Nur 004 Exam Questions With Complete Solutions
A 16-year-old walks in unaccompanied by a parent and
approaches the clinic nurse. The adolescent asks to be tested for
a sexually transmitted infection (STI). How should the clinic
nurse respond?
1. Determine if the client wore protection
2. Inform that parental consent is required
3. Inform that the request is honored if the client has symptoms
4. Provide requested service Correct Answers 4
A 2-year-old child seen in the emergency department is assessed
as being dehydrated and malnourished. The child's parent
reports that the child has had diarrhea for the past 2 weeks.
Which observation is of most concern to the nurse?
1. The parent cannot stay at the hospital due to potential job loss
if late for work
2. The parent does not seem to be concerned about the child's
condition
3. The parent is single
4. The parent left a 3-year-old and a 5-year-old in the care of a
9-year-old Correct Answers 4
A category 4 hurricane has disrupted a rural local health care
system, creating a significant increase in emergency department
admissions. Which client would the nurse assessfirst?
1. 55-year-old with type 2 diabetes mellitus complaining of a
headache after being involved in a minor motor vehicle accident
2. 45-year-old with type 1 diabetes mellitus with a blood
glucose of 690 mg/dL (38.3 mmol/L) complaining of abdominal
pain and fatigue
, 3. 7-year-old with status asthmaticus and an oxygen saturation
of 89%
4. 34-year-old with gestational diabetes, 11 weeks pregnant,
who has not been able to "hold anything down" due to nausea
and vomiting over the past 2 days Correct Answers 3
A charge nurse suspects that the unlicensed assistive personnel
(UAP) is falsifying the documentation of clients' capillary
glucose results rather than performing the test. What is the best
action by the charge nurse to handle this situation?
1. Ask a client if the UAP has performed the test
2. Discuss the importance of task completion and accurate
documentation in a staff meeting
3. Give the UAP a verbal warning not to falsify data
4. Take a client's capillary glucose personally and compare it to
the recorded result Correct Answers 4
A client has a chest tube for hemopneumothorax. The chest tube
is connected to wall suction at 20 cm of H2O. The registered
nurse can delegate which action to unlicensed assistive
personnel?
1. Checking the water seal chamber for the presence of an air
leak
2. Measuring and documenting the amount of drainage every 4
hours
3. Milking the chest tube to remove clots from the tubing
4. Teaching the client to cough and deep breathe to facilitate
drainage Correct Answers 2
A client is admitted with a lower urinary tract infection from an
obstructing ureteral stone. Which tasks can the registered nurse
,(RN) delegate to the experienced unlicensed assistive personnel
(UAP)? Select all that apply.
1. Assisting the client in completing a health history form
2. Collecting a urine specimen for culture and sensitivity
3. Instructing the client to strain urine when voiding
4. Measuring and documenting urine output
5. Monitoring the color and characteristics of urine output
Correct Answers 2,4
A client is being discharged with plans to return home alone.
The client cannot get up from a chair without help and is very
unsteady when standing, even with a walker. The nurse
expresses concern, but the primary health care provider is
adamant that the client be discharged today. Which team
member would be most appropriate to assist the nurse in
advocating for this client?
1. Clinical psychologist
2. Occupational therapist
3. Physical therapist
4. Social worker Correct Answers 4
A client is being transferred to another hospital for specialized
care in their burn unit. What is the nurse required to do prior to
transport under the Emergency Medical Treatment and Active
Labor Act (EMTALA)? Select all that apply.
1. Call a report to the receiving nurse
2. Check if the client's family was notified of the transfer
3. Confirm that the client's primary health care provider (HCP)
is on staff
4. Notify the client's insurance company
, 5. Verify that the receiving facility has available space and staff
Correct Answers 1,5
A client was treated in the emergency department 2 days ago.
The nurse makes a follow-up call to say that a culture shows that
the client needs an antibiotic. The client's spouse answers the
phone, says that the client is at work and doing fine, and that the
client does not need the antibiotic. Which is a priority action for
the nurse?
1. Call the prescription into the client's pharmacy
2. Document the spouse's statement in the client's chart
3. Notify the emergency department physician
4. Request that the spouse tell the client to call back Correct
Answers 4
A client with a 10-year history of methadone use for chronic leg
pain is being treated with azithromycin for pneumonia. On the
third hospital day, both medications are discontinued as the QT
interval on EKG has lengthened, increasing arrhythmia risk. The
client wants to be discharged against medical advice to return
home and take the client's own medications to prevent going
into withdrawal without the methadone. Which is the most
appropriate nursing response?
1. "I will ask the HCP to come talk with us so that we can
develop a plan to prevent withdrawal while reducing your risk of
heart problems."
2. "I will talk with the HCP about your concerns, but in the
meantime it's important that you stay here."
3. "It's important that you stay in the hospital so that we can
treat you quickly if you have problems."
