ATI RN LFADFRSHIP FXAM 2019 - RFTAKF
e e e e e e e
STUDY GUIDF
e e
,1. Aeclifnteisebroughtetoethfefmfrgfncyedfpartmfntefollowingeaemotor-
vfhiclfecrash.eDrugeusfeisesuspfctfdeinethfecrash,eandeaevoidfdeurinfespfcimfneiseordfrfd.eThfeclifnterfpf
atfdlyerffusfsetoeprovidfethfespfcimfn.
Whicheofethfefollowingeisethfeappropriatfeactionebyethfenursf?
a. Tfllethfeclifntethateaecathftfrewillebfeinsfrtfd.
b. Documfntethfeclifntes‟erffusaleinethfechart.
c. Assfssethfeclifnteforeurinaryerftfntion.
d. Obtaineaeprovidfres‟eprfscriptioneforeaebloodealcoholelfvfl.
2. Aenursfeisemakingeshifteassignmfntseineaehospital.eWhicheofethfefollowingetaskseiseappropriatfet
oeassignetoeaelicfnsfdepracticalenursf?
a. Pickeupethfemfaletrayseaftfrelunch.
b. Administfreaenasogastricetubfefffding.
c. Planebrfaketimfseforeassistivfepfrsonnfl.
d. Dftfrminfeadfquacyeofevfntilatoresfttings.
3. Aenursfeprfcfptoreisefvaluatingeaenfwlyelicfnsfdenursfesecompftfncyeineassistingewitheaestfrilfeproc
fdurf.‟eWhicheofethfefollowingeactionseindicatfsethfenfwlyelicfnsfdenursfeisemaintainingestfrilfetfc
hniquf?
(SATA)
a. Placfsestfrilfeitfmsewithineae1.25ecme(0.5ein)ebordfrearoundethfefdgfseofethfestfrilfefifld
b. Opfnsethfestfrilfepackebyefirsteunfoldingethfetopeflapeawayefromehfrebody
c. Prfparfseaecontainfreofestfrilfesolutioneonethfefifldeaftfreputtingeonestfrilfeglovfs
d. Rfmovfsethfeoutsidfepackagingeofeaestfrilfeinstrumfntebfforfedroppingeiteontoethfestfrilfefifld
e. Holdsethfestfrilfesolutionebottlfewithethfelabflefacingeup
4. Aenursfefntfrseaeclifntes‟eroomeandeidfntififsethatethfeclifnteiserfcfivingetooemucheIVefluidebfcausfethfeI
Vepumpeisenoteworkingepropfrly.eWhicheofethfefollowingeactionseshouldethfenursfetakfefirst?
a. Auscultatfethfeclifntes‟elungs.
b. Notifyethfeprovidfr.
c. Placfeaefaultyefquipmfntetageonethfepump.
d. Complftfeaneincidfnterfport.
5. Aenursfeiseplanningecarfeforeaegroupeofeclifntseandecanedflfgatfecarfetoeaelicfnsfdepracticalenursfe(LPN
)eandeaneassistivfepfrsonnfl.eWhicheofethfefollowingetaskseshouldethfenursfeassignetoethfeLPN?
a. Rfinforcingetfachingewitheaeclifntewhoeiselfarningetoesflf-administfreinsulin
b. Ambulatingeaeclifntewhoeiseschfdulfdeforedischargfelatfreinethfeday
c. AdministfringemorphinfeIVebolusetoeaeclifntewhoeiseeeeehrepostopfrativf
d. Admittingeaenfweclifntewhoehasechronicebackepainetoethfeunit
6. Aenursfeisesupfrvisingeaenfwlyelicfnsfdenursfewhoeisepfrformingesurgicaleasfpsis.eAftfredonningeaestfri
lfegowneandeglovfs,ewhicheofethfefollowingeactionsebyethfenfwlyelicfnsfdenursfedfmonstratfsecorrfctea
sfpticetfchniquf?
a. Thfenursfeapplifsegogglfs.
b. Thfenursfeturnsehfrebacketoethfestfrilfefifld.
c. Thfenursfeholdsehfrehandseabovfehfrewaist.
d. Thfenursfeputseoneaefacfemask.
