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
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