PRACTICE TEST 1

SAFE AND EFFECTIVE CARE ENVIRONMENT

1. A client diagnosed with leukemia asks the nurse questions about preparing a living will. The nurse informs the
client that the initials step in preparing this document is to:
a. Consult with the American Cancer Society
b. Talk to the hospital chaplain
c. Contact a lawyer
d. Discuss the request with the physician

2. Which nursing action regarding intubation equipment/supplies is most appropriate following intubation of a
postoperative client who had a respiratory arrest?
a. soak the intubation equipment in concentrated Betadine solution
b. place intubation blade in bag and arrange for gas sterilization
c. soak intubation blade in Cidex solution
d. wash with soap and water and allow to air dry

3. To promote safety in the care of a client receiving internal radiation therapy, the nurse would:
a. restrict visitors who may have an upper respiratory infection
b. assign only male care givers to the client
c. plan nursing activities to decrease nurse exposure
d. wear a lead lined apron whenever delivering client care

4. A nurse was on weekend call for the operating room. Late Saturday night, the nursing supervisor called the nurse
to say that they were expecting an emergency appendectomy within the hour. While gowning the surgeon, the
nurse smelled alcohol on the doctor’s breath. The nurse mentioned this to the anesthesiologist, who also admitted
smelling alcohol on the surgeon. Both the nurse and the anesthesiologist felt the surgeon was somewhat unstable
on his feet. However, neither the nurse nor the other doctor said anything. If the client had been injured during
the surgery, who would have been liable?
a. Nurse, anesthesiologist, surgeon, and hospital
b. Nurse and surgeon
c. Surgeon and hospital
d. Hospital, surgeon, and anesthesiologist

5. A patient, just returned from the recovery room, complains of pain that is “not too severe” and requests pain
medication. The nurse notes that the client has been given pain medication in the recovery room. Which statement
indicates the best action to take?
a. Administer the dosage the physician had ordered on a prn basis
b. Consult the physician and let him or her know that the patient is requesting medication for “pain that is
not too severe.”
c. Give half of the pain medication dosage ordered as prn by the physician
d. Chart that the patient was complaining of pain but that it was “not too severe”

6. An 85-year old client is on postoperative day 2 following repair of a fractured hip. The nurse has observed that
the client has episodes of extreme agitation. Which of the following nursing interventions would be most
appropriate for the nurse to implement to avoid these episodes of agitation?

a. Walk up behind the client and gently put a hand on the client’s shoulder while
speaking
b. Speak to the client at the entrance of the room to avoid any episode of violence
c. Speak and move slowly toward the client while assessing the client’s needs
d. Wait until the client’s agitation has subsides before approaching the client

7. A nurse is preparing to suction a client through a tracheostomy tube. Which of the following protective items
would the nurse wear to perform this procedure?
a. Gown, mask, and sterile gloves
b. Goggles, mask, and sterile gloves

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 c. Mask, gown, and a cap
d. Mask, sterile gloves, and a cap

8. A client asks the nurse how to become an organ donor. Which of the following would not be a component of the
nurse’s response?
a. the donor must be 18 year s of age or older
b. the donation is done by written consent
c. the family is responsible for making that decision at the time of death
d. clients have the right to donate their own organs for transplantation

9. A new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in
the facility. The nurse is told that the nursing model is a primary nursing approach. The nurse understands that
which of the following is a characteristic of this type of nursing model of practice?
a. The nurse manager assigns tasks to the staff members
b. Critical paths are used in providing client care
c. A single registered nurse (RN) is responsible for planning and providing individualized nursing care
d. Nursing staff are led by an RN leader in providing care to a group of clients

10. In which one of the following CLient situations would it be inappropriate for the RN to delegate the care to the
nurse assistant?
a. A postoperative patient who is stable needs to ambulate
b. Routine temperature check that must be done for a patient at end of shift
c. A confused elderly woman who needs assistance with eating
d. Patient in soft restraints who is very agitated and crying

11. An elderly client is admitted with tuberculosis. Which of the following infection control protocol is correct?
a. Maintain the patient’s door open at all times.
b. Wear a gown while communicating with the patient.
c. Place the client in a private room with negative airflow.
d. Leave the mask and stethoscope inside the patient’s room after use.

12. The nurse on the postpartum unit is giving medications at 10:00 a.m. the nurse enters the room of a client,
calls the patient by name, checks the name band for accuracy, and administers an oral vitamin. After the
client swallows the pill, she states that another nurse has also given her this same and fins that another
nurse has signed off the drug entry. The most appropriate action by the nurse is to:
a. Report the first nurse to the nurse manager for not informing the medication
nurse that a drug had been given
b. Submit an incident report describing the circumstances of the medication error
c. Do nothing because the patient was not harmed by the second vitamin
d. Notify the client’s physician and ask for advice

13. A clinic nurse is assessing a client for environmental risk factors related to neurological disorders. The
nurse understands that which of the following is least likely associated with neurological disorders?
a. Exposure to fumes, such as paints or bonding agents (glue)
b. Exposure to pesticides
c. Ventilation in the work area
d. Number of windows in the work area

14. A child is diagnosed with MRSA and he has an infected draining lower leg lesion. Which of the following
statements indicate that the health care team is maintaining proper infection control measures?
a. Nursing assistant keeps the door of the room closed.
b. The child is wearing a surgical mask.
c. The UAP wears a gown while ambulating the child to bathroom
d. The child is wearing a gown while in contact with the UAP.