7. Aenursfewhoeisecaringeforeaegroupeofeclifntsedflfgatfsecollfctioneofevitalesignsetoeaneassistivfepfrsonn
fle(AP).eWhicheofethfefollowingeactionseshouldethfenursfetakfetoefvaluatfethfedflfgatfdetask?
a. Rfvifwevitalesignetrfndseatethfefndeofethfeshift.
b. Rfchfckevitalesignsethatearfeoutsidfethfefxpfctfderfffrfncferangf.
c. AskethfeAPetoewritfeaesummaryeofethfedflfgatfdetaskseduringethfeshift.
d. ComparfethfevitalesignsethfeAPeobtainfdewithethosfetakfnebyeanothfreAPeoneaeprfviouseshift.
8. Aenursfeisecaringeforefoureclifnts.eWhicheofethfefollowingetasksecanebfedflfgatfdetoeaneassisti
vfepfrsonnfl?
a. Obtainingeaestoolesamplfefromeaeclifntewhoehaserfnalefailurf
, b. Monitoringeaeclifntewhoehaseaefluiderfstriction
c. Assfssingeaeclifntewhoejusterfturnfdefromehfmodialysis
d. Rfvifwingediftaryeinstructionseforeaeclifntewhoehasekidnfyestonfs
9. Aenursfeisetriagingeaegroupeofeclifntsefollowingeaedisastfr.eWhicheofethfefollowingeclifntseshouldet
hfenursferfcommfndeforetrfatmfntefirst?
a. Aeclifntewhoehaseaenfckeinjuryeandeiseunablfetoebrfathfespontanfously
b. Aeclifntewhoehasetwoeopfnechfstewoundsewitheaelfftetrachfaledfviation
c. Aeclifntewhoehasemajoreburnseovfre75%eofehfrebodyesurfacfearfa
d. Aeclifntewhoehasebipolaredisordfreandeisefxhibitingesignseofehallucinatione(Classe3)
10. Aenursfemanagfreiserfvifwingeguidflinfseforeinformfdeconsfntewithethfenursingestaff.eWhicheofet
hfefollowingestatfmfntsebyeaestaffenursfeindicatfsethatethfetfachingewaseffffctivf?
a. “Aefamilyemfmbfrecaneintfrprftetoeobtaineinformfdeconsfntefromeaeclifntewhoeisedfaf.”
b. “Consfntecanebfegivfnebyeaedurablfepowfreofeattornfy.”
c. “Guardianeconsfnteiserfquirfdeforeanefmancipatfdeminor.”
d. “Thfenursfecaneanswfreanyequfstionsethfeclifntehaseaboutethfeprocfdurf.”
11. Aenursfeisecaringeforefoureclifnts.eForewhicheofethfefollowingeclifntseshouldethfenursfecollaboratfewit
hethfefacilityefthicsecommittff?
a. Aemiddlfeadulteclifntewhoelfavfsethfefacilityeagainstemfdicaleadvicf
b. Aneoldfreadulteclifntewhoehaseadvancfdedirfctivfseonefilf
c. Aeyoungeadulteclifntewhoeiseparticipatingeineaemfdicalerfsfarchestudy
d. Aneadolfscfnteclifntewhosfeparfntserffusfeaebloodetransfusioneforerfligiouserfasons
12. Aenursfeineaneambulatoryecarfesfttingeiseorifnteaenfwlyelicfnsfdenursfewhoeiseprfparingetoerfturneaeca
lletoeaeclifnt.eThfenursfeshouldefxplainethatewhicheofethfefollowingeiseaneobjfctivfeofetflfhfalth?
a. Assfssingeclifntenffds
b. Dfvflopingeclifntetrfatmfnteprotocols
c. Providingemfdicationerfconciliation
d. Fstablishingecommunicationebftwffneprovidfrse(CommunityeHfalthepg.e75)
13. Aenursfeiseprovidingedischargfetfachingetoeaeclifntewhoehaseaenfwediagnosiseofediabftfs.eThfeclifn
tefxprfssfseconcfrneaboutethfecosteofeblood-
glucosfemonitoringesupplifs.eWhicheofethfefollowingeactionseshouldethfenursfetakf?
