CPNRE Test Bank Exam Questions And Correct Verified
6
Answers New Updated Version
2
20
Bryan, a salesman, has had difficulty holding a job because he accuses coworkers of conspiring
to take his sales. Today he argued with several officemates and threatened to kill one of them.
am
The police were called, and he was brought to the urgent care health centre for evaluation.
Bryan has had previous admissions to the inpatient psychiatric unit for stabilization of symptoms
of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station
Ex
and shouts loudly, "They are all plotting to destroy me! Isn't that true?" An appropriate
response for the nurse would be:
a. "No, that 's not true. People here are trying to help you, if you'll let them."
s
b. "Everyone is trying to help you. No one wants to harm you."
rt
c. "Thinking that people want to destroy you must be very frightening."
d. "That's absurd, Bryan. The staff here are health care workers, not members of the mob."
pe
c. “Thinking that people want to destroy you must be very frightening.”
It is important to validate the feelings and experience of a person in a delusional state without
Ex
reinforcing the delusion. Providing the support and acknowledgement assists in building a
trusting relationship even when the client is feeling suspicious. Denying the experience or
ignoring the feelings would be counter therapeutic and would not establish trust.
,The nurse is informed by the team leader that Mrs. BT needs her intravenous solution changed to
normal saline at 125 ml/h. Which one of the following actions is most appropriate for the nurse to
take?
a. Change the intravenous solution and infusion rate immediately
b.Check the new order and then change the solution when the bag is empty
c. Obtain the new solution bag and prepare to hang the new infusion
6
d. Verify the new order and then change the solution and confirm the rate
2
d. Verify the new order and then change the solution and confirm the rate
20
Best Practice-as per guidelines. All new orders must be verified, prior to intervening. Any order that is
directed by another staff member should always be verified!!!
While assisting Mr. Heart, 78 years old, the nurse finds that his anti-embolic stockings are more
difficult to apply. He receives furosemide (Lasix) and digoxin (Lanoxin) daily. Which of the following
am
interventions would be most appropriate for the nurse to take?
a. Measure both of his calves and order new stockings
b. Lower both of his legs prior to applying the stockings
Ex
c. Apply the stockings after the digoxin has been administered
d. Weigh Mr. Heart daily and document the finding
d. Weigh Mr. Heart daily and document the finding
Critical Thinking Question—The stockings are more difficult to apply—considering the patient is on a
ts
diuretic, and a antiarrhythmic/inotropic agent for the heart, we can believe that this patient has
congestive heart failure, and is experiencing fluid volume excess. Our next intervention is to weigh
r
patient, to help confirm our assessment. Option a is good for DVT assessment. Option b will increase
pe
swelling.
Mr. Sharp, 70 years old, lives independently. While making an initial home visit, the nurse notes that
Mr. Sharp has poor personal hygiene and his house is untidy and dirty. How can the nurse best respond
Ex
to the situation?
a. "Many community services are available. Would you like some assistance with
information and contacts?"
b. "I am concerned about you living alone. Do you have neighbours who could assist you
regularly?"
C. "A lot of seniors live at home with community support services. Why don't you look into one
of these services?"
,d. "You are having difficulty taking care of yourself and your home. Would you consider going
to a long-term care facility?"
a. “Many community services are available. Would you like some assistance with information and
contacts?"”
Providing information and teaching-at this time of the intial visit-most therapeutic response
An adult client is receiving intravenous therapy of normal saline (0.9%) via a peripheral line.Which
6
statement by the nurse is correct?
2
a. "The intravenous solution bag should be changed when there is 100-200 ml remaining."
20
b. "Assess the client's intravenous therapy every 2 hours for rate offlow and level of fluid."
c. "Check the physician's orders every 4 hours."
d. "The intravenous administration sets are changed every 48-72 hours."
am
d. "The intravenous administration sets are changed every 48-72 hours."
IV's must be assessed HOURLY. We do not change the bag when there is 100-200 ml remaining.There
are no guidelines to checking the physician's orders every 4 hours.
