PAGE1
,MULTIPLE CHOICES
A client is brought to the emergency department following a motor-vehicle crash. Drug use
is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly
refuses to provide the specimen. Which of the following is the appropriate action by the
nurse?
B* Document the client‟s refusal in the chart.
A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
Administer a nasogastric tube feeding.
A nurse preceptor is evaluating a newly licensed nurse‟s competency in assisting with a
sterile procedure. Which of the following actions indicates the newly licensed nurse is
maintaining sterile technique? (SATA)
b. Opens the sterile pack by first unfolding the top flap away from her body
d. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field
A nurse enters a client‟s room and identifies that the client is receiving too much IV fluid
because the IV pump is not working properly. Which of the following actions should the
nurse take first?
Auscultate the client‟s lungs.
A nurse is planning care for a group of clients and can delegate care to a licensed practical
nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse
assign to the LPN?
Reinforcing teaching with a client who is learning to self-administer insulin
A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After
donning a sterile gown and gloves, which of the following actions by the newly licensed
nurse demonstrates correct aseptic technique?
PAGE2
,The nurse holds her hands above her waist.
A nurse who is caring for a group of clients delegates collection of vital signs to an assistive
personnel (AP). Which of the following actions should the nurse take to evaluate the
delegated task?
Recheck vital signs that are outside the expected reference range.
A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?
Obtaining a stool sample from a client who has renal failure
A nurse is triaging a group of clients following a disaster. Which of the following clients
should the nurse recommend for treatment first?
A client who has two open chest wounds with a left tracheal deviation
A nurse manager is reviewing guidelines for informed consent with the nursing staff.
Which of the following statements by a staff nurse indicates that the teaching was effective?
"Consent can be given by a durable power of attorney."
A nurse is caring for four clients. For which of the following clients should the nurse
collaborate with the facility ethics committee?
An adolescent client whose parents refuse a blood transfusion for religious reasons
A nurse in an ambulatory care setting is orient a newly licensed nurse who is preparing to
return a call to a client. The nurse should explain that which of the following is an objective
of telehealth?
Establishing communication between providers
A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes. The
client expresses concern about the cost of blood-glucose monitoring supplies. Which of the
following actions should the nurse take?
Refer the client to the social services department
PAGE3
, A charge nurse is receiving change-of-shift report. Which of the following situations should
the charge nurse address first?
The emergency department nurse is waiting to give report on a new admission.
A nurse who is precepting a newly licensed nurse is discussing the client assignment for the
shift. Which of the following actions should the nurse preceptor take first to demonstrate
appropriate time management?
Determine client care goals (set/plan goals)
A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which
of the following statements by a staff nurse indicates understanding?
"HIPAA allows clients to request a review of their own medical records."
A nurse is caring for a client who has a tumor. The provider recommends surgery. The
client refuses, but the client‟s partner wants the surgery performed. Which of the following
is the deciding factor in determining if the surgery will be done?
Whether the client understands the risk of refusing the procedure
A charge nurse is planning the care of four newborns. An assistive personnel and licensed
practical nurse are available for staffing. Which of the following tasks should the nurse
assign to a licensed practical nurse?
Administer a hepatitis B vaccine.
During a staff meeting a unit manager reviews the results for documenting client education
and finds that they are below the benchmark. Which of the following strategies should the
nurse manager implement first?
Determine factors that interfere with the documentation of client education.
A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain
that preventing client injury by removing a fall hazard demonstrates which of the following
ethical principles?
Nonmaleficence
PAGE4
,MULTIPLE CHOICES
A client is brought to the emergency department following a motor-vehicle crash. Drug use
is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly
refuses to provide the specimen. Which of the following is the appropriate action by the
nurse?
B* Document the client‟s refusal in the chart.
A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
Administer a nasogastric tube feeding.
A nurse preceptor is evaluating a newly licensed nurse‟s competency in assisting with a
sterile procedure. Which of the following actions indicates the newly licensed nurse is
maintaining sterile technique? (SATA)
b. Opens the sterile pack by first unfolding the top flap away from her body
d. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field
A nurse enters a client‟s room and identifies that the client is receiving too much IV fluid
because the IV pump is not working properly. Which of the following actions should the
nurse take first?
Auscultate the client‟s lungs.
A nurse is planning care for a group of clients and can delegate care to a licensed practical
nurse (LPN) and an assistive personnel. Which of the following tasks should the nurse
assign to the LPN?
Reinforcing teaching with a client who is learning to self-administer insulin
A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After
donning a sterile gown and gloves, which of the following actions by the newly licensed
nurse demonstrates correct aseptic technique?
PAGE2
,The nurse holds her hands above her waist.
A nurse who is caring for a group of clients delegates collection of vital signs to an assistive
personnel (AP). Which of the following actions should the nurse take to evaluate the
delegated task?
Recheck vital signs that are outside the expected reference range.
A nurse is caring for four clients. Which of the following tasks can be delegated to an
assistive personnel?
Obtaining a stool sample from a client who has renal failure
A nurse is triaging a group of clients following a disaster. Which of the following clients
should the nurse recommend for treatment first?
A client who has two open chest wounds with a left tracheal deviation
A nurse manager is reviewing guidelines for informed consent with the nursing staff.
Which of the following statements by a staff nurse indicates that the teaching was effective?
"Consent can be given by a durable power of attorney."
A nurse is caring for four clients. For which of the following clients should the nurse
collaborate with the facility ethics committee?
An adolescent client whose parents refuse a blood transfusion for religious reasons
A nurse in an ambulatory care setting is orient a newly licensed nurse who is preparing to
return a call to a client. The nurse should explain that which of the following is an objective
of telehealth?
Establishing communication between providers
A nurse is providing discharge teaching to a client who has a new diagnosis of diabetes. The
client expresses concern about the cost of blood-glucose monitoring supplies. Which of the
following actions should the nurse take?
Refer the client to the social services department
PAGE3
, A charge nurse is receiving change-of-shift report. Which of the following situations should
the charge nurse address first?
The emergency department nurse is waiting to give report on a new admission.
A nurse who is precepting a newly licensed nurse is discussing the client assignment for the
shift. Which of the following actions should the nurse preceptor take first to demonstrate
appropriate time management?
Determine client care goals (set/plan goals)
A charge nurse is reviewing information about HIPAA with a group of staff nurses. Which
of the following statements by a staff nurse indicates understanding?
"HIPAA allows clients to request a review of their own medical records."
A nurse is caring for a client who has a tumor. The provider recommends surgery. The
client refuses, but the client‟s partner wants the surgery performed. Which of the following
is the deciding factor in determining if the surgery will be done?
Whether the client understands the risk of refusing the procedure
A charge nurse is planning the care of four newborns. An assistive personnel and licensed
practical nurse are available for staffing. Which of the following tasks should the nurse
assign to a licensed practical nurse?
Administer a hepatitis B vaccine.
During a staff meeting a unit manager reviews the results for documenting client education
and finds that they are below the benchmark. Which of the following strategies should the
nurse manager implement first?
Determine factors that interfere with the documentation of client education.
A nurse is explaining ethics and values to a newly licensed nurse. The nurse should explain
that preventing client injury by removing a fall hazard demonstrates which of the following
ethical principles?
Nonmaleficence
PAGE4
