finger in the client’s bed frame.
C. A patient throws a box of tissues at a nurse.
D. A nurse gives a medication 30 min late.
Answer: D. A nurse gives a medication 30 min late.
308. Patient satisfaction surveys from a surgical unit indicate that pain is not being adequately
relieved during the first 12 hr post operatively. The unit manager decides to identify
postoperative pain as a quality indicator. Which of the following data sources will be helpful in
determining the reason why clients are not receiving adequate pain management after surgery?

A. Prospective chart audit
B. Retrospective chart audit
C. Postoperative care policy
D. Pain assessment policy
Answer: B. Retrospective chart audit
309. A nurse is precepting a newly licensed nurse who is caring for a patient who is confused and
has an IV infusion. The newly licensed nurse has placed the patient in wrist restraints to prevent
dislodging the IV catheter. Which of the following questions should the precepting nurse ask?
A. “Did you secure the restraints to the side of the rails of the bed?”
B. “Are you able to slip two fingers between the restraints and the client’s skin?”
C. “Did you tie the restraints using a double knot?”
D. “Are you removing the client’s restraints every 4 hours?”
Answer: B. “Are you able to slip two fingers between the restraints and the client’s skin?”
310. A nurse is caring for an older adult patient who has a stage III pressure ulcer. The nurse
requests a consultation with the wound care specialist. Which of the following actions by the
nurse is appropriate when working with a consultant?
A. Arrange the consultation for a time when the nurse caring for the patient is able to be present
for the consultation.
B. Provide the consultant with subjective opinions and beliefs about the client’s wound care.
C. Request the consultation after several wound care treatments are tried.
D. Arrange for the wound care nurse specialist to see the patient daily to provide the
recommendation treatment.
Answer: C. Request the consultation after several wound care treatments are tried.
311. A patient is admitted with tuberculosis and placed in a negative pressure room. Which of the
following nursing actions is appropriate?
A. Notify the local health department of the admission.
B. Place a sign on the client’s door with the diagnosis
C. Ensure that admitting staff undergo PPD skin tests.

D. Determine who had contact with the patient in the last 48 hr.
Answer: A. Notify the local health department of the admission.
312. A nurse is caring for a patient who is unconscious and whose partner is his health care
proxy. The partner has spoken with the provider and wishes to discontinue the client’s feeding
tube. The provider states to the nurse, “I will not discontinue this client’s treatment. His partner
has no right to make decisions regarding the client’s care.” Which of the following responses by
the nurse is appropriate?
A. “You should consider speaking with the facility’s ethics committee before making your
decision.”
B. “You have the right to make that decision, even if the partner is the client’s health care proxy.”
C. “The patient has designated his partner as health care proxy in his advanced directives.”
D. “We’ll need to have the nursing supervisor review the client’s advanced directives.”
Answer: C. “The patient has designated his partner as health care proxy in his advanced
directives.”
313. A nurse is caring for a patient who has increased intracranial pressure and is receiving IV
corticosteroids. Which of the following information is most important for the nurse to report at
shift change?
A. Glasgow coma scale score
B. Most recent blood glucose reading
C. Laboratory tests scheduled for next shift
D. Reddened area on the coccyx
Answer: A. Glasgow coma scale score
314. A nurse is assigned the four following client’s for the current shifts. Which of the following
clients should the nurse assets first?
A. A patient who has a hip fracture and is in buck’s traction
B. A patient who bas aspiration pneumonia and a respiratory rate of 28/min
C. A patient who has diabetes mellitus and a stage 2 pressure ulcer on his foot
D. A patient who has a clostridium difficile infection and needs a stool specimen collected

Answer: B. A patient who bas aspiration pneumonia and a respiratory rate of 28/min
315. A nurse is caring for a patient who fell and is reporting pain in the left hip with external
rotation of the left leg. 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. Notify the nursing supervisor about the issue
B. Contact the client’s physical therapist
C. Apply a warm compress to the hip
D. Reposition the patient for comfort
Answer: A. Notify the nursing supervisor about the issue
316. The mother of a patient with breast cancer states, “It’s been hard for her, especially after
losing her hair. And it has been difficult to pay for all the treatments.” Which of the following
actions is appropriate patient advocacy?
A. The nurse investigates potential resources to help the patient purchase a wig
B. The nurse explains to the mother that most client’s with cancer lose their hair
C. The nurse informs the next shift nurse regarding the mother’s concerns
D. The nurse suggests counseling for the client’s body image issues
Answer: A. The nurse investigates potential resources to help the patient purchase a wig
317. Which of the following items must be discarded in a biohazard waste receptacle?
A. A urinary catheter drainage bag from a patient who is postoperative
B. A bed sheet from a patient with bacterial pneumonia
C. A perineal pad from a patient who is 24 hr post vaginal delivery
D. An empty IV bag removed from a patient who has HIV
Answer: D. An empty IV bag removed from a patient who has HIV
318. A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t get
better, I’m going to quit.” Which of the following responses by the unit manager is appropriate?
A. so you are upset about all the changes on the unit
B. I think you have a right to be upset. I am tired of changes too

