Client call lights come on while the unlicensed assistive personnel (UAP) sits at a
desk and reads a magazine. When the nurse asks the UAP to answer the lights, the
UAP says, "Those aren't my clients." What is the best response by the nurse?
1. "Would you mind answering the lights anyway?"
2. "I need you to answer the lights because we want to provide good client care."
3. Say nothing and answer the lights, but write up a disciplinary action
4. Tell the UAP that this is unacceptable and speak to the nurse manager. -
ANSWER 2
The risk management nurse is reviewing client records. Which nursing
intervention could have contributed to a sentinel event?
1. Administered flumazenil to a client who overdosed on lorazepam
2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2
mmol/L)
3. Administered warfarin to a client with International Normalized Ratio of 6
4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
- ANSWER 3
The registered nurse is caring for multiple clients on a busy surgical unit and
should delegate which action to the unlicensed assistive personnel?
,1. Assist client, post hip fracture repair, to the bathroom
2. Check the appearance of client's wound
3. If client tolerates oral liquids, discontinue nasogastric tube
4. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L)
- ANSWER 1
Which statements related to ethical nursing practices are correct? Select all that
apply.
1. Accountability is documenting that the nurse administered the wrong
,medication
2. Autonomy is informing the client of the decision the family made for the client
3. Confidentiality is respecting a client's request to keep suicidal ideation a secret
4. Justice is providing the same cardiac care to a homeless person as a
businessperson 5.Nonmaleficence is reporting abuse for a client with Alzheimer
disease - ANSWER 1,4,5
A major earthquake has occurred. Local gas lines and water pipes are breaking
with resulting fires and flooding in collapsed buildings. Multiple victims come to
the triage area. Which client would the nurse care for first?
1. Charred leathery skin over entire back, chest, and legs
2. Client shivering from sitting in water until rescued
3. Diabetic client who was unable to take insulin today
4. High-pitched, crowing inspiratory respirations - ANSWER 4
The charge nurse on a medical-surgical step-down unit is responsible for making
assignments. Which client is most appropriate to assign to a new graduate nurse
who is still in orientation?
1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery
with a diminished pedal pulse
2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure
currently 180/102 mm Hg; reports headache and blurred vision
3. 75-year-old client with an ischemic stroke transferred from the intensive care
unit 1 hour ago; unresponsive with right-sided paralysis
4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent
dressing changes due to excessive drainage - ANSWER 4
An unaccompanied 16-year-old female comes to the emergency department with
severe abdominal pain and vomiting. The minor has a temperature of 102.2 F (39 C)
and a pulse of 120 /min and is lethargic. The parents are out of town, and no
guardians could be reached. How should the care be handled?
1. Administer care until parents or guardians can be reached
2. Keep the minor but without giving care until parents or guardians can be
, reached
3. Perform bba bbpregnancy bbtest bbto bbsee bbif bbthe bbminor bbqualifies bbas bban bbemancipated
bbminor
4. Provide bbhealth bbcare bband bbfollow-up bbadvice bbbut bbdo bbnot bbgive bbany bbdirect
bbcare bb- bbANSWER 1
A bbstaff bbnurse bbautomatically bbtakes bba bblunch bbbreak bbfirst bbevery bbday bbinstead bbof
bbasking bbother bbstaff bbnurses bbabout bbtheir bbpreferences. bbAnother bbnurse bbwould bblike
bbto bbtake bbthe bbfirst bblunch bbbreak bbtime bbsometimes. bbWhich bbis bbthe bbbest bbway bbfor
bbthe bbstaff bbnurse bbto bbhandle bbthe bbsituation bbinitially?