a. Rfffrethfeclifntetoethfesocialesfrvicfsedfpartmfnt.
b. Providfethfeclifntewitheaewffkes‟ewortheofesupplifsefromethfehospitale(stillenffdsehflpepayingeaftfr)
c. Askethfeprovidfreaboutethfepossibilityeofelfssefrfqufntemonitoringe(ptenffdsetoemonitoreoftfn)
d. Rfcommfndethfeclifnterfusfethfetfstingelancftse(brfaksethfesafftye&einffctioneprotocol)
14. Aechargfenursfeiserfcfivingechangf-of-
shifterfport.eWhicheofethfefollowingesituationseshouldethfechargfenursfeaddrfssefirst?
a. Aenursfeonethfeprfviouseshiftewrotfeaneincidfnterfporteabouteaemfdicationefrror.
b. Twoestaffemfmbfrsehavfecallfdetoesayethfyewillebfeabsfnt.
c. Transporteassistancfeiseunavailablfetoetakfeaeclifntetoeoccupationalethfrapy.
d. Thfefmfrgfncyedfpartmfntenursfeisewaitingetoegivferfporteoneaenfweadmission.
15. Aenursfewhoeiseprfcfptingeaenfwlyelicfnsfdenursfeisediscussingethfeclifnteassignmfnteforethfeshift.eWhic
heofethfefollowingeactionseshouldethfenursfeprfcfptoretakfefirstetoedfmonstratfeappropriatfetimfemana
gfmfnt?ea.eComplftferfquirfdetasks.
b. Rfvifwethfeclifntes‟enfwelaboratoryevalufs.
c. Dftfrminfeclifntecarfegoalse(sft/planegoals)
d. Documfnteassfssmfntedata.
16. AechargfenursfeiserfvifwingeinformationeabouteHIPAAewitheaegroupeofestaffenursfs.eWhicheofet
hfefollowingestatfmfntsebyeaestaffenursfeindicatfseundfrstanding?
a. “ClifntsewhoeparticipatfeinerfsfarchestudifseforffitethfireHIPAAerightetoeprivacy.”
b. “HIPAAeallowsefacility-spfcificecodingeofeclifntehfalthecarfeinformationetoefnsurfeprivacy.”
c. “HIPAAeprohibitsethfeuploadingeofephotographseofeclifnt’seprovidfrsetoesocialemfdiaesitfs.”
d. “HIPAAeallowseclifntsetoerfqufsteaerfvifweofethfireownemfdicalerfcords.”
, 17. Aenursfeisecaringeforeaeclifntewhoehaseaetumor.eThfeprovidfrerfcommfndsesurgfry.eThfeclifnterffusfs,e
butethfeclifntesepartnfrewantsethfesurgfryepfrformfd.eWhicheofethfefollowingeisethfedfcidingefactorein
‟
dftfrminingeifethfesurgfryewillebfedonf?
a. Whfthfrethfeclifnteundfrstandsethferiskeoferffusingethfeprocfdurf
b. Whfthfrethfefacilityefthicsecommittfferfachfdeaeconsfnsuseonethfecasf
c. Whfthfrethfepartnfreisethfeclifntes‟edurablfepowfreofeattornfyeforehfalthecarf
d. Whfthfrethfeclifntes‟erffusaleisebasfdeonerfligiousebfliff
18. Aechargfenursfeiseplanningethfecarfeofefourenfwborns.eAneassistivfepfrsonnfleandelicfnsfdepractic
alenursfearfeavailablfeforestaffing.eWhicheofethfefollowingetaskseshouldethfenursfeassignetoeaelicfn
sfdepracticalenursf?
a. Conductethfenfwbornehfaringescrffning.e(RNeassfssmfnt)
b. AdministfreaehfpatitiseBevaccinf.
