NUR 100 Exam 1
A nurse in a long term care facility is performing client checks and observes a fire in a client's room. Which of the following
should be the first action by the nurse?
A- Activate the fire alarm
B- Close all the doors and windows
C- Evacuate the client from the room
D- Extinguish the fire
C- Evacuate the client from the room.
Client safety is the priority, therefore evacuating the client from teh room is the first action the nurse should take.
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the
nurse take?
A - provide support by holding the client's arm
B - Lean the client toward the wall
C- Lower the client to the floor
D- Assume a narrow base of support
C - lower the client to the floor
This is an appropriate action. The nurse should gently lower the client to the floor.
Which activity would be most appropriate for the RN to delegate to the unlicensed assistive personnel (UAP)?
,A - Assessing the patient for fall risk and complications of restraint use
B - Evaluating the patient's ability to performs ADLs
C - Assisting the patient with ADLs
D- Teaching the patient how to use an assistive device for walking
C - Assisting the patient with ADLs
UAP can assist with the performance of ADLS
A nurse is planning care for a client admitted with a positive culture for methicillin-resistant Staphylococcus aureus
(MRSA). Which prevention should be implemented to prevent spreading the infection to health care workers and other
clients?
A - Wearing a mask within 3 feet of the client
B - Placing the client in a private room
C - Wearing a N95 respirator mask
D - Ensuring a negative air pressure room
B - Placing the client in a private room
Contact isolation
A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following
statements should the nurse include?
A - If you wear gloves, you do not have to wash your hands
B - Hand hygiene is crucial in preventing the spread of germs.
C- Use an alcohol rub when your hands are visibly soiled
, D - If you do not have an infection, your hand won't infect others
B- Handy hygiene is crucial in preventing the spread of germs
Hand hygiene is one of the most effective ways to prevent the transmission of pathogens. Either the nurse or the client
may have microorganisms on or in their body that do not harm them but may harm others.
The nurse is documenting the client's nursing diagnosis as "Altered speech related to recent neurological disturbance as
evidenced by inability to speak in complete sentences". Identify the defining characteristics below.
A - "Altered speech"
B - "As evidenced by"
C - "Inability to speak in complete sentences"
D - "recent neurological disturbance"
C - "Inability to speak in complete sentences"
The 3 step nursing diagnosis process is Problem r/t etiology aeb defining characteristics
An unlicensed personnel (UAP) is obtaining a client's oral temperature. The client informs the UAP that he has just had
some ice chips. Which of the following is an appropriate action by the UAP?
A- Wait 20-30 minutes and return to take the oral temperature
B - provide a sip of warm water, wait 5 minutes and take the temperature
C- Document that a temperature was unable to be obtained
D - Proceed to take the oral temperature
A - Wait 20-30 minutes and return to take the oral temperature
A nurse in a long term care facility is performing client checks and observes a fire in a client's room. Which of the following
should be the first action by the nurse?
A- Activate the fire alarm
B- Close all the doors and windows
C- Evacuate the client from the room
D- Extinguish the fire
C- Evacuate the client from the room.
Client safety is the priority, therefore evacuating the client from teh room is the first action the nurse should take.
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the
nurse take?
A - provide support by holding the client's arm
B - Lean the client toward the wall
C- Lower the client to the floor
D- Assume a narrow base of support
C - lower the client to the floor
This is an appropriate action. The nurse should gently lower the client to the floor.
Which activity would be most appropriate for the RN to delegate to the unlicensed assistive personnel (UAP)?
,A - Assessing the patient for fall risk and complications of restraint use
B - Evaluating the patient's ability to performs ADLs
C - Assisting the patient with ADLs
D- Teaching the patient how to use an assistive device for walking
C - Assisting the patient with ADLs
UAP can assist with the performance of ADLS
A nurse is planning care for a client admitted with a positive culture for methicillin-resistant Staphylococcus aureus
(MRSA). Which prevention should be implemented to prevent spreading the infection to health care workers and other
clients?
A - Wearing a mask within 3 feet of the client
B - Placing the client in a private room
C - Wearing a N95 respirator mask
D - Ensuring a negative air pressure room
B - Placing the client in a private room
Contact isolation
A nurse is teaching a new group of assistive personnel (AP) about the importance of hand hygiene. Which of the following
statements should the nurse include?
A - If you wear gloves, you do not have to wash your hands
B - Hand hygiene is crucial in preventing the spread of germs.
C- Use an alcohol rub when your hands are visibly soiled
, D - If you do not have an infection, your hand won't infect others
B- Handy hygiene is crucial in preventing the spread of germs
Hand hygiene is one of the most effective ways to prevent the transmission of pathogens. Either the nurse or the client
may have microorganisms on or in their body that do not harm them but may harm others.
The nurse is documenting the client's nursing diagnosis as "Altered speech related to recent neurological disturbance as
evidenced by inability to speak in complete sentences". Identify the defining characteristics below.
A - "Altered speech"
B - "As evidenced by"
C - "Inability to speak in complete sentences"
D - "recent neurological disturbance"
C - "Inability to speak in complete sentences"
The 3 step nursing diagnosis process is Problem r/t etiology aeb defining characteristics
An unlicensed personnel (UAP) is obtaining a client's oral temperature. The client informs the UAP that he has just had
some ice chips. Which of the following is an appropriate action by the UAP?
A- Wait 20-30 minutes and return to take the oral temperature
B - provide a sip of warm water, wait 5 minutes and take the temperature
C- Document that a temperature was unable to be obtained
D - Proceed to take the oral temperature
A - Wait 20-30 minutes and return to take the oral temperature