15. A nurse is preparing to ambulate a client with Parkinson’s disease who has recently been started on L-
dopa (levodopa). The nurse assesses which most important item before performing this activity with

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 the client?
a. Assistive devices used by the client
b. The degree of intention tremors exhibited by the client
c. The client’s history of falls
d. The client’s postural (orthostatic) vital signs

16. When planning the discharge of a client with chronic anxiety, the nurse directs the goals at
promoting a safe environment at home. The most appropriate maintenance goal for the client should
focus on which of the following?
a. Maintaining continued contact with a crisis counselor
b. Identifying anxiety-producing situations
c. Ignoring feelings of anxiety
d. Eliminating all anxiety from daily situations

17. A nurse is assisting in the care of a client who is to be cardioverted. The nurse plans to set the
defibrillator to which of the following starting energy range levels, depending on the specific
physician order?
a. 50 to 100 joules
b. 150 to 200 joules
c. 250 to 300 joules
d. 350 to 400 joules

18. A nurse is assessing the corneal reflex on an unconscious client. The nurse would use which of the
following as the safest stimulus to touch the client’s cornea?
a. Wisp of cotton
b. Sterile drop of saline solution
c. Sterile glove
d. Tip of a 1 mL syringe with the needle removed

19. Which would have the highest priority when caring for a terminally ill client during the final stage of
dying?
a. encourage family to discuss legal matters with an attorney
b. provide privacy for the client and his family to spend time together
c. keep client sedate
d. encourage family to limit visiting hours so they can rest

20. A client has arrived at the labor and delivery unit in active labor. The nursing assessment reveals a
history of recurrent genital herpes and the presence of lesions in the genital tract. The nurse plans to:
a. Prepare the client for a cesarean delivery
b. Limit visitors and maintain reverse isolation
c. Prepare the client for a spontaneous vaginal delivery
d. Rupture the membranes artificially, looking for meconium-stained fluid

21. A nurse has an order to obtain a sputum culture from a client admitted to the hospital with a
diagnosis of pneumonia. The nurse avoids which action when obtaining the specimen?
a. Placing the lid of the culture container face down on the bedside table
b. Obtaining the specimen early in the morning
c. Having the client brush teeth before expectoration
d. Instructing the client to take deep breaths before coughing

22. A nurse instructs a client with a diagnosis of valvular disease to use an electric razor for shaving.
The nurse tells the client that the importance of its use is that:
a. Any cut may cause infection
b. Electric razors can be disinfected
c. All straight razors contain bacteria
d. Cuts need to be avoided

23. A client with a history of cardiac disease is admitted to the hospital with a diagnosis of congestive

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 heart failure. The doctor’s orders are: continue al previous medications which include digoxin
(Lanoxin) .25 mg po each AM, and propranolol (Inderal) 20 mg pot id; oxygen at 4L/minute via nasal
cannula, establish an IV and give furosemide (Lasix) 40 mg IV now, bathroom privileges, full liquid
diet. Which part of the order would be a priority for the nurse to discuss with the doctor?
a. digoxin (Lanoxin) 0.25 mg PO in AM
b. level of oxygen concentration
c. propranolol (Inderal) 20 mg tid
d. how fast should the IV infuse

24. When irrigating a draining wound with a sterile saline solution, which sequence would be most
appropriate for the nurse to follow?
a. pour solution, wash hands, and remove soiled dressing
b. wash hands, prepare sterile field, remove soiled dressing
c. prepare sterile field, put on sterile gloves, and remove soiled dressing
d. remove soiled dressing, flush wound, wash hands

25. Which symptom would cause a nurse to be concerned about post infusion phlebitis in a client who has
been on an IVPB antibiotic mixed in D5W every 8 hours for four days?
a. tenderness at the IV site
b. increased swelling at the insertion site
c. reddened area or red streaks at the site
d. leaking of fluid around the IV catheter

26. Which nursing implication is important regarding spinal anesthesia?

a. the client should be adequately hydrated in order to prevent hypotension after anesthesia is
established
b. the client must be NPO at least 12 hours prior to the initiation of the anesthesia to decrease the risk of
aspiration
c. assess the client for any allergies to Betadine or iodine preparations
d. determine the specific gravity of the urine and prepare the client for a central line

27. A nurse is preparing to nasotracheally suction a client with acquired immunodeficiency syndrome
(AIDS) who has had blood-tinged sputum with previous suctioning. The nurse plans to use which of
suctioning. The nurse plans to use which of the following items as part of universal precautions for
this client?
a. Gloves, mask and protective eye wear
b. Gloves, gown, and mask
c. Gown, mask, and protective eye wear
d. Gloves, gown, and protective eye wear

28. A client has a risk for infection following radical vulvectomy. The nurse avoids which of the following
when giving perineal care to this client?
a. cleanses using warm tap water and a bulb syringe
b. intermittently exposes the wound to air
c. provides perineal care after each voiding and bowel movement (BM)
d. provides prescribed sitz baths after the sutures are removed

29. A nurse provides medication instructions to a home health care client. To ensure safe administration
of medication in the home, the nurse:
a. Demonstrates the proper procedure for taking prescribed medications
b. Allows the client to verbalize and demonstrate correct administration procedures
c. Instructs the client that is OK to double up on medications if a dose has been missed
d. Conducts pill counts on each home visit

30. A magnetic resonance imaging (MRI) is prescribed for a client with Bell’s palsy. Which nursing action
is included in the client’s plan of care to prepare for this test?

