1. The nurse is reviewing medical prescriptions for newly admitted clients. It wouldbe a
priority for the nurse to follow up with the physician if a client with
(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed
(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions(c) sensitivity
to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen)
(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin)
2. The nurse should intervene if the nurse notes a staff member
(a) obtaining a clients consent prior to their operative procedure after receiving Ativan
(lorazepam)
(b) placing a client on the affected side following surgical repair of a retinal
detachment
(c) handling a wet cast with the palms of the hands
(d) using a broad base of support while transferring a client
3. The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who is
(a) 12 years old with Autism who is starting a new school and recently had aURI
(upper respiratory tract infection)
(b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent
Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon
(pyridostigmine) and employed as a mail carrier
(d) 70 years old, has schizophrenia, lives alone and reports hearing non threateningvoices.
4. The nurse from the postpartum unit has been temporarily assigned to the medical
surgical unit. It would be most appropriate to assign this nurse to the client who*
(a) has returned from right total hip replacement surgery four hours ago
(b) is being observed for increased intracranial pressure
(c) had surgery two hours ago to remove the appendix
1
,(d) is two weeks post partum being maintained on a mechanical ventilator for
respiratory failure
2
,5. The nurse in a well baby clinic has assessed several children today. It would be a priority
for the nurse to suggest follow up for the child who is (a) 2 months old with apositive
babinski refl ex
(b) 5 months old and does not hold their own bottle
(c) 10 months old who cries around strangers
(d) 18 months old who needs support while ambulating
6. The nurse is caring for a mechanically ventilated client who was declared brain dead.
An Advance Directive is not documented on the medical record. It would be most
appropriate to obtain consent for organ donation from the
(a) client‘s primary care provider
(b) client‘s nurse manager
(c) closest living family member
(d) hospital‘s ethics committee
7. The nurse has received report on four clients. The nurse should fi rst assess theclient
who has*
(a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of90%
(b) Parkinson‘s Disease and is demanding to leave the hospital against medical advice(AMA)
(c) been admitted with suspected Guillian-Barre´ Syndrome and has begun
plasmapheresis therapy
(d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+)
8. It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change
9. The nurse should intervene if a staff member is observed
(a) discussing a client‘s diagnosis with visiting family members
(b) collaborating with another nurse to review a prescription for blood transfusion
(c) interrupting other staff members discussing a client in the cafeteria
(d) reviewing a clients lab values with the nutritionist
3
,
priority for the nurse to follow up with the physician if a client with
(a) a potassium level of 4.5mEq/L has Kayexalate (sodium polystyrene) prescribed
(b) a Dilantin (phenytoin) level of 8 mcg/ml is placed on seizure precautions(c) sensitivity
to Aspirin (acetylsalicylic acid) is prescribed Tylenol (acetaminophen)
(d) sensitivity to Penicillin is prescribed Zithromax (azithromycin)
2. The nurse should intervene if the nurse notes a staff member
(a) obtaining a clients consent prior to their operative procedure after receiving Ativan
(lorazepam)
(b) placing a client on the affected side following surgical repair of a retinal
detachment
(c) handling a wet cast with the palms of the hands
(d) using a broad base of support while transferring a client
3. The community health nurse is caring for the following clients. It would be a
priority for the nurse to initiate a multidisciplinary conference for the client who is
(a) 12 years old with Autism who is starting a new school and recently had aURI
(upper respiratory tract infection)
(b) 16 years old, has type 1 Diabetes Mellitus, is unemployed and had a recent
Hemoglobin A1c of 13%
(c) 52 years old, with Myasthenia Gravis, recently prescribed Mestinon
(pyridostigmine) and employed as a mail carrier
(d) 70 years old, has schizophrenia, lives alone and reports hearing non threateningvoices.
4. The nurse from the postpartum unit has been temporarily assigned to the medical
surgical unit. It would be most appropriate to assign this nurse to the client who*
(a) has returned from right total hip replacement surgery four hours ago
(b) is being observed for increased intracranial pressure
(c) had surgery two hours ago to remove the appendix
1
,(d) is two weeks post partum being maintained on a mechanical ventilator for
respiratory failure
2
,5. The nurse in a well baby clinic has assessed several children today. It would be a priority
for the nurse to suggest follow up for the child who is (a) 2 months old with apositive
babinski refl ex
(b) 5 months old and does not hold their own bottle
(c) 10 months old who cries around strangers
(d) 18 months old who needs support while ambulating
6. The nurse is caring for a mechanically ventilated client who was declared brain dead.
An Advance Directive is not documented on the medical record. It would be most
appropriate to obtain consent for organ donation from the
(a) client‘s primary care provider
(b) client‘s nurse manager
(c) closest living family member
(d) hospital‘s ethics committee
7. The nurse has received report on four clients. The nurse should fi rst assess theclient
who has*
(a) Chronic Obstructive Pulmonary Disease (COPD) with a pulse oximetry reading of90%
(b) Parkinson‘s Disease and is demanding to leave the hospital against medical advice(AMA)
(c) been admitted with suspected Guillian-Barre´ Syndrome and has begun
plasmapheresis therapy
(d) Congestive Heart Failure (CHF) whose pitting edema has increased to 2(+)
8. It would be appropriate to assign which of these tasks to the CNA?
(a) Feeding a client who is experiencing dysphagia
(b) One-on-one client observation for safety
(c) Removal of an indwelling catheter
(d) Performing a simple dressing change
9. The nurse should intervene if a staff member is observed
(a) discussing a client‘s diagnosis with visiting family members
(b) collaborating with another nurse to review a prescription for blood transfusion
(c) interrupting other staff members discussing a client in the cafeteria
(d) reviewing a clients lab values with the nutritionist
3
,
