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ATI Leadership NURSING Proctored Exam Converted 2 of 3
Community Health Nursing (Alcorn State University)
ATI LEADERSHIP - Proctored (Complete) 2021. Detailed 70
Questions And 100% Correct Answers.
1. A client 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 client repeatedly
refuses to provide the specimen. Which of the following is the appropriate action by the
nurse?
a. Tell the client that a catheter will be inserted.
b. Document the client’s refusal in the chart.
c. Assess the client for urinary retention.
d. Obtain a provider’s prescription for a blood alcohol level.
Answer: b. Document the client’s refusal in the chart.
Rationale:
It is essential for the nurse to document the client’s refusal in the medical record as this
protects the client’s rights and ensures that there is documentation of the refusal. This also
informs the healthcare team of the situation.
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.
Rationale:
Administering a nasogastric tube feeding falls within the scope of practice for a licensed
practical nurse (LPN) as it involves routine, stable procedures that do not require critical
thinking or complex assessment.
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.
c. Prepares a container of sterile solution on the field after putting on sterile gloves.
Rationale:
- Opening the sterile pack by first unfolding the top flap away from the body helps to
maintain the sterile field by preventing the nurse’s hand from contaminating the contents.
- Preparing a container of sterile solution on the field after putting on sterile gloves ensures
that the solution remains sterile.
4. A nurse enters a client’s room and identifies that the client 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: b. Notify the provider.
Rationale:
The nurse should first notify the provider to ensure prompt action to address the situation and
prevent harm to the client.
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 client who is learning to self-administer insulin
b. Ambulating a client who is scheduled for discharge later in the day
c. Administering morphine IV bolus to a client who is hr postoperative
d. Admitting a new client who has chronic back pain to the unit
Answer: c. Administering morphine IV bolus to a client who is hr postoperative
Rationale:
Administering an IV bolus of morphine is within the scope of practice for an LPN as it is a
routine procedure that does not require complex assessment or critical thinking.

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: a. The nurse applies goggles.
Rationale:
Wearing goggles helps to protect the eyes from potential splashes or sprays of blood or other
body fluids during the procedure, maintaining the principles of surgical asepsis.
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.
Rationale:
The nurse should recheck vital signs that are outside the expected reference range to ensure
accuracy and identify any abnormalities that may require further intervention.
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 client who has renal failure
b. Monitoring a client who has a fluid restriction
c. Assessing a client who just returned from hemodialysis
d. Reviewing dietary instructions for a client who has kidney stones
Answer: b. Monitoring a client who has a fluid restriction
Rationale:
Monitoring a client with a fluid restriction involves routine, stable procedures that do not
require nursing judgment or assessment, making it appropriate to delegate to an assistive
personnel.

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 client who has a neck injury and is unable to breathe spontaneously
b. A client who has two open chest wounds with a left tracheal deviation
c. A client who has major burns over 75% of her body surface area
d. A client who has bipolar disorder and is exhibiting signs of hallucination (Class 3)
Answer: a. A client who has a neck injury and is unable to breathe spontaneously
Rationale:
This client's condition represents an immediate threat to life and requires immediate
intervention to establish an airway and ensure adequate breathing.
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 client 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 client has about the procedure.”
Answer: b. “Consent can be given by a durable power of attorney.”
Rationale:
Informed consent can be given by a durable power of attorney when the client is unable to
provide consent themselves. This indicates understanding of the guidelines for informed
consent.
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 client who leaves the facility against medical advice
b. An older adult client who has advanced directives on file
c. A young adult client who is participating in a medical research study
d. An adolescent client whose parents refuse a blood transfusion for religious reasons
Answer: d. An adolescent client whose parents refuse a blood transfusion for religious
reasons
Rationale:
In this scenario, there is a conflict between the parents' religious beliefs and the medical
treatment recommended for the adolescent client. Collaboration with the facility ethics
committee can help resolve this conflict and ensure that the client receives appropriate care
while respecting the parents' beliefs.

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 client needs
b. Developing client treatment protocols
c. Providing medication reconciliation
d. Establishing communication between providers
Answer: d. Establishing communication between providers
Rationale:
One of the main objectives of telehealth is to establish communication between providers,
enabling them to consult with each other remotely and collaborate on patient care.
13. A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes.
The client expresses concern about the cost of blood-glucose monitoring supplies. Which of
the following actions should the nurse take?
a. Refer the client to the social services department.
b. Provide the client with a week’s worth of supplies from the hospital
c. Ask the provider about the possibility of less frequent monitoring
d. Recommend the client reuse the testing lancets
Answer: a. Refer the client to the social services department.
Rationale:
Referring the client to the social services department can help the client access resources and
assistance programs to help cover the cost of blood-glucose monitoring supplies, ensuring
that the client can manage their condition effectively.
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 client to occupational therapy.
d. The emergency department nurse is waiting to give report on a new admission.
Answer: a. A nurse on the previous shift wrote an incident report about a medication error.
Rationale:
Addressing the medication error is the first priority as it involves potential harm to the client
and requires immediate investigation and intervention.

15. A nurse who is precepting a newly licensed nurse is discussing the client 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 client care goals
d. Document assessment data.
Answer: c. Determine client care goals
Rationale:
Determining client care goals is the first step in planning and organizing care for the shift,
ensuring that the nurse's time is effectively managed to meet the needs of the clients.
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 client 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.”
Rationale:
HIPAA grants clients the right to review and obtain copies of their own medical records,
ensuring their privacy and access to their health information.
17. A nurse is caring for a client who has a tumor. The provider recommends surgery. The
client 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 client 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: c. Whether the partner is the client’s durable power of attorney for health care
Rationale:
The client's durable power of attorney for health care has the legal authority to make
healthcare decisions on behalf of the client if the client is unable to make decisions for
themselves. Therefore, the partner's decision would prevail in this situation.

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.
b. Administer a hepatitis B vaccine.
c. Perform a New Ballard screening.
d. Obtain vital signs.
Answer: b. Administer a hepatitis B vaccine.
Rationale:
Administering a hepatitis B vaccine is within the scope of practice for a licensed practical
nurse and does not require nursing judgment or assessment.
19. During a staff meeting a unit manager reviews the results for documenting client
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 client education.
c. Include documentation of client 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 client education.
Rationale:
Before implementing any changes, it is important to understand the reasons behind the
below-benchmark results. Determining the factors that interfere with the documentation of
client education will help identify areas for improvement and guide the development of
effective strategies.
20. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should
explain that preventing client injury by removing a fall hazard demonstrates which of the
following ethical principles?
a. Utility
b. Autonomy
c. Nonmaleficence
d. Veracity
Answer: c. Nonmaleficence

Rationale:
Nonmaleficence is the ethical principle that requires healthcare providers to do no harm to
their patients. Removing a fall hazard to prevent client injury aligns with this principle by
ensuring the client's safety and well-being.
21. A nurse is caring for a group of clients. Which of the following clients should the nurse
plan to assess first?
a. A client who has congestive heart failure and has lost 0.9 kg (2 lb) in the past 24 hr
(improvement)
b. A client who has diabetes mellitus and reports paresthesia in his fingers and toes (ABC-circulation)
c. A client who has a nasogastric tube and has crackles in the lungs (ABC--airway)
d. A client who has a new diagnosis of Graves’ disease and a TSH level of 0.2 microunits/mL
Answer: c. A client who has a nasogastric tube and has crackles in the lungs (ABC--airway)
Rationale:
Crackles in the lungs indicate a potential respiratory problem, and since the client has a
nasogastric tube, there is a risk of aspiration. Therefore, this client needs to be assessed first
to ensure airway patency and respiratory function.
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 client who is in Buck’s traction for a left hip fracture (can’t necessarily move too much)
b. A client who is 1 day postoperative following thoracic surgery and has a chest tube
(possible physical instability)
c. A client who is confused and restrained for safety (still needs continual nursing
care/assessment)
d. A client who is receiving IV chemotherapy and is ambulatory
Answer: b. A client who is 1 day postoperative following thoracic surgery and has a chest
tube (possible physical instability)
Rationale:
The client who is 1 day postoperative with a chest tube is at risk for physical instability and
complications related to the recent surgery. Therefore, this client should be evacuated first to
ensure safety and appropriate care.
23. A nurse enters the room of a client 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 client 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.
Rationale:
The first action the nurse should take is to protect the client's confidentiality by ensuring that
unauthorized individuals do not have access to the client's electronic medical records.
24. A nurse is preparing a client for cardiac catheterization. Just before the procedure, the
client 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: c. Check to see if the medical record indicates the provider explained the procedure
to the client.
Rationale:
Before providing information about the risks of the procedure, the nurse should first check
the medical record to ensure that the client has already received this information from the
provider as part of the informed consent process.
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 client who reports a headache with sensitivity to light
b. A client who reports an urge to void but has not urinated during the prior shift
c. A client who reports indigestion and pain in her jaw
d. A client who reports feeling lightheaded when he stands up from a lying position
Answer: d. A client who reports feeling lightheaded when he stands up from a lying position
Rationale:
This client's report of feeling lightheaded when standing up indicates a potential orthostatic
hypotension, which requires immediate assessment to prevent falls and further complications.

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.
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.
Rationale:
Before implementing any interventions, it is important to understand the reasons behind the
nurses not taking their scheduled breaks. Determining the reasons will help identify
appropriate strategies to address the issue effectively.
27. A nurse is preparing to delegate bathing and turning of a newly admitted client who has
end-stage 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?
b. Is the client’s family present so the AP can show them how to turn the client?
c. Has data been collected about specific client needs related to turning?
d. Does the AP have the time to change the client’s central IV line dressing after turning her?
Answer: c. Has data been collected about specific client needs related to turning?
Rationale:
Before delegating the task of bathing and turning the client, the nurse should assess if data
has been collected about specific client needs related to turning. This ensures that the AP has
the necessary information to provide appropriate care.
28. A nurse is preparing to transfer a client 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: d. The client’s code status -under situation
Rationale:

In the background portion of the SBAR report, the nurse should include relevant background
information about the client, including the client's code status, to ensure that the receiving
nurse has all necessary information for providing appropriate care.
29. A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the
following statements by the client should the nurse identify as an indication that a referral to
an occupational 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: c. “I’m having difficulty climbing the stairs at my house.”
Rationale:
Difficulty climbing stairs indicates a need for assistance with activities of daily living and
mobility, which is within the scope of practice of an occupational therapist. Therefore, this
statement indicates a need for referral to an occupational therapist.
30. A nurse in the emergency department is caring for a 16-year-old client who reports
abdominal pain and is accompanied by an adult neighbour. The provider diagnoses a ruptured
appendix and states that the client requires an emergency appendectomy. Which of the
following actions should the nurse?
a. Ask the adult neighbor to sign the consent form.
b. Obtain consent from the hospital administrator.
c. Witness the client 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.
Rationale:
Since the client is a minor, the nurse should attempt to notify the client's guardian to obtain
consent for the emergency appendectomy, as minors cannot provide legal consent for medical
procedures.
31. A nurse on a medical-surgical unit is caring for four clients. Which of the following
findings is the highest priority?
a. A client who had a cardiac catheterization whose capillary refill in the great toe is 4
seconds
b. A client who has COPD and has an oxygen saturation of 90%
c. A client who had a cholecystectomy 6 hr ago and is requesting pain medication

d. A client whose TPN was discontinued 4 hr ago and is requesting clear liquids
Answer: c. A client who had a cholecystectomy 6 hr ago and is requesting pain medication
Rationale:
Pain management is a priority following surgery to promote comfort and prevent
complications such as respiratory compromise and delayed healing.
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.
Rationale:
Before taking any formal action, the charge nurse should collect data to support the suspicion
of chemical impairment. This may include observations, witness statements, and any other
relevant information.
33. A nurse is assessing a client’s comprehension of a pulmonary function test prior to the
procedure. Which of the following client statements indicates to the nurse an understanding
of the procedure?
a. “I will be given contrast dye during this test.”
b. “I might have to wear a nose clip during this test.”
c. “I 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.”
Rationale:
Wearing a nose clip is often part of pulmonary function testing to ensure that the client
breathes only through the mouth during the procedure, providing accurate results.
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 client who has an injured ankle and reports a pain level of 8 on a scale from
0 to 10
c. An older adult client who has dyspnea and a respiratory rate of 26/min
d. An adult client who has large ecchymosis on both legs

Answer: c. An older adult client who has dyspnea and a respiratory rate of 26/min
Rationale:
Dyspnea and an elevated respiratory rate indicate potential respiratory distress, which
requires immediate evaluation and intervention.
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 client 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: c. Accommodating
Rationale:
Accommodating involves meeting the other party's needs or concerns while neglecting one's
own, which is what the nurse has done by allowing the client to move the newspapers to the
living room instead of discarding them.
36. A nurse is planning to delegate client care assignments. Which of the following tasks
should the nurse plan to delegate to an assistive personnel?
a. Advising a client on self-administration of acetaminophen
b. Informing a family of a client’s progress in physical therapy
c. Teaching a client to perform a finger-stick for testing blood glucose levels
d. Performing post-mortem care prior to transferring the client to the morgue
Answer: d. Performing post-mortem care prior to transferring the client to the morgue
Rationale:
Post-mortem care is within the scope of practice of an assistive personnel and can be safely
delegated to them.
37. A nurse is providing discharge teaching to a client 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
Rationale:
Contact information for the physical therapist, medication guidelines information, and
information about follow-up care are essential components of discharge teaching for a client
following knee arthroplasty.
38. A nurse is planning to discharge a client 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.”
Rationale:
Respite care provides temporary relief to caregivers, allowing them to have some time away
from caregiving responsibilities, which can be physically and emotionally demanding.
39. A nurse is teaching a client 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.
c. Elevate the arm for 1 min before taking the blood sample.
d. Obtain the blood sample from the finger pads.
Answer: a. Warm the hands prior to piercing the skin.
Rationale:
Warming the hands can help increase blood flow to the fingers, making it easier to obtain an
adequate blood sample for testing.
40. A nurse is assessing a client who had a recent stroke. Which of the following findings
should indicate the need for referral to an occupational therapist?
a. Receptive aphasia
b. Facial drooping
c. Memory loss
d. Unilateral neglect

Answer: d. Unilateral neglect
Rationale:
Unilateral neglect is a common deficit following a stroke and can significantly impact a
client's ability to perform activities of daily living. Therefore, referral to an occupational
therapist is necessary to address this deficit and facilitate rehabilitation.
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 client information
Answer: c. A sufficient supply of personal protective equipment
Rationale:
In a bioterrorism event, the highest priority is to ensure the safety of healthcare workers and
prevent the spread of infection. Personal protective equipment is crucial for this purpose.
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
Rationale:
Pertussis is a reportable disease. Healthcare providers are required to report cases of pertussis
to the state health department to monitor and prevent the spread of the disease.
43. A charge nurse is teaching a newly licensed nurse about proper cleaning of equipment
used for a client 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

Rationale:
Chlorine bleach is effective in killing Clostridium difficile spores and is recommended for
cleaning equipment used for clients with C. difficile infection.
44. A nurse is assessing an older adult client who was brought to the emergency department
by his adult son, who reports that the client fell at home. The nurse suspects elder abuse.
Which of the following actions should the nurse take?
a. 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 client about his injuries with the son present
Answer: b. Ask the client’s son to go to the waiting area.
Rationale:
When elder abuse is suspected, the nurse should ensure the safety and privacy of the client by
asking the potential abuser to leave the room.
45. A nurse is completing discharge teaching with a client who is being treated for
tuberculosis (TB). Which of the following statements by the client 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: d. “I should wear a mask while around my family.”
Rationale:
Wearing a mask while around family members helps prevent the spread of tuberculosis to
others.
46. An older adult client 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
Rationale:
Recording vital signs is a task that can be safely delegated to an assistive personnel.

