Anda di halaman 1dari 7

1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel 6.

6. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is
(UAP). Which of the following task could the registered nurse safely assigned to a responsible for every aspect of care such as formulating the care of plan, intervention
UAP? and evaluating the care during her shift. At the end of her shift, the RN will pass this
same task to the next RN in charge. This nursing care illustrates of what kind of
A. Monitor the I&O of a comatose toddler client with salicylate poisoning method?
B. Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall
C. Check the IV of a preschooler with Kawasaki disease A. primary nursing method
D. Give an outmeal bath to an infant with eczema B. case method
2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics C. team method
unit. There were three patients assigned to the RN. Which of the following patients D. functional method
should not be assigned to the floated nurse? 7. A newly hired nurse on an adult medicine unit with 3 months experience was asked
to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an
A. A 9-year-old child diagnosed with rheumatic fever interesting assignment that feels overwhelming. The nurse should:
B. A young infant after pyloromyotomy
C. A 4-year-old with VSD following cardiac catheterization A. resign on the spot from the nursing position and apply for a position that does not
D. A 5-month-old with Kawasaki disease require floating
3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to B. Inform the nursing supervisor and the charge nurse on the pediatric floor about the
assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following nurse’s lack of skill and feelings of hesitations and request assistance
patients could the nurse manager safely assign to the float nurse? C. Ask several other nurses how they feel about pediatrics and find someone else who is
willing to accept the assignment
A. A child who had multiple injuries from a serious vehicle accident D. Refuse the assignment and leave the unit requesting a vacation a day
B. A child diagnosed with Kawasaki disease and with cardiac complications 8. An experienced nurse who voluntarily trained a less experienced nurse with the
C. A child who has had a nephrectomy for Wilm’s tumor intention of enhancing the skills and knowledge and promoting professional
D. A child receiving an IV chelating therapy for lead poisoning advancement to the nurse is called a:
4. The registered nurse is planning to delegate task to a certified nursing assistant.
Which of the following clients should not be assigned to a CAN? A. mentor
B. team leader
A. A client diagnosed with diabetes and who has an infected toe C. case manager
B. A client who had a CVA in the past two months D. change agent
C. A client with Chronic renal failure 9. The pediatrics unit is understaffed and the nurse manager informs the nurses in the
D. A client with chronic venous insufficiency obstetrics unit that she is going to assign one nurse to float in the pediatric units.
5. The nurse in the medication unit passes the medications for all the clients on the Which statement by the designated float nurse may put her job at risk?
nursing unit. The head nurse is making rounds with the physician and coordinates
clients’ activities with other departments. The nurse assistant changes the bed lines A. “I do not get along with one of the nurses on the pediatrics unit”
and answers call lights. A second nurse is assigned for changing wound dressings; a B. “I have a vacation day coming and would like to take that now”
licensed practitioner nurse takes vital signs and bathes theclients. This illustrates of C. “I do not feel competent to go and work on that area”
what method of nursing care? D. “ I am afraid I will get the most serious clients in the unit”
10. The newly hired staff nurse has been working on a medical unit for 3 weeks. The
A. Case management method nurse manager has posted the team leader assignments for the following week. The
B. Primary nursing method new staff knows that a major responsibility of the team leader is to:
C. Team method
D. Functional method A. Provide care to the most acutely ill client on the team
B. Know the condition and needs of all the patients on the team
C. Document the assessments completed by the team members
D. Supervise direct care by nursing assistants
11. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. 15. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The
The nurse prepared the consent form and it should be signed by: nurse is tasks to bring the informed consent document into the client’s room for a
signature. The client asks the nurse for details of the procedure and demands an
A. The Physician explanation why the process of informed consent is necessary. The nurse responds
B. The Registered Nurse caring for the client that informed consent means:
C. The 15-year-old mother of the baby boy
D. The mother of the girl A. The patient releases the physician from all responsibility for the procedure.
12. A nurse caring to a client with Alzheimer’s disease overheard a family member say B. The immediate family may make decision against the patient’s will.
to the client, “if you pee one more time, I won’t give you any more food and drinks”. C. The physician must give the client or surrogates enough information to make health
What initial action is best for the nurse to take? care judgments consistent with their values and goals.
D. The patient agrees to a procedure ordered by the physician even if the client does not
A. Take no action because it is the family member saying that to the client understand what the outcome will be.
B. Talk to the family member and explain that what she/he has said is not appropriate 16. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for
for the client an amputation. The client tells the nurse that he will not sign the consent form and he
C. Give the family member the number for an Elder Abuse Hot line does not want any surgery or treatment because of religious beliefs about
D. Document what the family member has said reincarnation. What is the role of the RN?