C. just stick with it a little longer. Things will get better soon
D. you should file a written complaint with hospital administration
Answer: A. so you are upset about all the changes on the unit
319. According to HIPPA regulation, which of the following is a violation of patient
confidentiality?
A. telephoning the pharmacy with a prescription for the spouse to pick up
B. providing a copy of the record to the transporting paramedic
C. reporting a client’s disposition to the referring provider
D. informing housekeeping staff that the patient is in the dialysis unit.
Answer: D. informing housekeeping staff that the patient is in the dialysis unit.
320. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with sterile
procedure. Which of the following actions indicates the nurse is maintaining sterile techniques
(select all that apply)
A. opens the sterile pack by first unfolding the flap farthest from her body
B. rests the cap of solution container upside down on the sterile field
C. holds a bottle of sterile solution 15cm (6 inches) above the sterile field
D. Places sterile items within a 1.25cm (.5inch) border around the edges of the sterile field.
Answer: A. opens the sterile pack by first unfolding the flap farthest from her body
C. holds a bottle of sterile solution 15cm (6 inches) above the sterile field
321. A nurse is providing care for four postoperative clients. The nurse should assess the client
A. whose pulse has been steadily increasing during the past shift
B. who is reporting pain level of 8 on a scale of 0-10
C. whose urine output has averaged 32ml/hr for the past 24hrs
D. Who is reporting nausea after the prescribed antiemetic was administered
Answer: A. whose pulse has been steadily increasing during the past shift

322. A nurse is preparing to transcribe a client’s medication prescription in the medical record.
Which of the following should the nurse recognize as containing the essential components o f a
medication order
A. NPH insulin 10 units before meals and at bedtime
B. Haloperidol(Haldol)1mgbymouth
C. Multivitamin every morning by mouth
D. Aspirin 650mg by mouth every 4 hours
Answer: D. Aspirin 650mg by mouth every 4 hours
323. A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse
is having trouble focusing and has difficulty completing care for his assigned clients. Which of
the following interventions is appropriate?
A. Recommend that he take time to plan at the beginning of his shift
B. Advise him to complete less time consuming tasks first
C. Ask other staff members to take over some of his tasks
D. Offer to provide care for his clients while he takes a break
Answer: A. Recommend that he take time to plan at the beginning of his shift
324. A nurse is in an urgent care clinic is admitting a patient who has been exposed to a liquid
chemical in an industrial setting. Which of the following actions should the nurse take first?
A. Remove the clients clothing
B. Irrigate the exposed area with water
C. Report the incident to OSHA
D. Don personal protective equipment
Answer: D. Don personal protective equipment
325. A facility provides annual staff education regarding ethical practice. A charge nurse
recognizes a need for further education when which of the following behaviours is observed
A. A nurse refuses to actively participate during an elective abortion procedure scheduled for her
client
B. A nurse gives prescribed opioids to a patient who has terminal illness and respirations of 8/m

C. A nurse explains to a client’s family that DNR orders includes withholding comfort measures
D. A nurse informs a confused patient who wants to go home that he is going to stay at the
facility until he is better
Answer: C. A nurse explains to a client’s family that DNR orders includes withholding comfort
measures
326. A nurse in an ambulatory care setting is orienting a newly licensed nurse who is preparing to
return a call to a client. The nurse should explain that which of the following is an objective of
telehealth
A. Assessing patient needs
B. Providing medication reconciliation
C. Establishing communication between providers
D. Developing patient treatment protocols
Answer: A. Assessing patient needs
327. Which of the following puts a hospital at the highest risk for infringement of patient record
confidentiality?
A. A nurse clusters documentation of care for multiple clients
B. A provider and nurse access patient information using one access code
C. Paper based charts are stored at the nurse’s station
D. A nurse performs electronic documentation outside a client’s room
Answer: B. A provider and nurse access patient information using one access code
328. Which of the following observations requires a charge nurse to intervene and demonstrate
safe handling techniques
A. A nurse cleans up a blood spill with a 1:10 bleach solution
B. A nurse uses goggles to perform tracheostomy suctioning
C. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a
specimen
D. A nurse places a mask on a patient with tuberculosis before transport to the radiology
department

