CBC Practice Exam 4 Practice Questions And Answers | Verified
1. A nurse is assessing A) Begin CPR on the client.
a client who has a Rationale: The nurse should not begin CPR on the client, because this
do-not-resuscitate (DNR) action goes against the client's DNR order.
order and has stopped B) Respect the client's preferences.
breathing. The family asks Rationale: The nurse should inform the client's family that he is
the nurse to resuscitate obligated to respect the client's preferences and follow the DNR
the client. Which of the fol- order.
lowing actions should the C) Apply oxygen at 4 L/min via nasal cannula.
nurse take? Rationale: The nurse should not apply oxygen at 4 L/min via nasal
A) Begin CPR on the cannula, because this action goes against the client's DNR order.
client. D) Gather equipment for mechanical ventilation.
B) Respect the client's Rationale: The nurse should not gather equipment for mechanical
preferences. ventilation, because this action goes against the client's DNR order.
C) Apply oxygen at 4 L/min
via nasal cannula.
D) Gather equipment for
mechanical ventilation.
2. A nurse is caring for a A) Ask the provider to respect the family's decision to withhold the
client who has a new diagnosis.
diagnosis of esophageal Rationale: The nurse is demonstrating paternalism by asking the
cancer. The client's family provider to respect the family's decision to withhold the diagnosis.
tells the nurse that they do B) Tell the family the client has the right to know about her health.
not want the client Rationale: The nurse is demonstrating the ethical principle of au-
to know the diagnosis. tonomy by respecting the client's right to make decisions about her
Which of the following ac- health.
tions should the nurse take C) Agree to keep the diagnosis information from the client.
to uphold client au- Rationale: The nurse is demonstrating paternalism by agreeing to
tonomy? keep the diagnosis information from the client.
A) Ask the provider to re- D) Request pastoral care to inform the client of her condition.
spect the family's decision Rationale: The nurse is breaching confidentiality by requesting pas-
to withhold the diagno- toral care to inform the client of her condition.
, CBC Practice Exam 4 Practice Questions And Answers | Verified
sis.
B) Tell the family the client
has the right to know about
her health.
C) Agree to keep the di-
agnosis information from
the client.
D) Request pastoral care
to inform the client of her
condition.
3. A nurse is teaching a A) Side-lying
group of assistive per- Rationale: The nurse should teach the assistive personnel to avoid
sonnel about prevention positioning the client in the lateral position directly on the trochanter, but
pressure ulcers. Which of should tilt the client back with pillow support and pillows be-tween the
the following images legs at the knees. Lying directly on the trochanter or having the knees
should the nurse include against each other can cause excess pressure from bony prominences
in the teaching? on blood vessels at the point of contact and lead to a pressure ulcer.
A) Side-lying B) Fowler's
B) Fowler's Rationale: The nurse should teach the assistive personnel to avoid
C) Semi Fowler's with positioning the head of bed at greater than 30° for an extended pe-
heels raised
D) Wheelchair with a cush- riod of time. Shearing can occur from the client sliding down in bed
ion causing the client's skin to remain stationary while the underlying
tissue shifts, decreasing blood supply to the skin tissue, which can
lead to a pressure ulcer.
C) Semi Fowler's with heels raised
Rationale: The nurse should teach the assistive personnel to place a
pillow or blankets under the client's legs or ankles to prevent the heel
from rubbing on the bed linens and causing a friction rub that can lead
to a pressure ulcer. The head of the bed should be positioned at less
than 30° to prevent shearing pressure.
, CBC Practice Exam 4 Practice Questions And Answers | Verified
D) Wheelchair with a cushion
Rationale: The nurse should teach the assistive personnel to not place
a donut-shaped pillow in a wheelchair or chair because the pillow can
compress and damage capillaries and increase tissue breakdown,
which can lead to pressure ulcers.
4. A community health nurse A) Partial hospitalization program
is teaching a newly Rationale: Partial hospitalization programs provide clients with short,
licensed nurse about the intensive mental health treatments similar to inpatient treatments.
types of psychiatric health However, patients are allowed to return home each day. Typically, the
care settings available in program lasts 5 to 6 hr per day.
the community. Which of B) Locked inpatient unit
the following should the Rationale: The most acute treatment facility for clients seeking mental
nurse identify as a prima-ry health care is a locked inpatient unit.
care setting? C) Day treatment program
A) Partial hospitalization Rationale: Day treatment programs provide clients with behavioral
program regulation and social skills development. However, patients are al-
B) Locked inpatient unit lowed to return home each day.
