ned clients. Which of the following referrals is
1. The nur~e is assisting with discharge planning for assig
appropriate for the nurse to make?
discharged with a prescription for a
a. A social worker referral for a client who will be
benzodiazepine.
has rheumatoid arthritis (RA) and requires
b. A physical therapist (PT) referral for a client who
g.
instruction in the use of an assistive device for eatin
t who has Parkinson's disease and is
c. An occupational therapist (OT) referral for a clien
living (AOL).
experiencing difficulty performing activities of daily
be discharged with intermittent tube feedings .
d. A speech therapist referral for a client who will
ram on legal issues in nursing practice. Which of
2. The nurse has attended a continuing education prog
ct understanding of the conference?
the following statements by the nurse indicates a corre
t's consent is an example of assault."
a. "Threatening to touch a client without the clien
client who is confused and is being
b. "Failure to communicate concerns about an elderly
got
discharged home is an example of defamation."
condition or expected outcome is an
c. "Giving clients false assurance about a health care
example of libel."
ut the client's permission is an
d. "Posting information about a client on social media witho
example of slander."
g for assigned clients. Which of the following
3. The nurse working in a medical-surgical unit is carin
tasks is appropriate to delegate?
teach a client who has a newly created
a. Asking a licensed practical nurse (LPNNN) to
ileostomy how to change the appliance.
obtain a capillary blood glucose reading on a
b. Asking a licensed practical nurse {LPNNN) to
client who has become diaphoretic.
) to flush the Jackson-Pratt (JP) drain of a
c. Asking an unlicensed assistive personnel {UAP
ndectomy.
client who is 2 days postoperative from an open appe
tum off the tube feeding for a client who is
d. Asking an unlicensed assistive personnel (UAP) to
receiving continuous tube feedings and is vomiting.
It is most appropriate for the nurse to initiate an
4. The nurse is caring for the following pediatric clients.
interdisciplinary conference for the client who is
rreflexia, and a report that the mother
a. 3 days old, has been readmitted with rhinorrhea, hype
has a history of substance abuse during pregnancy.
school playground, and is being
b. 5 years old, has a fractured arm from falling on the
discharged with a fiberglass cast.
drainage, a red, bulging tympanic
c. 6 months old, has acute otitis media with purulent ear
membrane, and is crying.
(OOH), unequal leg lengths, limited
d. 2 months old, has developmental dysplasia of the hip
al folds.
abduction of the left hip, and asymmetry of the glute
,I
The nurse working in the labor and delivery unit is caring for a client in labor whose mernbta~
5.
spontaneously ruptured. Which of the following findings is a priority for the nurse to report to~
primary health care provider (PHCP)?
a. Contractions lasting 60 seconds.
b. Four contractions in a 10-mlnute period.
c. A maternal temperature of 99.5° F.
d. Appearance of bloody fluid from the vagina.
6. The nurse is caring for a client who weighs 150 lb (68 kg) and has developed hepatic
encephalopathy. It is a priority for the nurse to notify the primary heaffh care provider (PHCP) if
client develops
a. a decrease in urine output to 450 mUday. 0.5mg x kg x hr
b. a change in pupil size from 7 to 5 mm.
c. n
an increase in alanine aminotransferase (AL levels.
d. the development of a musty odor to the breath.
7. The nurse has received report for the following clients. The nurse should first assess the client wh
a. had a stroke 24 hours ago and has become restJess and irritable.
b. has meningitis and reports a headache and photosensitivity.
c. has an abdominal aneurysm and reports mild lower back pain.
d. has epilepsy and remains drowsy 30 minutes after having a seizure.
8. The nurse is caring for assigned clients. It is a priority for the nurse to follow up with a client who
a. has a closed-chest drainage system attached to 20 cm of suction and has 3 cm of water In th
water seal chamber.
b. has end-stage renal disease (ESRD), a history of hyperkalemia, and is drinking orange juice
brought in by a visitor.
c. is receiving a continuous heparin Infusion and received the first dose of warfarin 1 hour ago.
d. is receiving intravenous {IV) fluid at a prescribed rate of 100 mUhr and has received 400 ml
after 2 hours.
9. The nurse working in the emergency department (ED) Is precepting a newly hired nurse. It Indicates
correct care If the newly hired nurse
0. rewarm& the trunk before the extremities of a client who has moderate hypothermia.
b. prepares to give lorazepam to a client who Is anxious and needs to sign a consent form.
c. removes the pants of a client who has chemical burns by soaking them off with water.
d. raises the head of bed {HOB) to 30 degrees for a client who has a BP of 95/58 mm Hg.