A. call a family meeting

13. Which is true about informed consent? B. discuss the religious beliefs with the physician
C. encourage the client to have the surgery
A. A nurse may accept responsibility signing a consent form if the client is unable D. inform the client of other options
B. Obtaining consent is not the responsibility of the physician 17. While in the hospital lobby, the RN overhears the three staff discussing the health
C. A physician will not subject himself to liability if he withholds any facts that are condition of her client. What would be the appropriate nursing action for the RN to
necessary to form the basis of an intelligent consent take?
D. If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the
signature is that of the purported person and that the person’s condition is as A. Tell them it is not appropriate to discuss the condition of the client
indicated at the time of signing B. Ignore them, because it is their right to discuss anything they want to
14. A mother in labor told the nurse that she was expecting that her baby has no C. Join in the conversation, giving them supportive input about the case of the client
chance to survive and expects that the baby will be born dead. The mother accepts D. Report this incident to the nursing supervisor
the fate of the baby and informs the nurse that when the baby is born and requires 18. A staff nurse has had a serious issue with her colleague. In this situation, it is best
resuscitation, the mother refuses any treatment to her baby and expresses hostility to:
toward the nurse while the pediatric team is taking care of the baby. The nurse is
legally obligated to: A. Discuss this with the supervisor
B. Not discuss the issue with anyone. It will probably resolve itself
A. Notify the pediatric team that the mother has refused resuscitation and any treatment C. Try to discuss with the colleague about the issue and resolve it when both are calmer
for the baby and take the baby to the mother D. Tell other members of the network what the team member did
B. Get a court order making the baby a ward of the court 19. The nurse is caring to a client who just gave birth to a healthy baby boy. The
C. Record the statement of the mother, notify the pediatric team, and observe carefully nurse may not disclose confidential information when:
for signs of impaired bonding and neglect as a reasonable suspicion of child abuse
D. Do nothing except record the mother’s statement in the medical record A. The nurse discusses the condition of the client in a clinical conference with other
B. The client asks the nurse to discuss the her condition with the family
C. The father of a woman who just delivered a baby is on the phone to find out the sex
of the baby
D. A researcher from an institutionally approved research study reviews the medical
record of a patient
20. A 17-year-old married client is scheduled for surgery. The nurse taking care of the 26. The nurse is conducting a discharge instructions to a client diagnosed with
client realizes that consent has not been signed after preoperative medications were diabetes. What sign of hypoglycemia should be taught to a client?
given. What should the nurse do?
A. warm, flushed skin
A. Call the surgeon B. hunger and thirst
B. Ask the spouse to sign the consent C. increase urinary output
C. Obtain a consent from the client as soon as possible D. palpitation and weakness
D. Get a verbal consent from the parents of the client 27. A client admitted to the hospital and diagnosed with Addison’s disease. What
21. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to would be the appropriate nursing action to the client?
the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most
correct in mixing it with: A. administering insulin-replacement therapy
B. providing a low-sodium diet
A. Normal Saline C. restricting fluids to 1500 ml/day
B. Heparinized normal saline D. reducing physical and emotional stress
C. 5% dextrose in water 28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which
D. Lactated Ringer’s solution nursing action is essential to prevent hypoxemia?
22. The nurse is caring to a client who is hypotensive. Following a large hematemesis,
how should the nurse position the client? A. aucultating the lungs to determine the baseline data to assess the effectiveness of
A. Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow B. removing oral and nasal secretions
B. Low Fowler’s with knees gatched at 30 degrees C. encouraging the patient to deep breathe and cough to facilitate removal of upper-
C. Supine with the head turned to the left airway secretions
D. Bed sloped at a 45 degree angle with the head lowest and the legs highest D. administering 100% oxygen to reduce the effects of airway obstruction during
23. The client is brought to the emergency department after a serious accident. What suctioning.
would be the initial nursing action of the nurse to the client? 29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red
marks on the swollen face resembling a handprint. The nurse does further assessment
A. assess the level of consciousness and circulation to the client. How would the nurse document the finding?
B. check respirations, circulation, neurological response
C. align the spine, check pupils, check for hemorrhage A. Facial edema with ecchymosis and handprint mark: crackles and wheezes
D. check respiration, stabilize spine, check circulation B. Facial edema, with red marks; crackles in the lung
24. A nurse is assigned to care to a client with Parkinson’s disease. What interventions C. Facial edema with ecchymosis that looks like a handprint
are important if the nurse wants to improve nutrition and promote effective D. Red bruise mark and ecchymosis on face
swallowing of the client? 30. On the evening shift, the triage nurse evaluates several clients who were brought
to the emergency department. Which in the following clients should receive highest
A. Eat solid food priority?
B. Give liquids with meals
C. Feed the client A. an elderly woman complaining of a loss of appetite and fatigue for the past week
D. Sit in an upright position to eat B. A football player limping and complaining of pain and swelling in the right ankle
25. During tracheal suctioning, the nurse should implement safety measures. Which of C. A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his
the following should the nurse implements? jaw
D. A mother with a 5-year-old boy who says her son has been complaining of nausea
A. limit suction pressure to 150-180 mmHg and vomited once since noon
B. suction for 15-20 seconds
C. wear eye goggles
D. remove the inner cannula
31. A 80-year-old female client is brought to the emergency department by her 37. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s
caregiver, on the nurse’s assessment; the following are the manifestations of the family members come to visit, they would be adhering to respiratory isolation
client: anorexia, cachexia and multiple bruises. What would be the best nursing precautions when they:
A. wash their hands when leaving
A. check the laboratory data for serum albumin, hematocrit, and hemoglobin B. put on gowns, gloves and masks
B. talk to the client about the caregiver and support system C. avoid contact with the client’s roommate
C. complete a police report on elder abuse D. keep the client’s room door open
D. complete a gastrointestinal and neurological assessment 38. An infant is brought to the emergency department and diagnosed with pyloric
32. The night shift nurse is making rounds. When the nurse enters a client’s room, the stenosis. The parents of the client ask the nurse, “Why does my baby continue to
client is on the floor next to the bed. What would be the initial action of the nurse? vomit?” Which of the following would be the best nursing response of the nurse?

