Nur 004 ACTUAL EXAM 220 QUESTIONS AND CORRECT
ANSWERS 2025 LATEST UPDATE//ALL YOU NEED TO PASS
NURS 004 EXAM//GRADED A+
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 day nurse gives the hand-off report to the evening nurse. Which statements are most
appropriate to include in the report? Select all that apply.
1. "The client had morphine 2 mg IV 30 minutes ago for chest pain and now reports 3 on a pain scale
of 0-10."
2. "The client just had acetaminophen 500 mg PO for headache with good relief."
3. "The continuous heparin infusion bag needs to be replaced at 2100."
4. "The last potassium level was 3.2 mEq/L, and potassium chloride was prescribed 30 minutes ago
but has not yet arrived from the pharmacy."
5. "The social worker is scheduled to speak with the spouse about home care at 0900 tomorrow."
6. "The unlicensed assistive personnel bathed the client at 0700." - ANSWER-1,3,4,5
A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at the
nurse in the hallway. People in the hallway are staring. What is the bestinitial reaction by the nurse?
1. Firmly indicate that the HCP cannot speak to the nurse in that manner
2. Immediately apologize and attempt to fix the situation
3. Say nothing and let the HCP vent frustrations
4. State that the conversation needs to take place in private and walk to a room - ANSWER-4
The nurse has received report on the following pediatric clients. Which action should the nurse
perform first?
1. Administer water enema to the 2-year-old with intussusception who has severe abdominal pain
,2. Call the health care provider about the 4-year-old with leukemia who has a low-grade fever
3. Measure head circumference of the 3-month-old with ventriculoperitoneal shunt placement
4. Suction the 3-month-old with bronchiolitis who is irritable and scheduled for a feeding -
ANSWER-4
Which of the following are examples of violating the Health Insurance Portability and Accountability
Act (HIPAA) Privacy Rule on privileged health information (PHI) confidentiality? Select all that apply.
1. A visitor talking in the waiting room states that the client is an alcoholic
2. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home
3. The nursing assistant tells the hospital roommate that the client went for a gallbladder test
4. The registered nurse tells a visitor to wear a mask because the client is on airborne precautions
5. Two LPNs are discussing a cure for AIDS on a crowded elevator - ANSWER-2,3
After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care
for first?
1. Client 1-day postoperative who was medicated with tramadol 50 mg orally 1.5 hours ago
2. Client 1-day postoperative with pink colored urine after transurethral resection of the prostate
(TURP)
3. Client scheduled for discharge today who needs instruction on how to change a sterile dressing
4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM who was restless and awake
all night - ANSWER-4
The nurse receives the following information in the hand-off report. Which client should the nurse
assess first?
1. Client with a paralytic ileus following a colon resection who has abdominal distension, no audible
bowel sounds, and nausea
2. Client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of
90/60 mm Hg, and pulse of 110/min
3. Client with bacterial peritonitis following surgery for a ruptured appendix who is receiving IV
tobramycin and has a temperature of 101 F (38.3 C)
4. Client with dysphagia and a sore throat who has a nasogastric tube to administer contrast media
for an abdominal CT scan - ANSWER-2
,A nurse in the pediatric unit is preparing a 16-year-old for a surgical procedure and observes that the
client has signed the informed consent for surgery. What should be thefirst action by the nurse?
1. Cancel the procedure until a valid consent form is signed
2. Determine if the client meets legal requirements to sign the consent form
3. Locate the client's parent or guardian to sign the consent form
4. Verify that the consent is properly witnessed and send the client to surgery - ANSWER-2
Which situations would prompt the health care team to use the client's advance directive to make a
decision regarding care? Select all that apply.
1. Client diagnosed with lumbar spinal cord compression has paraplegia
2. Client's Glasgow Coma Scale (GCS) score is 3
3. Client is refusing a life-saving treatment due to religious beliefs
4. Client with intracerebral hemorrhage has aphasia
5. Oriented client has cancer and is on a ventilator - ANSWER-2,4
The nurse is working with a client admitted with delirium and reduced level of consciousness due to
pneumonia and respiratory failure. The nurse anticipates that the client may need to be intubated
soon. The client is not able to make decisions. Who will make decisions for the client?