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 a. Keep the client NPO for 6 hours before the test
b. Remove all metal-containing objects from the client
c. Shave the groin for insertion of a femoral catheter
d. Instruct the client in inhalation techniques for the administration of gas

31. Which sequence is correct when providing care for a client immediately prior to surgery?
a. administer preoperative medication, client signs operative permit, determine vita signs
b. check operative permit for signature, advise client to remain in bed, administer preoperative medications
c. remove client’s dentures, administer preoperative medication, client empties bladder
d. verify client has been NPO. Client empties bladder, family leaves room

32. How should the nurse administer the DPT immunization to 6-months old?
a. by mouth in three divided doses
b. as an IM injection into the gluteus maximus
c. as an injection into the vastus lateralis
d. as a Z track injection into the deltoid

33. Which observation should the nurse make on initial assessment of a client with multiple facial
fractures?
a. vital signs
b. patent airway
c. breath sounds
d. skin color

34. The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving
today to prepare a living will. The client asks the nurse to act as one of the witnesses for the will.
The most appropriate nursing action is to:
a. agree to act as a witness
b. refuse to help the client
c. inform the client that a nurse caring for a client cannot serve as a witness to a
living will
d. call the physician

35. A home care nurse is working with a family to assist them in caring for a newborn with congenital
tracheoesophageal fistula who is receiving enteral feedings. A woman identifying herself as a family
friend telephones the nurse to inquire if there is anything she can do to assist the parents. The best
nursing action is to:
a. Request that the friend come to the client’s home where she can be taught to administer the feedings
b. Inform the friend to directly contract the family and offer her assistance to them
c. Report the friend’s telephone call to the nurse manager for referral to the client’s social worker
d. Inform the friend that the family has no need for assistance at this time because the nurse is making
daily visits

36. A nurse is assisting with transferring a client from the operating room table to a stretcher. To
provide safety for the client, the nurse:
a. Moves the client rapidly from the table to the stretcher
b. Uncovers the client completely before transferring to the stretcher
c. Secure the client with safety belts after transferring to the stretcher
d. Instructs the client to move himself or herself from the table to the stretcher

37. A moderately depressed client who was admitted to the mental health unit 2 days ago suddenly
begins smiling and reporting that the crisis is over. The client says to the nurse, “Call the doctor.
I’m finally cured.” The nurse interprets this behavior as a cue to modify the treatment plan by:
a. Allowing off-unit privileges prn
b. Suggesting a reduction of medication
c. Allowing increased “in room” activities
d. Increasing the level of suicide precautions

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38. Which postoperative nursing goal will assist in preventing deep vein thrombosis?
a. decrease the flow of the venous blood
b. increase the coagulation of the blood
c. increase the flow of the venous blood
d. improve the oxygen capacity of the blood

39. Which observation indicates the need for a nurse to stay with a client admitted to the emergency
room following a car wreck?
a. disorientation and irregular vital signs
b. irregular vital signs and hostility
c. rapid respirations and agitation
d. elevated vital sign and apprehension

40. A 54 year old client with tertiary syphilis is admitted to a nursing unit exhibiting signs of marked
dementia and disorientation. Which nursing action should be done initially?
a. place the nurse call bell within reach
b. frequently observe client behavior
c. apply a vest-type restraint
d. provide an around-the-clock sitter

41. Which measure should a nurse take to prevent the spread of active pulmonary tuberculosis?
a. restrict visitors to immediate family only
b. wear gown and gloves at all times
c. wear mask and gloves when in direct contact
d. dispose of waste article more frequently

42. A nurse witnesses an automobile accident and provides care to the open wound of a young child at the
scene of the accident. The family is extremely grateful and insists that the nurse accept monetary
compensation for the care provided to the child. Because of the family insistence, the nurse accepts
the compensation to avoid offending the family. The child develops an infection and sepsis and is
hospitalized. The family files suit against the nurse who provided care to the child at the scene of
the accident. Which of the following is accurate regarding the nurse’s immunity from this suit?
a. The Good Samaritan Law will protect the nurse
b. The Good Samaritan Law will protect the nurse if the care given at the scene was not negligent
c. The Good Samaritan Law will not provide immunity from suit if the nurse accepted compensation for the
care provided
d. The Good Samaritan Law protects lay persons and not professional heath care providers

43. A client is brought to the emergency room by the ambulance team following collapse at home.
Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the
nurse that the client is an organ donor and that the eyes are to be donated. Which of the following is the
most appropriate nursing action?
a. Elevate the head of the bed of the deceased and place dry sterile dressing over the eyes
b. Call the National Donor Association to confirm that the client is a donor
c. Close the decreased client’s eyes and place wet saline gauze pads and an ice pack on the eyes
d. Ask the wife to obtain the legal documents regarding organ donation from the lawyer

44. An elderly client in a long-term care facility has a nursing diagnosis of Risk for Injury related to
confusion. The client’s gait is stable. The nurse uses which of the following methods of restraint to
prevent injury to the client?

a. Vest restraint
b. Waist restraint
c. Chair with locking lap tray
d. Alarm-activating bracelet

45. A nurse receives a call that a client is being admitted who will undergo implantation of a sealed
internal radiation source. The nurse contacts the admission office clerk to ensure that which of the

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 following rooms is selected for the client?
a. A single room at the distant end of the hall
b. A single room near the nurse’s station
c. A semiprivate room between two isolation room
d. A semiprivate room near the nurse’s station

46. A client who is immunosuppressed is being admitted to the hospital and will be placed on neutropenic
precautions. The nurse plans to ensure that which of the following does not occur in the care of the
client?
a. Placing a mask on the client if the client leaves the room
b. Removing a vase with fresh flowers left by a previous client
c. Admitting the client to a semi private room
d. Placing a precaution sign on the door to the room

