EXAM 1 N112 | 123 QUESTIONS | WITH
ACTUAL SOLUTIONS GRADED A+
A nurse receives a shift report and is preparing to care for clients assigned on a
medicalsurgical unit. Which client should the nurse plan to assess first?
A) The client who needs assistance with activities of daily living
B) The client who needs help ambulating to the bathroom
C) The client with a pain rating of 3/10
D) The client experiencing shortness of breath Answer - D
2) A client with congestive heart failure (CHF) is having difficulty breathing.
Before leaving the room, the nurse ensures the client has an overbed table to
lean on when awake if needed to ease breathing. Which technique did the
nurse use to make this decision? A) Delegating a task
B) Priority setting
C) Conflict resolution
D) Critical thinking Answer - D
3) A postoperative client prescribed pain medication every 4 to 6 hours is
requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a
rating scale of 1 to 10. The nurse decides to give the pain medication now.
What does this nurse's action exemplify?
A) Meeting a client goal
B) Time management skills
C) Prioritizing the client's care
D) Responding to a change in the client's condition Answer - D
,4) The nurse is assigned two clients. One client needs postoperative teaching in
preparation for discharge, and the other client with pneumonia has a PaCO2 of
85. Why does the nurse decide to see the client with pneumonia first?
A) The nurse can delegate postoperative teaching to unlicensed assistive
personnel (UAP).
B) The client with pneumonia needs more care than the client needing
postoperative teaching.
C) The client with pneumonia may be experiencing respiratory distress.
D) The room of the client with pneumonia is closer than that of the client
needing postoperative teaching Answer - C
5) The urgent care clinic nurse is treating a client who is experiencing
abdominal pain. The client states, "I think I ate tainted food last night." What
should the nurse do after the client states that the food was tainted?
A) Ask the client open-ended questions to further assess the situation.
B) Tell the client the healthcare provider does not need to assess the client.
C) Call an ambulance before assessing the client any further.
D) Advise the client to take an antacid. Answer - A
6) A client with aspiration pneumonia is diaphoretic, pale, and taking gasping
breaths. Which is the priority nursing action?
A) Notify the healthcare provider.
B) Complete a thorough cardiopulmonary assessment.
C) Administer 10 L of oxygen per face mask.
D) Reposition the client to help with breathing. Answer - B
7) The home health nurse is visiting a client who is 2 weeks postoperative from
a coronary artery bypass surgery. The client has lost 10 pounds, is continuing to
experience pain, and is not eating. What should be the nurse's next action?
,A) Examine the current interventions for pain relief.
B) Refer the client to social services.
C) Contact Meals on Wheels so that the client will eat.
D) Revise the goals in the current plan of care. Answer - A
8) The nurse is caring for an older adult client with decreased energy who
needs to get up to prevent the development of pressure ulcers. The client is
unable to ambulate and wants to be alone. What should the nurse do?
A) Notify the healthcare provider of the client's noncompliance.
B) Leave the client alone until ready to get out of bed.
C) Gain knowledge about the client from family to gain compliance. D) Proceed
to get help to get the client out of bed. Answer - C
9) The nurse is caring for an older school-age client who is sleeping when the
menu choices for dinner are brought to the room. Which intervention should
the nurse use to meet the dietary needs of this client?
A) Wake the child to choose a meal for dinner.
B) Order chicken nuggets because most children like this meal.
C) Ask the dietary worker to come back later.
D) Ask the parents to bring dinner from home for the client. Answer - C
10) A client asks the student nurse to explain the pathophysiology of diabetes.
The student nurse does not know the answer to this question. What should the
student respond to the client? A) "I do not know, but I will find out." B) "You'll
have to ask the doctor that question." C) "Why do you need to know that?" D)
"I do not know." Answer - A
11) A novice nurse is planning care for an older adult client with a wound
infection and systemic blood infection. The nurse completes the plan of care
and decides to complete which action to enhance the skill of critical thinking?
, A) Discuss the plan with the physician.
B) Request that the client review the plan.
C) Request a review of the plan with the nurse's preceptor.
D) Place the plan on the client's chart. Answer - C
12) The nurse is taking the time to reflect on a care situation in which a client
sustained a cardiac arrest and died. On which areas should the nurse focus
when performing this reflection? Select all that apply.
A) Things that could have been done differently
B) Gut reactions to the situation
C) Things that were done well
D) Resources that were used at the time
E) Resources that were needed but not available Answer - A, C, D, E
13) A client begins to vomit blood. The nurse immediately measures the blood
pressure and prepares to insert a nasogastric tube while directing others to
notify the healthcare provider and prepare to perform iced saline lavage.
Which features of the Tanner Clinical Judgment Model did this nurse
demonstrate? Select all that apply.
A) Presencing
B) Noticing
C) Reflecting
D) Interpreting
E) Responding Answer - B, D, E
14) The nurse who uses clinical decision making to start CPR on a client is
concerned about what other nursing concept?
