Nur 004 Actual Exam Questions and Answers|
Updated 2025 (answers highlighted)
A nurse notices that a client who is 1-day postoperative knee replacement surgery has
a cool numb foot with a weak peripheral pulse. The nurse pages and asks the health
care provider (HCP) to come see the client. The HCP states that the client's foot has
been like that since surgery and that there is no need to come. Under the Team
Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)
process, what step should the nurse take next?
1. Continue to assess the foot hourly
2. Document the HCP's statement
3. Elevate the affected leg on a pillow
4. Repeat request for HCP to come
4
Four clients come to the emergency department (ED). Which client should the triage
registered nurse (RN) assign as highest priority for definitive diagnosis and treatment?
1. Client with chronic obstructive pulmonary disease (COPD) with yellow
expectoration and an oxygen saturation of 91%
2. Healthy child with new-onset fiery-red rash on cheeks and the "flu"
3. Middle-aged client with vaginal itching and white, curdlike discharge
4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face
4
The nurse is working in a busy emergency department and is assigned 4 clients. Which
client should the nurse see first?
1. Client receiving cyclophosphamide reporting bloody urine
2. Client who reports severe nausea and vomiting after chemotherapy
,3. Client with an elbow abrasion and a lip laceration possibly requiring sutures
4. Homeless client who appears drowsy with a temperature of 95 F (35 C)
4
Which of these tasks are appropriate for the registered nurse (RN) to delegate to
unlicensed assistive personnel (UAP)? Select all that apply.
1. Assign lunch times to the other UAP on the unit
2. Assist a client with a new ostomy with bathing and changing pouches
3. Collect vital signs on a client 4 hours after laparoscopic appendectomy
4. Pick up an intravenous antibiotic from the pharmacy
5. Record intake and output for a client with metabolic alkalosis
3,4,5
The nurse on a medical unit is preparing to assess assigned clients after receiving
change of shift report. Which client should the nurse assess first?
1. Client with Grave's disease and heart rate of 110/min
2. Client with pneumonia on day 3 of antibiotics needs a new IV line
3. Client with sickle cell disease who rates pain as 9 on a scale of 0-10
4. Client with type 2 diabetes and fingerstick glucose level of 220 mg/dL (12.2 mmol/L)
3
A client with terminal cancer has named the sister as the durable power of attorney
for health care (health care proxy). The client arrives unconscious at the emergency
department with a heart rate of 20/min. The client's spouse and sister are present.
How should the caregiving be handled?
1. Ask the spouse what should be done
2. Get directions about care from the sister
,3. Immediately administer epinephrine
4. Provide only comfort measures
2
The emergency department nurse is triaging clients. Which client is a priority for
diagnostic workup and definitive care?
1. Fell, twisting the right knee; heard a "pop"
2. History of glomerulonephritis; has "iced tea"-colored urine
3. Pain 10/10 in reddened eye; wears contact lens
4. Took a handful of amitriptyline tablets after a fight with spouse
4
The nurse receives report on 4 clients. Which client should the nurse see first?
1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with
bright red blood
2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the infected
foot ulcer fall off
3. Client with arteriovenous graft for hemodialysis access has new-onset pain and
redness at graft site
4. Client with urinary retention and infection receiving antibiotics is confused and
trying to pull out Foley catheter
1
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon
explains to the client's child, who speaks both Spanish and English, that an exploratory
laparotomy is needed to determine the cause of the obstruction and possible causes
include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to
translate this information for the client and assist with translating the consent form.
, Which is the most appropriate action by the nurse?
1. Act as a witness for the informed consent process
2. Provide additional information about what the client can expect
3. Report the surgeon to the ethics board for using an inappropriate consent process
4. Talk to the surgeon privately about using a trained Spanish-language medical
interpreter
4
Which client should the charge nurse assign to the room closest to the nurses' station?
1. Client with a Salem sump tube to continuous suction who is deaf
2. Client with gastroenteritis and dementia who wanders
3. Client with herpes zoster under airborne isolation precautions
4. Client with sickle cell crisis who requires frequent intravenous opioids
2
The day nurse gets the following hand-off report from the night nurse. The nurse
should assess which client first?
1. Client with cellulitis, medicated with hydromorphone IV 1 hour ago, reports pain of
6 on a scale of 0-10
2. Client with chronic kidney disease with hemoglobin 8 g/dL (80 g/L) and hematocrit
24% (0.24), is short of breath with activity
3. Client with heart failure and bilateral pleural effusions with serum sodium of 133
mEq/L (133 mmol/L), is scheduled for a thoracentesis this morning
4. Client with pneumonia and reactive airway disease, developed increased shortness
of breath and high-pitched wheezing 10 minutes ago
4
Updated 2025 (answers highlighted)
A nurse notices that a client who is 1-day postoperative knee replacement surgery has
a cool numb foot with a weak peripheral pulse. The nurse pages and asks the health
care provider (HCP) to come see the client. The HCP states that the client's foot has
been like that since surgery and that there is no need to come. Under the Team
Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)
process, what step should the nurse take next?
