1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following task could the registered nurse safely assigned to a UAP?
2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse?
3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse?
4. The registered nurse is planning to delegate task to a certified nursing assistant. Which of the following clients should not be assigned to a CAN?
5. The nurse in the medication unit passes the medications for all the clients on the nursing unit. The head nurse is making rounds with the physician and coordinates clients’ activities with other departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes the clients. This illustrates of what method of nursing care?
6. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for every aspect of care such as formulating the care of plan, intervention and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This nursing care illustrates of what kind of method?
7. A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that feels overwhelming. The nurse should:
8. An experienced nurse who voluntarily trained a less experienced nurse with the intention of enhancing the skills and knowledge and promoting professional advancement to the nurse is called a:
9. The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit that she is going to assign one nurse to float in the pediatric units. Which statement by the designated float nurse may put her job at risk?
10. The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager has posted the team leader assignments for the following week. The new staff knows that a major responsibility of the team leader is to:
11. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared the consent form and it should be signed by:
12. A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client, “if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for the nurse to take?
13. Which is true about informed consent?
14. A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to:
15. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to bring the informed consent document into the client’s room for a signature. The client asks the nurse for details of the procedure and demands an explanation why the process of informed consent is necessary. The nurse responds that informed consent means:
16. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN?
17. While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take?
18. A staff nurse has had a serious issue with her colleague. In this situation, it is best to:
19. The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when:
20. A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do?
21. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with:
22. The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client?
23. The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client?
24. A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client?
25. During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements?
26. The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client?
27. A client admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action to the client?
28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia?
29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding?
30. On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority?
31. A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention?
32. The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the floor next to the bed. What would be the initial action of the nurse?
33. The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask:
34. The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast?
35. The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to:
36. A client visits the clinic for screening of scoliosis. The nurse should ask the client to:
37. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they:
38. An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse?
39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this?
40. The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure:
41. A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern?
42. After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse?
43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas?
44. The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be:
45. A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is:
46. Which of the following would be the most important goal in the nursing care of an infant client with eczema?
47. The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk for bone marrow depression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included?
48. The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the nurse to use in handwashing is:
49. The mother of the client tells the nurse, “ I’m not going to have my baby get any immunization”. What would be the best nursing response to the mother?
50. The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when doing the examination for detection of breast cancer?