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.
b. Answer the parents’ questions about newborn circumcision.
c. Show a new mother how to change the newborn’s diaper.
d. Obtain the weight of a newborn that is receiving formula
Answer: d. Obtain the weight of a newborn that is receiving formula
Rationale:
Obtaining the weight of a newborn is a task that can be safely delegated to an assistive
personnel.
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: a. “A provider can write a prescription for restraints ‘as needed’.”
Rationale:
Restraints should be used only with a provider's prescription, and the prescription should
specify the type of restraint, the reason for use, and the duration.
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, b. Rubeola
Rationale:
Mumps and Rubeola are both diseases that require droplet precautions due to their mode of
transmission.
50. A nurse is caring for a client who has cancer. The client and her partner are asking the
nurse about hospice care. 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.”
Rationale:
Hospice care provides comprehensive care for terminally ill clients and their families,
addressing physical, emotional, and spiritual needs. It is a multidisciplinary program aimed at
providing comfort and support rather than prolonging life.
51. A nurse is planning care for a client 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 client about a 24-hr urine specimen collection.
c. Determine the client’s muscle strength prior to ambulation.
d. Remind the client to change positions slowly.
Answer: d. Remind the client to change positions slowly.
Rationale:
Reminding the client to change positions slowly is within the scope of practice for an
assistive personnel and does not require nursing judgment or assessment.
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.
Rationale:
Before taking further action, the charge nurse should gather information about the nurse's
medication administration procedure to identify any potential issues or gaps.
53. A case manager is reviewing documentation on several clients and notes a progress report
that falsely identifies a client as HIV-positive due to multiple sexual partners. The nurse
manager should identify that which of the following torts has occurred?
a. Libel
b. Battery
c. Slander

d. Negligence
Answer: c. Slander
Rationale:
Slander involves defamation with the spoken word. In this case, the false identification of the
client as HIV-positive due to multiple sexual partners is defamation spoken verbally.
54. A nurse is preparing a client for an elective mastectomy. The client 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 bag with the client’s clothing.
d. Agree to keep the ring for the client until after surgery.
Answer: a. Place the client’s ring in the facility safe.
Rationale:
Placing the client's ring in the facility safe ensures that it will be secure during the surgery
and can be returned to the client afterward.
55. A nurse is prioritizing postpartum care for four clients. Which of the following actions
should the nurse take first?
a. Assist a client who requests help breastfeeding her 4-hr-old newborn.
b. Administer RH immune globulin to a client who is Rh-negative and 6 hr postpartum.
c. Check uterine tone for a client who received methylergonovine.
d. Instruct a client who has an episiotomy about a sitz bath.
Answer: c. Check uterine tone for a client who received methylergonovine.
Rationale:
Checking uterine tone is a priority after administration of methylergonovine to prevent
postpartum hemorrhage.
56. A hospice nurse is caring for a client who has a terminal illness and reports severe pain.
After the nurse administers the prescribed opioid and benzodiazepine, the client 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: a. Withhold the benzodiazepine but continue the opioid.

Rationale:
The client's somnolence and difficulty in arousing could be due to the benzodiazepine.
Withholding the benzodiazepine while continuing the opioid may alleviate the client's
symptoms.
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 client on her left side with knees flexed
d. Inserts the tubing 8 cm (3.1 in) into the rectum
Answer: d. Inserts the tubing 8 cm (3.1 in) into the rectum
Rationale:
The tubing should be inserted only about 3 to 4 inches (7.5 to 10 cm) into the rectum, not 8
cm.
58. A nurse is providing information to a client about advance directives. The nurse should
explain that advance directives include which of the following?
a. Instructions regarding treatments the client desires or does not desire
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 client desires or does not desire
Rationale:
Advance directives include instructions regarding the treatments a client desires or does not
desire if they become unable to communicate their wishes.
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 client who has peripheral vascular disease and has an absent pedal pulse in the right foot
b. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy.
c. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38°C (101°F)
d. A client who is postoperative following a laminectomy 12 hr ago and is unable to void
Answer: d. A client who is postoperative following a laminectomy 12 hr ago and is unable to
void

Rationale:
The client who is postoperative and unable to void is at risk for urinary retention, which
could lead to complications such as urinary tract infection or bladder distention. This is the
highest priority.
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
client advocate?
a. “In the role of client advocate, I should take responsibility for coordinating each client’s
care.”
b. “As a client advocate, I will suggest the best course of action for clients who are
indecisive.”
c. “My role as a client advocate is to empower the clients to make informed healthcare
decisions.”
d. “As a client advocate, I will adhere to the provider’s prescribed treatments.”
Answer: c. “My role as a client advocate is to empower the clients to make informed
healthcare decisions.”
Rationale:
Advocacy in nursing involves empowering clients to make informed decisions about their
healthcare and ensuring that their rights are respected and upheld.
61. A nurse manager observes an assistive personnel (AP) incorrectly transferring a client 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 client with the transfer.
d. Demonstrate the proper client transfer technique for the AP.
Answer: d. Demonstrate the proper client transfer technique for the AP.
Rationale:
The nurse should first demonstrate the correct technique for transferring the client to the
bedside commode to ensure the AP understands the appropriate procedure and can perform
the task safely.
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
Rationale:
Chlamydia trachomatis is a reportable communicable disease. Reporting communicable
diseases to the state health department helps to track and control the spread of infections.
63. A charge nurse witnesses two nurses having a loud discussion at the nurses’ station about
not wanting to care for a client 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: d. Contact the house supervisor to mediate the conflict.
Rationale:
The charge nurse should contact the house supervisor to mediate the conflict and address the
nurses' concerns about caring for the client with drug-resistant tuberculosis.
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.
Rationale:
The nurse should request that the charge nurse modify the assignment to ensure that he is
safely caring for clients within his scope of practice and experience level.
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 client 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 client who requires physical therapy
Rationale:
Advocacy in nursing involves actions that protect and support the client's safety and rights,
such as recommending a referral for physical therapy to improve the client's health and wellbeing.
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 nitroglycerin to a client who is experiencing chest pain.
b. Perform a urinary catheterization for a client who has experienced a cerebrovascular
accident.
c. Set up a trauma room for an incoming client who was in a motor-vehicle crash.
d. Complete a SAD PERSONS assessment scale for a client who has attempted suicide.
Answer: c. Set up a trauma room for an incoming client who was in a motor-vehicle crash.
Rationale:
Setting up a trauma room is within the scope of practice for a nurse floating from a medicalsurgical unit to an emergency department.
67. A home health nurse is assessing the home environment during an initial visit to a client
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 folding chair without armrests
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 client with ambulation
e. A raised vinyl seat on the toilet in the bathroom
Answer: 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 client with ambulation
Rationale:
All of these findings increase the risk of falls. Wheeled chairs can easily slide, throw rugs can
cause tripping, and two-wheeled walkers may not provide adequate stability.

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
Rationale:
Setting alarms on exits helps prevent clients with dementia from wandering away from the
facility unsupervised, providing security and safety.
69. A nurse in the emergency department is preparing to care for a client who arrived via
ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following
actions should the nurse take?
a. Have the client 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)
Rationale:
Implied consent applies when emergency treatment is required to preserve the life or health
of the client. The client's disorientation and cardiac arrhythmia indicate the need for
immediate treatment.
70. A nurse is reviewing the medication administration record of a client 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.
Rationale:
The nurse should first observe the client's condition to ensure there are no adverse effects
from the additional dose of medication.

1. 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 color on the center of the client's wound
c. Inflammation noted on the tissue edges of a client's wound
d. Increase in serosanguineous exudate from the client's wound
Answer: b. Deep red color on the center of the client's wound
Rationale:
A deep red color in the center of the wound indicates granulation tissue, which is a sign of
wound healing. Granulation tissue is a part of the proliferative phase of wound healing,
where new tissue is formed.
2. 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 client who received a morning dose of insulin aspart
b. Administer pain medication to a client who has rheumatoid arthritis and received the last
dose at 0400
c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
d. Replace a client's enteral nutrition feeding solution that has been hanging for 24 hours.
Answer: c. Restart an infiltrated IV for a client whose IV antibiotic is scheduled for 0900
Rationale:
Restoring IV access takes priority to ensure that the client receives scheduled IV antibiotics
as planned.
3. 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 client who has multiple sclerosis and ataxia
b. A client who has a brain tumor and is admitted for chemotherapy
c. A client who has Guillain-Barre syndrome and a tracheostomy
d. A client who sustained a concussion and is being monitored for complications
Answer: d. A client who sustained a concussion and is being monitored for complications
Rationale:
A client with a concussion is stable and requires monitoring for complications, making this
assignment appropriate for a newly licensed nurse.
4. A nurse is providing teaching to a client about advance directives. Which of the following
statements by the client 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 problem to sign my advance directives.”
c. “My doctor will need to provide approval for the decisions outlined 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.”
Rationale:
A durable power of attorney for health care is a component of advance directives, allowing
the client to appoint someone to make health care decisions on their behalf if they become
unable to do so.
5. A nurse is chairing a committee about preventing infant abduction in a new birth care
center. Which of the following quality control tasks should the nurse assign to be completed
first?
a. Identify the industry standards for infant safety.
b. 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.
Rationale:
Identifying industry standards for infant safety is the first step to ensure that the birth care
center is following best practices for preventing infant abduction.
6. A nurse notes that a client is eating about half of the food on his plate and coughs
frequently during meals. The nurse plans to perform dysphagia screening to determine the
client's need for a referral to which of the following providers?
a. Physical therapist
b. Respiratory therapist
c. Speech therapist
d. Occupational therapist
Answer: c. Speech therapist
Rationale:
A speech therapist evaluates swallowing difficulties (dysphagia) and determines appropriate
interventions, such as swallowing exercises or dietary modifications.
7. A home health nurse is assessing the home environment during an initial visit to a client
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 armrests
e. A two-wheeled walker used to assist the client with ambulation
Answer: All of the above:
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 armrests
e. A two-wheeled walker used to assist the client with ambulation
Rationale:
All these findings increase the risk of falls by compromising the client's stability and creating
hazards in the environment.
8. 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 client who has a below-the-knee amputation and requires a dressing change
c. A young adult client who is postoperative, receiving morphine via epidural, and reports
pruritus
d. An adolescent who requires teaching regarding insulin administration
Answer: b. A middle adult client who has a below-the-knee amputation and requires a
dressing change
Rationale:
Dressing changes are within the scope of practice for an LPN.
9. 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 this information on record to the
nursing staff
c. Meet with the nursing staff to review the policy regarding advance directives
d. Ask nurses who are caring for clients without this information in the medical record to
obtain it

Answer: c. Meet with the nursing staff to review the policy regarding advance directives
Rationale:
Meeting with the nursing staff to review the policy regarding advance directives ensures that
all staff members understand the importance of obtaining this information and are aware of
the correct procedures to follow.
10. A nurse is caring for a group of clients. Which of the following should the nurse see first?
a. A client who is postoperative and has a fever.
b. A client whose pressure ulcer has serosanguineous drainage on the dressing.
c. A client who has diabetes mellitus and is diaphoretic.
d. A client who has a fractured hip and reports a pain level of 7 on a scale from 0-10.
Answer: a. A client who is postoperative and has a fever.
Rationale:
Fever in a postoperative client can indicate an infection, which requires immediate
assessment and intervention.
11. A nurse is receiving change-of-shift report for four clients. Which of the following clients
should the nurse care for first?
a. A client who is 4 hr postoperative following a hernia repair and has pitting edema of the
right leg.
b. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea.
c. A client who has pneumonia and requires a tracheostomy dressing change.
d. A client who has a new colostomy and requires discharge teaching.
Answer: c. A client who has pneumonia and requires a tracheostomy dressing change.
Rationale:
The client with pneumonia and a tracheostomy dressing change needs immediate attention to
maintain airway patency and prevent complications.
12. 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.
Rationale:

Gathering information helps the nurse manager understand the nature and causes of the
conflict, which is the first step in addressing it effectively.
13. A nurse in an urgent care clinic is admitting a client 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.
Rationale:
The nurse's safety is the priority when dealing with hazardous substances. Donning personal
protective equipment helps prevent exposure to the chemical.
14. 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.
Rationale:
Assessing the client's vital signs helps determine the impact of the medication error on the
client's condition and guides further interventions.
15. A nurse is assessing a client 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 the trunk.
c. Increased temperature.
d. Report of photophobia.
Answer: a. Decreased level of consciousness.
Rationale:
Decreased level of consciousness can indicate worsening neurological status and requires
immediate attention to prevent further complications.