C) Day treatment pro- D) Outpatient counseling clinic
gram Rationale: Outpatient counseling clinics are primary care settings that
D) Outpatient counseling provide strategies for clients to prevent or delay mental health issues.
clinic
A) Check the client for sacral edema.
5. A nurse suspects that a Rationale: The nurse should check the client for sacral edema to
client is experiencing assess for fluid retention or bleeding in the body. However, there is
a pulmonary embolism. another action the nurse should take first.
Which of the following ac- B) Raise the head of the client's bed.
tions should the nurse take Rationale: The first action the nurse should take when using the air-way,
first? breathing, circulation approach to client care is to raise the head of the
A) Check the client for bed to allow for ease of breathing and better oxygenation.
sacral edema. C) Obtain the client's blood pressure in both arms.
B) Raise the head of the
, CBC Practice Exam 4 Practice Questions And Answers | Verified
client's bed. Rationale: The nurse should obtain the client's blood pressure in both
C) Obtain the client's arms to assess his cardiac status and adequacy of perfusion. However,
blood pressure in both there is another action the nurse should take first.
arms. D) Prepare the client for a chest x-ray.
D) Prepare the client for a Rationale: The nurse should prepare the client for a chest x-ray to
chest x-ray. diagnose the presence of a pulmonary embolism in his lung.
However, there is another action the nurse should take first.
6. A nurse is caring for A) The nurse treats each of his assigned clients with equal respect.
clients on a medical-sur- Rationale: This action by the nurse is an example of the professional
gical unit. Which of the characteristic of human dignity, which includes treating all clients
following actions by the equally regardless of medical history or background.
nurse demonstrates the B) The nurse otters to help overwhelmed coworkers with client care.
professional characteris- Rationale: This action by the nurse is an example of the professional
tic of human dignity? characteristic of altruism.
A) The nurse treats each of C) The nurse respects the right of a client who has chronic kidney
his assigned clients with disease to choose to stop dialysis.
equal respect. Rationale: This action by the nurse is an example of the professional
B) The nurse offers to help characteristic of autonomy.
overwhelmed coworkers D) The nurse contacts an interpreter for a client who does not speak the
with client care. same language as the nurse.
C) The nurse respects the Rationale: This action is an example of the professional characteristic of
right of a client who has social justice.
chronic kidney disease to
choose to stop dialysis.
D) The nurse contacts an
interpreter for a client who
does not speak the same
language as the nurse.
7.
1. A nurse is assessing A) Begin CPR on the client.
a client who has a Rationale: The nurse should not begin CPR on the client, because this
do-not-resuscitate (DNR) action goes against the client's DNR order.
order and has stopped B) Respect the client's preferences.
breathing. The family asks Rationale: The nurse should inform the client's family that he is
the nurse to resuscitate obligated to respect the client's preferences and follow the DNR
the client. Which of the fol- order.
lowing actions should the C) Apply oxygen at 4 L/min via nasal cannula.
nurse take? Rationale: The nurse should not apply oxygen at 4 L/min via nasal
A) Begin CPR on the cannula, because this action goes against the client's DNR order.
client. D) Gather equipment for mechanical ventilation.
B) Respect the client's Rationale: The nurse should not gather equipment for mechanical
preferences. ventilation, because this action goes against the client's DNR order.
C) Apply oxygen at 4 L/min
via nasal cannula.
D) Gather equipment for
mechanical ventilation.
2. A nurse is caring for a A) Ask the provider to respect the family's decision to withhold the
client who has a new diagnosis.
diagnosis of esophageal Rationale: The nurse is demonstrating paternalism by asking the
cancer. The client's family provider to respect the family's decision to withhold the diagnosis.
tells the nurse that they do B) Tell the family the client has the right to know about her health.
not want the client Rationale: The nurse is demonstrating the ethical principle of au-
to know the diagnosis. tonomy by respecting the client's right to make decisions about her
Which of the following ac- health.
tions should the nurse take C) Agree to keep the diagnosis information from the client.
to uphold client au- Rationale: The nurse is demonstrating paternalism by agreeing to
tonomy? keep the diagnosis information from the client.
A) Ask the provider to re- D) Request pastoral care to inform the client of her condition.
spect the family's decision Rationale: The nurse is breaching confidentiality by requesting pas-
to withhold the diagno- toral care to inform the client of her condition.
, CBC Practice Exam 4 Practice Questions And Answers | Verified
sis.
B) Tell the family the client
has the right to know about
her health.
C) Agree to keep the di-
agnosis information from
the client.
D) Request pastoral care
to inform the client of her
condition.