1. The client's sibling
2. The client's spouse
3. The health care provider (HCP)
4. The health care proxy - ANSWER-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 - ANSWER-2
Which client assignment is most appropriate for the nurse on an orthopedic unit to assign to a float
nurse from a general medical unit?
, 1. Client 1-day postoperative with external fixators to stabilize a complex fracture of the wrist
2. Client 3-days post knee replacement surgery awaiting discharge
3. Client who is scheduled for an above-the-knee amputation today
4. Client with a long leg cast applied yesterday morning to treat a fractured ankle - ANSWER-4
During shift change, the night nurse notices that the graduate nurse administered IV dopamine
instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do
first?
1. Administer the correct medication and obtain current vital signs
2. Alert the graduate nurse and complete an incident report
3. Assess the client and notify the health care provider
4. Discontinue the dopamine and inform the nursing supervisor - ANSWER-3
A registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel are
caring for a client who is 1-day postoperative gastric bypass surgery. Which pain management-related
tasks should the RN delegate to the LPN? Select all that apply.
1. Administering oral pain medication
2. Assessing characteristics of pain
3. Measuring vital signs before and after analgesic administration
4. Monitoring pain level using a numeric scale
5. Providing discharge teaching about pain management - ANSWER-1,4
The nurse reads a journal article about a study using a new pain management protocol for clients
with terminal cancer. What should the nurse first consider in determining whether the protocol is
appropriate to implement on the unit?
1. Did the study have institutional review board approval?
2. Do the characteristics of the sample population match those of the nurse's unit?
3. What are the credentials of the study's researcher?
4. What was the financial support provided for the study? - ANSWER-2
The charge nurse in the coronary care unit must transfer a client to the medical unit to accommodate
another acutely ill client from the emergency department. The nurse suggests the transfer of which
client to the health care provider?
ANSWERS 2025 LATEST UPDATE//ALL YOU NEED TO PASS
NURS 004 EXAM//GRADED A+
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 day nurse gives the hand-off report to the evening nurse. Which statements are most
appropriate to include in the report? Select all that apply.
1. "The client had morphine 2 mg IV 30 minutes ago for chest pain and now reports 3 on a pain scale
of 0-10."
2. "The client just had acetaminophen 500 mg PO for headache with good relief."
3. "The continuous heparin infusion bag needs to be replaced at 2100."
4. "The last potassium level was 3.2 mEq/L, and potassium chloride was prescribed 30 minutes ago
but has not yet arrived from the pharmacy."
5. "The social worker is scheduled to speak with the spouse about home care at 0900 tomorrow."
6. "The unlicensed assistive personnel bathed the client at 0700." - ANSWER-1,3,4,5
A health care provider (HCP) is screaming, "Why didn't you get surgery scheduled sooner!?," at the
nurse in the hallway. People in the hallway are staring. What is the bestinitial reaction by the nurse?
1. Firmly indicate that the HCP cannot speak to the nurse in that manner
2. Immediately apologize and attempt to fix the situation
3. Say nothing and let the HCP vent frustrations
4. State that the conversation needs to take place in private and walk to a room - ANSWER-4
The nurse has received report on the following pediatric clients. Which action should the nurse
perform first?
1. Administer water enema to the 2-year-old with intussusception who has severe abdominal pain
,2. Call the health care provider about the 4-year-old with leukemia who has a low-grade fever
3. Measure head circumference of the 3-month-old with ventriculoperitoneal shunt placement
4. Suction the 3-month-old with bronchiolitis who is irritable and scheduled for a feeding -
ANSWER-4
Which of the following are examples of violating the Health Insurance Portability and Accountability
Act (HIPAA) Privacy Rule on privileged health information (PHI) confidentiality? Select all that apply.
1. A visitor talking in the waiting room states that the client is an alcoholic
2. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home
3. The nursing assistant tells the hospital roommate that the client went for a gallbladder test
4. The registered nurse tells a visitor to wear a mask because the client is on airborne precautions
5. Two LPNs are discussing a cure for AIDS on a crowded elevator - ANSWER-2,3
After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care
for first?