16. A client 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: c. An allergy to penicillin required an alternative antibiotic to be prescribed.
Rationale:
An allergy requiring a change in antibiotic therapy represents a variance from the standard
care pathway and should be documented.
17. 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 medicalsurgical unit?
a. A client who is post-term and is receiving oxytocin for labor induction.
b. A client who gave birth to her first child and requires instruction on breastfeeding
techniques.
c. A client who is 2 days post-operative following a cesarean birth and is having difficulty
ambulating.
d. A client who has preeclampsia and is receiving a continuous magnesium sulfate infusion.
Answer: c. A client who is 2 days post-operative following a cesarean birth and is having
difficulty ambulating.
Rationale:
A client with postoperative difficulty in ambulating aligns with the medical-surgical
experience of a float nurse.
18. 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.
Rationale:

The infection control nurse is the most appropriate member to consult for reducing the
transmission of MRSA.
19. A nurse is caring for a client who has uterine prolapse. The provider has recommended a
total abdominal hysterectomy, but the client 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 client her concerns regarding the procedure.
b. Provide the client with information on treatment options and outcomes.
c. Inform the client 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 client her concerns regarding the procedure.
Rationale:
Discussing the client's concerns helps the nurse understand her perspective and address any
fears or misconceptions she may have about the surgery.
20. A nurse in the emergency department is assessing a client who is unconscious following a
motor-vehicle crash. The client 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 anesthesiologist to sign the consent.
d. Transport the client to the operating room without verifying informed consent.
Answer: b. Obtain telephone consent from the facility administrator before the surgery.
Rationale:
In emergency situations where the client is unable to provide consent, obtaining telephone
consent from the facility administrator is appropriate.
21. A nurse is planning to delegate client care assignment. Which of the following tasks
should the nurse plan to delegate to an assistive personnel?
a. Performing postmortem care prior to transferring the client to the morgue
b. Advising a client on self-administration of acetaminophen
c. Teaching a client 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 client to the morgue
Rationale:
Providing postmortem care is within the scope of practice for assistive personnel, and it
allows the nurse to focus on the needs of living clients.

22. A nurse is working on a quality improvement team that is assessing an increase in client
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. Notify staff of the increased fall rate
b. Review current literature regarding client 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
Rationale:
Identifying clients at risk of falls is the first step in implementing a fall prevention plan.
23. 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 client who has Clostridium difficile.
b. The AP closes the door of a client who is on airborne precautions.
c. The AP removes cut flowers from the room of a client who is in protective environment.
d. The AP wears a mask when caring for a client who has varicella.
Answer: c. The AP removes cut flowers from the room of a client who is in protective
environment.
Rationale:
Removing cut flowers from a client's room is unnecessary for a client in protective isolation.
24. A charge nurse notices that the staff nurses are having difficulty using new IV infusion
pumps for medication administration. Which of the following is the 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 the use of the pump during medication administration.
d. Plan an in-service education program on the unit.
Answer: c. Demonstrate the use of the pump during medication administration.
Rationale:
Demonstrating the use of the pump during medication administration is the priority to ensure
the safe and effective use of the equipment.
25. A nurse is preparing a shift assignment for an assistive personnel (AP) on the unit. Which
of the following tasks should the nurse assign to the AP?
a. Administer the initial bolus feeding to a client who has an NG tube.

b. Check a client's pain level 30 minutes after receiving acetaminophen.
c. Collect a urine specimen for a newly admitted client.
d. Instruct a client to splint an abdominal incision.
Answer: c. Collect a urine specimen for a newly admitted client.
Rationale:
Collecting urine specimens is within the scope of practice for assistive personnel.
26. 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 minutes.
b. Provide treatment for life-threatening injuries.
c. Provide treatment for minor injuries.
d. Allow the client to die without further intervention.
Answer: b. Provide treatment for life-threatening injuries.
Rationale:
Red tagging indicates that the client has life-threatening injuries and requires immediate
treatment.
27. 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 client 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 client stores cleaning supplies in a locked cabinet above his head.
Answer: b. The client’s electrical cord is taped to the floor.
Rationale:
Taping electrical cords to the floor poses a tripping hazard and is considered unsafe.
28. A charge nurse is observing a newly licensed nurse provide care for a client who has
Clostridium difficile infection. Which of the following actions by the newly licensed nurse
indicates an understanding of proper infection control procedures?
a. Applies a mask before entering the client’s room.
b. Removes fresh flowers from the client’s room.
c. Washes her hands with an alcohol-based hand rub after caring for the client.
d. Wears a gown when caring for the client.
Answer: a. Applies a mask before entering the client’s room.
Rationale:

Applying a mask before entering the room of a client with Clostridium difficile infection is a
proper infection control measure.
29. A nurse is preparing discharge planning for a client 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.
Rationale:
Pipe cleaners are used to clean the inner cannula, petroleum jelly is used to lubricate the
tracheostomy tube, and an obturator is used during tube replacement.
30. 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 client who has alcohol intoxication.
b. An adolescent client who is legally emancipated.
c. An older adult client who has questions about the procedure.
d. An adult client who has moderate Alzheimer’s disease.
Answer: b. An adolescent client who is legally emancipated.
Rationale:
Emancipated minors can provide informed consent for medical treatment.
31. A nurse is discussing the safekeeping of valuables with a client who is scheduled for
surgery. Which of the following client statements indicates the need for further teaching?
a. “I can wear my ankle bracelet since I am just having a local anesthetic.”
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: a. “I can wear my ankle bracelet since I am just having a local anesthetic.”
Rationale:
Ankle bracelets should be removed before surgery due to safety concerns, regardless of the
type of anesthesia.

32. A nurse is caring for an older adult client 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 for the wound care nurse specialist to see the client daily to provide the
recommended treatments.
c. Arrange the consultation for a time when the nurse caring for the client 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 client is able to
be present for the consultation.
Rationale:
Having the nurse present during the consultation ensures a comprehensive understanding of
the wound care plan and fosters collaborative decision-making.
33. A nurse is observing an AP administer a 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 client on her left side with knees flexed.
b. Administers the solution at room temperature.
c. Points tubing in the direction of the umbilicus during insertion.
d. Inserts the tubing 8 cm (3.1 in) into the rectum.
Answer: c. Points tubing in the direction of the umbilicus during insertion.
Rationale:
The tubing should be directed toward the client's hip, not the umbilicus, during insertion to
facilitate comfortable administration of the enema.
34. A nurse is orienting a newly licensed nurse about client 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.”
Rationale:

Protecting client confidentiality involves encryption of electronic communications to
safeguard personal health information.
35. 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? (2016 practice)
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
Rationale:
The State Nurse Practice Act outlines the scope of nursing practice and dictates the legal
authority of nurses to perform certain procedures.
36. A charge nurse observes a licensed practical nurse tell a client 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
Rationale:
Fidelity refers to the nurse's obligation to follow through with the care promised to the client.
37. 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.
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.
Rationale:
Benchmarking involves comparing practices within the facility against those of highperforming facilities to identify areas for improvement.

38. A nurse enters a client’s room and identifies that the client 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.
Rationale:
The nurse should first assess the client's condition, including lung sounds, to identify any
respiratory distress caused by the excess fluid.
39. A client 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: c. “This won’t take long and it will be over before you know it.”
Rationale:
Offering reassurance and encouragement can help alleviate the client's anxiety before the
procedure.
40. 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: d. MRSA
Rationale:
MRSA is a reportable infection that must be reported to the public health department for
tracking and surveillance.
41. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility.
Which of the following information should the nurse include in the change-of-shift report?
a. The steps to follow when providing wound care

b. The client’s preferred time for bathing
c. The belief that the client has a difficult relationship with his son
d. The time the client received his last dose of pain medication
Answer: d. The time the client received his last dose of pain medication
Rationale:
Providing the time of the last pain medication administration ensures continuity of care and
prevents delays in pain management.
42. 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
Rationale:
Reading back the prescription helps ensure accuracy and prevents errors in transcription.
43. 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
Rationale:
Addressing the issue directly with the AP allows for immediate correction of the problem and
provides an opportunity for education.
44. A nurse is planning care for a client 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 client during the day
Answer: d. Provide distractions for the client during the day
Rationale:

Providing distractions helps redirect the client's attention and reduce wandering behavior.
45. A nurse is caring for a client who has a new diagnosis of chlamydia. Which of the
following actions should the nurse take?
a. Initiate contact precautions
b. Report the infection to the local health department
c. Apply an antiviral cream to lesions
d. Instruct the client to use condoms until the treatment is completed
Answer: d. Instruct the client to use condoms until the treatment is completed
Rationale:
Instructing the client to use condoms during treatment helps prevent transmission to sexual
partners.
46. 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 client care 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
Rationale:
Developing a clinical question is the first step in evidence-based practice as it helps focus the
search for evidence.
47. 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 designated 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
Rationale:
Removing contaminated clothing helps prevent further exposure and spread of hazardous
materials.

48. A case manager is reviewing documentation on several clients and notes a progress report
that falsely identifies a client 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: d. Slander
Rationale:
Slander involves making false statements about a person that damages their reputation.
49. 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 client who had a bladder scan that indicated 250 mL of urine in the bladder
b. A client who is 3 days postoperative and who’s dressing has serosanguinous drainage
c. A client who has diabetes and an early morning blood glucose of 220 mg/dL
d. A client who has a nasogastric tube to intermittent suction and reports nausea
Answer: d. A client who has a nasogastric tube to intermittent suction and reports nausea
Rationale:
A client reporting nausea with an NG tube needs immediate assessment to prevent
complications.
50. 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 client 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 client in a public area.”
Rationale:
Reminding the staff nurse to refrain from discussing client information in public areas
maintains confidentiality and compliance with HIPAA regulations.
51. 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.
Rationale:
Using sterile forceps prevents contamination of the wound during dressing changes.
52. A nurse working in a long-term care facility is assessing an older adult client who has
been receiving antibiotics for 10 days. The client reports frequent loose stools. Which of the
following actions should the nurse take?
a. Place the client 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.
Rationale:
Cleaning the equipment with bleach helps prevent the spread of infection, especially when
diarrhea is present.
53. 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. 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 takes a break
d. Ask other staff members to take over some of his tasks
Answer: b. Recommend that he takes time to plan at the beginning of his shifts.
Rationale:
Planning can help the newly licensed nurse organize his workload and approach tasks more
efficiently.
54. A nurse is planning discharge for a client who has had lung resection. The nurse initiates a
referral for a social worker. Which of the following assessment data supports this referral?
a. The client needs to have someone bring O2 tanks and equipment to her home
b. The client needs to have range-of-motion exercises to assist with ambulation
c. The client needs to arrange financial resources to purchase equipment
d. The client needs to have someone come in to help her bathe at home

Answer: c. The client needs to arrange financial resources to purchase equipment.
Rationale:
A social worker can assist with financial planning and resources for equipment and other
needs after discharge.
55. A nurse initiates a referral to an occupational therapist for a client who has rheumatoid
arthritis. Which of the following assessment findings supports the need for this referral?
(SATA)
a. The client reports pain when chewing solid foods.
b. The client expresses the desire to join a support group.
c. The client requires assistance with completing oral hygiene.
d. The client has difficulty ambulating with a walker.
Answer: d. The client has difficulty ambulating with a walker.
Rationale:
An occupational therapist can assist the client in regaining independence in activities of daily
living, including ambulation.
56. A nurse is caring for a client who has anorexia nervosa. Which of the following
interdisciplinary team members should be consulted regarding this client’s care?(SATA)
a. Nutritional therapists
b. Case Manager
c. Mental Health counselor
d. Occupational therapist
e. Physical therapist
Answer: a. Nutritional therapists, c. Mental Health counselor
Rationale:
Anorexia nervosa is a complex disorder that requires a multidisciplinary approach, including
nutritional therapy and mental health counseling.
57. 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 client who reports a headache with sensitivity to light.
b. A client who reports feeling lightheaded when he stands up from a lying position.
c. A client who reports indigestion and pain in her jaw.
d. A client who reports an urge to void but has not urinated during the prior shift.
Answer: b. A client who reports feeling lightheaded when he stands up from a lying position.
Rationale:

This could indicate orthostatic hypotension, which requires immediate assessment to prevent
injury.
58. A nurse on an acute mental health unit is assessing four clients. Which of the following
clients is the highest priority?
a. A client who has depressive disorder and has poor personal hygiene.
b. A client who has dementia and exhibits aphasia.
c. A client who has bipolar disorder and displays constant pacing.
d. A client who has schizophrenia and uses neologisms.
Answer: c. A client who has bipolar disorder and displays constant pacing.
Rationale:
Constant pacing can lead to physical exhaustion and needs to be addressed immediately.
59. 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 client whose total parenteral nutrition was discontinued 4 hrs
ago.
b. Auscultate the bowel sounds of a client who has not had a bowel movement after taking a
laxative 12 hrs ago.
c. Provide instruction to the caregiver of a client who has dementia and a new diagnosis of
diabetes mellitus.
d. Check a client who has a leg cast and reports a new onset of pain.
Answer: d. Check a client who has a leg cast and reports a new onset of pain.
Rationale:
Pain in a client with a leg cast could indicate a complication such as compartment syndrome
and requires immediate assessment.
60. A nurse on a med-surg unit is caring for a client 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 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.”
Rationale:
This response provides accurate information about the role of a health care proxy.

61. A nurse in a rehabilitation facility is administering medications to a client who was
admitted earlier that day. The client 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 client's prescribed medications.
Answer: c. Review the intended purpose of the prescribed medication with the client.
Rationale:
Before contacting the provider or pharmacist, the nurse should first clarify the medication's
intended purpose with the client. This can help alleviate the client's concerns and provide an
opportunity to address any misunderstandings.
62. 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 client who is postoperative following laminectomy 12 hrs ago is unable to void
b. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV
chemotherapy
c. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
d. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38°C (101°F)
Answer: a. A client who is postoperative following laminectomy 12 hrs ago is unable to void.
Rationale:
A postoperative client who is unable to void requires immediate assessment to prevent
urinary retention and possible complications.
63. A nurse in the emergency department admits a client 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 client during transfer to the unit.
Answer: c. Prepare to administer antibiotics to the client.
Rationale:
Cutaneous anthrax is treated with antibiotics, typically ciprofloxacin or doxycycline.