A) Cognition
ACTUAL SOLUTIONS GRADED A+
A nurse receives a shift report and is preparing to care for clients assigned on a
medicalsurgical unit. Which client should the nurse plan to assess first?
A) The client who needs assistance with activities of daily living
B) The client who needs help ambulating to the bathroom
C) The client with a pain rating of 3/10
D) The client experiencing shortness of breath Answer - D
2) A client with congestive heart failure (CHF) is having difficulty breathing.
Before leaving the room, the nurse ensures the client has an overbed table to
lean on when awake if needed to ease breathing. Which technique did the
nurse use to make this decision? A) Delegating a task
B) Priority setting
C) Conflict resolution
D) Critical thinking Answer - D
3) A postoperative client prescribed pain medication every 4 to 6 hours is
requesting medication every 6 hours. At 4 hours the client's pain level is 8 on a
rating scale of 1 to 10. The nurse decides to give the pain medication now.
What does this nurse's action exemplify?
A) Meeting a client goal
B) Time management skills
C) Prioritizing the client's care
D) Responding to a change in the client's condition Answer - D
,4) The nurse is assigned two clients. One client needs postoperative teaching in
preparation for discharge, and the other client with pneumonia has a PaCO2 of
85. Why does the nurse decide to see the client with pneumonia first?
A) The nurse can delegate postoperative teaching to unlicensed assistive
personnel (UAP).
B) The client with pneumonia needs more care than the client needing
postoperative teaching.
C) The client with pneumonia may be experiencing respiratory distress.
D) The room of the client with pneumonia is closer than that of the client
needing postoperative teaching Answer - C
5) The urgent care clinic nurse is treating a client who is experiencing
abdominal pain. The client states, "I think I ate tainted food last night." What
should the nurse do after the client states that the food was tainted?
A) Ask the client open-ended questions to further assess the situation.
B) Tell the client the healthcare provider does not need to assess the client.
C) Call an ambulance before assessing the client any further.
D) Advise the client to take an antacid. Answer - A
6) A client with aspiration pneumonia is diaphoretic, pale, and taking gasping
breaths. Which is the priority nursing action?
A) Notify the healthcare provider.
B) Complete a thorough cardiopulmonary assessment.
C) Administer 10 L of oxygen per face mask.
D) Reposition the client to help with breathing. Answer - B
7) The home health nurse is visiting a client who is 2 weeks postoperative from
a coronary artery bypass surgery. The client has lost 10 pounds, is continuing to
experience pain, and is not eating. What should be the nurse's next action?
,A) Examine the current interventions for pain relief.
B) Refer the client to social services.
C) Contact Meals on Wheels so that the client will eat.
D) Revise the goals in the current plan of care. Answer - A
8) The nurse is caring for an older adult client with decreased energy who
needs to get up to prevent the development of pressure ulcers. The client is
unable to ambulate and wants to be alone. What should the nurse do?
A) Notify the healthcare provider of the client's noncompliance.
B) Leave the client alone until ready to get out of bed.
C) Gain knowledge about the client from family to gain compliance. D) Proceed
to get help to get the client out of bed. Answer - C
9) The nurse is caring for an older school-age client who is sleeping when the
menu choices for dinner are brought to the room. Which intervention should
the nurse use to meet the dietary needs of this client?
A) Wake the child to choose a meal for dinner.
B) Order chicken nuggets because most children like this meal.
C) Ask the dietary worker to come back later.
D) Ask the parents to bring dinner from home for the client. Answer - C
10) A client asks the student nurse to explain the pathophysiology of diabetes.
The student nurse does not know the answer to this question. What should the
student respond to the client? A) "I do not know, but I will find out." B) "You'll
have to ask the doctor that question." C) "Why do you need to know that?" D)
"I do not know." Answer - A
11) A novice nurse is planning care for an older adult client with a wound
infection and systemic blood infection. The nurse completes the plan of care
and decides to complete which action to enhance the skill of critical thinking?
, A) Discuss the plan with the physician.
B) Request that the client review the plan.
C) Request a review of the plan with the nurse's preceptor.
D) Place the plan on the client's chart. Answer - C
12) The nurse is taking the time to reflect on a care situation in which a client
sustained a cardiac arrest and died. On which areas should the nurse focus
when performing this reflection? Select all that apply.
A) Things that could have been done differently
B) Gut reactions to the situation
C) Things that were done well
D) Resources that were used at the time
E) Resources that were needed but not available Answer - A, C, D, E
13) A client begins to vomit blood. The nurse immediately measures the blood
pressure and prepares to insert a nasogastric tube while directing others to
notify the healthcare provider and prepare to perform iced saline lavage.
Which features of the Tanner Clinical Judgment Model did this nurse
demonstrate? Select all that apply.
A) Presencing
B) Noticing
C) Reflecting
D) Interpreting
E) Responding Answer - B, D, E
14) The nurse who uses clinical decision making to start CPR on a client is
concerned about what other nursing concept?
A) Cognition