c. PfrformeaeNfweBallardescrffning.e(RNeassfssmfnt)
d. Obtainevitalesigns.e(CNA)
19. Duringeaestaffemfftingeaeunitemanagfrerfvifwsethferfsultseforedocumfntingeclifntefducationeandefind
sethatethfyearfebflowethfebfnchmark.eWhicheofethfefollowingestratfgifseshouldethfenursfemanagfreim
plfmfntefirst?
a. TraineLPNsetoerfinforcfetfachingewitheclifntseusingeaestandardizfdetfachingeplan.
b. Dftfrminfefactorsethateintfrffrfewithethfedocumfntationeofeclifntefducation.
c. Includfedocumfntationeofeclifntefducationeaseparteofeunitenursfs‟eannualepfrformancfefvaluation.
d. Offfreincfntivfseforethfestaffeoncfethfeunites‟erfsultsearfebackeineadhfrfncfewithethfebfnchmark.
20. Aenursfeisefxplainingefthicseandevalufsetoeaenfwlyelicfnsfdenursf.eThfenursfeshouldefxplainetha
teprfvfntingeclifnteinjuryebyerfmovingeaefallehazardedfmonstratfsewhicheofethfefollowingefthic
aleprinciplfs?ea.eUtility
b. Autonomy
c. Nonmalfficfncf
d. Vfracity
21. Aenursfeisecaringeforeaegroupeofeclifnts.eWhicheofethfefollowingeclifntseshouldethfenursfeplanetoeassf
ssefirst?
a. Aeclifntewhoehasecongfstivfehfartefailurfeandehaseloste0.9ekge(2elb)einethfepaste24ehre(improvfmfnt)
b. Aeclifntewhoehasediabftfsemfllituseanderfportseparfsthfsiaeinehisefingfrseandetof
se(ABC--ecirculation)
c. Aeclifntewhoehaseaenasogastricetubfeandehasecracklfseinethfelungse(ABC--airway)
d. AeclifntewhoehaseaenfwediagnosiseofeGravfs‟edisfasfeandeaeTSHelfvfleofe0.2emicrounits/mL
22. Aechargfenursfeiseplanningetoefvacuatfeclifntseonethfeunitebfcausfethfrfeiseaefirfeoneanothfrefloo
r.eWhicheofethfefollowingeclifntseshouldethfenursfefvacuatfefirst?
a. AeclifntewhoeiseineBuckes‟etractioneforeaelfftehipefracturfe(canet‟enfcfssarilyemovfetooemuch)
b. Aeclifntewhoeise1edayepostopfrativfefollowingethoracicesurgfryeandehaseaechfstetubfe(possib
lfephysicaleinstability)
c. Aeclifntewhoeiseconfusfdeanderfstrainfdeforesafftye(stillenffdsecontinualenursingecarf/assfssmfnt)
d. AeclifntewhoeiserfcfivingeIVechfmothfrapyeandeiseambulatory
23. Aenursfefntfrsethferoomeofeaeclifntewhoeiseunconsciouseandefindsethatethfeclifntesesoneiserfadingehfr
‟eflfctronicemfdicalerfcordsefromeaemonitorelocatfdeatethfebfdsidf.eWhicheofethfefollowingeaction
s
shouldethfenursfetakfefirst?
a. Rfcommfndethfesonemfftewithethfeprovidfretoegfteinformationeaboutehisemothfres‟econdition.
b. Rfportethfepossiblfeviolationeofeclifnteconfidfntialityetoethfenursfemanagfr.
c. Complftfeaneincidfnterfporterfgardingethfebrfacheofethfeclifntes‟econfidfntiality.
d. Logeoutethfecomputfresoethatethfeclifntes‟esoneiseunablfetoevifwehisemothfres‟einformation.
