A B AND C ACTUAL EXAM EACH FORM CONTAINS 70
QUESTIONS AND CORRECT DETAILED ANSWERS WITH
RATIONALES (VERIFIED ANSWERS)
A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other
clients, and visitors. Which of the following actions should the nurse take.
a. . Keep the client in her room with the door closed
b. . Contact a family member to come and sit with the client
c. Place the client in a wheelchair with a lap tray
d. Administer a sedative to the client - ...ANSWER...b. B. Contact a family member
to come and sit with the client
A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse
is having trouble focusing and has difficulty (completing?) care for his assigned clients.
Which of the following interventions is appropriate?
A. Offer to provide care for his clients while he takes a break
B. Advise him to complete less time-consuming tasks first
C. Ask other staff members to take over some of his tasks
D. Recommend that he take time to plan at the beginning of his shift - ...ANSWER...D.
Recommend that he take time to plan at the beginning of his shift
A nurse is preparing to delegate bathing and turning of a newly admitted client who has end-
stage cancer to an experienced assistive personnel (AP). Which of the following assessments
should the nurse make before delegating care?
a. is the client's family present so the AP can show them how to turn the client?
b. Has data been collected about specific client needs related
to turning?
c. Does the AP have time to change the client9s central IV line dressing after turning
her?
d. Has the AP checked the client9s pain level prior to turning her? - ...ANSWER...b. Has
data been collected about specific client needs related to turning?
A nurse is participating in the development of a disaster management plan for a hospital.
The nurse should recognize that which of the following resources is the highest priority to
have available in response to a bioterrorism event?
A. A mental health specialist on the response team
b. a sufficient supply of ppe
c. a system for tracking client information
d. a network for communication between staff members and families - ...ANSWER...b. a
sufficient supply of ppe
A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the
bedside commode. Which of the following should the nurse take first?
,a. Refer the AP to the facility procedure manual
b. Demonstrate the proper client transfer technique for the AP?
,c. Instruct the AP to request assistance when unsure about a task
d. Help the AP assist the client with the transfer -
...ANSWER...d. Help the AP assist the client with the transfer
A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist
restraints to a client who is agitated and does not have a prescription for restraints. Which of
the following actions should the nurse take first?
A. Remove the restraints from the client's wrists
B. Review the chart for nonrestraint alternatives for agitation
C. Speak with the AP about the incident
D. Inform the unit manager of the incident - ...ANSWER...A. Remove the restraints from
the client's wrists
A nurse manager is leading a discussion about ethical dilemmas. Which of the following
situations should the nurse manager include as an example of ethical dilemma?
a. A visitor experiences a minor burn after spilling coffee
B. A client receives an operation on the wrong side of her body
C. A parent wants her 14-year-old adolescent to receive radiation treatment against his will
D. A nurse witnesses another nurse administer an incorrect medication - ...ANSWER...C. A
parent wants her 14-year-old adolescent to receive radiation treatment against his will
A nurse is caring for a client who requests information about the prevalence of Tay-Sachs
disease. Which of the following resources should the nurse use to obtain this information?
A. The clients health care provider
B. A Collaborative, user-edited website
C. The facility's case manager
D. An evidence-based nursing journal - ...ANSWER...D. An evidence-based nursing
journal
A nurse is orientating a newly licensed nurse about client confidentiality. Which of the
following statements by the newly licensed nurse indicates an understanding of the teaching?
A. "I can use another nurse's password as long as I log off after using the computer"
B. "I should encrypt personal health information when sending emails"
C. "I can post the client's vital signs in the client's room"
D. "I should discard personal health information documents in the trash before leaving the
unit" - ...ANSWER...B. "I should encrypt personal health information when sending emails"
A nurse is assessing a client who is postoperative following a left leg below-the-knee
amputation. Which of the following client statements indicates the potential need for a
referral to an occupational therapist?
a. I hope I can adjust to using crutches while I am recovering
b. I am worried about taking care of my toddler at home
c. I just don't think I can handle looking at my leg
, d. I am not sure how I will pay for all the therapy I will need -
...ANSWER...a. I hope I can adjust to using crutches while I am recovering
A nurse in the emergency department is assessing a client who is unconscious following a
motor-vehicle crash. the client requires immediate surgery. Which of the following actions
should the nurse take?
a. Transport the client to the operating room without verifying informed consent
b. ask the anesthesiologist to sign the consent
c. obtain telephone consent from the facility administrator before the surgery d. delay the
surgery until the nurse can obtain informed consent - ...ANSWER...a. Transport the client to
the operating room without verifying informed consent
A nurse enters a client room to witness an informed consent for a gastroscopy. The client
states he does not understand the procedure. Which of the following actions should the nurse
take?
a. Educate the client about the risks of refusing medications
b. Complete an incident report
c. Answer the client question concerning the procedure
d. Inform the provider that the client requires clarification about the procedure -
...ANSWER...d. Inform the provider that the client requires clarification about the
procedure
A case manager is preparing discharge plan for a client following coronary artery bypass
grafting surgery. Which of the following client issues should the nurse address first?
A. Inadequate food supply
B. Low pain tolerance
C. Limited social support
D. Decreased self-esteem - ...ANSWER...A. Inadequate food supply
A nurse in a clinic is reviewing laboratory reports for a group of clients. Which of the
following diseases should the nurse report to the state health department?
a. pertussis
b. Group B streptococcal disease c.Respiratory
syncytial virus
d. rotavirus - ...ANSWER...a. pertussis
Afollowing actions should the nurse plan to take? (Select all that apply)
nurse is preparing to complete an incident report regarding a
medication error. Which of the
a) Make a copy of the incident report for personal keeping
b) Identify the medication name and dosage administered to the client in the report
c) Obtain an order from the client9s provider to complete the report