47. A nurse has given a subcutaneous injection to the client with acquired immunodeficiency syndrome
(AIDS). The nurse disposes of the used needle and syringe by:
a. Placing the uncapped needle and syringe in labeled, rigid plastic container
b. Recapping the needle and discarding the syringe in the disposal unit
c. Breaking the needle before discarding it
d. Placing the uncapped needle and syringe in a labeled cardboard box

48. A 17-year old client is about to be discharged with her newborn baby. Which statement if made by
the client would alert the nurse that further teaching is required regarding child care?
a. “I have locks on all my cabinets that contain my cleansing supplies”
b. “I have a car seat that I will put in the front seat to keep my baby safe”
c. “I will not use the microwave to heat my baby’s formula”
d. “I keep all my pots and pans in my lower cabinets”

49. A nurse is assigned to care for a client who is in traction. The nurse prepares a plan of care fro the
client and includes which nursing in the plan?
a. Monitoring the weights to be sure that they are resting on a firm surface
b. Check the weights to be sure that they are off the floor
c. Make sure that the knots are at the pulleys
d. Make sure the head of the bed is kept at a 45 to 90 degree angel

50. A client is fitted for crutches and the nurse observes the client to evaluate for the correct height
of the crutches. The nurse expects to note which of the following?
a. The client is able to rest the axillae on the axillary bars
b. The nurse is able to place two fingers comfortably between the axillae and the axillary bars
c. The client is able to maintain the arms in a straight position when standing with the crutches
d. The nurse is able to place four fingers comfortably between the axillae and the axillary bars

51. A well-known individual from the community is admitted to the hospital with a diagnosis of Parkinson’s
disease. The nurse gives medical information regarding the client’s condition to a person assumed to
be a family member. Later, the nurse discovers that this person is not a family member and realizes
that this is a violation of which legal concept of the nurse-client relationship?
a. Invasion of privacy
b. Lack of experience
c. Teaching/learning principles
d. Performing a focused physical assessment

52. Which assignment would the RN give to a nursing assistant?

a. Assisting a recently admitted post-cerebrovascular accident patient to eat
b. Admitting a patient to the unit who is being transferred from ICU
c. Taking vital signs on a postoperative patient whose blood transfusion is about to end
d. Irrigating a Foley catheter that is not draining well

53. A nurse is preparing to care for a client who has undergone left pneumonectomy. The nurse plans to

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 do which o the following immediately after transfer from the post-anesthesia care unit?
a. Place the IV on a pump
b. Assist the client to sit in the bedside chair
c. Position the client supine
d. Position the client on the left side

54. A client with a history of silicosis is admitted with respiratory distress and impending respiratory
failure. The nurse plans to have which of the following items readily available at the client’s
bedside?
a. Chest tube and drainage system
b. Intubation tray
c. Thoracentesis tray
d. Code cart

55. A nurse is preparing to administering amiodarone (Cordarone) intravenously. The nurse ensures that
which of the following is in place for the client before administering the medication?
a. Noninvasive blood pressure cuff
b. Oxygen saturation monitor
c. Oxygen therapy
d. Continuous cardiac monitoring

56. To protect a post heart transplant client from potential sources of infection, the nurse would:
a. keep client in total isolation
b. limit participation unit activities
c. adhere to and monitor strict hand-washing techniques
d. monitor vital signs, especially temperature, every 2 hours

57. To maintain client safety, which equipment should be readily available when inserting an Ewall tube?
a. suction equipment
b. blood pressure cuff
c. Levine tube
d. Emesis basin

58. A nurse has inserted a nasogastric tube (NG) into the stomach of a client and prepares to check for
accurate tube placement. The nurse avoids which least reliable method for checking tube
placement?
a. Aspirating the tube with a 50 mL syringe to obtain gastric contents
b. Measuring the pH of gastric aspirate
c. Placing the end of the tube in water to check for bubbling
d. Instilling 10 to 20 mL of air into the tube while auscultating over the stomach

59. A nurse is caring for a client during the recovery phase following a myocardial infarction. A cardiac
catheterization, using the femoral artery approach, is performed to assess the degree of coronary
artery thrombosis. Which nursing action following the procedure is unsafe for the client?
a. Placing the client’s bed in the Fowler’s position
b. Encouraging the client to increase fluid intake
c. Instructing the client to move the toes when checking circulation, motion, and sensation
d. Resuming prescribed precatheterization medications

60. The nurse is changing a dressing on an infected abdominal wound with Penrose drains and a large
amount of purulent drainage. What is the best way to perform this procedure?
a. obtain clean gloves and dressing, remove the soiled dressing, and use another pair of clean gloves to dress
the wound
b. use clean gloves to remove the soiled dressing, change to sterile gloves and use sterile dressing to cover
the wound
c. use the sterile gloves to remove the dressing, obtain clean gloves and sterile dressing to reapply to the
wound

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 d. initiate protective isolation, utilize only sterile gloves when removing the dressing, and reapply using
sterile technique

61. After taking the vital signs of a client returning from abdominal exploratory surgery, which action
should be taken next?
a. position the client on her left side supported with pillows
b. check the chart and determine the status of fluid balance from surgery
c. check the client’s abdominal dressing for any evidence of bleeding
d. monitor the incision and pulmonary status for presence of infection

62. While assessing the incision of a 2 day postoperative client, a shiny pink open area is noted with
underlying visible bowel. Which action should the nurse take first?
a. cover gaping area with sterile gauze soaked in normal saline
b. reapply sterile dressing after cleaning with peroxide
c. pack opened area with sterile ¾ inch gauze soaked in normal saline
d. apply Neosporin ointment and cover with Tegaderm dressing