Answer: C. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a
specimen
329. Which of the following should lead a nurse to suspect abuse that must be reported?
A. A school age child has several bruises on her lower legs
B. A toddler cries whenever his parent enters the hospital room
C. An adolescent admitted to the emergency department won’t speak to his parents
D. A preschool child who previously toilet trained now requires diapers in the hospital
Answer: B. A toddler cries whenever his parent enters the hospital room
330. A parish nurse is making referral to a community meal delivery program for a member of
the congregation. This is an example of which of the following functions of the parish nurse
A. Liaison
B. Pastoral care provider
C. Health educator
D. Personal health counsellor
Answer: A. Liaison
331. A nurse performing triage during a mass casualty incident should recognize that which of
the following clients should be transported to the hospital first
A. A patient who reports substernal chest pain radiating to the neck
B. A patient who has an open fracture of the femur
C. A patient who has a 4 inch laceration on the forearm
D. A patient who has a penetrating head injury and fixed and dilated pupils
Answer: A. A patient who reports substernal chest pain radiating to the neck
332. A nurse manager over hears a provider and a staff nurse talking about a client’s diagnosis in
the cafeteria. Which of the following actions should the nurse take first?
A. Provide a staff in-service about patient confidentiality.
B. Report the incident to the nursing supervisor
C. Remind them that patient information is confidential

D. Fill out an incident report regarding the situation.
Answer: C. Remind them that patient information is confidential
333. A patient who has substance use disorder is admitted to the mental health unit and reports
that he has been depressed lately. When preparing for discharge the next day, the patient states,
“It’s okay. Soon everything will be just fine.” Which of the following is the nurse’s priority
action?
A. Ask the patient if he has considered hurting himself.
B. Provide the patient with information about Alcoholics Anonymous
C. Encourage the patient to participate in physical activities
D. Reinforce the need to follow up with discharge referral.
Answer: A. Ask the patient if he has considered hurting himself.
334. A nurse is caring for a patient who reports acute pain but refuses IM medication. The nurse
distracts the patient and quickly administers the injection. This illustrates which of the
following?
A. False imprisonment
B. Battery
C. Assault
D. Libel
Answer: B. Battery
335. A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of the
following actions should the nurse manager take first?
A. Report the situation to the director of nursing
B. Have a blood alcohol level drawn from the nurse.
C. Document a factual description of the situation.
D. Remove the nurse form the unit.
Answer: D. Remove the nurse form the unit.

336. A nurse observes a paper bag at the bedside of a client. The finding suggests that a patient is
receiving treatment for which of the following respiratory disorders?
A. Asthma
B. Hyperventilation
C. Stridor
D. Atelectasis
Answer: A. Asthma
337. A nurse is preparing to discharge a patient back to a long-term care facility after he was
admitted to an acute care facility 2 days ago for pneumonia. Which of the following information
should the nurse include in the verbal transfer report?
A. Laboratory results within the expected reference range
B. List of regularly prescribed medications
C. Date of last bowel movement
D. Level of consciousness
Answer: D. Level of consciousness
338. A nurse who is precepting a newly licensed nurse is discussing the patient assignment for
the shift. Which of the following actions should the nurse preceptor take first to demonstrate
appropriate time management?
A. Review the client’s new laboratory values.
B. Document assessment data.
C. Complete required tasks
D. Determine patientcare goals.
Answer: D. Determine patientcare goals.
339. 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 patient who is on contact precautions.”
B. “I will place a patient who has compromised immunity in a negative-pressure airflow room.”

