CORRECT DEFINITIONS PASS GUIDE
1. 25 (BMI) - ANS ✅✅-the upper boundary of a healthy weight
2. 25 to 29.9 (BMI) - ANS ✅✅-overweight
3. 30 to 34.9 (BMI) - ANS ✅✅-obesity class I
4. 35 to 39.9 (BMI) - ANS ✅✅-obesity class 2
5. 40 and above (BMI) - ANS ✅✅-obesity class 3
6. A charge nurse is assigning client care for four clients. Which of the
following tasks should the nurse assign to a PN?
A. Creating a plan of care for a client who is recovering following a
stroke.
B. Assessing a pressure injury on a client who is on bed rest
C. Providing nasopharyngeal suctioning for a client who has
pneumonia
D. Teaching a client who has asthma to use a metered-dose inhaler
- ANS ✅✅-C
7. Providing nasopharyngeal suctioning is within the scope of practice of
the PN.
,8. A charge nurse is observing a newly licensed nurse care for a client
who reports pain. The nurse checked the client's MAR and noted the
last dose of pain medication was 6 hr ago. The prescription reads every
4 hr PRN for pain. The nurse administered the medication and checked
with the client 40 min later, when the client reported improvement.
The newly licensed nurse left out which of the following steps of the
nursing process?
A. Assessment
B. Planning
C. Intervention
D. Evaluation - ANS ✅✅-A
9. The newly licensed nurse should have used the assessment step of the
nursing process by asking the client to evaluate the severity of pain on
a 0 to 10 scale. The nurse also should have asked about the
characteristics of the pain and assessed for any changes that might
have contributed to worsening of the pain.
10. A charge nurse is reviewing documentation with a group of newly
licensed nurses. Which of the following legal guidelines should be
followed when documenting in a client's record? (Select all that apply.)
A. Cover errors with correction fluid, and write in the correct
information.
B. Put the date and time on all entries.
C. Document objective data, leaving out opinions.
D. Use as many abbreviations as possible.
E. Wait until the end of the shift to document. - ANS ✅✅-B, C
11. B. The day and time confirm the recording of the correct
sequence of events.
12. C. Documentation must be factual, descriptive, and objective,
without opinions or criticism.
,13. A charge nurse is reviewing the steps of the nursing process with
a group of nurses. Which of the following data should the charge nurse
identify as objective data? (Select all that apply.)
A. Respiratory rate is 22/min with even, unlabored respirations.
B. The client's partner states, "They said they hurt after walking
about 10 minutes."
C. The client's pain rating is 3 on a scale of 0 to 10.
D. The client's skin is pink, warm, and dry.
E. The assistive personnel reports that the client walked with a
limp. - ANS ✅✅-A, D, E
14. Objective data includes information the nurse measures (vital
signs).
15. D. Objective data includes information the nurses observes (skin
appearance).
16. E. Objective data includes information from the observations of
others (family and staff).
17. A charge nurse is talking with a newly licensed nurse and is
reviewing nursing interventions that do not require a provider's
prescription. Which of the following interventions should the charge
nurse include? (Select all that apply.)
A. Writing a prescription for morphine sulfate as needed for pain
B. Inserting a nasogastric (NG) tube to relieve gastric distention
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hr to reduce pressure injury risk -
ANS ✅✅-C, D, E
18. Showing a client how to use progressive muscle relaxation is an
appropriate nurse-initiated intervention for stress relief. Unless there is
, a contraindication for a specific client, use this technique with clients
without a provider's prescription.
19. Performing a bath is a routine nursing care procedure. Unless
there is a contraindication for a specific client, determine when bathing
is optimal for a client without a provider's prescription.
20. Repositioning a client every 2 hr is an appropriate nurse-initiated
intervention for clients. Unless there is a contraindication for a specific
client, use this strategy without a provider's prescription.
21. A client who had a cerebrovascular accident has persistent
problems with dysphagia. The nurse caring for the client should initiate
a referral with which of the following members of the interprofessional
care team?
A. Social worker
B. Certified nursing assistant
C. Occupational therapist
D. Speech-language pathologist - ANS ✅✅-D
22. A speech-language pathologist can initiate specific therapy for
clients who have difficulty with feeding due to swallowing difficulties.
23. A client who is postoperative following knee arthroplasty is
concerned about the adverse effects of the medication prescribed for
pain management. Which of the following members of the
interprofessional care team can assist the client in understanding the
medication's effects? (Select all that apply.)
A. Provider
B. Certified nursing assistant
C. Pharmacist
D. Registered nurse
E. Respiratory therapist - ANS ✅✅-A, C, D