63. A community health nurse is providing instructions to a group of mothers regarding the safe use of
car seats for toddlers. The nurse determines that the mother of a toddler understands the
instructions if the mother states which of the following?
a. “The car seat can be placed in a face-forward position when the height of the toddler is 27 inches”
b. “The care seat should never be placed in a face-forward position”
c. “The car seat can be placed in a face-forward position at any time”
d. “The car seat is suitable for a toddler until the toddler reaches the weight of 40 pounds”

64. A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate
for the nursing assistant?
a. Assist a 12-year old boy who is profoundly developmentally disabled to eat lunch
b. Obtain frequent oral temperatures on a client
c. Accompany a 51-year old man, being discharged to home following a bowel resection 8 days ago, to
his transportation
d. Collect a urine specimen from a 70 year old woman admitted three days ago

65. A nurse practicing in a Nurse Managed Clinic wants to set up a diabetic teaching seminar. The nurse
understands that to meet the needs of the clients, the nurse must first:
a. Assess the clients’ functional abilities
b. Ensure that the insurance documentation is up-to-date
c. Discuss the focus of the seminar with the multidisciplinary team
d. Include everyone who comes into the clinic in the teaching sessions

66. A nurse is caring for a hospitalized client who is having a prescribed dosage of clonazepam (Klonopin)
adjusted. The nurse plans to:
a. Monitor blood glucose levels
b. Institute seizure precautions
c. Weight the client daily
d. Observe for ecchymoses

67. The nurse is changing the dressing on a client with a large abdominal wound. There are two Penrose
drains in place. What is the priority information for the nurse to include when recording this
procedure?
a. condition of the surrounding tissue, time necessary to change the dressing, the type of dressing used
b. client’s tolerance of the procedure, time the dressing was changed, amount of wound drainage
c. client’s response to the dressing change, status of Penrose drains, type of drainage from Penrose drains
d. time dressing was changed, description of the wound, color and amount of drainage from Penrose drains

68. Which nursing observation is most important to report to the physician on a client with a second
degree thermal injury to right arm?
a. pain around the periphery of injury

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 b. gastric pH less than 6.0
c. increased edema of right arm
d. an elevated hematrocrit

69. A nurse places a hospitalized client with active tuberculosis in a private, well ventilated room. In
addition, which of the following critical actions is most appropriate or the nurse to do before
entering this client’s room?
a. Wash the hands
b. Wash the hands and place a HEPA respiratory over the nose and mouth
c. The nurse needs no special precautions, but the client is instructed to cover his or her mouth and nose
when coughing or sneezing
d. Wash the hands and wear a gown and gloves

70. A client is being transferred to the nursing unit from the post-anesthesia care unit following spinal
fusion with Harrington rod insertion. The nurse prepares to transfer the client from the stretcher
to the bed by using:
a. A bath blanket and the assistance of 3 people
b. A bath blanket and the assistance of people
c. A slider board and the assistance of 2 people
d. A slider board and the assistance of 4 people

71. A clinical nurse manager is planning an in-service educational session for the staff nurses. The topic
of the discussion is case management. Which of the following is not a characteristic of case
management and would not be included in the discussion?
a. Represents a primary health prevention focus managed by a single case manager
b. Manages client care by managing the client care environment
c. Designed to promote appropriate use of hospital personnel and material resources
d. Maximizes hospital revenues while providing for optimal outcome of client care

72. A hospitalized client with a history of alcohol abuse tells the nurse, “I am leaving now. I have to go.
I don’t want any more treatment. I have things that I have to do right away.” The client has not
been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in
1 hour. After discussing the client’s concerns with the client, the client dresses and begins to walk
out of the hospital room. The most appropriate nursing action is to:
a. Restrain the client until the physician can be reached
b. Call security to block all exit areas
c. Tell the client that he cannot return to this hospital again if he leaves now
d. Call the nursing supervisor

73. Following initial assessment, the nurse determines the need to place a vest restraint on a client. The
client tells the nurse that he does not want the vest restraint applied. The best nursing action is to:
a. Apply the restraint anyway
b. Contract the physician
c. Medicate the client with a sedative then apply the restraint
d. Compromise with the client and use wrist restraints

74. A client’s vital sign have noticeably deteriorated over the past four hours following surgery. A nurse
does not recognize the significance of these changes in vital signs and takes no action. The client
later requires emergency surgery. The nurse could be prosecuted for inaction according to the
definition of which of these?
a. Tort
b. Misdemeanor
c. Common law
d. Statutory law

75. Regular insulin by continuous intravenous (IV) infusion is prescribed for a client with a blood glucose
level of 700 mg/dL. The nurse plans to:
a. Infuse the medication via an electronic infusion pump

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 b. Mix the solution in 5% dextrose
c. Change the solution every 6 hours
d. Titrate the infusion according to the client’s urine glucose levels

76. Which assignment would be appropriate for the Labor and Delivery (L & D) nurse who will be working
for one shift on the Medical Surgical unit?
a. a 3-year old with croup
b. a 30-year old with malignant hypertension
c. a 40-year old with unstable angina
d. a 50-year old with congestive heart failure

77. The nurse arrives for the day shift and receives her assignment around 7:30 a.m. the assignment
includes:
o a man with a diagnosis of rule-out an MI. He is on a monitor and having 4-6 premature beats per hour
o an elderly lady who is confused and has constant urinary dribbling
o pneumonia client with increasing confusion and a temperature of 104º ad 6:30 a.m.
o a diabetic client who experienced a restless night and 7:00 a.m. blood sugar was 170mg
Which client is a priority and how should the nurse plan her care?
a. the pneumonia client has priority; his condition should be assessed immediately
b. the elderly lady is probably wet and uncomfortable and should be taken care of first. Then obtain a stat
blood glucose to determine the diabetic client’s current blood sugar level
c. the cardiac client should be assessed immediately as the monitor indicates cardiac irritability. Then the
temperature on the pneumonia client should be reassessed
d. the diabetic client should be seen immediately to assess for evidence of hyprglycemia. Then the
temperature on the pneumonia client should be reassessed