C. “I will wear a N95 respirator mask when caring for a patient who is on droplet precautions.”
D. “I will have a patient who is on airborne precautions wear a mask when out of her room.”
Answer: D. “I will have a patient who is on airborne precautions wear a mask when out of her
room.”
340. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is
appropriate to delegate to a licensed practical nurse?
A. Changing the dressing on a postoperative wound
B. Referring to a patient to social services for assistance with transportation
C. Instructing a patient who is obese with a low-fat diet
D. Providing the first oral feeding to a patient following a stroke
Answer: A. Changing the dressing on a postoperative wound
341. A case manager working in a rehabilitation unit is discharging to home a patient who has a
spinal cord injury at vertebral level C-7. Which of the following is the priority action when
creating the discharge plan?
A. Select strategies for cost-effective home care.
B. Identify the client’s ability to perform activities of daily living.
C. Provide educational handouts related to care requirements.
D. Recommend community resources available to assist with patientcare.
Answer: B. Identify the client’s ability to perform activities of daily living.
342. A nurse is preparing to complete morning assessments on several assigned clients. Which of
the following clients should the nurse plan to assess first?
A. A patient who has a nasogastric tube to intermittent suction and reports nausea
B. A patient who has an early morning blood glucose of 220 mg/dL
C. A patient who had a bladder scan that indicated 250 mL of urine in the bladder
D. A patient who is 3 days postoperative and whose dressing has serosanguinous drainage
Answer: A. A patient who has a nasogastric tube to intermittent suction and reports nausea

343. A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
A. Plan break times for assistive personnel.
B. Pick up the meal trays after lunch.
C. Administer a nasogastric tube feeding.
D. Determine adequacy of ventilator settings.
Answer: C. Administer a nasogastric tube feeding.
344. A RN is planning patient assignments for a licensed practical nurse (LPN) and three
assistive personnel. The RN should assign the LPN to the patient who requires
A. Recording of daily intake and output
B. Assistance with meals
C. A complete bed bath
D. Frequent dressing changes.
Answer: D. Frequent dressing changes.
345. A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?
A. Assessing a patient who just returned from haemodialysis
B. Reviewing dietary instructions for a patient with kidney stones
C. Obtaining a stool sample from a patient with renal failure
D. Monitoring a patient with a fluid restriction
Answer: C. Obtaining a stool sample from a patient with renal failure
346. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist
restraints to a patient who is agitated and does not have a prescription for restraints. Which of the
following actions should the nurse take first?
A. Inform the unit manager of the incident
B. Remove the restraints from the client’s wrists
C. Speak with the AP about the incident
D. Review the chart for non-restraint alternatives for agitation

Answer: B. Remove the restraints from the client’s wrists
347. A patient is brought to the emergency department (ED) following a motor-vehicle crash.
Drug use is suspected in the crash, and a voided urine specimen is ordered. The patient
repeatedly refuses to provide the specimen. Which of the following is the appropriate action by
the nurse?
A. Document the client’s refusal in the chart
B. Tell the patient that a catheter will be inserted
C. Obtain a provider’s prescription for the blood alcohol level
D. Assess the patient for urinary retention
Answer: A. Document the client’s refusal in the chart
348. Nurses on an in-patient care unit are working to help reduce unit costs. Which of the
following is appropriate to include in the cost-containment plan?
A. Use clean gloves rather than sterile gloves for colostomy care
B. Wait to dispose of sharps container until they are completely full
C. Return unused supplies from the bedside to the unit’s supply stock
D. Store opened bottles of normal saline in a refrigerator for up to 48 hr
Answer: A. Use clean gloves rather than sterile gloves for colostomy care
349. An older adult patient is awaiting surgery for a fractured right hip. The nurse should
recognize that which of the following can be delegated to an assistive personnel?
A. Turning the client
B. Recording the client’s vital signs
C. Determining the client’s pain level
D. Checking the pulses of the client’s right food
Answer: B. Recording the client’s vital signs
350. To resolve the conflict between staff members regarding potential changes in policy, a nurse
manager decides to implement the changes she prefers regardless of the feelings of those who