A. chart that the patient fell A. “Your baby eats too rapidly and overfills the stomach, which causes vomiting
B. call the physician B. “Your baby can’t empty the formula that is in the stomach into the bowel”
C. chart that the client was found on the floor next to the bed C. “The vomiting is due to the nausea that accompanies pyloric stenosis”
D. fill out an incident report D. “Your baby needs to be burped more thoroughly after feeding”
33. The nurse on the night shift is about to administer medication to a preschooler 39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care
client and notes that the child has no ID bracelet. The best way for the nurse to facilities. An intradermal tuberculosis test is schedule to be done. The client asks the
identify the client is to ask: nurse what is the purpose of the test. Which of the following would be the best
rationale for this?
A. The adult visiting, “The child’s name is ____________________?”
B. The child, “Is your name____________?” A. reactivation of an old tuberculosis infection
C. Another staff nurse to identify this child B. increased incidence of new cases of tuberculosis in persons over 65 years old
D. The other children in the room what the child’s name is C. greater exposure to diverse health care workers
34. The nurse caring to a client has completed the assessment. Which of the following D. respiratory problems are characteristic in this population
will be considered to be the most accurate charting of a lump felt in the right breast? 40. The nurse is making a health teaching to the parents of the client. In teaching
parents how to measure the area of induration in response to a PPD test, the nurse
A. “abnormally felt area in the right breast, drainage noted” would be most accurate in advising the parents to measure:
B. “hard nodular mass in right breast nipple”
C. “firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’ A. both the areas that look red and feel raised
D. “mass in the right breast 4cmx1cm B. The entire area that feels itchy to the child
35. The physician instructed the nurse that intravenous pyelogram will be done to the C. Only the area that looks reddened
client. The client asks the nurse what is the purpose of the procedure. The D. Only the area that feels raised
appropriate nursing response is to: 41. A community health nurse is schedule to do home visit. She visits to an elderly
person living alone. Which of the following observation would be a concern?
A. outline the kidney vasculature
B. determine the size, shape, and placement of the kidneys A. Picture windows
C. test renal tubular function and the patency of the urinary tract B. Unwashed dishes in the sink
D. measure renal blood flow C. Clear and shiny floors
36. A client visits the clinic for screening of scoliosis. The nurse should ask the client D. Brightly lit rooms
to: 42. After a birth, the physician cut the cord of the baby, and before the baby is given
to the mother, what would be the initial nursing action of the nurse?
A. bend all the way over and touch the toes
B. stand up as straight and tall as possible A. examine the infant for any observable abnormalities
C. bend over at a 90-degree angle from the waist B. confirm identification of the infant and apply bracelet to mother and infant
D. bend over at a 45-degree angle from the waist C. instill prophylactic medication in the infant’s eyes
D. wrap the infant in a prewarmed blanket and cover the head
43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the 49. The mother of the client tells the nurse, “ I’m not going to have my baby get any
scalp, face, neck and arms. The client is scratching the affected areas. What would be immunization”. What would be the best nursing response to the mother?
the best nursing intervention to prevent the client from scratching the affected areas?
A. “You and I need to review your rationale for this decision”
A. elbow restraints to the arms B. “Your baby will not be able to attend day care without immunizations”
B. Mittens to the hands C. “Your decision can be viewed as a form of child abuse and neglect”
C. Clove-hitch restraints to the hands D. “You are needlessly placing other people at risk for communicable diseases”
D. A posey jacket to the torso 50. The nurse is teaching the client about breast self-examination. Which observation
44. The parents of the hospitalized client ask the nurse how their baby might have should the client be taught to recognize when doing the examination for detection of
gotten pyloric stenosis. The appropriate nursing response would be: breast cancer?