64. 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 not taking scheduled breaks.
Answer: d. Determine the reasons the nurses are not taking scheduled breaks.
Rationale:
Before taking action, it's important to determine the reasons the nurses are not taking
scheduled breaks, which could help identify and address any underlying issues.
65. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse
distracts the client and quickly administers the injection. This illustrates which of the
following?
a. False imprisonment
b. Libel
c. Assault
d. Battery
Answer: d. Battery
Rationale:
Battery is the unauthorized touching of another person. Administering the injection without
the client's consent constitutes battery.
66. A nurse is speaking with a visitor who asks a question about the status of a relative who is
a client 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: b. “I will have your relative’s nurse come and talk with you about her care.”
Rationale:
Directing the visitor to the client's nurse is the appropriate response, ensuring that
confidentiality is maintained.
67. A nurse suggests respite care for the partner of a client who has mild cognitive
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. 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
Rationale:
Respite care provides short-term relief for caregivers, allowing them time away from their
caregiving responsibilities.
68. A charge nurse observes a client 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
Rationale:
The nurse has an ethical obligation to ensure that the incident report accurately reflects what
happened, guided by the principle of veracity.
69. A nurse is caring for a client 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
Rationale:
Assessing the client's understanding after the provider explains the procedure ensures that the
client is fully informed before signing the consent form.
70. 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 restraints with a square knot
Answer: b. Allow 1 fingerbreadth between the restraint and the client’s wrists
Rationale:
Allowing one fingerbreadth between the restraint and the client’s wrists prevents injury and
ensures proper circulation while still restraining movement.
1. A nurse is preparing an educational program for staff members 2 a new intravenous pump.
Identify the sequence of actions the nurse should taken 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 - 1
b. Develop learning objectives for the program - 2
c. Identify resources available to meet objectives - 3
d. Review the staff member’s evaluation of the program – 4
Answer: 1. Determine what skills to teach the staff members
2. Develop learning objectives for the program
3. Identify resources available to meet objectives
4. Review the staff members' evaluation of the program
Rationale:
The rationale for the sequence of actions when developing the educational program for staff
members on a new intravenous pump is as follows:
1. Determine what skills to teach the staff members: This is the initial step to identify the
specific skills and knowledge that the staff members need to effectively use the new
intravenous pump.
2. Develop learning objectives for the program: Once the necessary skills are identified,
specific learning objectives can be developed to guide the content and structure of the
educational program.
3. Identify resources available to meet objectives: After determining the learning objectives,
the nurse should identify what resources are available (such as training materials, equipment,
and expert personnel) to help achieve those objectives effectively.
4. Review the staff members' evaluation of the program: Finally, after the program is
conducted, the nurse should review the staff members' evaluation of the program to assess its
effectiveness, gather feedback, and make any necessary improvements for future sessions.

This step ensures continuous improvement and adaptation of the educational program to
better meet the needs of the staff members.
2. A nurse suggest respite care for the partner of a client 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. Allow her to take time off attending to her partner
b. Provide her with additional training in caring for her partner
c. Provide her with counseling services
d. Enable her to spend more quality time with her partner
e. Provide financial assistance for caregiving services
Answer: a. Allow her to take time off attending to her partner
Rationale:
Respite care provides temporary relief for caregivers by allowing them to take breaks from
caregiving responsibilities. This can help reduce caregiver stress and burnout, allowing them
to better care for their partner in the long term.
3. A case manager observes a family member of a client who has Alzheimer’s disease
throwing books on the floor and sobbing while the client is having a diagnostic test. Which of
the following actions should the case manager take first?
a. Offer to have a brief talk with the caregiver
b. Ask the family member to leave the testing area
c. Comfort the family member and ensure their needs are met
d. Call for additional staff to assist
Answer: c. Comfort the family member and ensure their needs are met
Rationale:
In this situation, the immediate priority is to provide emotional support to the family member
who is clearly distressed. Comforting the family member and ensuring their needs are met
can help de-escalate the situation and provide reassurance.
4. A nurse is caring for a client who has early stage Alzheimer’s disease. In which of the
following actions is the nurse acting as a client advocate?
a. Requesting a referral for the client to attend reminiscent therapy sessions
b. Administering medications to manage the client’s agitation
c. Updating the client’s family members on the client’s condition
d. Assisting the client with activities of daily living
Answer: a. Requesting a referral for the client to attend reminiscent therapy sessions

Rationale:
As a client advocate, the nurse is ensuring that the client receives appropriate care and
support. Reminiscent therapy sessions can be beneficial for clients with Alzheimer's disease,
helping to improve cognitive function and quality of life.
5. 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.”
b. “I can delegate the removal of an IV catheter to an LPN on the unit.”
Rationale:
Statement a demonstrates the nurse's commitment to professional growth and development,
which is in line with the nursing code of ethics.
Statement b shows understanding of the scope of practice and delegation principles, which
are also important aspects of the nursing code of ethics.
Statement c, however, goes against the principles of nursing ethics as administering pain
medication to a client with a history of narcotic addiction without appropriate assessment and
consideration of alternative pain management strategies may not be in the client's best
interest. Therefore, this statement does not demonstrate understanding of the nursing code of
ethics.
6. A nurse is discussing advance directives with a client. Which of the following statements
by the client indicates an understanding of advance directives?
a. “I know I have the right to determine if I remain on a breathing machine.”
b. “I want my daughter to make all my medical decisions for me.”
c. “I don't really understand what advance directives are.”
d. “I signed the form, but I didn't read it.”
Answer: a. “I know I have the right to determine if I remain on a breathing machine.”
Rationale:
This statement demonstrates the client's understanding that advance directives allow them to
make decisions about life-sustaining treatments, such as being on a breathing machine, in the
event they are unable to communicate their wishes.

7. A nurse is caring for a client who has a pressure ulcer on the coccyx. Which of the
following findings indicated the need for referral to a wound care specialist?
a. Presence of slough in the wound bed
b. Absence of drainage from the wound
c. Decreased wound size
d. Intact surrounding skin
Answer: a. Presence of slough in the wound bed
Rationale:
The presence of slough in the wound bed indicates necrotic tissue, which needs to be
debrided to promote wound healing. A wound care specialist would be needed to assess the
wound and perform appropriate debridement to facilitate healing.
8. A nurse on a medical-surgical unit delegating client care. Which of the following tasks
should the nurse delegate to an assistive personnel?
a. Suctioning a client’s long-term tracheostomy
b. Administering IV antibiotics
c. Assessing a client’s lung sounds
d. Teaching a client about incentive spirometry
Answer: a. Suctioning a client’s long-term tracheostomy
Rationale:
Suctioning a client's long-term tracheostomy can be safely delegated to an assistive personnel
who has been trained in this procedure. It is within the scope of practice for an assistive
personnel and does not require the specialized skills of a licensed nurse.
9. A nurse is providing teaching about infection control measures to a client 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. Clean the urinary meatus with soap and water daily
c. Change the catheter bag every other day
d. Empty the catheter bag when it is half full
Answer: b. Clean the urinary meatus with soap and water daily
Rationale:
Using sterile technique to collect specimens from the drainage system is not necessary.
Instead, the nurse should instruct the client to clean the urinary meatus with soap and water
daily to reduce the risk of infection.

10. 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. Nurses can make decisions about organ allocation
c. Nurses can initiate discussions about organ donation with families
d. Nurses can declare a client brain dead
Answer: a. Nurses may witness the signing of organ donation consents
Rationale:
Nurses may witness the signing of organ donation consents, but they cannot make decisions
about organ allocation, declare a client brain dead, or initiate discussions about organ
donation with families.
11. A client 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. “I understand you’re feeling anxious. Would you like to talk about it?”
c. “Don’t worry, this is a routine procedure.”
d. “You’ll feel much better once the surgery is over.”
Answer: b. “I understand you’re feeling anxious. Would you like to talk about it?”
Rationale:
Option b acknowledges the client's emotions and offers support by inviting her to express her
feelings. This response demonstrates empathy and provides an opportunity for the client to
discuss her concerns.
12. 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. Inflates the NG tube balloon
c. Measures the pH of gastric aspirate
d. Positions the client in a high-Fowler’s position
Answer: a. Clamps the air vent tubing
Rationale:
Clamping the air vent tubing prevents air from entering the stomach during suctioning, which
helps maintain suction and prevents the introduction of air into the client's gastrointestinal
tract.

13. A nurse working in an emergency department is performing triage. To which of the
following clients should the nurse assign priority?
a. A client who has soot markings around each naris following a house fire
b. A client who has a leg laceration and is bleeding profusely
c. A client who reports severe abdominal pain with a history of cholecystitis
d. A client who has a fever and productive cough
Answer: a. A client who has soot markings around each naris following a house fire
Rationale:
The presence of soot markings around the nares suggests inhalation injury, which can
compromise the client's airway. Airway compromise takes priority in the triage process.
14. 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 client who has bacterial pneumonia and a new onset of restlessness
b. A client who had a total knee arthroplasty 2 days ago and reports incisional pain of 5 on a 0
to 10 scale
c. A client who is postoperative following an appendectomy and has a temperature of 38.3 °C
(100.9°F)
d. A client who has chronic kidney disease and a serum potassium level of 5.8 mEq/L
Answer: a. An older adult client who has bacterial pneumonia and a new onset of
restlessness
Rationale:
New onset of restlessness in an older adult client with bacterial pneumonia may indicate
hypoxia or worsening respiratory status, which requires immediate assessment and
intervention.
15. A charge nurse is making assignments for a medical surgical unit. Which of the following
clients is appropriate to assign to a licensed practical nurse?
a. A client who has emphysema and has oxygen saturation of 92%
b. A client who had a myocardial infarction 2 days ago and is receiving IV heparin
c. A client who had a bowel resection and has a nasogastric tube to low intermittent suction
d. A client who is 24 hr postoperative following a thyroidectomy and has a calcium level of
8.1 mg/dL
Answer: a. A client who has emphysema and has oxygen saturation of 92%
Rationale:

A client with emphysema and oxygen saturation of 92% can be safely cared for by a licensed
practical nurse, as oxygen therapy and monitoring are within the scope of practice for LPNs.
16. A nurse is admitting a client who is scheduled for cholecystectomy. The client 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 her mother
c. Proceed with the admission process without an interpreter
d. Request the assistance of a bilingual staff member
Answer: a. Access a language line to interpret what is being said
Rationale:
The nurse should access a language line to ensure effective communication with the client
and her daughter. Using a language line will provide accurate interpretation, ensuring the
client understands the admission process and any instructions related to the cholecystectomy.
17. A nurse is caring for a client who has an MI. The client’s daughter asks the nurse to
review her father’s medical record 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’m sorry, but I am not authorized to share your father’s medical information with you.”
c. “Sure, I can review the record with you right now.”
d. “You need to speak with the doctor before I can share any medical information with you.”
Answer: a. “Your father will have to give permission for you to review the record.”
Rationale:
The nurse should respect the client’s privacy and confidentiality. Without the client’s
permission, the nurse cannot share the medical information with anyone, including family
members.
18. A nurse is teaching a client 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. “Avoid contact with anyone who is sick.”
Answer: b. “Wear gloves and a gown whenever you need to leave your room.”

Rationale:
The client requires protective isolation due to immune system compromise. Wearing gloves
and a gown whenever leaving the room helps prevent the spread of infection from the client
to others and vice versa.
19. A nurse in the emergency department is preparing a married 17-year-old client 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 client sign the consent form after the surgeon explains the procedure
b. Wait until the parents arrive to have the client sign the consent form
c. Ask the client if they want to sign the consent form without the parents present
d. Proceed with the surgery without parental consent
Answer: a. Have the client sign the consent form after the surgeon explains the procedure
Rationale:
In most jurisdictions, a married minor is considered emancipated and can consent to their
own medical treatment. The nurse should have the client sign the consent form after the
surgeon explains the procedure to ensure informed consent.
20. A nurse is preparing a client for surgery. The client 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 have already signed the consent form, so the surgery will proceed as planned.”
c. “I can give you some medication to help you relax.”
d. “Let me get the surgeon to come and talk to you about your concerns.”
Answer: a. “I understand, and it’s not too late to change your mind.”
Rationale:
The nurse should acknowledge the client’s concerns and reassure her that it is okay to change
her mind. The client's autonomy and right to withdraw consent should be respected.
21. A nurse is completing discharge teaching with a client who is being treated for
tuberculosis (TB). Which of the following statements by the client 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 to feel better.”
c. “I don’t need to cover my mouth when I cough anymore.”
d. “It’s okay for me to go back to work as long as I wear a mask.”

Answer: a. “I should have a sputum culture done every 2-4 weeks”
Rationale:
Regular sputum cultures are necessary to monitor the effectiveness of TB treatment and to
ensure that the infection is not spreading. This statement indicates that the client understands
the importance of ongoing monitoring and treatment compliance.
22. A nurse is preparing discharge planning for a client 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? (Select all that apply)
a. Obturator
b. Oxygen tank
c. Suction machine
Answer: a. Obturator, c) Suction machine
Rationale:
Obturator: The obturator is necessary for reinserting the tracheostomy tube if it becomes
dislodged.
Suction machine: A suction machine is required to maintain a patent airway and remove
secretions from the tracheostomy tube.
Oxygen tank: While oxygen may be needed, it is not specifically required to manage the
tracheostomy itself at home. The need for oxygen should be assessed separately based on the
client's condition.
23. A nurse is completing discharge teaching about dietary supplements for nitrogen loss with
a client who has cancer. Which of the following nutrients should the nurse recommend the
client increase?
a. Protein
b. Carbohydrates
c. Fat
d. Fiber
Answer: a. Protein
Rationale:
Clients with cancer often experience increased protein catabolism, leading to nitrogen loss.
Therefore, the nurse should recommend increasing protein intake to help offset this loss and
support tissue repair and maintenance.

