VERSION 1
1. 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 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 stage 2 pressure ulcer on his foot
D. A client who has a C diff infection and needs a stool specimen collected
2. 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 issues
B. Contact the client’s physical therapist
C. Apply a warm compress to the hip
D. Reposition the client for comfort
3. 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 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
4. Which of the following items must be discarded in a biohazard waste receptacle?
A. A urinary catheter drainage bag from a client who is post-opt
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
5. 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 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 the changes too”
C. “Just stick with it a little longer. Things will get better soon
D. “ You should file complaints with hospital administrator
6. According to the HIPAA regulations, which of the following is a violation of client
confidentiality?
A. Telephone 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 dialysis unit
7. 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? (Select all that apply.)
A. Open the sterile pack by first unfolding the flap farthest from her body
B. Rests the cap of a solution container upside down on the sterile field
C. Removes the outside packaging of a sterile instrument before dropping into the sterile
field
D. Holds a bottle of a sterile solution 15 cm (6 inches) above the sterile field
E. Places sterile items within 1.25 cm (0.5 inch) border around the edge of the sterile
field
8. A nurse is providing care for 4 post-opt clients. The nurse should first 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 to 10.
C. Whose urine output averaged 32 ml/hr for the past 24 hr
D. Who is reporting nausea after the prescribed antiemetic was administered
9. A nurse is preparing to transcribe a client’s med 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 and at bedtime
B. Haloperidol (Hadol) 1mg per mouth
C. Multivit every morning by mouth
D. Aspirin 650 mg by mouth every 4hr
, 10. A nurse is assisting with orientation of a newly licensed nurse. The newly licensed nurse
is having trouble focusing and has difficulty completing care for his assigned clients. Which
of the following interventions is appropriate?
A. Recommend that he takes time to plan at the beginning of shift
B. Advise him to complete less time-consuming tasks first
C. Ask other staff members to take over some of his staffs
D. Offer to provide care for his clients while he takes a break
11. 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
Don personal protective equipment.
12. 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 a terminal illness and respirations
of 8/min
C. A nurse explains to a client’s family that a DNR order includes 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
13. 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 tele health?
A. Assessing client needs
B. Providing med reconciliation
C. Establishing communication between providers
D. Developing client treatment protocols
14. Which of the following put a hospital at the highest risk of infringement of client record
confidentiality?
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