3. A nurse is teaching a A) Side-lying
group of assistive per- Rationale: The nurse should teach the assistive personnel to avoid
sonnel about prevention positioning the client in the lateral position directly on the trochanter, but
pressure ulcers. Which of should tilt the client back with pillow support and pillows be-tween the
the following images legs at the knees. Lying directly on the trochanter or having the knees
should the nurse include against each other can cause excess pressure from bony prominences
in the teaching? on blood vessels at the point of contact and lead to a pressure ulcer.
A) Side-lying B) Fowler's
B) Fowler's Rationale: The nurse should teach the assistive personnel to avoid
C) Semi Fowler's with positioning the head of bed at greater than 30° for an extended pe-
heels raised
D) Wheelchair with a cush- riod of time. Shearing can occur from the client sliding down in bed
ion causing the client's skin to remain stationary while the underlying
tissue shifts, decreasing blood supply to the skin tissue, which can
lead to a pressure ulcer.
C) Semi Fowler's with heels raised
Rationale: The nurse should teach the assistive personnel to place a
pillow or blankets under the client's legs or ankles to prevent the heel
from rubbing on the bed linens and causing a friction rub that can lead
to a pressure ulcer. The head of the bed should be positioned at less
than 30° to prevent shearing pressure.
, CBC Practice Exam 4 Practice Questions And Answers | Verified
D) Wheelchair with a cushion
Rationale: The nurse should teach the assistive personnel to not place
a donut-shaped pillow in a wheelchair or chair because the pillow can
compress and damage capillaries and increase tissue breakdown,
which can lead to pressure ulcers.
4. A community health nurse A) Partial hospitalization program
is teaching a newly Rationale: Partial hospitalization programs provide clients with short,
licensed nurse about the intensive mental health treatments similar to inpatient treatments.
types of psychiatric health However, patients are allowed to return home each day. Typically, the
care settings available in program lasts 5 to 6 hr per day.
the community. Which of B) Locked inpatient unit
the following should the Rationale: The most acute treatment facility for clients seeking mental
nurse identify as a prima-ry health care is a locked inpatient unit.
care setting? C) Day treatment program
A) Partial hospitalization Rationale: Day treatment programs provide clients with behavioral
program regulation and social skills development. However, patients are al-
B) Locked inpatient unit lowed to return home each day.
C) Day treatment pro- D) Outpatient counseling clinic
gram Rationale: Outpatient counseling clinics are primary care settings that
D) Outpatient counseling provide strategies for clients to prevent or delay mental health issues.
clinic
A) Check the client for sacral edema.
5. A nurse suspects that a Rationale: The nurse should check the client for sacral edema to
client is experiencing assess for fluid retention or bleeding in the body. However, there is
a pulmonary embolism. another action the nurse should take first.
Which of the following ac- B) Raise the head of the client's bed.
tions should the nurse take Rationale: The first action the nurse should take when using the air-way,
first? breathing, circulation approach to client care is to raise the head of the
A) Check the client for bed to allow for ease of breathing and better oxygenation.
sacral edema. C) Obtain the client's blood pressure in both arms.
B) Raise the head of the
, CBC Practice Exam 4 Practice Questions And Answers | Verified
client's bed. Rationale: The nurse should obtain the client's blood pressure in both
C) Obtain the client's arms to assess his cardiac status and adequacy of perfusion. However,
blood pressure in both there is another action the nurse should take first.
arms. D) Prepare the client for a chest x-ray.
D) Prepare the client for a Rationale: The nurse should prepare the client for a chest x-ray to
chest x-ray. diagnose the presence of a pulmonary embolism in his lung.
However, there is another action the nurse should take first.
6. A nurse is caring for A) The nurse treats each of his assigned clients with equal respect.
clients on a medical-sur- Rationale: This action by the nurse is an example of the professional
gical unit. Which of the characteristic of human dignity, which includes treating all clients
following actions by the equally regardless of medical history or background.
nurse demonstrates the B) The nurse otters to help overwhelmed coworkers with client care.
professional characteris- Rationale: This action by the nurse is an example of the professional
tic of human dignity? characteristic of altruism.
A) The nurse treats each of C) The nurse respects the right of a client who has chronic kidney
his assigned clients with disease to choose to stop dialysis.
equal respect. Rationale: This action by the nurse is an example of the professional
B) The nurse offers to help characteristic of autonomy.
overwhelmed coworkers D) The nurse contacts an interpreter for a client who does not speak the
with client care. same language as the nurse.
C) The nurse respects the Rationale: This action is an example of the professional characteristic of
right of a client who has social justice.
chronic kidney disease to
choose to stop dialysis.
D) The nurse contacts an
interpreter for a client who
does not speak the same
language as the nurse.
7.