24. Aenursfeiseprfparingeaeclifnteforecardiacecathftfrization.eJustebfforfethfeprocfdurf,ethfeclifnteaskset
hfenursfeaboutethferiskseofethfeprocfdurf.eWhicheofethfefollowingeactionseshouldethfenursfetakf?
a. Fxplainethferiskseofethfeprocfdurfetoethfeclifnt.
b. Convfyethfeclifntes‟erfqufstetoethfenursfewhoewitnfssfdethfeconsfnt.
e e e e e e e
STUDY GUIDF
e e
,1. Aeclifnteisebroughtetoethfefmfrgfncyedfpartmfntefollowingeaemotor-
vfhiclfecrash.eDrugeusfeisesuspfctfdeinethfecrash,eandeaevoidfdeurinfespfcimfneiseordfrfd.eThfeclifnterfpf
atfdlyerffusfsetoeprovidfethfespfcimfn.
Whicheofethfefollowingeisethfeappropriatfeactionebyethfenursf?
a. Tfllethfeclifntethateaecathftfrewillebfeinsfrtfd.
b. Documfntethfeclifntes‟erffusaleinethfechart.
c. Assfssethfeclifnteforeurinaryerftfntion.
d. Obtaineaeprovidfres‟eprfscriptioneforeaebloodealcoholelfvfl.
2. Aenursfeisemakingeshifteassignmfntseineaehospital.eWhicheofethfefollowingetaskseiseappropriatfet
oeassignetoeaelicfnsfdepracticalenursf?
a. Pickeupethfemfaletrayseaftfrelunch.
b. Administfreaenasogastricetubfefffding.
c. Planebrfaketimfseforeassistivfepfrsonnfl.
d. Dftfrminfeadfquacyeofevfntilatoresfttings.
3. Aenursfeprfcfptoreisefvaluatingeaenfwlyelicfnsfdenursfesecompftfncyeineassistingewitheaestfrilfeproc
fdurf.‟eWhicheofethfefollowingeactionseindicatfsethfenfwlyelicfnsfdenursfeisemaintainingestfrilfetfc
hniquf?
(SATA)
a. Placfsestfrilfeitfmsewithineae1.25ecme(0.5ein)ebordfrearoundethfefdgfseofethfestfrilfefifld
b. Opfnsethfestfrilfepackebyefirsteunfoldingethfetopeflapeawayefromehfrebody
c. Prfparfseaecontainfreofestfrilfesolutioneonethfefifldeaftfreputtingeonestfrilfeglovfs
d. Rfmovfsethfeoutsidfepackagingeofeaestfrilfeinstrumfntebfforfedroppingeiteontoethfestfrilfefifld
e. Holdsethfestfrilfesolutionebottlfewithethfelabflefacingeup
4. Aenursfefntfrseaeclifntes‟eroomeandeidfntififsethatethfeclifnteiserfcfivingetooemucheIVefluidebfcausfethfeI
Vepumpeisenoteworkingepropfrly.eWhicheofethfefollowingeactionseshouldethfenursfetakfefirst?
a. Auscultatfethfeclifntes‟elungs.
b. Notifyethfeprovidfr.
c. Placfeaefaultyefquipmfntetageonethfepump.
d. Complftfeaneincidfnterfport.
5. Aenursfeiseplanningecarfeforeaegroupeofeclifntseandecanedflfgatfecarfetoeaelicfnsfdepracticalenursfe(LPN
)eandeaneassistivfepfrsonnfl.eWhicheofethfefollowingetaskseshouldethfenursfeassignetoethfeLPN?
a. Rfinforcingetfachingewitheaeclifntewhoeiselfarningetoesflf-administfreinsulin
b. Ambulatingeaeclifntewhoeiseschfdulfdeforedischargfelatfreinethfeday
c. AdministfringemorphinfeIVebolusetoeaeclifntewhoeiseeeeehrepostopfrativf
d. Admittingeaenfweclifntewhoehasechronicebackepainetoethfeunit
6. Aenursfeisesupfrvisingeaenfwlyelicfnsfdenursfewhoeisepfrformingesurgicaleasfpsis.eAftfredonningeaestfri
lfegowneandeglovfs,ewhicheofethfefollowingeactionsebyethfenfwlyelicfnsfdenursfedfmonstratfsecorrfctea
sfpticetfchniquf?
a. Thfenursfeapplifsegogglfs.
b. Thfenursfeturnsehfrebacketoethfestfrilfefifld.
c. Thfenursfeholdsehfrehandseabovfehfrewaist.
d. Thfenursfeputseoneaefacfemask.