The nurse is caring for Mr. Albert, 72 years old, who has peripheral vascular disease. When assisting
Ex
him back to bed following ambulation, the nurse observes cool, edematous extremities due to venous
stasis. What should the nurse do?
s
a. Apply anti-embolytic stockings
b. Massage his legs and feet
rt
c. Wrap his legs in a warm blanket
d. Elevate his legs above the level of the heart
pe
a. Apply anti-embolytic stockings-requires order, also should be applied before ambulation
b. Massage his legs and feet-not required, painful and could lead to skin breakdown
Ex
c. Wrap his legs in a warm blanket-heat increases oxygen demand and blood flow of tissue
d. Elevate his legs above the level of the heart-increases venous return by gravity
A nurse and colleague are assisting Mrs. Bell, an 82-year-old paraplegic client, to bed. This facility
requires the use of a mechanical lift for non-weight bearing clients but the colleague insists that
the mechanical lift is unnecessary. What should the nurse do?
a. Perform the client transfer alone using the mechanical lift
b. Work with the colleague to transfer the client to the bed without the lift
, c. Explain to the colleague that the client has functional limitations
d. Remind the colleague that the policy should be followed.
a. Perform the client transfer alone using the mechanical lift—not appropriate/against policy
b. Work with the colleague to transfer the client to the bed without the lift-YIKES UNSAFE
c. Explain to the colleague that the client has functional limitations—does not address
6
colleague's request
d. Remind the colleague that the policy should be followed.-consistent with facility's policy and
2
promotes safety of the client and the employees
20
Mr. Wall, 72 years old, is preparing for discharge. He lives alone but his daughter lives in the same city.
After discharge, he will require assistance with daily activities. Which action would be most appropriate
to include in his discharge plan?
am
a. Recommend that he stay with his daughter for a few weeks
b. Suggest that a neighbor check on him daily
c. Recommend that a health-care-worker provide assistance at home
d. Suggest that he stay in hospital for a few more days.
Ex
a. Recommend that he stay with his daughter for a few weeks-not appropriate or desired
b. Suggest that a neighbor check on him daily- not optimal or appropriate
c. Recommend that a health-care-worker provide assistance at home-appropriate
ts
recommendation for assistance with ADL's
d. Suggest that he stay in hospital for a few more days. -limited resources, money, not permitted Mrs.
r
Akbar, 65 years old, had a hip replacement yesterday. She has been unable to void for 10hours. How
pe
should the nurse proceed?
a. Perform a straight catheterization
Ex
b. Offer Mrs. Akbar the use of a fracture bedpan
c. Encourage Mrs. Akbar to drink additional fluids
d. Check the physician's orders on the chart
a. Perform a straight catheterization-Require a doctor's order
b. Offer Mrs. Akbar the use of a fracture bedpan-this is an acceptable option following hip
replacement surgery
c. Encourage Mrs. Akbar to drink additional fluids-pushing fluids will add to urinary retention
6
Answers New Updated Version
2
20
Bryan, a salesman, has had difficulty holding a job because he accuses coworkers of conspiring
to take his sales. Today he argued with several officemates and threatened to kill one of them.
am
The police were called, and he was brought to the urgent care health centre for evaluation.
Bryan has had previous admissions to the inpatient psychiatric unit for stabilization of symptoms
of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station
Ex
and shouts loudly, "They are all plotting to destroy me! Isn't that true?" An appropriate
response for the nurse would be:
a. "No, that 's not true. People here are trying to help you, if you'll let them."
s
b. "Everyone is trying to help you. No one wants to harm you."
rt
c. "Thinking that people want to destroy you must be very frightening."
d. "That's absurd, Bryan. The staff here are health care workers, not members of the mob."
pe
c. “Thinking that people want to destroy you must be very frightening.”
It is important to validate the feelings and experience of a person in a delusional state without
Ex
reinforcing the delusion. Providing the support and acknowledgement assists in building a
trusting relationship even when the client is feeling suspicious. Denying the experience or
ignoring the feelings would be counter therapeutic and would not establish trust.
,The nurse is informed by the team leader that Mrs. BT needs her intravenous solution changed to
normal saline at 125 ml/h. Which one of the following actions is most appropriate for the nurse to
take?
a. Change the intravenous solution and infusion rate immediately
b.Check the new order and then change the solution when the bag is empty
c. Obtain the new solution bag and prepare to hang the new infusion
6
d. Verify the new order and then change the solution and confirm the rate
2
d. Verify the new order and then change the solution and confirm the rate
20
Best Practice-as per guidelines. All new orders must be verified, prior to intervening. Any order that is
directed by another staff member should always be verified!!!
While assisting Mr. Heart, 78 years old, the nurse finds that his anti-embolic stockings are more
difficult to apply. He receives furosemide (Lasix) and digoxin (Lanoxin) daily. Which of the following
am
interventions would be most appropriate for the nurse to take?
a. Measure both of his calves and order new stockings
b. Lower both of his legs prior to applying the stockings
Ex
c. Apply the stockings after the digoxin has been administered
d. Weigh Mr. Heart daily and document the finding
d. Weigh Mr. Heart daily and document the finding
Critical Thinking Question—The stockings are more difficult to apply—considering the patient is on a
ts
diuretic, and a antiarrhythmic/inotropic agent for the heart, we can believe that this patient has
congestive heart failure, and is experiencing fluid volume excess. Our next intervention is to weigh
r
patient, to help confirm our assessment. Option a is good for DVT assessment. Option b will increase
pe
swelling.