24. A case manager is preparing a client 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 client referrals for community resources
b. Arrange for home modifications to accommodate the client’s needs
c. Schedule follow-up appointments with the client’s healthcare providers
d. Provide the client and family with education on managing the spinal cord injury at home
Answer: a. Facilitate client referrals for community resources
Rationale:
The case manager's priority is to ensure that the client has access to necessary community
resources that will support their ongoing care and rehabilitation after discharge. This may
include referrals for home health services, durable medical equipment, support groups,
vocational rehabilitation, and other community-based services.
1. A nurse is chairing a committee about preventing infant abduction in a new birth care
center. Which of the following quality control tasks should the nurse assign to be completed
first?
a. 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: Identify the industry standards for infant safety.
Rationale:
Before choosing an infant safety system, it's essential to identify the industry standards for
infant safety to ensure that the chosen system meets the necessary criteria and requirements.
2. 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: Pediculosis capitis (head lice)
Rationale:

Pediculosis capitis is a reportable communicable disease, and healthcare providers are
required to report cases of head lice to the state health department.
3. 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. Gonorrhea
c. Trichomoniasis
d. Human papillomavirus
Answer: Gonorrhea
Rationale:
Gonorrhea is a reportable sexually transmitted infection. Healthcare providers are required to
report cases of gonorrhea to the health department for tracking and control of the spread of
the disease.
4. 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: Identify education opportunities for the nurse regarding safe medication
administration.
Rationale:
The first action should be to identify education opportunities for the nurse regarding safe
medication administration. This allows for corrective action to be taken before involving
other departments or escalating the issue.
5. The family members of an older adult client are expressing conflict over whether the client
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 client 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: The client
Rationale:
As long as the client is oriented and capable of making their own decisions, they have the
legal authority to make healthcare decisions for themselves, regardless of the preferences of
their family members or the recommendations of the provider.
6. 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: 1. Determine goals
2. Create a revised protocol
3. Implement the revised protocol
4. Review the results of the provisions.
Rationale:
The stages of change follow a logical sequence: first, determining the goals, then creating a
plan (revised protocol), followed by implementation, and finally, reviewing the results to
assess effectiveness and make any necessary adjustments.
7. 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 client is the president of a local bank.”
c. “ The client will need vital signs checked every 4 hours.”
d. “ The client is currently in the radiology department for a chest x-ray.”
Answer: “The client will need vital signs checked every 4 hours.”
Rationale:
During a shift change report, it is essential to include pertinent information about the client's
care needs. Vital signs needing to be checked every 4 hours is important for the oncoming
nurse to know to ensure timely assessments.
8. 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: Social worker
Rationale:
A social worker can assist the family in finding resources to help cover the cost of necessary
medical equipment. This can include financial assistance programs, charity organizations, or
other resources to help the family obtain the nebulizer for their child.
9. 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 client who has an NG tube
c. Collect a urine specimen from a newly admitted client
d. Instruct a client to splint an abdominal incision
Answer: Collect a urine specimen from a newly admitted client
Rationale:
Collecting a urine specimen is within the scope of practice for assistive personnel and does
not require specialized training or nursing judgment. Therefore, it is appropriate to delegate
this task to the assistive personnel.
10. 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 client care practice
d. Critically assess the evidence

Answer: Develop a clinical question

Rationale:
Developing a clinical question is the first step in the evidence-based practice process. It
involves identifying a clinical problem or area of interest and converting it into a searchable
question using the PICO (Patient, Intervention, Comparison, Outcome) format. This
structured approach helps guide the search for evidence to answer the clinical question.
11. A nurse is inspecting a client's 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: The electric plug has two short prongs - (Must be 3 prongs)
Rationale:
The electric plug having two short prongs instead of three is a safety hazard as it indicates
that the equipment is not properly grounded. This can increase the risk of electrical shock to
the patient or staff. It should be tagged and reported immediately to prevent potential harm.
12. 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: Review the vital sign trends at the end of the shift.
Rationale:
Reviewing the vital sign trends at the end of the shift allows the nurse to evaluate the
effectiveness and accuracy of the delegated task. It provides an overall picture of the client's
condition and helps identify any patterns or abnormalities that may need further attention.
13. A nurse is caring for a client who has signed consent for the removal of the tumor in the
left frontal lobe of the brain. The client states, “The tumor is on the right side of my head.”
Which of the following actions should the nurse take?
a. Continue with the surgery because the client 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 client to mark the right side of his head with indelible ink
Answer: Ask the surgeon to clarify the operative site with the client
Rationale:
The nurse should verify the operative site with the client and the surgeon to prevent a wrongsite surgery. Verifying the site of the surgery is a critical safety measure to ensure that the
correct procedure is performed on the correct side of the body.
14. 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 client appears competent to consent to the procedure
b. Discussing options for the alternative therapies with the client
c. Providing the client with a complete description of the procedure
d. Explaining the risks associated with the procedure to the client
Answer: Explaining the risks associated with the procedure to the client
Rationale:
It is the nurse's responsibility to ensure that the client understands the risks associated with
the procedure they are consenting to. While the other options are important aspects of the
informed consent process, explaining the risks ensures that the client is fully informed before
providing consent.
15. A charge nurse witnesses two nurses having a loud discussion at the nurses’ station about
not wanting to care for a client who has drug-resistant tuberculosis. Which of the following
actions should the charge nurse take?
a. Make arrangements to take over the client's 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: Contact the house supervisor to mediate the conflict
Rationale:
The charge nurse should involve the house supervisor to mediate the conflict and address the
situation appropriately. It is essential to resolve the conflict professionally and ensure that the
client's care is not compromised.
16. 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 client 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: Points tubing in the direction of the umbilicus during insertion
Rationale:
The nurse should intervene when the assistive personnel points the tubing in the direction of
the umbilicus during insertion. The correct direction for insertion is toward the client's
sacrum. This incorrect direction can cause injury or discomfort to the client.
17. A nurse is prioritizing care after receiving report on four clients. Which of the following
clients should the nurse assess first?
a. A client who reports feeling lightheaded when he stands up from a lying position
b. A client who reports an urge to void but has not urinated during the shift prior
c. A client who reports indigestion and pain in her jaw
d. A client who reports a headache with sensitivity to light
Answer: A client who reports feeling lightheaded when he stands up from a lying position
Rationale:
This client is at risk for falls and may be experiencing orthostatic hypotension. Assessing this
client first allows for timely intervention to prevent falls and potential injury.
18. 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: Close the doors of the unit before moving clients to a safe place
Rationale:
Closing the doors of the unit helps contain the fire and smoke, preventing its spread to other
areas of the facility and allowing more time for evacuation.
19. A nurse is providing teaching to an older adult client 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: Unplug humidifier before cleaning it
Rationale:
Unplugging the humidifier before cleaning it prevents the risk of electrical shock. It is an
essential safety measure to include in home safety instructions.
20. 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-assessment
Rationale:
In the SBAR communication tool, the assessment section includes the client's current
condition, including their pain level after receiving medication. Providing this information
allows for a comprehensive understanding of the client's status.
21. 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: Benchmarking
Rationale:
Benchmarking involves comparing performance measures, such as medication error rates,
with those of other similar institutions or units. In this scenario, the nurse is comparing the
medication error rate on their medical unit with the rate from a medical unit in a magnet
hospital to identify areas for improvement.
22. A nurse is planning a discharge for a client 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: Request a referral for a home safety assessment
Rationale:
The priority is to ensure the safety of the client at home. Requesting a referral for a home
safety assessment will help identify and address potential hazards in the client's home
environment, reducing the risk of injury or exacerbation of COPD symptoms.
23. A nurse is caring for a group of clients. Which of the following clients should the nurse
see first?
a. A client who is postoperative and has a fever (nonurgent)
b. A client who has a fractured hip and reports a pain level of 7 on a scale of 0 to 10
c. A client who has a pressure ulcer with serosanguineous drainage on the dressing
d. A client who has diabetes mellitus and is diaphoretic
Answer: A client who has a fractured hip and reports a pain level of 7 on a scale of 0 to 10
Rationale:
The client with a fractured hip reporting a pain level of 7 requires immediate assessment and
intervention to manage pain effectively and prevent complications.
24. A nurse manager is reviewing documentation on several clients and notes a progress
report that falsely identifies a client as 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: Libel
Rationale:
Libel is the written or published communication of false information that injures someone's
reputation. In this case, the progress report falsely identifying the client as HIV-positive is
considered libel.
25. A nurse initiates a referral to an occupational therapist for a client who has rheumatoid
arthritis. Which of the following assessment findings supports the need for the referral?
a. The client has difficulty ambulating with a walker
b. The client requires assistance with completing oral hygiene
c. The client reports pain when chewing on solid foods

d. The client expresses desire to join a support group
Answer: The client has difficulty ambulating with a walker
Rationale:
Difficulty ambulating with a walker indicates impairment in mobility, which is within the
scope of practice of an occupational therapist to address. Therefore, this finding supports the
need for a referral to an occupational therapist.
26. 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 client 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: Collaborating
Rationale:
Collaborating involves working together to find a mutually acceptable solution. In this
scenario, the nurse and the client worked together to find a solution to the safety issue of the
newspapers in the hallway.
27. 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: “Record the event on an occurrence report”
Rationale:
Recording the event on an occurrence report ensures that the incident is documented
appropriately for risk management purposes, regardless of whether the visitor denies injury.
28. 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 nurse's scope of practice
d. A code of ethics is a set of principles for nursing practice
Answer: A code of ethics is a set of principles for nursing practice
Rationale:
A code of ethics is a set of principles that guides nursing practice and provides a framework
for ethical decision-making. It is not a step-by-step approach, legally binding document, or a
description of the nurse's scope of practice.
29. 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: Rubeola
Rationale:
Rubeola (measles) is transmitted via droplets, so droplet precautions are necessary to prevent
its spread. Rotavirus, varicella, and mumps are transmitted via contact or airborne routes and
require different precautions.
30. 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 a committee of nurses from each shift to discuss issues related to the conflict
Answer: Gather information regarding the situation
Rationale:
Gathering information about the conflict is the first step in resolving it. The nurse manager
should gather facts from both sides to understand the nature and causes of the conflict before
taking further action.
31. 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: The nurse holds her hands above her waist
Rationale:
Holding hands above the waist helps maintain the sterility of the gown and gloves. Lowering
hands below the waist can contaminate the sterile field. Applying a face mask or goggles is
not necessary for surgical asepsis.
32. 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 client who has dyspnea and a respiratory rate of 26/min
d. An adult client who has large ecchymoses on both legs
Answer: An older adult client who has dyspnea and a respiratory rate of 26/min
Rationale:
Dyspnea and a respiratory rate of 26/min in an older adult are indicative of respiratory
distress, requiring immediate attention and examination.
33. A nurse is caring for a client 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: Physical therapist
Rationale:
The physical therapist is responsible for assisting with the use and application of
transcutaneous electrical nerve stimulation (TENS) devices.
34. 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: Accompany residents older than 85 years of age during ambulation
Rationale:
Older adults over the age of 85 are at a higher risk of falls, and providing assistance during
ambulation can help prevent falls.
35. A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility.
Which of the following information should the nurse include in the change of shift report?
a. The time the client received his last dose of pain medication
b. The client's preferred bath time
c. The belief that the client has a difficult relationship with his son
d. The steps to follow when providing wound care
Answer: The time the client received his last dose of pain medication
Rationale:
The time of the last dose of pain medication is important information to include in the change
of shift report to ensure continuity of care.
36. 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 client who has moderate Alzheimer’s disease
b. An older adult client who has questions about the procedure
c. An adult client who has alcohol intoxication
d. An adolescent client who is legally emancipated
Answer: An adolescent client who is legally emancipated
Rationale:
A legally emancipated minor has the legal authority to give informed consent for medical
procedures.
37. 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 client who has varicella
b. The AP removes cut flowers from the room of a client who is in a protective environment
c. The AP closes the door of a client who is on airborne precaution
d. The AP uses alcohol hand antiseptic after caring for a client who has C-Diff
Answer: The AP closes the door of a client who is on airborne precaution
Rationale:

Closing the door of a client who is on airborne precautions may prevent proper airflow and
containment of pathogens. It is not recommended as a standard precaution.
38. 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 client who is participating in a medical research study
b. An older adult client who has advance directives on file
c. An adolescent client whose parents refuse a blood transfusion for religious reasons
d. A middle adult client who leaves the facility against medical advice
Answer: An adolescent client whose parents refuse a blood transfusion for religious reasons
Rationale:
When parents refuse a necessary medical treatment for their child due to religious reasons,
ethical considerations come into play, and it is appropriate to involve the facility's ethics
committee.
39. 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 client who has leukemia and requires an updated plan of care
b. A client who is transferring from the PACU following abdominal hernia repair
c. A client who has type 1 diabetes mellitus and receives insulin before meals
d. A client who requires discharge teaching about a newly described medication
Answer: A client who has type 1 diabetes mellitus and receives insulin before meals
Rationale:
Administering insulin to a client with diabetes is within the scope of practice of an LPN.
40. 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: Infection control nurse
Rationale:
Infection control nurses specialize in preventing and controlling infections within healthcare
settings and would be best suited to provide expertise on reducing the transmission of MRSA.

41. 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 client who is confused
b. A nurse refuses to care for a client who has had an abortion
c. A nurse withholds nutrition from a client who has DNR order
d. A nurse administers prescribed opioids to a client who has a terminal illness and
respiratory rate of 8/min.
Answer: A nurse administers prescribed opioids to a client who has a terminal illness and
respiratory rate of 8/min.
Rationale:
Administering prescribed opioids to a client with a terminal illness and a low respiratory rate
is an example of ethical practice, ensuring the client's comfort and quality of life.
42. 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 client 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: Recommending a referral for a client who requires physical therapy
Suggesting a client’s partner attend a support group for emotional support
Rationale:
Advocacy involves actions to promote the client's well-being. Recommending referrals and
support services are examples of advocacy as they support the client's holistic health needs.
43. A nurse enters a client’s room and identifies that the client 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 an incident report
Answer: Auscultate the client’s lungs
Rationale:

Auscultating the client's lungs to assess for signs of fluid overload is the first action the nurse
should take to ensure the client's safety.
44. A nurse is documenting and completing an incident report after a client 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 client lying prone on the
floor’
b. Document in the nurses report, ‘Photocopy of incident report sent to risk management’
c. Document in incident report, ‘Client found lying on the floor after falling out of bed’
d. Document in nurses notes, ‘Incident report completed and filed’
Answer: Document in incident report, ‘Client found lying on the floor after falling out of
bed’
Rationale:
The incident report should include factual information about the event, such as what
happened and what actions were taken immediately after the incident.
45. A nurse is planning discharge teaching for a client 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: Cotton-twill tracheostomy ties
Suction machine
Petroleum jelly lubricated gauze
Rationale:
Cotton-twill tracheostomy ties, a suction machine, and petroleum jelly lubricated gauze are
necessary supplies for managing a tracheostomy at home.
46. A nurse is providing discharge teaching to a client 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: Information about follow-up care
Medication guideline information
Contact information for the physical therapist
Insurance information
Rationale:
Discharge teaching following total knee arthroplasty should include information about
follow-up care, medication guidelines, contact information for the physical therapist, and
insurance information.
47. 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 client in a public area”
d. “ Do you understand HIPAA regulations?”
Answer: “ Please stop discussing the client in a public area”
Rationale:
Reminding the staff nurse to stop discussing the client's diagnosis in a public area is
appropriate to maintain patient confidentiality.
48. A nurse is caring for a client 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: Compare website’s information with a variety of sources
Rationale:
Instructing the client to compare website information with a variety of sources helps ensure
the information's accuracy and reliability.
49. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should
explain that preventing client injury by removing a fall hazard demonstrates which of the
following ethical principles?
a. 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 client to make personal decisions
Answer: Nonmaleficence - nurse’s obligation to avoid causing harm to the client
Rationale:
Removing a fall hazard to prevent client injury demonstrates the ethical principle of
nonmaleficence, which is the nurse’s obligation to avoid causing harm to the client.
50. A nurse is preparing a client for surgery. The client expresses concern that someone might
steal her purse during the procedure. Which of the following actions should the nurse take?
a. Tell the client 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: Offer to place the purse in the facility’s safe
Rationale:
Offering to place the client's purse in the facility’s safe ensures the security of the client's
belongings during the surgical procedure.
51. 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 colored food dye to the formula
Answer: Check residual volume before each feeding
Rationale:
Checking residual volume before each feeding helps ensure that the client's stomach is
emptying properly and reduces the risk of aspiration.
52. A home health nurse is assessing the home environment during an initial visit to a client
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 client 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
c. A two-wheeled walker used to assist the client with ambulation
d. A raised vinyl seat on the toilet in the client’s bathroom
Rationale:
Throw rugs, two-wheeled walkers, and raised toilet seats increase the risk of falls in clients
with mobility issues.
53. A nurse on a medical-surgical unit is caring for a client 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. “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: “A health care proxy can make decisions for you when you are unable to do so”
Rationale:
A health care proxy is a legal document that allows someone else to make medical decisions
on behalf of the client when they are unable to do so.
54. A nurse is preparing to transfer a client 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 client 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: Push the wheelchair into the elevator, large wheels last
Rationale:
Pushing the wheelchair into the elevator with the large wheels last helps maintain control
during the transfer process.
55. A nurse is providing an in-service about client 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 client 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: “A nurse is responsible for informing clients about treatment options”
Rationale:
Part of client rights involves ensuring they are informed about their treatment options and can
make decisions about their care.
56. 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
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: Collect data about the staff nurse to support further action Always assess first
Rationale:
Before taking any further action, the charge nurse should collect data to ensure that there is
evidence to support the suspicion of chemical impairment.
57. A charge nurse is admitting a client who speaks a different language than the nurse and
will require an 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 client 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: Assign a bilingual staff member to be the interpreter when caring for the client
Rationale:
Using a bilingual staff member ensures effective communication between the nurse and the
client, maintaining confidentiality and accuracy.
58. A nurse is caring for a client who has Addison’s disease. Which of the following tasks
should the nurse plan to delegate to an assistive personnel?
a. Explain to the client about a 24hr urine specimen collection
b. Determine the client’s muscle strength prior to ambulation
c. Decide how often to measure vital signs
d. Remind the client to change positions slowly within AP scope
Answer: Remind the client to change positions slowly within AP scope
Rationale:

