Exam 2024 Questions and Answers (With
Rationale)
Question 1
A nurse is caring for a client who speaks limited English and is preparing for surgery. Which of
the following actions is most appropriate for obtaining informed consent?
A) Do nothing as this is the provider’s primary concern.
B) Explain the procedures using pictures and hand gestures.
C) Have the nurse respond to the client’s concerns so the provider can prepare for surgery.
D) Seek the assistance of a nurse uent in the client’s language.
Answer: D) Seek the assistance of a nurse uent in the client’s language.
Rationale: The nurse is responsible for ensuring the client understands the procedure. Using a
uent nurse ensures accurate communication.
Question 2
A nurse manager is developing an orientation plan for newly licensed nurses. Which of the
following should be included? (Select all that apply.)
A) Skill pro ciency
B) Assignment to a preceptor
C) Budgetary principles
D) Computerized charting
E) Socialization into unit culture
F) Facility policies and procedures
Answer: A, B, D, E, F
Rationale: Orientation should cover skill pro ciency, preceptorship, charting, unit culture, and
policies. Budgetary principles are not typically included.
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,Question 3
A client with a terminal illness states, “I don’t want to go to a nursing home to die. I would rather
die at home.” What is the most appropriate nursing action?
A) Contact the client’s case manager.
B) Continue to make the discharge arrangements.
C) Assess the client’s reasons for feeling this way.
D) Inform the provider of the client’s decision.
Answer: A) Contact the client’s case manager.
Rationale: The case manager can explore options to align with the client’s wishes.
Question 4
A nurse observes a colleague removing small amounts of morphine sulfate from syringes before
administering medication. What is the appropriate action?
A) Confront the nurse directly.
B) Ignore the incident as it may be a mistake.
C) Inform the nurse manager after documenting the incident.
D) Report the nurse to the state board immediately.
Answer: C) Inform the nurse manager after documenting the incident.
Rationale: This ensures proper handling of a potential substance misuse issue while maintaining
protocol.
Question 5
A nurse is triaging clients after a tornado disaster. A 22-year-old client has asymmetrical chest
movement, shortness of breath, and absent lung sounds on the left side. What triage category
should the nurse assign?
A) Nonurgent Class III
B) Emergent Class I
C) Expectant Class IV
D) Urgent Class II
, Answer: B) Emergent Class I
Rationale: These symptoms suggest a pneumothorax, requiring immediate intervention.
Question 6
A nurse is delegating tasks to unlicensed assistive personnel (UAP). Which of the following
tasks can be delegated? (Select all that apply.)
A) Bathing
B) Checking NG tube patency
C) Feeding a client with dysphagia
D) Collecting specimens
E) Suctioning
F) Ambulating
Answer: A, D, F
Rationale: UAPs can perform noninvasive tasks like bathing, collecting specimens, and
ambulating. Feeding clients with dysphagia, checking NG tube patency, and suctioning require
licensed personnel.
Question 7
A nurse nds a client lying on the oor. Which action should the nurse take rst?
A) Call the provider.
B) Ask a staff member for assistance getting the client back in bed.
C) Inspect the client for injuries.
D) Instruct the client to ask for help if they need to get out of bed.
Answer: C) Inspect the client for injuries.
Rationale: Assessing for injuries is the priority to ensure the client’s safety.
Question 8
A nurse is caring for four clients receiving chemotherapy. Which client should the nurse see rst?
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, A) A client with cervical cancer and a hemoglobin level of 8.2 mg/dL
B) A client with breast cancer and a sodium level of 115 mEq/L
C) A client with ovarian cancer with a white blood cell count of 4,500 cells/mcL
D) A client with endometrial cancer and a potassium level of 5.0 mEq/L
Answer: B) A client with breast cancer and a sodium level of 115 mEq/L
Rationale: A sodium level below 120 mEq/L is a medical emergency requiring immediate
attention.
Question 9
A nurse is participating in a quality improvement study for a procedure. Which information
provides data on the procedure’s ef cacy?
A) Frequency with which the procedure is performed
B) Client satisfaction with the performance of the procedure
C) Incidence of complications related to the procedure
D) Accurate documentation of how the procedure was performed
Answer: C) Incidence of complications related to the procedure
Rationale: Ef cacy is best measured by outcomes, such as complication rates.
Question 10
A provider informs the wife of a comatose client with terminal cancer to sign consent for a
gastrostomy tube, against the client’s wishes. What should the nurse do?
A) Inform the wife she cannot sign the consent.
B) Prepare the consent for the wife to sign.
C) Ask the provider for an order for an NG tube instead.
D) Consult the hospital’s ethics committee.
Answer: D) Consult the hospital’s ethics committee.
Rationale: Ethical con icts require multidisciplinary review to ensure the client’s wishes are
respected.
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