1 >>The nurse working at the county hospital is admitting a client who is Rh-negative to the labor and delivery unit. The client is gravida 2, para 0. Which assessment data is most important for the nurse to assess? ?
- (A) Why the client did not have a viable baby with the first pregnancy.
- (B) If the mother received a Rhogam injection after the last pregnancy.
- (C) The period of time between the client’s pregnancies.
- (D) When the mother terminated the previous pregnancy.
2 >>The 24-month-old toddler is admitted to the pediatric unit with vomiting and diarrhea. Which interventions should the nurse implement? Rank in order of performance. ?
- (A) Teach the parent about weighing diapers to determine output status.
- (B) Show the parent the call light and explain safety regimens.
- (C) Assess the toddler’s tissue turgor.
- (D) Take the toddler’s vital signs.
3 >>The nurse has received the shift report. Which client should the nurse assess first? ?
- (A) The client diagnosed with a deep vein thrombosis (DVT) who complains of a feeling of doom.
- (B) The client diagnosed with gallbladder ulcer disease who refuses to eat the food served.
- (C) The client diagnosed with pancreatitis who wants the nasogastric tube removed.
- (D) The client diagnosed with osteoarthritis who is complaining of stiff joints.
4 >>The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a pediatric unit. Which task should the nurse delegate to the UAP? ?
- (A) Sit with the 6-year-old client while the parent goes outside to smoke.
- (B) Stay with the 4-year-old client during scheduled play therapy sessions.
- (C) Position the 2-year-old client for the postural drainage therapy.
- (D) Weigh the diaper of the 6-month-old client who is on intake and output (I&O).
5 >>The home health nurse is planning his rounds for the day. Which client should the nurse plan to see first? ?
- (A) The 56-year-old client diagnosed with multiple sclerosis who is complaining of a cough.
- (B) The 78-year-old client diagnosed with congestive heart failure (CHF) who reports losing 3 pounds.
- (C) The 42-year-old client diagnosed with an L-5 spinal cord injury who has developed a Stage 4 pressure ulcer.
- (D) The 80-year-old client diagnosed with a cerebrovascular accident (CVA) who has right-sided paralysis.
6 >>The nurse is preparing to perform a sterile dressing change on a client with full-thickness burns on the right leg. Which intervention should the nurse implement first? ?
- (A) Pre-medicate the client with a narcotic analgesic.
- (B) Prepare the equipment and bandages at the bedside.
- (C) Remove the old dressing with non-sterile gloves.
- (D) Place a sterile glove on the dominant hand.
7 >>The physical therapist has notified the unit secretary that the client will be ambulated in 45 minutes. After receiving notification from the unit secretary, which task should the charge nurse delegate to the unlicensed assistive personnel (UAP)? ?
- (A) Administer a pain medication 30 minutes before therapy.
- (B) Give the client a washcloth to wash his or her face before walking.
- (C) Check to make sure the client has been offered the use of the bathroom.
- (D) Find a walker that is the correct height for the client to use.
8 >>The volunteer on a medical unit tells the nurse that one of the clients on the unit is her neighbor and asks about the client’s condition. Which information should the nurse discuss with the volunteer? ?
- (A) Determine how well she knows the client before talking with the volunteer.
- (B) Tell the volunteer the client’s condition in layperson’s terms.
- (C) Ask the client if it is all right to talk with the volunteer.
- (D) Explain that client information is on a need-to-know basis only.
9 >>The medical unit is governed by a system of shared governance. Which statement best describes an advantage of this system? ?
- (A) It guarantees that unions will not be able to come into the hospital.
- (B) It makes the manager responsible for sharing information with the staff.
- (C) It involves staff nurses in the decision-making process of the unit.
- (D) It is a system used to represent the nurses in labor disputes.
10 >>The visitor on a medical unit is shouting and making threats about harming the staff because of perceived poor care his loved one has received. Which statement is the nurse’s best initial response? ?
- (A) “If you don’t stop shouting, I will have to call security.”
- (B) “I hear that you are frustrated. Can we discuss the issues calmly?”
- (C) “Sir, you are disrupting the unit. Calm down or leave the hospital.”
- (D) “This type of behavior is uncalled for and will not resolve anything.”