1. Ask bbthe bbnurse bbmanager bbto bbtalk bbto bbthe bbnurse bbwho bbtakes bbthe bbfirst bbbreak bbtime
2. Poll bbthe bbother bbstaff bbnurses bbto bbsee bbwhat bbthey bbthink bbabout bbthe bbsituation
3. Realize bbthat bbsome bbmatters bbare bbnot bbworth bbbringing bbup bband bbsay bbnothing
4. Tell bbthe bbnurse bbdirectly bbof bbwanting bbto bbtake bbthe bbfirst bblunch bbbreak
bbsometimes bb- bbANSWER 4
The bbnurse bbreviews bbthe bblaboratory bbresults bbfor bb4 bbassigned bbclients. bbWhich bbresult
bbis bbmost bbimportant bbfor bbthe bbnurse bbto bbreport bbto bbthe bbprimary bbhealth bbcare
bbprovider?
1. Client bbwith bbatrial bbfibrillation bbreceiving bbwarfarin bbfor bb7 bbdays bbwith bban
bbInternational bbNormalized bbRatio bb(INR) bbof bb1.3
2. Client bbwith bbchronic bbbronchitis bbwho bbhas bba bbhematocrit bbof bb56% bb[0.56]
bband bbhemoglobin bbof bb19 bbg/dL bb(190 bbg/L)
3. Client bbwith bbClostridium bbdifficile bbinfection bbwho bbhas bba bbwhite bbblood bbcell
bbcount bbof bb15,000/mm3 bb(15 bb× bb109/L)
4. Client bbwith bbsepsis bbreceiving bbgentamycin bbwho bbhas bba bbcreatinine bbof bb0.6
bbmg/dL bb(53 bbµmol/L) bb- ANSWER 1
It bbis bbthe bbfirst bbday bbon bbthe bbjob bbfor bbthe bbnewly bbhired bbunlicensed bbassistive
bbpersonnel bb(UAP). bbWhich bbof bbthese bbillustrate bbappropriate bbdelegation
bbinstructions bbfor bbthe bbregistered bbnurse bb(RN) bbto bbgive bbthe bbUAP? bbSelect bball bbthat
bbapply.
1. "Elevate bbthe bbright bbleg bbon bbtwo bbpillows."
2. "Measure bbclient bbfor bbcompression bbstockings."
3. "Please bblet bbme bbknow bbwhat bbthe bburine bblooks bblike."
desk and reads a magazine. When the nurse asks the UAP to answer the lights, the
UAP says, "Those aren't my clients." What is the best response by the nurse?
1. "Would you mind answering the lights anyway?"
2. "I need you to answer the lights because we want to provide good client care."
3. Say nothing and answer the lights, but write up a disciplinary action
4. Tell the UAP that this is unacceptable and speak to the nurse manager. -
ANSWER 2
The risk management nurse is reviewing client records. Which nursing
intervention could have contributed to a sentinel event?
1. Administered flumazenil to a client who overdosed on lorazepam
2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2
mmol/L)
3. Administered warfarin to a client with International Normalized Ratio of 6
4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
- ANSWER 3
The registered nurse is caring for multiple clients on a busy surgical unit and
should delegate which action to the unlicensed assistive personnel?
,1. Assist client, post hip fracture repair, to the bathroom
2. Check the appearance of client's wound
3. If client tolerates oral liquids, discontinue nasogastric tube
4. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L)
- ANSWER 1
Which statements related to ethical nursing practices are correct? Select all that
apply.
1. Accountability is documenting that the nurse administered the wrong
,medication
2. Autonomy is informing the client of the decision the family made for the client
3. Confidentiality is respecting a client's request to keep suicidal ideation a secret
4. Justice is providing the same cardiac care to a homeless person as a
businessperson 5.Nonmaleficence is reporting abuse for a client with Alzheimer
disease - ANSWER 1,4,5
A major earthquake has occurred. Local gas lines and water pipes are breaking
with resulting fires and flooding in collapsed buildings. Multiple victims come to
the triage area. Which client would the nurse care for first?
1. Charred leathery skin over entire back, chest, and legs
2. Client shivering from sitting in water until rescued
3. Diabetic client who was unable to take insulin today
4. High-pitched, crowing inspiratory respirations - ANSWER 4
The charge nurse on a medical-surgical step-down unit is responsible for making
assignments. Which client is most appropriate to assign to a new graduate nurse
who is still in orientation?