1. The nur~e is assisting with discharge planning for assig
appropriate for the nurse to make?
discharged with a prescription for a
a. A social worker referral for a client who will be
benzodiazepine.
has rheumatoid arthritis (RA) and requires
b. A physical therapist (PT) referral for a client who
g.
instruction in the use of an assistive device for eatin
t who has Parkinson's disease and is
c. An occupational therapist (OT) referral for a clien
living (AOL).
experiencing difficulty performing activities of daily
be discharged with intermittent tube feedings .
d. A speech therapist referral for a client who will
ram on legal issues in nursing practice. Which of
2. The nurse has attended a continuing education prog
ct understanding of the conference?
the following statements by the nurse indicates a corre
t's consent is an example of assault."
a. "Threatening to touch a client without the clien
client who is confused and is being
b. "Failure to communicate concerns about an elderly
got
discharged home is an example of defamation."
condition or expected outcome is an
c. "Giving clients false assurance about a health care
example of libel."
ut the client's permission is an
d. "Posting information about a client on social media witho
example of slander."
g for assigned clients. Which of the following
3. The nurse working in a medical-surgical unit is carin
tasks is appropriate to delegate?
teach a client who has a newly created
a. Asking a licensed practical nurse (LPNNN) to
ileostomy how to change the appliance.
obtain a capillary blood glucose reading on a
b. Asking a licensed practical nurse {LPNNN) to
client who has become diaphoretic.
) to flush the Jackson-Pratt (JP) drain of a
c. Asking an unlicensed assistive personnel {UAP
ndectomy.
client who is 2 days postoperative from an open appe
tum off the tube feeding for a client who is
d. Asking an unlicensed assistive personnel (UAP) to
receiving continuous tube feedings and is vomiting.
It is most appropriate for the nurse to initiate an
4. The nurse is caring for the following pediatric clients.
interdisciplinary conference for the client who is
rreflexia, and a report that the mother
a. 3 days old, has been readmitted with rhinorrhea, hype
has a history of substance abuse during pregnancy.
school playground, and is being
b. 5 years old, has a fractured arm from falling on the
discharged with a fiberglass cast.
drainage, a red, bulging tympanic
c. 6 months old, has acute otitis media with purulent ear
membrane, and is crying.
(OOH), unequal leg lengths, limited
d. 2 months old, has developmental dysplasia of the hip
al folds.
abduction of the left hip, and asymmetry of the glute
,I
The nurse working in the labor and delivery unit is caring for a client in labor whose mernbta~
5.
spontaneously ruptured. Which of the following findings is a priority for the nurse to report to~
primary health care provider (PHCP)?
a. Contractions lasting 60 seconds.
b. Four contractions in a 10-mlnute period.
c. A maternal temperature of 99.5° F.
d. Appearance of bloody fluid from the vagina.
6. The nurse is caring for a client who weighs 150 lb (68 kg) and has developed hepatic
encephalopathy. It is a priority for the nurse to notify the primary heaffh care provider (PHCP) if
client develops
a. a decrease in urine output to 450 mUday. 0.5mg x kg x hr
b. a change in pupil size from 7 to 5 mm.
c. n
an increase in alanine aminotransferase (AL levels.
d. the development of a musty odor to the breath.
7. The nurse has received report for the following clients. The nurse should first assess the client wh
a. had a stroke 24 hours ago and has become restJess and irritable.
b. has meningitis and reports a headache and photosensitivity.
c. has an abdominal aneurysm and reports mild lower back pain.
d. has epilepsy and remains drowsy 30 minutes after having a seizure.
8. The nurse is caring for assigned clients. It is a priority for the nurse to follow up with a client who
a. has a closed-chest drainage system attached to 20 cm of suction and has 3 cm of water In th
water seal chamber.
b. has end-stage renal disease (ESRD), a history of hyperkalemia, and is drinking orange juice
brought in by a visitor.
c. is receiving a continuous heparin Infusion and received the first dose of warfarin 1 hour ago.
d. is receiving intravenous {IV) fluid at a prescribed rate of 100 mUhr and has received 400 ml
after 2 hours.
9. The nurse working in the emergency department (ED) Is precepting a newly hired nurse. It Indicates
correct care If the newly hired nurse
0. rewarm& the trunk before the extremities of a client who has moderate hypothermia.
b. prepares to give lorazepam to a client who Is anxious and needs to sign a consent form.
c. removes the pants of a client who has chemical burns by soaking them off with water.
d. raises the head of bed {HOB) to 30 degrees for a client who has a BP of 95/58 mm Hg.