A. There is no way to determine this preoperatively A. tender, movable lump

B. Their baby was born with this condition B. pain on breast self-examination
C. Their baby developed this condition during the first few weeks of life C. round, well-defined lump
D. Their baby acquired it due to a formula allergy D. dimpling of the breast tissue
45. A male client comes to the clinic for check-up. In doing a physical assessment, the
nurse should report to the physician the most common symptom of gonorrhea, which

A. pruritus
B. pus in the urine
C. WBC in the urine
D. Dysuria
46. Which of the following would be the most important goal in the nursing care of an
infant client with eczema?

A. preventing infection
B. maintaining the comfort level
C. providing for adequate nutrition
D. decreasing the itching
47. The nurse is making a discharge instruction to a client receiving chemotherapy.
The client is at risk for bone marrow depression. The nurse gives instructions to the
client about how to prevent infection at home. Which of the following health teaching
would be included?

A. “Get a weekly WBC count”

B. “Do not share a bathroom with children or pregnant woman”
C. “Avoid contact with others while receiving chemotherapy”
D. “Do frequent hand washing and maintain good hygiene”
48. The nurse is assigned to care the client with infectious disease. The best
antimicrobial agent for the nurse to use in handwashing is:

A. Isopropyl alcohol
B. Hexachlorophene (Phisohex)
C. Soap and water
D. Chlorhexidine gluconate (CHG) (Hibiclens)
Answers and Rationales 22. A. This position increases venous return, improves cardiac volume, and promotes
1. D. Bathing an infant with eczema can be safely delegated to an aide; this task is basic adequate ventilation and cerebral perfusion
and can competently performed by an aid. 23. D. Checking the airway would be a priority, and a neck injury should be suspected
2. B. The RN floated from the telemetry unit would be least prepared to care for a young 24. D. Client with Parkinson’s disease are at a high risk for aspiration and undernutrition.
infant who has just had GI surgery and requires a specific feeding regimen. Sitting upright promotes more effective swallowing.
3. C. RN floated from the obstetrics unit should be able to care for a client with major 25. C. It is important to protect the RN’s eyes from the possible contamination of
abdominal surgery, because this nurse has experienced caring for clients with coughed-up secretions
cesarean births. 26. D. There has been too little food or too much insulin. Glucose levels can be markedly
4. A. The patient is experiencing a potentially serious complication related to diabetes decreased (less than 50 mg/dl). Severe hypoglycemia may be fatal if not detected
and needs ongoing assessment by an RN 27. D. Because the client’s ability to react to stress is decreased, maintaining a quiet
5. D. It describes functional nursing. Staff is assigned to specific task rather than specific environment becomes a nursing priority. Dehydration is a common problem in
clients. Addison’s disease, so close observation of the client’s hydration level is crucial.
6. B. Case management. The nurse assumes total responsibility for meeting the needs of 28. D. Presuctioning and postsuctioning ventilation with 100% oxygen is important in
the client during her entire duty. reducing hypoxemia which occurs when the flow of gases in the airway is obstructed
7. B. The nurse is ethically obligated to inform the person responsible for the assignment by the suctioning catheter.
and the person responsible for the unit about the nurse’s skill level. The nurse 29. B. This is an example of objective data of both pulmonary status and direct
therefore avoids a situation of abandoningclients and exposing them to greater risks observation on the skin by the nurse.
8. A. This describes a mentor 30. C. These are likely signs of an acute myocardial infarction (MI). An acute MI is a
9. B. This action demonstrates a lack of responsibility and the nurse should attempt cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal
negotiation with the nurse manager. if not treated immediately.
10. B. The team leader is responsible for the overall management of all clients and staff 31. D. Assessment and more data collection are needed. The client may have
on the team, and this information is essential in order to accomplish this gastrointestinal or neurological problems that account for the symptoms. The anorexia
11. C. Even though the mother is a minor, she is legally able to sign consent for her own could result from medications, poor dentition, or indigestion, and the bruises may be