1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery
with a diminished pedal pulse
2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure
currently 180/102 mm Hg; reports headache and blurred vision
3. 75-year-old client with an ischemic stroke transferred from the intensive care
unit 1 hour ago; unresponsive with right-sided paralysis
4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent
dressing changes due to excessive drainage - ANSWER 4
An unaccompanied 16-year-old female comes to the emergency department with
severe abdominal pain and vomiting. The minor has a temperature of 102.2 F (39 C)
and a pulse of 120 /min and is lethargic. The parents are out of town, and no
guardians could be reached. How should the care be handled?
1. Administer care until parents or guardians can be reached
2. Keep the minor but without giving care until parents or guardians can be
, reached
3. Perform bba bbpregnancy bbtest bbto bbsee bbif bbthe bbminor bbqualifies bbas bban bbemancipated
bbminor
4. Provide bbhealth bbcare bband bbfollow-up bbadvice bbbut bbdo bbnot bbgive bbany bbdirect
bbcare bb- bbANSWER 1
A bbstaff bbnurse bbautomatically bbtakes bba bblunch bbbreak bbfirst bbevery bbday bbinstead bbof
bbasking bbother bbstaff bbnurses bbabout bbtheir bbpreferences. bbAnother bbnurse bbwould bblike
bbto bbtake bbthe bbfirst bblunch bbbreak bbtime bbsometimes. bbWhich bbis bbthe bbbest bbway bbfor
bbthe bbstaff bbnurse bbto bbhandle bbthe bbsituation bbinitially?
1. Ask bbthe bbnurse bbmanager bbto bbtalk bbto bbthe bbnurse bbwho bbtakes bbthe bbfirst bbbreak bbtime
2. Poll bbthe bbother bbstaff bbnurses bbto bbsee bbwhat bbthey bbthink bbabout bbthe bbsituation
3. Realize bbthat bbsome bbmatters bbare bbnot bbworth bbbringing bbup bband bbsay bbnothing
4. Tell bbthe bbnurse bbdirectly bbof bbwanting bbto bbtake bbthe bbfirst bblunch bbbreak
bbsometimes bb- bbANSWER 4
The bbnurse bbreviews bbthe bblaboratory bbresults bbfor bb4 bbassigned bbclients. bbWhich bbresult
bbis bbmost bbimportant bbfor bbthe bbnurse bbto bbreport bbto bbthe bbprimary bbhealth bbcare
bbprovider?
1. Client bbwith bbatrial bbfibrillation bbreceiving bbwarfarin bbfor bb7 bbdays bbwith bban
bbInternational bbNormalized bbRatio bb(INR) bbof bb1.3
2. Client bbwith bbchronic bbbronchitis bbwho bbhas bba bbhematocrit bbof bb56% bb[0.56]
bband bbhemoglobin bbof bb19 bbg/dL bb(190 bbg/L)
3. Client bbwith bbClostridium bbdifficile bbinfection bbwho bbhas bba bbwhite bbblood bbcell
bbcount bbof bb15,000/mm3 bb(15 bb× bb109/L)
4. Client bbwith bbsepsis bbreceiving bbgentamycin bbwho bbhas bba bbcreatinine bbof bb0.6
bbmg/dL bb(53 bbµmol/L) bb- ANSWER 1
It bbis bbthe bbfirst bbday bbon bbthe bbjob bbfor bbthe bbnewly bbhired bbunlicensed bbassistive
bbpersonnel bb(UAP). bbWhich bbof bbthese bbillustrate bbappropriate bbdelegation
bbinstructions bbfor bbthe bbregistered bbnurse bb(RN) bbto bbgive bbthe bbUAP? bbSelect bball bbthat
bbapply.
1. "Elevate bbthe bbright bbleg bbon bbtwo bbpillows."
2. "Measure bbclient bbfor bbcompression bbstockings."
3. "Please bblet bbme bbknow bbwhat bbthe bburine bblooks bblike."
