1 >>The client asks the nurse why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? ?
- (A) The client asks the nurse why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system?
- (B) This type of system consists of combined documentation and daily care plans.
- (C) It improves interdisciplinary collaboration that improves efficiency in procedures.�
- (D) This type of system tracks medication administration and usage over 24 hours.
2 >>At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? ?
- (A) Complete an occurrence report before leaving.
- (B) Do nothing; the next nurse will document it was done.
- (C) Write the note of the dressing change into an earlier note.�
- (D) Make a late entry as an addition to the narrative notes.
3 >>The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets: ?
- (A) Are comprehensive charting forms that integrate assessments and nursing actions
- (B) Contain only graphic information, such as I&O, vital signs, and medication administration
- (C) Are used to record routine aspects of care; they do not contain assessment data
- (D) Contain vital data collected upon admission, which can be compared with newly collected data
4 >>When the nurse completes the patient’s admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? ?
- (A) NA
- (B) NDA
- (C) NKA
- (D) NPO
5 >>The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: ?
- (A) Separates the health record according to discipline
- (B) Organizes documentation around the patient’s problems
- (C) Highlights the patient’s concerns, problems, and strengths
- (D) Is designed to streamline documentation
6 >>Which of the following incidents requires the nurse to complete an occurrence report? ?
- (A) Medication given 30 minutes after scheduled dose time
- (B) Patient’s dentures lost after transfer
- (C) Worn electrical cord discovered on an IV infusion pump
- (D) Prescription without the route of administration
7 >>What is the rationale for hand washing? Hand washing is expected to remove: ?
- (A) transient flora from the skin.
- (B) resident flora from the skin
- (C) all microorganisms from the skin.
- (D) media for bacterial growth.
8 >>A mother who breastfeeds her child passes on which antibody through breast milk? ?
- (A) IgA
- (B) IgE
- (C) IgG
- (D) IgM
9 >>Which action demonstrates a break in sterile technique? ?
- (A) Remaining 1 foot away from nonsterile areas
- (B) Placing sterile items on the sterile field
- (C) Avoiding the border of the sterile drape
- (D) Reaching 1 foot over the sterile field
10 >>A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? ?
- (A) admitted with unstable diabetes mellitus.
- (B) who underwent surgical repair of a perforated bowel.
- (C) with a stage 3 sacral pressure ulcer.
- (D) admitted with a urinary tract infection.
11 >>A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? ?
- (A) A clean gown and gloves must be worn when in contact with the client.
- (B) Everyone who enters the room must wear a N-95 respirator mask.
- (C) All linen and trash must be marked as contaminated and send to biohazard waste.
- (D) Place the client in a room with a client with an upper respiratory infection.
12 >>A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? ?
- (A) Fever
- (B) Intact skin
- (C) Inflammation
- (D) Lethargy
13 >>For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? ?
- (A) Cover the mattress with a sheepskin.
- (B) Keep the linens wrinkle free.
- (C) Separate the skin folds with towels.
- (D) Apply petrolatum barrier creams.
14 >>The nurse notes a lesion that appears to be caused by tissue compression on the right hip of a patient who suffered a stroke 5 days ago. How should the nurse document this finding? ?
- (A) Maceration
- (B) Abrasion
- (C) Excoriation
- (D) Pressure ulcer
15 >>A 75-year-old patient who is 5 feet 7 inches tall and weighs 170 pounds is admitted with dehydration. A nursing diagnosis of Risk for Impaired Skin Integrity is identified for this patient. Which factor places the client at Risk for Impaired Skin Integrity? ?
- (A) Orthostatic hypotension
- (B) Appendectomy
- (C) Dizziness
- (D) Dehydration
16 >>A woman of Orthodox Jewish faith who underwent a hysterectomy for cancer is being cared for on the surgical floor. Which healthcare team member(s) could be assigned to bathe this patient? Choose all correct answers. ?
- (A) Male nursing assistant
- (B) Male licensed practical nurse
- (C) Female graduate nurse
- (D) Female graduate nurse and Female registered nurse
17 >>Which change in hygiene practices may be necessary as the patient ages? ?
- (A) Brushing teeth twice a day
- (B) Bathing every other day
- (C) Decreasing moisturizer use
- (D) Increasing soap use
18 >>What is the leading cause of unintentional death for the entire U.S. population? ?
- (A) Motor vehicle accidents
- (B) Poisoning
- (C) Choking
- (D) Falls
19 >>What should parents do to promote child safety in the home? ?
- (A) Attach the baby’s pacifier to a ribbon so that it does not fall on the floor.
- (B) Give a 2-year-old whole grapes instead of popcorn for a snack.�
- (C) Store firearms unloaded and out of sight in a location too high for the child to reach.
- (D) Install window guards; never leave a window wide open.
20 >>While teaching a health promotion group of adults, the nurse notices one person who is clutching his throat with both hands. What should the nurse do first? ?
- (A) Call 9-1-1.
- (B) Encourage the person to cough vigorously.
- (C) Ask, “Are you choking?”
- (D) Give five back blows.