oppose those changes. Which of the following conflict-resolution strategies is the nurse manager
using?
A. Compromising
B. Collaborating
C. Cooperating
D. Competing
Answer: D. Competing
351. 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 patient who has gestational diabetes and is receiving biweekly nonstress tests
B. A primigravida patient who is 1 day postoperative following a Caesarean section and has a
PCA pump
C. A multigravida patient who has preeclampsia and is receiving misoprostol (Cytotec) for
induction of labor
D. A patient who is at 32 weeks of gestation and has a premature rupture of membranes
Answer: B. A primigravida patient who is 1 day postoperative following a Caesarean section and
has a PCA pump
352. A nurse working on a medical-surgical unit is managing care of four clients. The nurse
should schedule an interdisciplinary conference for which of the following clients?
A. A patient who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
B. A patient who has Type 1 diabetes and uses an insulin pump
C. A patient who has orthostatic hypotension and is receiving IV fluids
D. patient who is receiving heparin and has an aPTT of 34 seconds (On heparin: 45-80 sec)
Answer: D. patient who is receiving heparin and has an aPTT of 34 seconds (On heparin: 45-80
sec)
353. A charge nurse is assessing staff knowledge about safety procedures regarding needle stick
injuries. Which of the following statements by a nurse indicates appropriate understanding of
these safety procedures?

A. “prophylactic treatment should be initiated after a needlestick during preparation of an
injection.”
B. “I should stop the bleeding as soon as possible following a needlestick injury.”
C. “an incident report should be completed if a patient receives a stick from her own used
needle.”
D. “the needle should be recapped to prevent injury during transport to the biohazard container.”
Answer: C. “an incident report should be completed if a patient receives a stick from her own
used needle.”
354. 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. Obtaining a urine specimen from an older adult patient(AP/CNA)
B. Providing postmortem care for a patient who has just died (AP/CNA)
C. Accompanying a patient who just had a wound debridement to physical therapy (AP/CNA)
D. Reinforcing dietary teaching with a patient who has heart disease
Answer: D. Reinforcing dietary teaching with a patient who has heart disease
355. A nurse enters the room of a patient who is unconscious and finds that the client’s son is
reading her electronic medical records from a monitor located at the bedside. Which of the
following actions should the nurse take first?
A. Recommend the son meet with the provider to get information about his mother’s condition
B. Complete an incident report regarding the breach of the client’s confidentiality
C. Log out the computer so that the client’s son is unable to view his mother’s information
D. Report the possible violation of patient confidentiality to the nurse manager
Answer: C. Log out the computer so that the client’s son is unable to view his mother’s
information
356. A home health nurse is assessing the home environment of a patient who is on continuous
oxygen therapy. Which of the following findings requires the nurse to intervene?
A. The oxygen machine has a grounded plug

B. The family keeps a spare oxygen tank in the room
C. The windows of the client’s room are open
D. The patient is covered with a woollen blanket
Answer: D. The patient is covered with a woollen blanket
357. A nurse is teaching a patient how to use a finger-stick glucometer at home. Which of the
following instructions should the nurse include?
A. Elevate the arm for 1 min before taking the blood sample
B. Cap the lancet prior to putting it in the trash
C. Obtain the blood sample from the finger pads
D. Warm the hands prior to piercing the skin
Answer: D. Warm the hands prior to piercing the skin
358. A nurse in the emergency department is preparing to care for a patient who arrived via
ambulance. The patient is disoriented and has a cardiac arrhythmia. Which of the following
actions should the nurse take?
A. Contact the client’s next of kin to obtain consent for treatment
B. Proceed with treatment without obtaining written consent
C. Have the patient sign a consent for treatment
D. Notify risk management before initiating treatment
Answer: B. Proceed with treatment without obtaining written consent
359. A patient has a new permanent pacemaker inserted. Which of the following home care
instructions should the nurse include?
A. The patient should avoid using a microwave oven to heat food
B. Regular programming evaluations can be conducted by telephone
C. the patient should avoid using remote control devices to prevent dysrhythmias
D. Swimming could cause the unit to have an electrical short
Answer: B. Regular programming evaluations can be conducted by telephone

360. While auditing the medical records of clients currently on an oncology unit, the nurse
manager finds that six of the 15 records lack documentation regarding advance directives. Which
of the following is the priority action for the nurse to take?
A. Reinforce the potential consequences of not having this information on record to the nursing
staff
B. Ask nurses who are caring for clients without this information in the medical record to obtain
it.
C. Meet with the nursing staff to review the policy regarding advance directives
D. Remind nurses to obtain this information during the admission process
Answer: C. Meet with the nursing staff to review the policy regarding advance directives
361. A patient is admitted with COPD. Which of the following findings should the nurse report
to the provider?
A. Oxygen saturation 89% on room air
B. White blood cell count 9,000/mm3
C. Report of dyspnea on exertion
D. Bilateral crackles on auscultation of lungs
Answer: D. Bilateral crackles on auscultation of lungs
362. A charge nurse notices that two staff nurses are not taking meal breaks during their regular
8-hr shifts. Which of the following actions should the nurse take first?
A. Providing coverage for the nurses’ breaks
B. Determining the reasons the nurses are not taking scheduled breaks
C. Discussing time management strategies with the nurses
D. Review facility policies for taking scheduled breaks
Answer: D. Review facility policies for taking scheduled breaks
363. A nurse is caring for a patient who has anorexia nervosa. Which of the following
interdisciplinary team members should be consulted in regard to this client’s care? (select all that
apply.)
A. Occupational therapist