child. attributed to ataxia, frequent falls, vertigo or medication.
12. B. This response is the most direct and immediate. This is a case of potential need 32. B. This is closest to suggesting action-assessment, rather than paperwork- and is
for advocacy and patient’s rights. therefore the best of the four.
13. D. The nurse who witness a consent for treatment or surgery is witnessing only that 33. C. The only acceptable way to identify a preschooler client is to have a parent or
the client signed the form and that the client’s condition is as indicated at the time of another staff member identify the client.
signing. The nurse is not witnessing that the client is “informed”. 34. C. It describes the mass in the greatest detail.
14. C. Although the statements by the mother may not create a suspicion of neglect, 35. C. Intravenous pyelogram tests both the function and patency of the kidneys. After
when they are coupled with observations about impaired bonding and maternal the intravenous injection of a radiopaque contrast medium, the size, location, and
attachment, they may impose the obligation to report child neglect. The nurse is patency of the kidneys can be observed by roentgenogram, as well as the patency of
further obligated to notify caregivers of refusal to consent to treatment the urethra and bladder as the kidneys function to excrete the contrast medium.
15. C. It best explains what informed consent is and provides for legal rights of the 36. C. This is the recommended position for screening for scoliosis. It allows the nurse to
patient inspect the alignment of the spine, as well as to compare both shoulders and both
16. B. The physician may not be aware of the role that religious beliefs play in making a hips.
decision about surgery. 37. A. Handwashing is the best method for reducing cross-contamination. Gowns and
17. A. The behavior should be stopped. The first step is to remind the staff that gloves are not always required when entering a client’s room.
confidentiality may be violated 38. B. Pyloric stenosis is an anomaly of the upper gastrointestinal tract. The condition
18. C. Waiting for emotions to dissipate and sitting down with the colleague is the first involves a thickening, or hypertrophy, of the pyloric sphincter located at the distal end
rule of conflict resolution. of the stomach. This causes a mechanical intestinal obstruction, which leads to
19. C. The nurse has no idea who the person is on the phone and therefore may not vomiting after feeding the infant. The vomiting associated with pyloric stenosis is
share the information even if the patient gives permission described as being projectile in nature. This is due to the increasing amounts of
20. A. The priority is to let the surgeon know, who in turn may ask the husband to sign formula the infant begins to consume coupled with the increasing thickening of the
the consent. pyloric sphincter.
21. A. Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it 39. B. Increased incidence of TB has been seen in the general population with a high
should be mixed with normal saline. incidence reported in hospitalized elderly clients. Immunosuppression and lack of
classic manifestations because of the aging process are just two of the contributing
factors of tuberculosis in the elderly.
40. D. Parents should be taught to feel the area that is raised and measure only that.
41. C. It is a safety hazard to have shiny floors because they can cause falls.
42. D. The first priority, beside maintaining a newborn’s patent airway, is body
43. B. The purpose of restraints for this child is to keep the child from scratching the
affected areas. Mittens restraint would prevent scratching, while allowing the most
movement permissible.
44. C. Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is
unknown. It develops during the first few weeks of life.
45. B. Pus is usually the first symptom, because the bacteria reproduce in the bladder.
46. A. Preventing infection in the infant with eczema is the nurse’s most important goal.
The infant with eczema is at high risk for infection due to numerous breaks in the
skin’s integrity. Intact skin is always the infant’s first line of defense against infection.
47. D. Frequent hand washing and good hygiene are the best means of preventing
48. D. CHG is a highly effective antimicrobial ingredient, especially when it is used
consistently over time.
49. A. The mother may have many reasons for such a decision. It is the nurse’s
responsibility to review this decision with the mother and clarify any misconceptions
regarding immunizations that may exist.
50. D. The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and
create a dimpling appearance.