78. A nurse is assigned to care for a hospitalized toddler. The nurse plans care, knowing that the
highest priority should be directed toward:
a. Protecting the toddler from injury
b. Adapting the toddler to the hospital routine
c. Allowing the toddler to participate in play and divisional activities
d. Providing a consistent caregiver

79. A nurse is caring for a client with a grave clinical condition who is a potential organ donor. Before
approaching the family to discuss organ donation, the nurse reviews the client’s medical record for
contraindications to organ donation, which would include:
a. Allergy to penicillin-type antibiotics
b. Age of 38 years
c. Hepatitis B infection
d. Negative rapid plasma regain (RPR) laboratory result

80. A male suicidal client is being discharged home with his family. Which statement by a family member
might constitute a criterion for delaying discharge?
a. The client’s wife asks, “Does he know that I’ve already moved out and filed for a divorce?”
b. The client’s son state, “One of his friends visited last week to tell us Dad’s union is out on strike”
c. The client’s daughter states, “I’ve decided to postpone my wedding until Dad’s feeling better”
d. The client’s brother asks. “Will my brother be able to continue as executor of our parent’s trust?”

81. A registered nurse (RN) asks a licensed practical nurse (LPN) to change the colostomy bag on a
client. The LPN tells the RN that although attendance at the hospital inservice was complete
regarding this procedure, the procedure has never been performed on a client. The most appropriate
action by the RN is:
a. Request that the LPN review the materials from the inservice before performing the procedure
b. Request that the LPN review the procedure in the hospital manual and to bring the written procedure
into the client’s room for guidance during the procedure
c. Request that another LPN observe the procedure when it is performed
d. Perform the procedure with the LPN

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82. A nurse is assisting at a code and the physician is going to defibrillate the client. Of the following
items, which is the only one that the nurse does not need to remove from the bedside just before
the client is defibrillated?
a. Backboard
b. Oxygen
c. Nitroglycerin patch
d. Ventilator

83. A nurse is administering a dose of intravenous hydralazien (Apresoine) to a client. The nurse ensures
that which of the following items is in place before injecting the medication?
a. Central line
b. Foley catheter
c. Cardiac monitor
d. Noninvasive blood pressure (BP) cuff

84. A nurse is caring for a client immediately following a bronchoscopy. The client received intravenous
sedation and a topical anesthetic for the procedure. In order to provide a safe environment for the
client at this time, the nurse plans to:
a. Place a padded tongue blade at the bedside in case of a seizure
b. Check the bedside to ensure no food or fluid is within the client’s reach to prevent aspiration
c. Connect the client to a bedside ECG to monitor for dysrhythmias
d. Place a water-seal chest drainage set at the bedside in case of a pneumothorax

85. A nurse is about to administer an intravenous dose of tobramycin (Tobrex) when the client complains
of vertigo and a ringing in the ears. The nurse most appropriately:
a. hangs the dose immediately
b. gives a dose of droperidol (In apsine) with the tobramycin
c. holds the dose and calls the physician
d. checks the client’s papillary responses

86. A client recovering from coardiogenic shock occasionally becomes disoriented. The most appropriate
nursing action to ensure safety for this client would be to:
a. Raise the head of the bed to 45 degrees
b. Keep the side rails up at all times and he call light within reach
c. Keep the over-the-bed light on in the client’s room
d. Request that only two visitors visit at a time

87. Which instruction is correct regarding the collection of a specimen from a 4-year old suspected of
having pinworms?
a. collect the specimen 30 minutes after the child falls asleep at night
b. save a portion of the child’s first stool of the day and take it to the physician’s office immediately
c. collect the specimen in the early morning with a piece of scotch tape touched to the child’s anus
d. feed the child a high fat meal; then save the first stool following the meal

88. Which would be the most appropriate to assign to the LPN?

a. a client who is being discharged and needs new diabetic teaching
b. a client who is a new admission with chest pain
c. a client who is receiving chemotherapy
d. a client who has the diagnosis of Myasthenia Gravis

89. A home health nurse is providing instructions to the mother of a toddler regarding safety measures
in the home to prevent an accidental burn injury. Which statement, if made by the mother, indicates
a need for further instruction?
a. “I need to remain in the kitchen when I prepare meals”
b. “I need to be sure to place my cup of coffee on the counter”
c. “I need to use the back burners for cooking”
d. “I need to turn pot handles inward and to the middle of the stove”

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90. A client is admitted to the emergency room after a motor vehicle accident. He does not remember
the accident. He is awake, oriented to person, but does not know what city he is in. He is confused
regarding the day and month. Pupils are equal in size and equally reactive to direct light reflex. He is
complaining of a severe headache and is becoming restless. The priority of care for this client is to:
a. continue to stimulate the client to keep him oriented to his surrounding
b. restrain the client to prevent him from injuring himself
c. perform bedside neuro checks every fifteen minutes
d. administer Meperidine hydrochloride (Demerol) for pain control and to decrease restlessness

91. A nurse receives a telephone call from the emergency room and is told that a child with a diagnosis
of tonic-clonic seizures will be admitted to the pediatric unit. The nurse prepares for the admission
of the child and instructs the nursing assistant to place which of the following items at the bedside?
a. Suction apparatus and airway
b. A tracheotomy set and oxygen
c. An emergency cart and padded side rails
d. An endotracheal tube and an airway