Reminding the client to change positions slowly falls within the assistive personnel's scope of
practice and is essential for preventing postural hypotension.
59. A nurse is caring for a client 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
b. Occupational therapist
c. Physical therapist
d. Social worker
Answer: Speech pathologist
Rationale:
A speech pathologist evaluates and makes recommendations regarding the impact of
disorders or injuries on speech, language, and swallowing.
60. 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 a priority?
a. A client who has a red tag
b. A client who has a yellow tag (delayed - serious but not life-threatening)
c. A client who has a green tag (minor, walking wounded)
d. A client who has a black tag
Answer: A client who has a red tag
Rationale:
In a disaster triage system, a client with a red tag signifies the highest priority, indicating the
need for immediate medical attention to survive.
61. A nurse is assessing an older adult client who was brought to the emergency department
by his adult son, who reports that the client fell at home. The nurse suspects elder abuse.
Which of the following actions should the nurse take?
a. File an incident report
b. Ask the client 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: Ask the client about his injuries with the son present
Rationale:

When elder abuse is suspected, the nurse should assess the client's injuries with the suspected
abuser not present to allow the client to speak freely.
62. A charge nurse is reviewing the actions by a nurse following a client 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: Documents in the client’s record, “Incident report was filed”
Rationale:
The incident report should be sent to risk management, but documenting in the client's record
that the report was filed is not necessary.
63. 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 client about a 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: Pouching a client’s established ostomy
Rationale:
Pouching an established ostomy is within the scope of practice for an assistive personnel.
64. A nurse is caring for a client 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. 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: Review the risks and benefits of the procedure with the client
Rationale:
It is the nurse's responsibility to ensure the client understands the risks and benefits of the
procedure before they give informed consent.
65. 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: “I will remove the client’s restraints every 4 hours”
Rationale:
Restraints should be removed every 2 hours for circulation and range-of-motion exercises.
66. A nurse is receiving change of shift report for four clients. Which of the following clients
should the nurse care for first?
a. A client has pneumonia and requires a tracheostomy dressing change
b. A client has a new colostomy and requires discharge teaching
c. A client who is scheduled for an intermittent enteral feeding in 2 hr and reports diarrhea
d. A client who is 4 hours postoperative following a hernia repair and has pitting edema of the
right leg - (Compartment syndrome)
Answer: A client who is 4 hours postoperative following a hernia repair and has pitting
edema of the right leg - (Compartment syndrome)
Rationale:
Pitting edema in a postoperative client suggests the development of compartment syndrome,
requiring immediate attention.
67. 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 client 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 they are absent
Answer: The emergency department nurse is waiting to give report on a new admission
Rationale:
Handing over report on new admissions promptly is essential for maintaining continuity of
care.
68. A nurse is providing information to a client about advance directives. The nurse should
explain that advance directives include which of the following?
a. Instructions regarding treatments the client 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: Instructions regarding treatments the client desires or does not desire
Rationale:
Advance directives provide instructions about medical treatment the client wishes to receive
in case they are unable to communicate them.
69. A nurse is reviewing the medication administration record of a client 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: Observe the client’s condition
Rationale:
The nurse should first assess the client's condition for any adverse effects due to the
additional dose.
70. A nurse is assessing a client who has meningitis. Which of the following findings should
the nurse report to the provider immediately?
a. Increased temperature
b. Report of photophobia
c. Decreased level of consciousness
d. Generalized rash over the trunk
Answer: Decreased level of consciousness
Rationale:
A decreased level of consciousness can indicate worsening of the client's condition and
requires immediate intervention.
1. 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
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
Rationale:
a. Applying gentle pressure at the site after injection helps prevent bruising and discomfort.
b. Aspirating the syringe for blood return after needle insertion helps ensure the needle is not
in a blood vessel, preventing accidental IV administration of the medication.
2. 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 client has about the procedure.”
d. “A family member can interpret to obtain informed consent from a client who is deaf.”
Answer: b. “Consent can be given by a durable power of attorney.”
Rationale:
A durable power of attorney is legally authorized to make healthcare decisions for the client
when the client is unable to do so.
3. A nurse is teaching a client 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: c. Cap the lancet prior to putting it in the trash.
Rationale:
Capping the lancet prevents accidental needlesticks when disposing of it.
4. A client 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: b. Oxygen saturation 89% on room air
Rationale:
Oxygen saturation of 89% on room air is below the expected range and requires intervention.

5. A client 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. “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: b. “This won’t take long and it will be over before you know it.”
Rationale:
This statement is reassuring and acknowledges the client's feelings without minimizing them.
6. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse
distracts the client and quickly administers the injection. This illustrates which of the
following?
a. Libel
b. False imprisonment
c. Battery
d. Assault
Answer: c. Battery
Rationale:
Battery involves the intentional touching of another person without their consent.
7. 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 inservice about client confidentiality.
b. Fill out an incident report regarding the situation.
c. Remind them that client information is confidential.
d. Report the incident to the nursing supervisor.
Answer: c. Remind them that client information is confidential.
Rationale:
Addressing the situation directly is the first step in handling a breach of confidentiality.
8. 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?
• Determine goals
• Implement recommended strategies
• Revise the plan.
• Evaluate the results

Answer: 1. Determine goals
2. Implement recommended strategies
3. Evaluate the results
4. Revise the plan
Rationale:
This sequence follows the quality improvement process: Plan-Do-Study-Act (PDSA) cycle.
9. 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
Rationale:
The provider suturing the client's injury is the best resource to learn proper suturing
technique.
10. A client 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 client
repeatedly refuses to provide the specimen. Which of the following is the appropriate action
by the nurse?
a. Assess the client for urinary retention.
b. Obtain a provider’s prescription for a blood alcohol level.
c. Tell the client 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.
Rationale:
Documenting the client's refusal is important for legal and continuity of care purposes.
11. 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.
Rationale:
The priority is to ensure the nursing staff understand the policy and importance of
documenting advance directives. Meeting with the staff to review the policy will help
reinforce its significance and ensure compliance.
12. A nurse who is precepting a newly licensed nurse is discussing the client assignment for
the shift. Which of the following actions should the nurse preceptor take first to demonstrate
appropriate time management?
a. Determine client care goals.
b. Review the client’s new laboratory values.
c. Complete required tasks.
d. Document assessment data.
Answer: a. Determine client care goals.
Rationale:
Determining client care goals helps establish priorities and manage time effectively by setting
clear objectives for the shift.
13. 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 client 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 client 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.
Rationale:
A DNR (Do Not Resuscitate) order only applies to resuscitative measures, not comfort
measures. Explaining this incorrectly to the client's family could cause unnecessary distress.
14. A nurse is caring for a client 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 client has designated his partner as health care proxy in his advance directives.”
Answer: d. “The client has designated his partner as health care proxy in his advance
directives.”
Rationale:
The health care proxy is legally designated to make healthcare decisions for the client when
the client is unable to do so.
15. 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 counselor
Answer: b. Liaison
Rationale:
Liaison involves linking community resources with the healthcare needs of individuals.
16. A nurse is preparing to discharge a client 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: c. List of regularly prescribed medications
Rationale:

Including the list of regularly prescribed medications in the verbal transfer report ensures
continuity of care and proper medication management.
17. A charge nurse on a postpartum unit is teaching a client 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.”
Rationale:
Checking the photo identification badge of staff members helps ensure that only authorized
personnel are caring for the newborn.
18. A nurse is assigned the following four clients for the current shift. Which of the following
clients should the nurse assess first?
a. A client who has diabetes mellitus and a stage 2 pressure ulcer on his foot
b. A client who has a hip fracture and is in Buck’s traction
c. A client who has aspiration pneumonia and a respiratory rate 28/min
d. A client who has a Clostridium difficile infection and needs a stool specimen collected
Answer: c. A client who has aspiration pneumonia and a respiratory rate 28/min
Rationale:
A client with aspiration pneumonia and a high respiratory rate requires immediate assessment
and intervention to maintain airway patency and improve oxygenation.
19. 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 client throws a box of tissues at a nurse.
d. A client refuses to attend physical therapy.
Answer: a. A visitor pinches his finger in the client’s bed frame.
Rationale:
An incident report is necessary to document incidents that result in injury to a client, visitor,
or staff member.

20. 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 client to social services for assistance with transportation
b. Providing the first oral feeding to a client following a stroke
c. Instructing a client 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
Rationale:
Changing a dressing on a postoperative wound is within the scope of practice for a licensed
practical nurse.
21. A nurse is precepting a newly licensed nurse who is caring for a client who is confused
and has an IV infusion. The newly licensed nurse has placed the client 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?”
Rationale:
This question helps ensure that the restraints are not too tight, preventing compromised
circulation or injury to the client.
22. A nurse observes a paper bag at the bedside of a client. This finding suggests that the
client is receiving treatment for which of the following respiratory disorders?
a. Stridor
b. Asthma
c. Hyperventilation
d. Atelectasis
Answer: c. Hyperventilation
Rationale:
Breathing into a paper bag is a common intervention for hyperventilation, as it helps to
rebreathe carbon dioxide and increase carbon dioxide levels in the blood.
23. 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 client 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.
Rationale:
Disconnecting the urinary catheter from the drainage bag increases the risk of introducing
infection. Proper technique involves using a sterile needle and syringe to collect urine from
the sampling port.
24. 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 maintaining 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
c. Places sterile items within a 1.25-cm (0.5-inch) border around the edges of the sterile field
Rationale:
These actions help maintain the sterility of the field by preventing contamination.
25. A nurse working on a medical-surgical unit is receiving shift report regarding four clients.
Which of the following client 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
Rationale:
New onset of confusion after surgery can indicate complications such as infection or cerebral
hypoxia, and requires immediate assessment to determine the cause.
26. An RN is planning client assignments for a licensed practical nurse (LPN) and three
assistive personnel. The RN should assign the LPN to the client 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
Rationale:
Frequent dressing changes require assessment and wound care skills, which fall within the
scope of practice of an LPN.
27. A client 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 client should avoid using remote control devices to prevent dysrhythmias.
c. Regular programming evaluations can be conducted by telephone.
d. The client should avoid using a microwave oven to heat food.
Answer: a. Swimming could cause the unit to have an electrical short.
Rationale:
Swimming or immersing the pacemaker in water can damage the device and cause an
electrical short.
28. According to HIPAA regulations, which of the following is a violation of client
confidentiality?
a. Reporting a client’s disposition to the referring provider
b. Informing housekeeping staff that the client 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 client is in the dialysis unit
Rationale:

Informing non-involved staff members about a client's condition or location is a violation of
HIPAA regulations.
29. A nurse is preparing discharge planning for a client 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: d. Oxygen tank
e. Obturator
Rationale:
An oxygen tank and an obturator are essential for managing a tracheostomy at home. The
other options are not typically used for tracheostomy care.
30. 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: c. Identify nurses who accept the change to help influence other staff nurses.
Rationale:
Identifying influential staff members who accept the change can help encourage others to
support the new scheduling system.
31. 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 client 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: b. Activate the first alarm system.

a. Remove the client from the area.
c. Confine the fire by closing doors and windows.
d. Extinguish the fire if possible.
Rationale:
In the event of a fire, the priority is to activate the alarm system to notify others, remove the
client from immediate danger, confine the fire, and then attempt to extinguish it if it is safe to
do so.
32. A nurse enters the room of a client 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? REPEAT
a. Complete an incident report regarding the breach of the client’s confidentiality.
b. Report the possible violation of client 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.
Rationale:
The nurse should first prevent further unauthorized access to the client's medical records by
logging out the computer, then report the incident according to the facility's policy.
33. 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: c. Wait to dispose of sharps containers until they are completely full.
Rationale:
Waiting to dispose of sharps containers until they are completely full helps to reduce waste
disposal costs.
34. Which of the following puts a hospital at the highest risk for infringement of client record
confidentiality?
a. Paper-based charts are stored at the nurses’’ station.
b. A provider and nurse access client 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: c. A nurse performs electronic documentation outside a client’s room.
Rationale:
Performing electronic documentation outside a client's room increases the risk of
unauthorized access to sensitive client information.
35. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist
restraints to a client 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-restraint 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.
Rationale:
The immediate action should be to remove the restraints, as they were applied without a
prescription, then follow up with appropriate measures according to facility policy.
36. 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 client is currently in the radiology department for a chest x-ray.”
c. “The client will need vital signs every 4 hours.”
d. “The client is the president of a local bank.”
Answer: b. “The client is currently in the radiology department for a chest x-ray.”
Rationale:
This information updates the oncoming nurse about the current location of the client.
37. A client 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 client states,
“It’s okay. Soon everything will be just fine.” Which of the following is the nurse’s priority
action?
a. Ask the client if he has considered hurting himself.
b. Provide the client with information about Alcoholics Anonymous.
c. Encourage the client to participate in physical activities.
d. Reinforce the need to follow up with discharge referral.

