Answers
84. The community health nurse develops a health education program about preventing the
transmission of hepatitis B. The nurse evaluates that the teaching has been effective when the
participants identify which of the following activities to be high risk for acquiring hepatitis B?
a. Ingestion of large amounts of acetaminophen (Tylenol).
b. Sharing needles for drug use.
c. Ingestion of contaminated seafood.
d. Frequent use of marijuana. - ANS B
85. Following abdominal surgery, a client refuses to deep breath and cough every 2 hours as
ordered. The nurse should do which of the following first?
a. Explain the risks of not expanding the lungs and why the exercise is important.
b. Respect the client's wishes and turn the client from side-to-side more frequently.
c. Ask the client's wife to insist that the client take the deep breaths every 2 hours.
d. Suggest that the client increase the daily fluid intake to at least 2500 ml. - ANS A
86. You are caring for a patient with an acute MI. You want to assign a certified nursing
assistant to the patient. Which of the following would be an appropriate job to give the CNA?
a. teaching the patient about a low salt diet
b. helping the patient to bathe
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,c. assessing their pain
d. nothing - ANS B
88. From the following list of patients which one can be assigned to a nursing assistant/CNA?
a. A patient with sudden unexplained bleeding
b. A patient with unresolved pain over the past 8 hour shift
c. A patient scheduled to have a chest x-ray done
d. A patient who has multiple allergies to medications? - ANS C
89. You are listening as one of your co-workers, an RN, giving out assignments to her team with
includes 2 LPN/LVN's and 2 nursing assistants. You know that one of the tasks she is assigning
to the CNA should only be done by a licensed nurse. What should you do?
a. Tell the charge nurse who is in a meeting.
b. Discuss it at the next staff meeting
c. Openly ask her about it and tell her that she is wrong and report her.
d. Discuss with her why the task is not appropriate for the CNA. - ANS D
90. An experienced LPN, under the supervision of the team leader RN, is providing nursing care
for a patient with a respiratory problem. Which actions are appropriate to the scope of practice
of an experienced LPN? (Select all that apply)
A. Auscultate breath sounds
B. Administer medications via metered-dose inhaler (MDI)
C. Complete in-depth admission assessment
D. Initiate the nursing care plan
E. Evaluate the patient's technique for using MDI's - ANS ABD
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, 91. You are supervising a student nurse who is performing tracheostomy care for a patient. For
which action by the student should you intervene?
A. Suctioning the tracheostomy tube before performing tracheostomy care
B. Removing old dressings and cleaning off excess secretions
C. Removing the inner cannula and cleaning using universal precautions
D. Replacing the inner cannula and cleaning the stoma site.
E. Changing the soiled tracheostomy ties and securing the tube in place - ANS C
92. A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted
sleep cycle. Which action should you delegate to the nursing assistant (PCT)?
A. Discuss weight-loss strategies such as diet and exercise with the patient
B. Teach the patient how to set up the BiPAP machine before sleeping
C. Remind the patient to sleep on his side instead of his back.
D. Administer modafinil (Provigil) to promote daytime wakefulness - ANS C
93. You are acting as preceptor for a newly graduated RN during her second week of
orientation. You would assign the new RN under your supervision to provide care to which
patients? (Select all that apply)
A. A 38-year old with moderate persistent asthma awaiting discharge
B. A 63-year old with a tracheostomy needing tracheostomy care every shift.
C. A 56-year old with lung cancer who has just undergone left lower lobectomy
D. A 49-year old just admitted with a new diagnosis of esophageal cancer. - ANS AB
94. The patient has chronic obstructive pulmonary disease (COPD). Which intervention for
airway management should you delegate to a nursing assistant (UNP)?
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