A 16-year-old walks in unaccompanied by a parent and
approaches the clinic nurse. The adolescent asks to be tested for
a sexually transmitted infection (STI). How should the clinic
nurse respond?
1. Determine if the client wore protection
2. Inform that parental consent is required
3. Inform that the request is honored if the client has symptoms
4. Provide requested service Correct Answers 4
A 2-year-old child seen in the emergency department is assessed
as being dehydrated and malnourished. The child's parent
reports that the child has had diarrhea for the past 2 weeks.
Which observation is of most concern to the nurse?
1. The parent cannot stay at the hospital due to potential job loss
if late for work
2. The parent does not seem to be concerned about the child's
condition
3. The parent is single
4. The parent left a 3-year-old and a 5-year-old in the care of a
9-year-old Correct Answers 4
A category 4 hurricane has disrupted a rural local health care
system, creating a significant increase in emergency department
admissions. Which client would the nurse assessfirst?
1. 55-year-old with type 2 diabetes mellitus complaining of a
headache after being involved in a minor motor vehicle accident
2. 45-year-old with type 1 diabetes mellitus with a blood
glucose of 690 mg/dL (38.3 mmol/L) complaining of abdominal
pain and fatigue
, 3. 7-year-old with status asthmaticus and an oxygen saturation
of 89%
4. 34-year-old with gestational diabetes, 11 weeks pregnant,
who has not been able to "hold anything down" due to nausea
and vomiting over the past 2 days Correct Answers 3
A charge nurse suspects that the unlicensed assistive personnel
(UAP) is falsifying the documentation of clients' capillary
glucose results rather than performing the test. What is the best
action by the charge nurse to handle this situation?
1. Ask a client if the UAP has performed the test
2. Discuss the importance of task completion and accurate
documentation in a staff meeting
3. Give the UAP a verbal warning not to falsify data
4. Take a client's capillary glucose personally and compare it to
the recorded result Correct Answers 4
A client has a chest tube for hemopneumothorax. The chest tube
is connected to wall suction at 20 cm of H2O. The registered
nurse can delegate which action to unlicensed assistive
personnel?
1. Checking the water seal chamber for the presence of an air
leak
2. Measuring and documenting the amount of drainage every 4
hours
3. Milking the chest tube to remove clots from the tubing
4. Teaching the client to cough and deep breathe to facilitate
drainage Correct Answers 2
A client is admitted with a lower urinary tract infection from an
obstructing ureteral stone. Which tasks can the registered nurse
,(RN) delegate to the experienced unlicensed assistive personnel
(UAP)? Select all that apply.
1. Assisting the client in completing a health history form
2. Collecting a urine specimen for culture and sensitivity
3. Instructing the client to strain urine when voiding
4. Measuring and documenting urine output
5. Monitoring the color and characteristics of urine output
Correct Answers 2,4
A client is being discharged with plans to return home alone.
The client cannot get up from a chair without help and is very
unsteady when standing, even with a walker. The nurse
expresses concern, but the primary health care provider is
adamant that the client be discharged today. Which team
member would be most appropriate to assist the nurse in
advocating for this client?
1. Clinical psychologist
2. Occupational therapist
3. Physical therapist
4. Social worker Correct Answers 4
A client is being transferred to another hospital for specialized
care in their burn unit. What is the nurse required to do prior to
transport under the Emergency Medical Treatment and Active
Labor Act (EMTALA)? Select all that apply.
1. Call a report to the receiving nurse
2. Check if the client's family was notified of the transfer
3. Confirm that the client's primary health care provider (HCP)
is on staff
4. Notify the client's insurance company
, 5. Verify that the receiving facility has available space and staff
Correct Answers 1,5
A client was treated in the emergency department 2 days ago.
The nurse makes a follow-up call to say that a culture shows that
the client needs an antibiotic. The client's spouse answers the
phone, says that the client is at work and doing fine, and that the
client does not need the antibiotic. Which is a priority action for
the nurse?
1. Call the prescription into the client's pharmacy
2. Document the spouse's statement in the client's chart
3. Notify the emergency department physician
4. Request that the spouse tell the client to call back Correct
Answers 4
A client with a 10-year history of methadone use for chronic leg
pain is being treated with azithromycin for pneumonia. On the
third hospital day, both medications are discontinued as the QT
interval on EKG has lengthened, increasing arrhythmia risk. The
client wants to be discharged against medical advice to return
home and take the client's own medications to prevent going
into withdrawal without the methadone. Which is the most
appropriate nursing response?
1. "I will ask the HCP to come talk with us so that we can
develop a plan to prevent withdrawal while reducing your risk of
heart problems."
2. "I will talk with the HCP about your concerns, but in the
meantime it's important that you stay here."
3. "It's important that you stay in the hospital so that we can
treat you quickly if you have problems."