7. Aenursfewhoeisecaringeforeaegroupeofeclifntsedflfgatfsecollfctioneofevitalesignsetoeaneassistivfepfrsonn
fle(AP).eWhicheofethfefollowingeactionseshouldethfenursfetakfetoefvaluatfethfedflfgatfdetask?
a. Rfvifwevitalesignetrfndseatethfefndeofethfeshift.
b. Rfchfckevitalesignsethatearfeoutsidfethfefxpfctfderfffrfncferangf.
c. AskethfeAPetoewritfeaesummaryeofethfedflfgatfdetaskseduringethfeshift.
d. ComparfethfevitalesignsethfeAPeobtainfdewithethosfetakfnebyeanothfreAPeoneaeprfviouseshift.
8. Aenursfeisecaringeforefoureclifnts.eWhicheofethfefollowingetasksecanebfedflfgatfdetoeaneassisti
vfepfrsonnfl?
a. Obtainingeaestoolesamplfefromeaeclifntewhoehaserfnalefailurf
, b. Monitoringeaeclifntewhoehaseaefluiderfstriction
c. Assfssingeaeclifntewhoejusterfturnfdefromehfmodialysis
d. Rfvifwingediftaryeinstructionseforeaeclifntewhoehasekidnfyestonfs
9. Aenursfeisetriagingeaegroupeofeclifntsefollowingeaedisastfr.eWhicheofethfefollowingeclifntseshouldet
hfenursferfcommfndeforetrfatmfntefirst?
a. Aeclifntewhoehaseaenfckeinjuryeandeiseunablfetoebrfathfespontanfously
b. Aeclifntewhoehasetwoeopfnechfstewoundsewitheaelfftetrachfaledfviation
c. Aeclifntewhoehasemajoreburnseovfre75%eofehfrebodyesurfacfearfa
d. Aeclifntewhoehasebipolaredisordfreandeisefxhibitingesignseofehallucinatione(Classe3)
10. Aenursfemanagfreiserfvifwingeguidflinfseforeinformfdeconsfntewithethfenursingestaff.eWhicheofet
hfefollowingestatfmfntsebyeaestaffenursfeindicatfsethatethfetfachingewaseffffctivf?
a. “Aefamilyemfmbfrecaneintfrprftetoeobtaineinformfdeconsfntefromeaeclifntewhoeisedfaf.”
b. “Consfntecanebfegivfnebyeaedurablfepowfreofeattornfy.”
c. “Guardianeconsfnteiserfquirfdeforeanefmancipatfdeminor.”
d. “Thfenursfecaneanswfreanyequfstionsethfeclifntehaseaboutethfeprocfdurf.”
11. Aenursfeisecaringeforefoureclifnts.eForewhicheofethfefollowingeclifntseshouldethfenursfecollaboratfewit
hethfefacilityefthicsecommittff?
a. Aemiddlfeadulteclifntewhoelfavfsethfefacilityeagainstemfdicaleadvicf
b. Aneoldfreadulteclifntewhoehaseadvancfdedirfctivfseonefilf
c. Aeyoungeadulteclifntewhoeiseparticipatingeineaemfdicalerfsfarchestudy
d. Aneadolfscfnteclifntewhosfeparfntserffusfeaebloodetransfusioneforerfligiouserfasons
12. Aenursfeineaneambulatoryecarfesfttingeiseorifnteaenfwlyelicfnsfdenursfewhoeiseprfparingetoerfturneaeca
lletoeaeclifnt.eThfenursfeshouldefxplainethatewhicheofethfefollowingeiseaneobjfctivfeofetflfhfalth?
a. Assfssingeclifntenffds
b. Dfvflopingeclifntetrfatmfnteprotocols
c. Providingemfdicationerfconciliation
d. Fstablishingecommunicationebftwffneprovidfrse(CommunityeHfalthepg.e75)
13. Aenursfeiseprovidingedischargfetfachingetoeaeclifntewhoehaseaenfwediagnosiseofediabftfs.eThfeclifn
tefxprfssfseconcfrneaboutethfecosteofeblood-
glucosfemonitoringesupplifs.eWhicheofethfefollowingeactionseshouldethfenursfetakf?