1. Client 1-day postoperative who was medicated with tramadol 50 mg orally 1.5 hours ago
2. Client 1-day postoperative with pink colored urine after transurethral resection of the prostate
(TURP)
3. Client scheduled for discharge today who needs instruction on how to change a sterile dressing
4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM who was restless and awake
all night - ANSWER-4
The nurse receives the following information in the hand-off report. Which client should the nurse
assess first?
1. Client with a paralytic ileus following a colon resection who has abdominal distension, no audible
bowel sounds, and nausea
2. Client with alcoholic cirrhosis who has coffee ground nasogastric drainage, blood pressure of
90/60 mm Hg, and pulse of 110/min
3. Client with bacterial peritonitis following surgery for a ruptured appendix who is receiving IV
tobramycin and has a temperature of 101 F (38.3 C)
4. Client with dysphagia and a sore throat who has a nasogastric tube to administer contrast media
for an abdominal CT scan - ANSWER-2
,A nurse in the pediatric unit is preparing a 16-year-old for a surgical procedure and observes that the
client has signed the informed consent for surgery. What should be thefirst action by the nurse?
1. Cancel the procedure until a valid consent form is signed
2. Determine if the client meets legal requirements to sign the consent form
3. Locate the client's parent or guardian to sign the consent form
4. Verify that the consent is properly witnessed and send the client to surgery - ANSWER-2
Which situations would prompt the health care team to use the client's advance directive to make a
decision regarding care? Select all that apply.
1. Client diagnosed with lumbar spinal cord compression has paraplegia
2. Client's Glasgow Coma Scale (GCS) score is 3
3. Client is refusing a life-saving treatment due to religious beliefs
4. Client with intracerebral hemorrhage has aphasia
5. Oriented client has cancer and is on a ventilator - ANSWER-2,4
The nurse is working with a client admitted with delirium and reduced level of consciousness due to
pneumonia and respiratory failure. The nurse anticipates that the client may need to be intubated
soon. The client is not able to make decisions. Who will make decisions for the client?
1. The client's sibling
2. The client's spouse
3. The health care provider (HCP)
4. The health care proxy - ANSWER-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 - ANSWER-2
Which client assignment is most appropriate for the nurse on an orthopedic unit to assign to a float
nurse from a general medical unit?
, 1. Client 1-day postoperative with external fixators to stabilize a complex fracture of the wrist
2. Client 3-days post knee replacement surgery awaiting discharge
3. Client who is scheduled for an above-the-knee amputation today
4. Client with a long leg cast applied yesterday morning to treat a fractured ankle - ANSWER-4
During shift change, the night nurse notices that the graduate nurse administered IV dopamine
instead of the prescribed norepinephrine for a client with sepsis. What should the night nurse do
first?
1. Administer the correct medication and obtain current vital signs
2. Alert the graduate nurse and complete an incident report
3. Assess the client and notify the health care provider
4. Discontinue the dopamine and inform the nursing supervisor - ANSWER-3
A registered nurse (RN), a licensed practical nurse (LPN), and unlicensed assistive personnel are
caring for a client who is 1-day postoperative gastric bypass surgery. Which pain management-related
tasks should the RN delegate to the LPN? Select all that apply.
1. Administering oral pain medication
2. Assessing characteristics of pain
3. Measuring vital signs before and after analgesic administration
4. Monitoring pain level using a numeric scale
5. Providing discharge teaching about pain management - ANSWER-1,4
The nurse reads a journal article about a study using a new pain management protocol for clients
with terminal cancer. What should the nurse first consider in determining whether the protocol is
appropriate to implement on the unit?
1. Did the study have institutional review board approval?
2. Do the characteristics of the sample population match those of the nurse's unit?
3. What are the credentials of the study's researcher?
4. What was the financial support provided for the study? - ANSWER-2
The charge nurse in the coronary care unit must transfer a client to the medical unit to accommodate
another acutely ill client from the emergency department. The nurse suggests the transfer of which
client to the health care provider?