Mr. Sharp, 70 years old, lives independently. While making an initial home visit, the nurse notes that
Mr. Sharp has poor personal hygiene and his house is untidy and dirty. How can the nurse best respond
Ex
to the situation?
a. "Many community services are available. Would you like some assistance with
information and contacts?"
b. "I am concerned about you living alone. Do you have neighbours who could assist you
regularly?"
C. "A lot of seniors live at home with community support services. Why don't you look into one
of these services?"
,d. "You are having difficulty taking care of yourself and your home. Would you consider going
to a long-term care facility?"
a. “Many community services are available. Would you like some assistance with information and
contacts?"”
Providing information and teaching-at this time of the intial visit-most therapeutic response
An adult client is receiving intravenous therapy of normal saline (0.9%) via a peripheral line.Which
6
statement by the nurse is correct?
2
a. "The intravenous solution bag should be changed when there is 100-200 ml remaining."
20
b. "Assess the client's intravenous therapy every 2 hours for rate offlow and level of fluid."
c. "Check the physician's orders every 4 hours."
d. "The intravenous administration sets are changed every 48-72 hours."
am
d. "The intravenous administration sets are changed every 48-72 hours."
IV's must be assessed HOURLY. We do not change the bag when there is 100-200 ml remaining.There
are no guidelines to checking the physician's orders every 4 hours.
The nurse is caring for Mr. Albert, 72 years old, who has peripheral vascular disease. When assisting
Ex
him back to bed following ambulation, the nurse observes cool, edematous extremities due to venous
stasis. What should the nurse do?
s
a. Apply anti-embolytic stockings
b. Massage his legs and feet
rt
c. Wrap his legs in a warm blanket
d. Elevate his legs above the level of the heart
pe
a. Apply anti-embolytic stockings-requires order, also should be applied before ambulation
b. Massage his legs and feet-not required, painful and could lead to skin breakdown
Ex
c. Wrap his legs in a warm blanket-heat increases oxygen demand and blood flow of tissue
d. Elevate his legs above the level of the heart-increases venous return by gravity
A nurse and colleague are assisting Mrs. Bell, an 82-year-old paraplegic client, to bed. This facility
requires the use of a mechanical lift for non-weight bearing clients but the colleague insists that
the mechanical lift is unnecessary. What should the nurse do?
a. Perform the client transfer alone using the mechanical lift
b. Work with the colleague to transfer the client to the bed without the lift
, c. Explain to the colleague that the client has functional limitations
d. Remind the colleague that the policy should be followed.
a. Perform the client transfer alone using the mechanical lift—not appropriate/against policy
b. Work with the colleague to transfer the client to the bed without the lift-YIKES UNSAFE
c. Explain to the colleague that the client has functional limitations—does not address
6
colleague's request
d. Remind the colleague that the policy should be followed.-consistent with facility's policy and
2
promotes safety of the client and the employees
20
Mr. Wall, 72 years old, is preparing for discharge. He lives alone but his daughter lives in the same city.
After discharge, he will require assistance with daily activities. Which action would be most appropriate
to include in his discharge plan?
am
a. Recommend that he stay with his daughter for a few weeks
b. Suggest that a neighbor check on him daily
c. Recommend that a health-care-worker provide assistance at home
d. Suggest that he stay in hospital for a few more days.
Ex
a. Recommend that he stay with his daughter for a few weeks-not appropriate or desired
b. Suggest that a neighbor check on him daily- not optimal or appropriate
c. Recommend that a health-care-worker provide assistance at home-appropriate
ts
recommendation for assistance with ADL's
d. Suggest that he stay in hospital for a few more days. -limited resources, money, not permitted Mrs.
r
Akbar, 65 years old, had a hip replacement yesterday. She has been unable to void for 10hours. How
pe
should the nurse proceed?
a. Perform a straight catheterization
Ex
b. Offer Mrs. Akbar the use of a fracture bedpan
c. Encourage Mrs. Akbar to drink additional fluids
d. Check the physician's orders on the chart
a. Perform a straight catheterization-Require a doctor's order
b. Offer Mrs. Akbar the use of a fracture bedpan-this is an acceptable option following hip
replacement surgery
c. Encourage Mrs. Akbar to drink additional fluids-pushing fluids will add to urinary retention