1. Continue to assess the foot hourly
2. Document the HCP's statement
3. Elevate the affected leg on a pillow
4. Repeat request for HCP to come
4
Four clients come to the emergency department (ED). Which client should the triage
registered nurse (RN) assign as highest priority for definitive diagnosis and treatment?
1. Client with chronic obstructive pulmonary disease (COPD) with yellow
expectoration and an oxygen saturation of 91%
2. Healthy child with new-onset fiery-red rash on cheeks and the "flu"
3. Middle-aged client with vaginal itching and white, curdlike discharge
4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face
4
The nurse is working in a busy emergency department and is assigned 4 clients. Which
client should the nurse see first?
1. Client receiving cyclophosphamide reporting bloody urine
2. Client who reports severe nausea and vomiting after chemotherapy
,3. Client with an elbow abrasion and a lip laceration possibly requiring sutures
4. Homeless client who appears drowsy with a temperature of 95 F (35 C)
4
Which of these tasks are appropriate for the registered nurse (RN) to delegate to
unlicensed assistive personnel (UAP)? Select all that apply.
1. Assign lunch times to the other UAP on the unit
2. Assist a client with a new ostomy with bathing and changing pouches
3. Collect vital signs on a client 4 hours after laparoscopic appendectomy
4. Pick up an intravenous antibiotic from the pharmacy
5. Record intake and output for a client with metabolic alkalosis
3,4,5
The nurse on a medical unit is preparing to assess assigned clients after receiving
change of shift report. Which client should the nurse assess first?
1. Client with Grave's disease and heart rate of 110/min
2. Client with pneumonia on day 3 of antibiotics needs a new IV line
3. Client with sickle cell disease who rates pain as 9 on a scale of 0-10
4. Client with type 2 diabetes and fingerstick glucose level of 220 mg/dL (12.2 mmol/L)
3
A client with terminal cancer has named the sister as the durable power of attorney
for health care (health care proxy). The client arrives unconscious at the emergency
department with a heart rate of 20/min. The client's spouse and sister are present.
How should the caregiving be handled?
1. Ask the spouse what should be done
2. Get directions about care from the sister
,3. Immediately administer epinephrine
4. Provide only comfort measures
2
The emergency department nurse is triaging clients. Which client is a priority for
diagnostic workup and definitive care?
1. Fell, twisting the right knee; heard a "pop"
2. History of glomerulonephritis; has "iced tea"-colored urine
3. Pain 10/10 in reddened eye; wears contact lens
4. Took a handful of amitriptyline tablets after a fight with spouse
4
The nurse receives report on 4 clients. Which client should the nurse see first?
1. Client 2 hours post foot amputation surgery has a surgical dressing saturated with
bright red blood
2. Client scheduled for whirlpool bath in 20 minutes has the dressing on the infected
foot ulcer fall off
3. Client with arteriovenous graft for hemodialysis access has new-onset pain and
redness at graft site
4. Client with urinary retention and infection receiving antibiotics is confused and
trying to pull out Foley catheter
1
A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon
explains to the client's child, who speaks both Spanish and English, that an exploratory
laparotomy is needed to determine the cause of the obstruction and possible causes
include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to
translate this information for the client and assist with translating the consent form.
, Which is the most appropriate action by the nurse?
1. Act as a witness for the informed consent process
2. Provide additional information about what the client can expect
3. Report the surgeon to the ethics board for using an inappropriate consent process
4. Talk to the surgeon privately about using a trained Spanish-language medical
interpreter
4
Which client should the charge nurse assign to the room closest to the nurses' station?
1. Client with a Salem sump tube to continuous suction who is deaf
2. Client with gastroenteritis and dementia who wanders
3. Client with herpes zoster under airborne isolation precautions
4. Client with sickle cell crisis who requires frequent intravenous opioids
2
The day nurse gets the following hand-off report from the night nurse. The nurse
should assess which client first?
1. Client with cellulitis, medicated with hydromorphone IV 1 hour ago, reports pain of
6 on a scale of 0-10
2. Client with chronic kidney disease with hemoglobin 8 g/dL (80 g/L) and hematocrit
24% (0.24), is short of breath with activity
3. Client with heart failure and bilateral pleural effusions with serum sodium of 133
mEq/L (133 mmol/L), is scheduled for a thoracentesis this morning
4. Client with pneumonia and reactive airway disease, developed increased shortness
of breath and high-pitched wheezing 10 minutes ago
4