B. Nutritional therapist
C. Physical therapist
D. Mental health counsellor
E. Case manager
Answer: B. Nutritional therapist
D. Mental health counsellor
E. Case manager
364. A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which
of the following statements by a staff nurse indicates that the teaching was effective?
A. “Guardian consent is required for an emancipated minor.”
B. “Consent can be given by a durable power of attorney.”
C. “A family member can interpret to obtain informed consent from a patient who is deaf.”
D. “The nurse can answer any questions the patient has about the procedure”
Answer: B. “Consent can be given by a durable power of attorney.”
365. A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that
which of the following clients is the highest priority?
A. A patient who is newly diagnosed with pancreatic cancer and scheduled to begin IV
chemotherapy
B. A patient who has peripheral vascular disease and has an absent pedal pulse in the right foot
C. A patient who is postoperative following a laminectomy 12 hours ago and is unable to void
D. A patient who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38 C (101 F)
Answer: B. A patient who has peripheral vascular disease and has an absent pedal pulse in the
right foot
366. A patient is scheduled for a tubal ligation procedure starts to cry as she is wheeled into the
surgical units. Which of the following nursing statements is an appropriate nursing response?
A. “It’s not too late to cancel the surgery if you want to.”
B. “This won’t take long and it will be over before you know it.”

C. “Why did you make the decision to have this procedure?”
D. “You shouldn’t be worried because the procedure is very safe”
Answer: A. “It’s not too late to cancel the surgery if you want to.”
367. A nurse working in the emergency department is assessing several clients. Which of the
following clients is the highest priority?
A. A patient who has a raised red skin rash on his arms, neck, and face
B. A patient who reports right-sided flank pain and is diaphoretic
C. A patient who reports shortness of breath and left neck and shoulder pain
D. A patient who has active bleeding from a puncture wound of the left groin area
Answer: C. A patient who reports shortness of breath and left neck and shoulder pain
368. A nurse is working on a quality improvement team that is assessing an increase in patient
falls at the facility. After problem identification, which of the following actions should the nurse
plan to take first as part of the quality improvement process?
A. Review current literature regarding patient falls
B. Implement a fall prevention plan
C. Notify staff of the increased fall rate
D. Identify clients who are at risk for falls
Answer: D. Identify clients who are at risk for falls
369. A nurse is evaluating a newly licensed nurse who is administering a vitamin K.
(Aquamephyton) injection to a newborn. Which of the following actions by the newly licensed
nurse indicates understanding of the teaching? (Select all that apply.)
A. Selects the dorsogluteal site to administer the injections
B. Cleans the injection site with alcohol
C. Applies gentle pressure at the site after injection
D. Aspirates the syringe for blood return after needle insertion
E. Inserts the needle at a 45 degree angle (90 degree)
Answer: B. Cleans the injection site with alcohol
C. Applies gentle pressure at the site after injection

D. Aspirates the syringe for blood return after needle insertion
370. A nurse enters a client’s room and observes a fire in the trash can. Identify the sequence of
actions the nurse should take. (Move all the actions into the box on the right, placing them in the
selected order of performance.)
Activate the fire alarm system
Confine the fire by closing doors and windows
Extinguish the fire if possible
Remove the patient from the area
Answer:
Activate the fire alarm system

2

Confine the fire by closing doors and windows

3

Extinguish the fire if possible

4

Remove the patient from the area

1

371. Which of the following actions taken by a nurse constitutes battery?
A. Failing to put up side rails on a confused client’s bed
B. Telling a patient who refused his oral medication that he will be given an injection
C. Inserting a feeding tube against the wishes of a patient who refuses to eat
D. Threatening to apply wrist restraints to control a patient who is agitated
Answer: C. Inserting a feeding tube against the wishes of a patient who refuses to eat