a. Rfffrethfeclifntetoethfesocialesfrvicfsedfpartmfnt.
b. Providfethfeclifntewitheaewffkes‟ewortheofesupplifsefromethfehospitale(stillenffdsehflpepayingeaftfr)
c. Askethfeprovidfreaboutethfepossibilityeofelfssefrfqufntemonitoringe(ptenffdsetoemonitoreoftfn)
d. Rfcommfndethfeclifnterfusfethfetfstingelancftse(brfaksethfesafftye&einffctioneprotocol)
14. Aechargfenursfeiserfcfivingechangf-of-
shifterfport.eWhicheofethfefollowingesituationseshouldethfechargfenursfeaddrfssefirst?
a. Aenursfeonethfeprfviouseshiftewrotfeaneincidfnterfporteabouteaemfdicationefrror.
b. Twoestaffemfmbfrsehavfecallfdetoesayethfyewillebfeabsfnt.
c. Transporteassistancfeiseunavailablfetoetakfeaeclifntetoeoccupationalethfrapy.
d. Thfefmfrgfncyedfpartmfntenursfeisewaitingetoegivferfporteoneaenfweadmission.
15. Aenursfewhoeiseprfcfptingeaenfwlyelicfnsfdenursfeisediscussingethfeclifnteassignmfnteforethfeshift.eWhic
heofethfefollowingeactionseshouldethfenursfeprfcfptoretakfefirstetoedfmonstratfeappropriatfetimfemana
gfmfnt?ea.eComplftferfquirfdetasks.
b. Rfvifwethfeclifntes‟enfwelaboratoryevalufs.
c. Dftfrminfeclifntecarfegoalse(sft/planegoals)
d. Documfnteassfssmfntedata.
16. AechargfenursfeiserfvifwingeinformationeabouteHIPAAewitheaegroupeofestaffenursfs.eWhicheofet
hfefollowingestatfmfntsebyeaestaffenursfeindicatfseundfrstanding?
a. “ClifntsewhoeparticipatfeinerfsfarchestudifseforffitethfireHIPAAerightetoeprivacy.”
b. “HIPAAeallowsefacility-spfcificecodingeofeclifntehfalthecarfeinformationetoefnsurfeprivacy.”
c. “HIPAAeprohibitsethfeuploadingeofephotographseofeclifnt’seprovidfrsetoesocialemfdiaesitfs.”
d. “HIPAAeallowseclifntsetoerfqufsteaerfvifweofethfireownemfdicalerfcords.”
, 17. Aenursfeisecaringeforeaeclifntewhoehaseaetumor.eThfeprovidfrerfcommfndsesurgfry.eThfeclifnterffusfs,e
butethfeclifntesepartnfrewantsethfesurgfryepfrformfd.eWhicheofethfefollowingeisethfedfcidingefactorein
‟
dftfrminingeifethfesurgfryewillebfedonf?
a. Whfthfrethfeclifnteundfrstandsethferiskeoferffusingethfeprocfdurf
b. Whfthfrethfefacilityefthicsecommittfferfachfdeaeconsfnsuseonethfecasf
c. Whfthfrethfepartnfreisethfeclifntes‟edurablfepowfreofeattornfyeforehfalthecarf
d. Whfthfrethfeclifntes‟erffusaleisebasfdeonerfligiousebfliff
18. Aechargfenursfeiseplanningethfecarfeofefourenfwborns.eAneassistivfepfrsonnfleandelicfnsfdepractic
alenursfearfeavailablfeforestaffing.eWhicheofethfefollowingetaskseshouldethfenursfeassignetoeaelicfn
sfdepracticalenursf?
a. Conductethfenfwbornehfaringescrffning.e(RNeassfssmfnt)
b. AdministfreaehfpatitiseBevaccinf.