92. A home health care nurse arrives at the client’s home for the scheduled home visit. The client’s
lawyers is present and the client is preparing a living will. The living will requires that the client’s
signature be witnessed, and the client asks the nurse to witness the signature. Which of the
following is the most appropriate nursing action?
a. Sign the will as a witness to signature only
b. Sign the will, clearly identifying credentials and employment agency
c. Decline to sign the will
d. Call the home health care office and notify the supervisor that the will is being witnessed

93. A nurse is planning activities for a depressed client who was just admitted to the hospital. The nurse
plans to:
a. Provide an activity that is quiet and solitary in nature to avoid increased fatigue, such as working on a
puzzle or reading a book
b. Plan nothing until the client asks to participate in milieu
c. Offer the client a menu of daily activities and insist the client participate and insist the client
participate in all of them
d. Provide a structured daily program of activities and encourage the client to participate

94. A nurse has an order to obtain a urinalysis from a client with an indwelling urinary catheter. The
nurse avoids which of the following, which could contaminate the specimen?
a. Obtaining the specimen from the urinary drainage bag
b. Clamping the tubing of the drainage bag
c. Aspirating a sample from the port on the drainage bag
d. Wiping the port with an alcohol swab before inserting the syringe

95. A nursing manager is reviewing the purpose for applying restraints with the nursing staff. The nurse
manager tells the staff that which of the following is not an indication for the use of a restraint?
a. To prevent falls
b. To restrict movement of a limb
c. To prevent the client from pulling out IV lines and catheters
d. To prevent the violent client from injuring self and others

96. A client requests pain medication and the nurse administer an intramuscular (IM) injection. After
administration of the injection, the nurse does which of the following first?
a. Recaps the needle
b. Removes the gloves
c. Washes the hands
d. Places the syringe in the puncture resistant needle box container

97. A client diagnosed with tuberculosis (TB) is scheduled to go to the radiology department for a chest
x-ray evaluation. Which nursing intervention would be appropriate when preparing to transport the

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 client?
a. Apply a mask to the client
b. Apply a mask and gown to the client
c. Apply a mask, gown, and gloves to the client
d. Notify the x-ray department so that the personnel can be sure to wear a mask the client arrives

98. A nurse is preparing the client’s morning NPH insulin dose. The nurse notices a clumpy precipitate
inside the insulin vial. The most appropriate nursing action is to:
a. Draw up and administer the dose
b. Shake the vial in an attempt to disperse the clumps
c. Draw the dose from a new vial
d. Warm the bottle under running water to dissolve the clump

99. A client is to undergo weekly intravesical chemotherapy for bladder cancer for the next 8 weeks.
The nurse interprets that the client understands how to manage the urine as a biohazard if the
client states to:
a. disinfect the urine and toilet with bleach for 6 hours following an treatment
b. have one bathroom strictly set aside for the client’s use for the next 2 months
c. purchase extra bottles of scented disinfectant for daily bathroom cleansing
d. void into a bedpan and then empty the urine into the toilet

100. A nurse working on a medical nursing unit during an external disaster is called to assist with care for
clients coming into the emergency room. Using principles of triage, the nurse initiates immediate
care for a client with which of the following injuries?
a. Bright red bleeding from a neck wound
b. Penetrating abdominal injury
c. Fractured tibia
d. Open massive head injury in deep coma

101. A nurse educator at the local community hospital is conducting an orientation session for nurses who
are newly employed at the hospital. The nurse educator informs the new nurses that the policy of
the hospital requires that nurses “float” to other nursing departments when client census is high on
other units. The nurse educator advises the new nurses that if this situation arises, and if the
nurse is unfamiliar with the unit in which the nurse must float to:
a. Refuse to float
b. Call the nurse educator
c. Report to the unit and identify tasks that can be safely performed
d. Call the nursing supervisor

102. A nurse manager employs a leadership style in which decisions regarding the management of the
nursing unit are made without input from the staff. The type of leadership style is implemented by
this nurse manager is:
a. Autocratic
b. Situational
c. Democratic
d. Laissez-faire

103. A registered nurse (RN) in charge is preparing the assignments for a day. The RN assigns a nursing
assistant to make beds and bathe one of the clients on the unit and assigns another nursing
assistant to fill the water pitches and to serve juice to all clients. Another RN is assigned to
administer all medications. Based on the assignments designed by the RN in charge, which type of
nursing care is being implemented?
a. Functional nursing
b. Team nursing
c. Exemplary model of nursing
d. Primary nursing

104. A clinic nurse is caring for a pregnant client with herpes genitalis. The nurse provides instructions

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 to the mother regarding treatment modalities that may be necessary for treatment of this
condition. Which of the following statements if made by the mother indicates an understanding of
these treatment measures?
a. “I need to abstain from sexual intercourse until after delivery”
b. “I need to use vaginal creams after the douche every day”
c. “I need to douche and perform a sitz bath three times a day”
d. “It may be necessary to have a cesarean section for delivery”

105. A delivery room nurse is preparing a client for a cesarean delivery. The client is placed on the
delivery room table and the nurse position the client:
a. In trendelenburg position
b. In semi-Fowler’s position
c. Supine position with a wedge under the right hip
d. In the prone position

106. A client begins to drain small amounts of bright red blood from the tracheostomy tube 24 hours
after a supraglottic laryngectomy. The best nursing action is to:
a. Notify the surgeon
b. Increase the frequency of suctioning
c. Add moisture to the oxygen delivery system
d. Document the character and amount of drainage

