Questions With Correct Marking
Scheme / A Grade
/. 1.A nurse is performing telephone triage at the clinic office. Which client has the most
acute problem and should be scheduled for the first available appointment? - Answer-
✅A 21 year old with a history of a kidney transplant. Today the client reports flu-like
symptoms with a fever of 100.4 F (38 C)
/.2.The nurse is admitting a woman who has an arteriovenous (AV) fistula in her right
arm that is used for hemodialysis. She missed her last hemodialysis session and is
experiencing shortness of breath and an irregular heartbeat. Which action should the
nurse assign to the UPA who is working with the nurse? - Answer-✅Measure Vital
Signs
/.3.The nurse should assess the client with which problem first? - Answer-✅Paresthesia
secondary to an arterial occlusion
/.4.A young adult client with a brain tumor refuses further treatment and requests to be
allowed to die a natural death. The healthcare provides does not agree with the client's
decision and refuses to write do-not-resuscitate instructions. Which action should the
nurse take? - Answer-✅Initiate a review of the situation by the hospital's ethics
committee.
/.5.A healthcare provider notifies the nurse that new prescriptions have been written for
a client. Which is the 1st action the nurse should implement? - Answer-✅Read all of the
new prescriptions for the client written by the provider
/.6.The nurse is observing the staff provide care to a client with acquired immune
deficiency syndrome - Answer-✅Unlicensed assistive personnel wearing a mask to take
client's blood pressure.
/.7.The nurse caring for a client with bacterial meningitis is preparing report for the
oncoming nurse. It is most important to include which assessment finding in the report?
- Answer-✅Increasing Pulse Pressure
/.8.The charge nurse notices that a respiratory therapist who has been cross-trained to
work as a phlebotomist and unlicensed assistive personnel (UAP) seems to be avoiding
HIV positive clients - Answer-✅Provide the employee with feedback about observed
behavior
, /.9.The nursing supervisor sends an unlicensed assistant personnel ( UAP) to a medical
unit to replace an absent UAP. When delegating the task of obtaining client's blood
sugar levels using a glucometer, which action is most important for the nurse to
implement? - Answer-✅Observe the UAP obtain a fingerstick glucose level using the
glucometer.
/.10.The nurse manager conducts regular audits of patient care medication records and
notices that the amount of narcotic pain medications administered during the evening
shift on a postsurgical unit - Answer-✅Conduct a closer examination of staff nurse's
distribution of pain medication from evening shift
/.11.The smell of cigarette smoke is coming from a client's bathroom. Which action
should the nurse - Answer-✅Educate the client about the hospital smoking policy.
/.12.The practical nurse (PN) reports to the charge nurse that the transparent dressing
covering a single lumen central venous catheter inserted in the subclavian vein of a
client has come loose and the insertion site is inflamed. Which action should the charge
nurse implement? - Answer-✅Confirm the findings of the PN while securing the
transparent dressing and notify the healthcare provider.
/.13.At 0200 the nurse phones the healthcare provider to request a PRN medication for
a client who is unable to sleep. The healthcare provider is awakened and gives the
nurse a prescription for four times the normal dosage. When questioned by the nurse,
the healthcare provider responds in a sleepy - Answer-✅Call the healthcare or back,
and report that the dosage prescribed is our times the normal dosage.
/.14.The charge nurse notices that a female practical nurse (PN), who has a long work
history on the unit and is a valued employee, seems tired and slow to respond verbally
during the change of shift report. One hour later the charge nurse overhears the PN
telling an unlicensed assistive personnel (UAP) that she took a sleeping pill 4 hours ago
and she is still feeling its effects. Which action should the charge nurse take? - Answer-
✅Send the PN to the employee health center for a urine drug Screen
/.15.It is most important to assign which client to a registered nurse rather than a
practical nurse? - Answer-✅After ambulating, a postoperative client grimaces and
reports incisional pain at a "9" on a point scale.
/.16.After receiving a change of shift report for clients on a medical surgical unit, which
task should the nurse - Answer-✅Apply hydrocolloid dressings to venous
/.17.The charge nurse observes unlicensed assistive personnel (UAP) and a nurse
arguing at the nurse's station. What action is best for the charge nurse to implement? -
Answer-✅Inform both individuals that their behavior is inappropriate in a work setting