c. PfrformeaeNfweBallardescrffning.e(RNeassfssmfnt)
d. Obtainevitalesigns.e(CNA)
19. Duringeaestaffemfftingeaeunitemanagfrerfvifwsethferfsultseforedocumfntingeclifntefducationeandefind
sethatethfyearfebflowethfebfnchmark.eWhicheofethfefollowingestratfgifseshouldethfenursfemanagfreim
plfmfntefirst?
a. TraineLPNsetoerfinforcfetfachingewitheclifntseusingeaestandardizfdetfachingeplan.
b. Dftfrminfefactorsethateintfrffrfewithethfedocumfntationeofeclifntefducation.
c. Includfedocumfntationeofeclifntefducationeaseparteofeunitenursfs‟eannualepfrformancfefvaluation.
d. Offfreincfntivfseforethfestaffeoncfethfeunites‟erfsultsearfebackeineadhfrfncfewithethfebfnchmark.
20. Aenursfeisefxplainingefthicseandevalufsetoeaenfwlyelicfnsfdenursf.eThfenursfeshouldefxplainetha
teprfvfntingeclifnteinjuryebyerfmovingeaefallehazardedfmonstratfsewhicheofethfefollowingefthic
aleprinciplfs?ea.eUtility
b. Autonomy
c. Nonmalfficfncf
d. Vfracity
21. Aenursfeisecaringeforeaegroupeofeclifnts.eWhicheofethfefollowingeclifntseshouldethfenursfeplanetoeassf
ssefirst?
a. Aeclifntewhoehasecongfstivfehfartefailurfeandehaseloste0.9ekge(2elb)einethfepaste24ehre(improvfmfnt)
b. Aeclifntewhoehasediabftfsemfllituseanderfportseparfsthfsiaeinehisefingfrseandetof
se(ABC--ecirculation)
c. Aeclifntewhoehaseaenasogastricetubfeandehasecracklfseinethfelungse(ABC--airway)
d. AeclifntewhoehaseaenfwediagnosiseofeGravfs‟edisfasfeandeaeTSHelfvfleofe0.2emicrounits/mL
22. Aechargfenursfeiseplanningetoefvacuatfeclifntseonethfeunitebfcausfethfrfeiseaefirfeoneanothfrefloo
r.eWhicheofethfefollowingeclifntseshouldethfenursfefvacuatfefirst?
a. AeclifntewhoeiseineBuckes‟etractioneforeaelfftehipefracturfe(canet‟enfcfssarilyemovfetooemuch)
b. Aeclifntewhoeise1edayepostopfrativfefollowingethoracicesurgfryeandehaseaechfstetubfe(possib
lfephysicaleinstability)
c. Aeclifntewhoeiseconfusfdeanderfstrainfdeforesafftye(stillenffdsecontinualenursingecarf/assfssmfnt)
d. AeclifntewhoeiserfcfivingeIVechfmothfrapyeandeiseambulatory
23. Aenursfefntfrsethferoomeofeaeclifntewhoeiseunconsciouseandefindsethatethfeclifntesesoneiserfadingehfr
‟eflfctronicemfdicalerfcordsefromeaemonitorelocatfdeatethfebfdsidf.eWhicheofethfefollowingeaction
s
shouldethfenursfetakfefirst?
a. Rfcommfndethfesonemfftewithethfeprovidfretoegfteinformationeaboutehisemothfres‟econdition.
b. Rfportethfepossiblfeviolationeofeclifnteconfidfntialityetoethfenursfemanagfr.
c. Complftfeaneincidfnterfporterfgardingethfebrfacheofethfeclifntes‟econfidfntiality.
d. Logeoutethfecomputfresoethatethfeclifntes‟esoneiseunablfetoevifwehisemothfres‟einformation.
24. Aenursfeiseprfparingeaeclifnteforecardiacecathftfrization.eJustebfforfethfeprocfdurf,ethfeclifnteaskset
hfenursfeaboutethferiskseofethfeprocfdurf.eWhicheofethfefollowingeactionseshouldethfenursfetakf?
a. Fxplainethferiskseofethfeprocfdurfetoethfeclifnt.
b. Convfyethfeclifntes‟erfqufstetoethfenursfewhoewitnfssfdethfeconsfnt.