11 >>The experienced nurse has recently taken a position on a medical unit in a community hospital, but after 1 week on the job, he finds that the staffing is not what was discussed during his employment interview. Which approach would be most appropriate for the nurse to take when attempting to resolve the issue? ?
- (A) Immediately give a 2-week notice and find a different job.
- (B) Discuss the situation with the manager who interviewed him.
- (C) Talk with the other employees about the staffing situation.
- (D) Tell the charge nurse the staffing is not what was explained to him.
12 >>The nurse is preparing to administer the client’s first intravenous antibiotic. Prioritize the nurse’s actions from first (1) to last (5). ?
- (A) Check the healthcare provider’s order in the chart.
- (B) Determine if the client has any known allergies.
- (C) Hang the secondary IV piggyback higher than the primary IV.
- (D) Set the intravenous pump at the correct rate.
13 >>A major disaster has been called, and the charge nurse on a medical unit must recommend to the medical discharge officer on rounds which clients to discharge. Which client should not be discharged? ?
- (A) The client diagnosed with chronic angina pectoris who has been on new medication for 2 days.
- (B) The client diagnosed with deep vein thrombosis (DVT) who has had heparin discontinued and has been on warfarin (Coumadin) for 4 days.
- (C) The client with an infected leg wound who is receiving vancomycin IVPB every 24 hours for methicillin-resistant Staphylococcus aureus (MRSA) infection.
- (D) The client diagnosed with COPD who has the following arterial blood gas (ABG) levels: pH, 7.34; PCO2, 55; HCO3, 28; PaO2, 89.
14 >>The nurse has been named in a lawsuit concerning the care provided. Which action should the nurse take first? ?
- (A) Consult with the hospital’s attorney.
- (B) Review the client’s chart.
- (C) Purchase personal liability insurance.
- (D) Discuss the case with the supervisor.
15 >>The nurse has accepted the position of clinical manager for a medical-surgical unit. Which role is an important aspect of this management position? ?
- (A) Evaluate the job performance of the staff.
- (B) Be the sole decision maker for the unit.
- (C) Take responsibility for the staff nurse’s actions.
- (D) Attend the medical staff meetings.
16 >>The charge nurse notices that one of the staff takes frequent breaks, has unpredictable mood swings, and often volunteers to care for clients who require narcotics. Which priority action should the charge nurse implement regarding this employee? ?
- (A) Discuss the nurse’s actions with the unit manager.
- (B) Confront the nurse about the behavior.
- (C) Do not allow the nurse to take breaks alone.
- (D) Prepare an occurrence report on the employee.
17 >>A male HCP frequently tells jokes with sexual overtones at the nursing station. Which action should the female charge nurse implement? ?
- (A) Tell the HCP that the jokes are inappropriate and offensive.
- (B) Report the behavior to the medical staff committee.
- (C) Discuss the problem with the chief nursing officer.
- (D) Call a Code Purple and have the nurses surround the HCP.
18 >>The night shift nurse is caring for clients on the surgical unit. Which client situation would warrant immediate notification of the surgeon? ?
- (A) The client who is 2 days postoperative for bowel resection and who refuses to turn, cough, and deep breathe.
- (B) The client who is 5 hours postoperative for abdominal hysterectomy who reported feeling a “pop” and then her pain went away.
- (C) The client who is 2 hours postoperative for TKR and who has 400 mL in the cell-saver collection device.
- (D) The client who is 1 day postoperative for bilateral thyroidectomy and who has a negative Chvostek sign.
19 >>Which client should the nurse in the post-anesthesia care unit (PACU) assess first? ?
- (A) The client who received general anesthesia who is complaining of a sore throat.
- (B) The client who had right knee surgery and has a pulse oximeter reading of 90%.
- (C) The client who received epidural surgery and has a palpable 2+ dorsalis pedal pulse.
- (D) The client who had abdominal surgery and has green bile draining from the N/G tube.
20 >>The client with a below-the-knee amputation (BKA) has a large amount of bright red blood on the residual limb dressing and the nurse suspects an arterial bleed. Which intervention should the nurse implement first? ?
- (A) Increase the client’s intravenous rate.
- (B) Assess the client’s vital signs.
- (C) Apply a tourniquet above the amputation.
- (D) Notify the client’s healthcare provider.