107. What should be included in the nurse’s response when the patient asks for factual information about
becoming an organ donor?
a. A donor can be any age
b. Verbal consent would be sufficient
c. Family members must also give their consent
d. There are some contraindications for being an organ donor

108. A nurse is reviewing the results of the rubella screening (titer) with a pregnant 24-year old client.
The test results are positive and the mother asks if it is safe for her toddler to receive the vaccine.
The most appropriate nursing response is:
a. “You are still susceptible to rubella, so your toddler should receive the vaccine”
b. “Most children do not receive the vaccine until 5 years of age”
c. “It is not advised for children of pregnant women to be vaccinated during their mother’s pregnancy”
d. “Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at
this time”

109. A physician’s order reads: theophylline timed-release capsules (Slo-bid), 100 mg PO every 6 hours.
The medication label reads: 50 mg capsules. The nurse prepares how may capsule(s) to administer
one dose?
a. 1 capsule
b. 2 capsules
c. 3 capsules
d. 4 capsules

110. A nurse calls the physician of a client scheduled for a cardiac catheterization because the client has
numerous questions regarding the procedure and has requested to speak to the physician. The
physician is very upset and arrives at the unit to visit the client after promoting by the nurse. The
nurse is outside of the client’s room and hears the physician tell the client in a derogatory manner
that the nurse “doesn’t know anything.” Which legal tort has the physician violated?
a. Libel
b. Slander
c. Assault
d. Negligence

111. In which situation should the nurse submit a report as a legally mandated reported?

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 a. A pregnant patient states that her boyfriend hit her once when he was drunk
b. A patient in the Family Planning Clinic has a positive HIV screening test result
c. An elder who is disoriented states that the nurse are yelling at her and calling her names at night
d. The neighbors of an elder complain that her son is verbally abusive to her. She denies it

112. A nurse is going to suction an adult client with a tracheostomy who has copious amounts of secretion.
The nurse does which of the following to perform this procedure safely?
a. Hyperoxygenate the client using a manual resuscitation bag
b. Set the suction pressure range between 160 to 180 mm Hg
c. Occlude the Y-port of the catheter while advancing it into the tracheostomy
d. Apply continuous suction in the airway for up to 15 seconds

113. A nurse enters a client’s room and finds the client sitting on the floor. The nurse performs a
thorough assessment and assists the client back to bed. The nurse completes an incident report and
notifies the physician of the incident. Which of the following is the next appropriate nursing action
regarding the incident?
a. Make a copy of the incident report for the physician
b. Place the incident report in the client’s chart
c. Document a complete entry in the client’s record concerning the incident
d. Document in the client’s record that an incident report has been completed

114. A home care nurse provides instructions to the mother of a child with croup. The mother expresses
concern regarding the occurrence of an acute spasmodic episode. The nurse instructs the mother
regarding management if an acute episode occurs. Which statement made by the mother indicates a
need for further instructions?
a. “I will place a steam vaporizer in the child’s room”
b. “I will place the child in a closed bathroom and allow the child to inhale steam from warm running water”
c. “I will place a cool mist humidifier in the child’s room”
d. “I will take the child out into the cool, humid night air”

115. Following delivery, the postpartum nurse instructs the client with known cardiac disease to call for
the nurse when she needs to get out of bed or when she plans to care for her infant. The nurse
informs the mother that this is necessary to:
a. Minimize the potential of postpartum hemorrhage
b. Help the mother assume the parenting role
c. Provide an opportunity for the nurse to teach infant care techniques
d. Avoid maternal/infant injury that may occur because of the potential for syncope or overexertion

116. A client who has experienced a cerebrovascular accident has partial hemiplegia of the left leg. The
straight leg cane formerly used by the client is not sufficient to provide support. The nurse
interprets that the client could benefit from the somewhat greater support and stability provided
by a:
a. Quad-cane
b. Wooden crutch
c. Lofstrand crutch
d. Wheelchair

117. A client with a diagnosis of recurrent major depression who is exhibiting psychotic features is
admitted to the psychiatric unit. In creasing a safe environment for the client, the nurse most
importantly develops a plan of care that deals specifically with the client’s:
a. Altered thought processes
b. Altered nutrition
c. Self-care deficit
d. Knowledge deficit

118. A pregnant client tests positive for the hepatitis B virus. The client asks the nurse if she will be
able to breastfeed the baby as planned after delivery. Which of the following responses is most
appropriate by the nurse?

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 a. “You will not be able to breastfeed the baby until 6 months after delivery”
b. “Breastfeeding is not a problem and you will be able to breastfeed immediately after delivery”
c. “Breastfeeding is allowed if the baby receives prophylaxis at birth and remains on the scheduled
immunization”
d. “Breastfeeding is not advised, and you should seriously consider bottle-feeding the baby”

119. A nurse has received the client assignment for the day and is organizing the required tasks. Which
of the following will not be a component of the plan for time management?
a. Prioritizing client needs and daily tasks
b. Providing time for unexpected task
c. Gathering supplies before beginning a tasks
d. Documenting task completion at the end of the day

120. A nursing instructor is discussing professional liability insurance to the senior class of nursing
students. The instructor most appropriately advises the students who will be graduating in two
months:
a. To obtain their own malpractice insurance
b. That malpractice insurance is not required and is expensive
c. To discuss liability insurance with the employment agency
d. That most lawsuits are filed against physicians

“Cast all your anxiety on him because he cares for you.” 1 Peter 5:7
“Believe in the Lord Jesus, and you will be saved – you and your household.” Acts 16:31

END

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