Answer: a. Ask the client if he has considered hurting himself.
Rationale:
The client's statement may indicate suicidal ideation, so the nurse should ask directly about
self-harm to ensure the client's safety.
38. 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.
Rationale:
Moving the discussion to a private location, addressing the situation assertively, and using
active listening are effective strategies to facilitate negotiations and conflict resolution.
39. 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.
Rationale:
Steadily increasing pulse rate may indicate bleeding or other complications postoperatively
and requires immediate assessment.
40. A nurse finds a client 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 client to prevent further injury.
d. Check the client for injuries.

Answer: d. Check the client for injuries.
Rationale:
Assessing the client for injuries is the first priority to determine the extent of harm and
whether further interventions are necessary.
41. 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 client who has pneumonia and has an oxygen saturation of 95%
b. A client who has atrial fibrillation and reports chest pain of 5 on a scale from 0 to 10
c. A client who has peripheral vascular disease and has +1 pedal pulses bilaterally
d. A client who has inflammatory bowel syndrome and reports two loose stools
Answer: b. A client who has atrial fibrillation and reports chest pain of 5 on a scale from 0 to
10
Rationale:
Chest pain in a client with atrial fibrillation could indicate cardiac ischemia or infarction,
which requires immediate assessment and intervention.
42. A nurse is caring for a client 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 client 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.
Rationale:
The nurse should inform the nursing supervisor about the inability to reach the provider to
ensure prompt attention to the client's needs.
43. 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: b. A preschool child who was previously trained now requires diapers in the
hospital.
Rationale:

Developmental regression such as loss of previously acquired skills, like toileting, is a red
flag for possible abuse or neglect.
44. A home health nurse is assessing the home environment of a client who is on continuous
oxygen therapy. Which of the following findings requires the nurse to intervene?
a. The client is covered with a woolen 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: d. The windows of the client’s room are open.
Rationale:
Open windows can affect the oxygen concentration in the room, potentially reducing its
effectiveness, so the nurse should intervene to ensure a safe oxygen environment.
45. A nurse is caring for a client 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
Rationale:
For a client with increased intracranial pressure, any change in neurological status, as
indicated by the Glasgow Coma Scale score, is the most critical information to report.
46. 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 client who has chronic atrial fibrillation and a digoxin level of 0.3 ng/mL
b. A client who has bleeding esophageal varices and a blood pressure of 90/50 mm Hg
c. A client who has a head injury and Glasgow Coma Scale score of 10
d. A client who has chronic kidney disease and a creatinine level of 15 mg/dL
Answer: b. A client who has bleeding esophageal varices and a blood pressure of 90/50 mm
Hg
Rationale:
Bleeding esophageal varices with hypotension requires intensive monitoring and
intervention, making transfer to the ICU the priority.

47. 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?”
Rationale:
The manager uses reflective communication to understand the nurse's feelings and provide an
opportunity to express concerns.
48. An older adult client 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: d. Turning the client
Rationale:
Turning a client is a task that can be delegated to assistive personnel while ensuring the
client's comfort and safety.
49. A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?
a. Assessing a client who just returned from hemodialysis
b. Reviewing dietary instructions for a client with kidney stones
c. Monitoring a client with a fluid restriction
d. Obtaining a stool sample from a client with renal failure
Answer: d. Obtaining a stool sample from a client with renal failure
Rationale:
Obtaining a stool sample is a task that can be delegated to an assistive personnel once the
procedure has been explained.
50. A nurse is providing teaching to a client who has a new diagnosis of diabetes mellitus.
The client 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
Rationale:
A case manager can assist the client in accessing financial resources to cover the cost of
blood glucose monitoring supplies.
51. 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: b. Use the chain-of-command for communication.
Rationale:
During a disaster, nurses should use the established chain-of-command for communication to
ensure an organized and effective response.
52. A client 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: d. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.
Rationale:
Delay in the initiation of antibiotic therapy as per the care pathway should be documented as
a variance and reported for quality improvement.
53. A nurse is working on a quality improvement team that is assessing an increase in client
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 client 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.
Rationale:
Identifying clients at risk for falls is the first step in implementing a targeted fall prevention
plan.
54. 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
Rationale:
Competing is a conflict-resolution strategy where one party imposes their solution over the
objections of others.
55. 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.
Rationale:
Encouraging the newly licensed nurse to plan his shift at the beginning can help him
prioritize and organize his tasks.
56. Client 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: d. Retrospective chart audit
Rationale:
Retrospective chart audit allows the unit manager to review past records to identify trends
and areas for improvement in pain management.
57. The mother of a client 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 client advocacy?
a. The nurse suggests counseling for the client’s body image issues.
b. The nurse investigates potential resources to help the client 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 client purchase a wig.
Rationale:
Investigating resources to help the client purchase a wig supports the client's emotional wellbeing and quality of life.
58. 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 client who has a 4-inch laceration on the forearm
b. A client who has an open fracture of the femur
c. A client who reports substernal chest pain radiating to the neck
d. A client who has a penetrating head injury and fixed and dilated pupils
Answer: d. A client who has a penetrating head injury and fixed and dilated pupils
Rationale:
Clients with life-threatening injuries such as penetrating head injuries should be transported
to the hospital first during a mass casualty incident.
59. A nurse is caring for an older adult client 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 client 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 client daily to provide the
recommended treatment.
Answer: b. Arrange the consultation for a time when the nurse caring for the client is able to
be present for the consultation.
Rationale:
The nurse should ensure that the consultant and the nurse providing care for the client can
meet to discuss the client's wound care and treatment plan.
60. Which of the following items must be discarded in a biohazard waste receptacle?
a. A bedsheet from a client with bacterial pneumonia
b. An empty IV bag removed from a client who has HIV
c. A urinary catheter drainage bag from a client who is postoperative
d. A peripheral pad from a client who is 24-hr post-vaginal delivery
Answer: b. An empty IV bag removed from a client who has HIV
Rationale:
Items that have come into contact with blood or body fluids from clients with infectious
diseases such as HIV must be discarded in biohazard waste receptacles to prevent
transmission of infection.
61. A client 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 client in the last 48 hr.
Answer: d. Determine who had contact with the client in the last 48 hr.
Rationale:
Identifying individuals who had contact with the client helps in implementing appropriate
infection control measures and preventing the spread of tuberculosis.
62. 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: d. NPH insulin 10 units before meals and at bedtime
Rationale:
The essential components of a medication order include the medication name, dosage, route,
frequency, and time of administration, all of which are included in the NPH insulin order.
63. A nurse is caring for a client 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 counselor
c. Physical therapist
d. Nutritional therapist
e. Occupational therapist
Answer: b. Mental health counselor
d. Nutritional therapist
Rationale:
Clients with anorexia nervosa require multidisciplinary care. Mental health counselors and
nutritional therapists are essential members of the team to address psychological and
nutritional aspects of the disorder.
64. 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 client 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.”
Rationale:

Initiating prophylactic treatment after a needlestick injury is important to prevent
transmission of bloodborne pathogens.
65. 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 client who is agitated
c. Inserting a feeding tube against the wishes of a client who refuses to eat
d. Telling a client who refused his oral medication that he will be given an injection
Answer: c. Inserting a feeding tube against the wishes of a client who refuses to eat
Rationale:
Inserting a feeding tube without the client's consent constitutes battery, which is the
unconsented touching of another person.
66. 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: c. Determine the reasons the nurses are not taking scheduled breaks.
Rationale:
Understanding the reasons why the nurses are not taking breaks is the first step in addressing
the issue and providing appropriate support.
67. 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.
b. Pick up the meal trays after lunch.
Answer: c. Administer a nasogastric tube feeding.
Rationale:
Administering a nasogastric tube feeding is within the scope of practice for a licensed
practical nurse.
68. 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 client needs
b. Providing medication reconciliation
c. Developing client treatment protocols
d. Establishing communication between providers
Answer: d. Establishing communication between providers
Rationale:
Telehealth serves to establish communication between providers and clients, facilitating
remote access to healthcare services.
69. 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: d. Document a factual description of the situation.
Rationale:
Documenting the observation is the first step in the process of addressing a situation where a
nurse may be impaired.
70. A case manager working in a rehabilitation unit is discharging to home a client 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 client care.
Answer: c. Identify the client’s ability to perform activities of daily living.
Rationale:
Identifying the client’s ability to perform activities of daily living helps in tailoring the
discharge plan to meet the client’s needs and level of independence.
1. 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: a. Identify nurses who accept the change to help influence other staff nurses.
Rationale:
Identifying nurses who accept the change and involving them in the process can help in
influencing other staff nurses positively. This method allows for peer influence and support,
fostering a more positive reception to the new scheduling system.
2. A client 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: d. An allergy to penicillin required an alternative antibiotic to be prescribed.
Rationale:
A variance report is required when there is a deviation from the standard care pathway. In this
case, changing the antibiotic due to an allergy to penicillin is a deviation from the standard
treatment plan.
3. A nurse should recognize that an incident report is required when
a. A client refuses to attend physical therapy.
b. A visitor pinches his finger in the client’s bed frame.
c. A client throws a box of tissues at a nurse.
d. A nurse gives a medication 30 min late.
Answer: b. A visitor pinches his finger in the client’s bed frame.
Rationale:
An incident report is required for any unexpected event that occurs in the healthcare setting,
including accidents or injuries involving visitors. This includes incidents like a visitor
pinching his finger in the client's bed frame.
5. Client 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
Rationale:
Retrospective chart audit allows for a review of past client records to identify patterns, trends,
and discrepancies in pain management postoperatively. This will help in understanding the
reasons behind inadequate pain management.
6. A nurse is precepting a newly licensed nurse who is caring for a client who is confused and
has an IV infusion. The newly licensed nurse has placed the client 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?”
Rationale:
This question addresses the correct application of restraints, ensuring they are not too tight,
preventing injury or compromise of circulation.
7. A nurse is caring for an older adult client 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 client 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 client daily to provide the
recommended treatment.
Answer: a. Arrange the consultation for a time when the nurse caring for the client is able to
be present for the consultation.
Rationale:

Ensuring that the nurse caring for the client is present during the consultation allows for the
exchange of information, understanding, and continuity of care.
8. A client 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 client in the last 48 hr.
Answer: a. Notify the local health department of the admission.
Rationale:
Notifying the local health department is essential to ensure proper public health measures are
taken, including contact tracing and infection control.
9. A nurse is caring for a client 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 client 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 client has designated his partner as health care proxy in his advanced
directives.”
Rationale:
Reminding the provider of the client's designation of the partner as a healthcare proxy
respects the client's autonomy and adheres to the advanced directives.
10. A nurse is caring for a client 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
Rationale:
The Glasgow coma scale score is crucial for monitoring the neurological status of a client
with increased intracranial pressure. It helps in assessing the client's level of consciousness
and detecting any deterioration or improvement in neurological status.
11. A nurse is assigned the four following clients for the current shift. Which of the following
clients should the nurse assess first?
a. A client who has a hip fracture and is in Buck’s traction
b. A client who has aspiration pneumonia and a respiratory rate of 28/min
c. A client who has diabetes mellitus and a stage 2 pressure ulcer on his foot
d. A client who has a Clostridium difficile infection and needs a stool specimen collected
Answer: b. A client who has aspiration pneumonia and a respiratory rate of 28/min
Rationale:
The nurse should assess the client with aspiration pneumonia and a respiratory rate of 28/min
first because this client is experiencing a life-threatening condition that requires immediate
intervention to ensure adequate oxygenation and prevent further deterioration.
12. A nurse is caring for a client 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 client for comfort
Answer: a. Notify the nursing supervisor about the issue
Rationale:
If the nurse is unable to reach the provider to report a change in the client's condition, the
next appropriate action is to notify the nursing supervisor to ensure that the client receives
timely and appropriate care.
13. The mother of a client 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 client advocacy?
a. The nurse investigates potential resources to help the client purchase a wig
b. The nurse explains to the mother that most clients 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 client purchase a wig
Rationale:
Client advocacy involves identifying and securing resources that will support the client's
physical and emotional needs. In this situation, the nurse should investigate potential
resources to help the client purchase a wig, addressing the client's concerns about body
image.
14. Which of the following items must be discarded in a biohazard waste receptacle?
a. A urinary catheter drainage bag from a client who is postoperative
b. A bed sheet from a client with bacterial pneumonia
c. A perineal pad from a client who is 24 hr post vaginal delivery
d. An empty IV bag removed from a client who has HIV
Answer: d. An empty IV bag removed from a client who has HIV
Rationale:
An empty IV bag removed from a client who has HIV should be discarded in a biohazard
waste receptacle to prevent the risk of transmission of infectious agents.
15. 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
Rationale:
The appropriate response by the unit manager is to acknowledge the nurse's concerns and
open up communication for further discussion.
16. According to HIPAA regulation, which of the following is a violation of client
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 client is in the dialysis unit

Answer: d. Informing housekeeping staff that the client is in the dialysis unit
Rationale:
Informing housekeeping staff about a client's location violates HIPAA regulations, as it
breaches the client's right to privacy and confidentiality.
17. 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
d. Places sterile items within a 1.25cm (.5inch) border around the edges of the sterile field
Rationale:
Maintaining sterile technique involves avoiding contamination of the sterile field. Opening
the sterile pack away from the body and placing sterile items within a designated border
around the sterile field help prevent contamination.
18. 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 a 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: b. Who is reporting a pain level of 8 on a scale of 0-10
Rationale:
Assessing the client reporting a pain level of 8 on a scale of 0-10 is the priority because pain
management is essential for postoperative recovery and client comfort.
19. 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. NPH insulin 10 units before meals and at bedtime
b. Haloperidol (Haldol) 1mg by mouth
c. Multivitamin every morning by mouth
d. Aspirin 650mg by mouth every 4 hours
Answer: a. NPH insulin 10 units before meals and at bedtime

Rationale:
A complete medication order should include the medication name, dose, route, frequency,
and any additional instructions. Option a includes all the essential components of a
medication order.
20. 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
Rationale:
Encouraging the newly licensed nurse to take time to plan at the beginning of his shift can
help him organize his tasks and prioritize his workload, potentially improving his ability to
focus and complete care for his assigned clients.
21. A nurse in an urgent care clinic is admitting a client 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 client's 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
Rationale:
The nurse's first priority should be to ensure their own safety by donning personal protective
equipment before providing care to the client exposed to the chemical.
22. 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 refuses to actively participate during an elective abortion procedure scheduled for
her client
b. A nurse gives prescribed opioids to a client who has terminal illness and respirations of
8/min
c. A nurse explains to a client’s family that DNR orders include withholding comfort
measures

d. A nurse informs a confused client 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 include withholding
comfort measures
Rationale:
The nurse's explanation about DNR orders is inaccurate. DNR orders do not include
withholding comfort measures. Comfort measures should be provided regardless of a client's
code status.
23. 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 client needs
b. Providing medication reconciliation
c. Establishing communication between providers
d. Developing client treatment protocols
Answer: a. Assessing client needs
Rationale:
One of the objectives of telehealth is to assess and meet client needs remotely, which can
include providing advice, education, and support.
24. Which of the following puts a hospital at the highest risk for infringement of client record
confidentiality?
a. A nurse clusters documentation of care for multiple clients
b. A provider and nurse access client 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 client information using one access code
Rationale:
Sharing access codes between providers and nurses increases the risk of unauthorized access
to client information, violating client record confidentiality.
25. 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 client 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
Rationale:
Disconnecting an indwelling urinary catheter from the drainage bag to collect a specimen
increases the risk of introducing infection. Safe handling techniques require maintaining a
closed urinary drainage system.
26. 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: a. A school-age child has several bruises on her lower legs
Rationale:
Unexplained injuries, especially in different stages of healing, are signs of possible abuse and
must be reported.
27. A parish nurse is making referrals 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 counselor
Answer: a. Liaison
Rationale:
As a liaison between the healthcare system and the community, the parish nurse facilitates
access to community resources such as meal delivery programs.
28. 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 client who reports substernal chest pain radiating to the neck
b. A client who has an open fracture of the femur
c. A client who has a 4-inch laceration on the forearm

d. A client who has a penetrating head injury and fixed and dilated pupils
Answer: a. A client who reports substernal chest pain radiating to the neck
Rationale:
During triage in a mass casualty incident, clients with life-threatening conditions, such as
potential myocardial infarction, are prioritized for transport to the hospital.
30. 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 client confidentiality.
b. Report the incident to the nursing supervisor
c. Remind them that client information is confidential
d. Fill out an incident report regarding the situation
Answer: c. Remind them that client information is confidential
Rationale:
The first action the nurse manager should take is to remind the provider and staff nurse that
client information is confidential and should not be discussed in public areas.
31. A client 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 client states,
“It’s okay. Soon everything will be just fine.” Which of the following is the nurse’s priority
action?
a. Ask the client if he has considered hurting himself.
b. Provide the client with information about Alcoholics Anonymous
c. Encourage the client to participate in physical activities
d. Reinforce the need to follow up with discharge referral
Answer: a. Ask the client if he has considered hurting himself.
Rationale:
The client's statement may indicate suicidal ideation, making it essential for the nurse to
assess the client's risk of self-harm or suicide as a priority.
32. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse
distracts the client and quickly administers the injection. This illustrates which of the
following?
a. False imprisonment
b. Battery
c. Assault
d. Libel

Answer: b. Battery
Rationale:
Battery occurs when the nurse administers treatment without the client's consent, even if the
intent is to benefit the client.
33. 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 from the unit
Answer: c. Document a factual description of the situation.
Rationale:
Documenting the observed behavior is the first step in addressing the situation. It provides a
factual record of the event, which can be used for further investigation or intervention.
34. A nurse observes a paper bag at the bedside of a client. The finding suggests that a client
is receiving treatment for which of the following respiratory disorders?
a. Asthma
b. Hyperventilation
c. Stridor
d. Atelectasis
Answer: a. Asthma
Rationale:
A paper bag at the bedside suggests the client is receiving treatment for hyperventilation by
rebreathing exhaled CO2, a common intervention for hyperventilation.
35. A nurse is preparing to discharge a client 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 the last bowel movement
d. Level of consciousness
Answer: b. List of regularly prescribed medications
Rationale:

Including the list of regularly prescribed medications in the transfer report ensures continuity
of care and helps prevent medication errors during the transition back to the long-term care
facility.
36. A nurse who is precepting a newly licensed nurse is discussing the client 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 client care goals.
Answer: c. Complete required tasks
Rationale:
Completing required tasks ensures that essential aspects of care are addressed in a timely
manner, demonstrating effective time management.
37. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of
the following statements by the newly licensed nurse indicates an understanding of isolation
guidelines?
a. “I will instruct visitors to wear a mask when visiting a client who is on contact
precautions.”
b. “I will place a client who has compromised immunity in a negative-pressure airflow
room.”
c. “I will wear an N95 respirator mask when caring for a client who is on droplet
precautions.”
d. “I will have a client who is on airborne precautions wear a mask when out of her room.”
Answer: a. “I will instruct visitors to wear a mask when visiting a client who is on contact
precautions.”
Rationale:
Instructing visitors to wear a mask when visiting a client on contact precautions helps prevent
the spread of infection.
38. 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 a client to social services for assistance with transportation
c. Instructing a client who is obese with a low-fat diet

d. Providing the first oral feeding to a client following a stroke
Answer: c. Instructing a client who is obese with a low-fat diet
Rationale:
Instructing a client on dietary modifications is within the scope of practice for a licensed
practical nurse.
39. A case manager working in a rehabilitation unit is discharging home a client 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 client care.
Answer: b. Identify the client’s ability to perform activities of daily living.
Rationale:
Identifying the client's ability to perform activities of daily living is the priority to ensure the
client's safety and independence upon discharge.
40. 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 client who has a nasogastric tube to intermittent suction and reports nausea
b. A client who has an early morning blood glucose of 220 mg/dL
c. A client who had a bladder scan that indicated 250 mL of urine in the bladder
d. A client who is 3 days postoperative and whose dressing has serosanguinous drainage
Answer: a. A client who has a nasogastric tube to intermittent suction and reports nausea
Rationale:
Assessing the client with a nasogastric tube and reports of nausea first allows the nurse to
address potential complications and provide necessary interventions promptly.
41. 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.
Rationale:

Administering a nasogastric tube feeding is within the scope of practice for a licensed
practical nurse.
42. A RN is planning client assignments for a licensed practical nurse (LPN) and three
assistive personnel. The RN should assign the LPN to the client 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.
Rationale:
Frequent dressing changes require nursing assessment and skill, making them appropriate to
be assigned to a licensed practical nurse (LPN).
44. A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?
a. Assessing a client who just returned from hemodialysis
b. Reviewing dietary instructions for a client with kidney stones
c. Obtaining a stool sample from a client with renal failure
d. Monitoring a client with a fluid restriction
Answer: d. Monitoring a client with a fluid restriction
Rationale:
Monitoring a client with a fluid restriction involves measuring intake and output, which is
within the scope of practice for assistive personnel.
45. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist
restraints to a client 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
Rationale:
The first action the nurse should take is to remove the restraints, ensuring the client's safety.
This is necessary as restraints were applied without a prescription, which is a violation of the
client's rights.

46. A client 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 client
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 client that a catheter will be inserted
c. Obtain a provider’s prescription for the blood alcohol level
d. Assess the client for urinary retention
Answer: a. Document the client’s refusal in the chart
Rationale:
The nurse should document the client's refusal in the chart to ensure that the refusal is on
record. Forcing a catheter insertion without a clear medical indication and without the client's
consent would be considered a violation of the client's rights.
47. 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: c. Return unused supplies from the bedside to the unit’s supply stock
Rationale:
Returning unused supplies to the unit’s supply stock helps reduce unnecessary waste and
contributes to cost containment.
48. An older adult client 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 foot
Answer: a. Turning the client
Rationale:
Turning the client is within the scope of practice for assistive personnel and is essential for
preventing complications such as pressure ulcers.

49. 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
Rationale:
The nurse manager is competing by imposing her preferred changes without considering the
opinions or preferences of others.
50. 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 client who has gestational diabetes and is receiving biweekly nonstress tests
b. A primigravida client who is 1 day postoperative following a Cesarean section and has a
PCA pump
c. A multigravida client who has preeclampsia and is receiving misoprostol (Cytotec) for
induction of labor
d. A client who is at 32 weeks of gestation and has a premature rupture of membranes
Answer: b. A primigravida client who is 1 day postoperative following a Cesarean section
and has a PCA pump
Rationale:
An RN with experience in medical-surgical care would be best suited to care for a
postoperative client with a PCA pump, as this requires knowledge and experience with pain
management and postoperative care.
51. 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 client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
b. A client who has Type 1 diabetes and uses an insulin pump
c. A client who has orthostatic hypotension and is receiving IV fluids
d. A client who is receiving heparin and has an aPTT of 34 seconds (On heparin: 45-80 sec)
Answer: a. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
Rationale:

An interdisciplinary conference is necessary for a client at risk for pressure ulcers and has a
low albumin level as this indicates a need for collaborative care involving the nursing,
dietary, and possibly wound care teams.
52. 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 client 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 client receives a stick from her own
used needle.”
Rationale:
Completing an incident report is essential if a client receives a stick from their own used
needle to ensure proper documentation and follow-up.
53. 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 client (AP/CNA)
b. Providing postmortem care for a client who has just died (AP/CNA)
c. Accompanying a client who just had a wound debridement to physical therapy (AP/CNA)
d. Reinforcing dietary teaching with a client who has heart disease
Answer: d. Reinforcing dietary teaching with a client who has heart disease
Rationale:
Reinforcing dietary teaching with a client who has heart disease involves providing education
and is within the scope of practice for a licensed practical nurse (LPN).
54. A nurse enters the room of a client 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 client 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
Rationale:
The first action the nurse should take is to ensure the client's confidentiality by logging out of
the computer, preventing unauthorized access to the client's electronic medical records.
55. A home health nurse is assessing the home environment of a client 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 client is covered with a woolen blanket
Answer: c. The windows of the client’s room are open
Rationale:
Open windows can affect the concentration of oxygen in the room, potentially reducing the
effectiveness of oxygen therapy, and should be closed to ensure the client receives the
prescribed oxygen concentration.
56. A nurse is teaching a client 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: b. Cap the lancet prior to putting it in the trash
Rationale:
Capping the lancet prior to disposal helps prevent accidental needlestick injuries.
57. A nurse in the emergency department is preparing to care for a client who arrived via
ambulance. The client 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 client sign a consent for treatment

d. Notify risk management before initiating treatment
Answer: b. Proceed with treatment without obtaining written consent
Rationale:
In emergency situations where the client is disoriented and treatment is required to prevent
further deterioration, implied consent is assumed, and treatment can proceed without
obtaining written consent.
58. A client has a new permanent pacemaker inserted. Which of the following home care
instructions should the nurse include?
a. The client should avoid using a microwave oven to heat food
b. Regular programming evaluations can be conducted by telephone
c. the client should avoid using remote control devices to prevent dysrhythmias
d. Swimming could cause the unit to have an electrical short
Answer: d. Swimming could cause the unit to have an electrical short
Rationale:
Swimming or immersing the area with the pacemaker should be avoided as it could cause
damage to the device.
59. 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: b. Ask nurses who are caring for clients without this information in the medical
record to obtain it.
Rationale:
The priority action is to ensure that all clients have documentation regarding advance
directives in their medical records, and this should be obtained promptly for clients who lack
this documentation.
60. A client 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/mm^3
c. Report of dyspnea on exertion
d. Bilateral crackles on auscultation of lungs
Answer: a. Oxygen saturation 89% on room air
Rationale:
An oxygen saturation level of 89% on room air indicates hypoxemia and should be reported
to the provider for further evaluation and intervention. 61. 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: b. Determining the reasons the nurses are not taking scheduled breaks
Rationale:
Before taking any action, the charge nurse should first determine why the nurses are not
taking their scheduled breaks. Understanding the reasons behind their behavior will help in
addressing the issue effectively.
62. A nurse is caring for a client 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 counselor
e. Case manager
Answer: b. Nutritional therapist
d. Mental health counselor
Rationale:
Consulting a nutritional therapist and a mental health counselor is essential for the
comprehensive care of a client with anorexia nervosa.
63. 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 client who is deaf.”
d. “The nurse can answer any questions the client has about the procedure”
Answer: c. “A family member can interpret to obtain informed consent from a client who is
deaf.”
Rationale:
A family member can act as an interpreter to obtain informed consent from a client who is
deaf, ensuring they fully understand the procedure.
64. 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 client who is newly diagnosed with pancreatic cancer and scheduled to begin IV
chemotherapy
b. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
c. A client who is postoperative following a laminectomy 12 hours ago and is unable to void
d. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary
temperature of 38 C (101 F)
Answer: b. A client who has peripheral vascular disease and has an absent pedal pulse in the
right foot
Rationale:
A client with peripheral vascular disease and an absent pedal pulse is at risk for impaired
tissue perfusion and requires immediate intervention to prevent complications such as tissue
necrosis.
65. A client 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: b. “This won’t take long and it will be over before you know it.”
Rationale:
This response provides reassurance to the client and offers positive reinforcement, which can
help alleviate anxiety.
66. A nurse working in the emergency department is assessing several clients. Which of the
following clients is the highest priority?

a. A client who has a raised red skin rash on his arms, neck, and face
b. A client who reports right-sided flank pain and is diaphoretic
c. A client who reports shortness of breath and left neck and shoulder pain
d. A client who has active bleeding from a puncture wound of the left groin area
Answer: d. A client who has active bleeding from a puncture wound of the left groin area
Rationale:
A client with active bleeding is the highest priority as it indicates a potentially lifethreatening situation requiring immediate intervention to prevent further blood loss.
67. A nurse is working on a quality improvement team that is assessing an increase in client
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 client 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
Rationale:
The first step in addressing an increase in client falls is to identify clients who are at risk for
falls, enabling targeted interventions to prevent falls.
68. 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
Rationale:
Cleaning the injection site with alcohol and applying gentle pressure after the injection help
prevent bleeding and discomfort at the injection site.

69. 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 client from the area
Answer:
1. Remove the client from the area
2. Activate the fire alarm system
3. Confine the fire by closing doors and windows
4. Extinguish the fire if possible
Rationale:
1. Activating the fire alarm system alerts others in the facility to the fire, initiating the

appropriate response and ensuring the safety of all occupants.
2. Confining the fire by closing doors and windows helps prevent the fire from spreading to
other areas of the facility.
3. Removing the client from the area ensures their safety and removes them from potential
harm.
4. If the fire is small and can be safely extinguished, the nurse may attempt to do so using an
appropriate fire extinguisher. However, this should only be done if it can be done safely and
without putting oneself or others at risk.
70. 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 client who refused his oral medication that he will be given an injection
c. Inserting a feeding tube against the wishes of a client who refuses to eat
d. Threatening to apply wrist restraints to control a client who is agitated
Answer: c. Inserting a feeding tube against the wishes of a client who refuses to eat
Rationale:
Battery occurs when there is unauthorized physical contact with another person, such as
performing a procedure against the client's will. Inserting a feeding tube against a client's
wishes constitutes battery.

Document Details

  • Subject: Nursing
  • Exam Authority: ATI
  • Semester/Year: 2021

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