MODULE 6

Questions
1.

1.ID: 383719745
Wrist restraints have been prescribed for a client who is constantly pulling at his
gastrostomy tube. Which of the following findings does the nurse, developing a
care plan, recognize as unexpected outcomes related to the use of
restraints? Select all that apply.
A.

The client is agitated. Correct

B.

The skin under the restraint is red. Correct

C.

The clients left hand is pale and cold. Correct

D.

The client verbalizes the reason for the restraints.

E.

The client is unable to reach the gastrostomy tube with his

hands.

F.

The client slips his hand from its restraint and pulls at his
gastrostomy tube. Correct
Rationale:A physical restraint is a mechanical or physical device used to
immobilize a client or extremity. The restraint restricts freedom of movement.
Unexpected outcomes in the use of restraints include signs of impaired skin
integrity, such as redness or skin breakdown; altered neurovascular status, such
as cyanosis, pallor, coldness of the skin, or complaints of tingling, numbness, or
pain; increased confusion, disorientation, or agitation; and escape from the
restraint device that results in a fall or injury. Client verbalization of the reason
for the restraints and the clients inability to reach the gastrostomy tube with his
hands are expected outcomes.
Test-Taking Strategy: Note the strategic word unexpected. This word indicates a
negative event query and asks you to select the options that indicate undesirable
effects of the use of the restraints. Focusing on the data in the question and
recalling the nursing responsibilities in the care of a client in restraints will help
you answer the question. Review expected and unexpected findings related to
the use of restraints if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
838). St. Louis: Mosby.
Level of Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.

2.

2.ID: 383718815
During a laboratory training session, the nurse is watching as a nursing assistant
repositions a client. Which observation tells the nurse that further training is
necessary?
A.

The nursing assistant positions himself close to the client.

B.

The nursing assistant keeps his neck, back, pelvis, and feet
aligned.

C.

The nursing assistant encourages the client to assist as much

as possible.

D.

The nursing assistant keeps his knees straight and his feet
close together. Correct
Rationale: To help prevent injury, the nurse needs to use and encourage staff
members to use good body mechanics and ergonomic principles in providing
care. When planning to reposition a client, the staff member must assess the
clients ability to assist and encourage the client to assist as much as possible.
The nursing assistant should position himself close to the client and keep the
back, neck, pelvis, and feet aligned, avoiding twisting; use the arms and legs (not
the back); and keep the knees flexed and the feet wide apart.
Test-Taking Strategy: Note the strategic words further training is necessary.
These words indicate a negative event query and the need to select the unsafe
action by the nursing assistant. Think about ergonomics and the principles of
good body mechanics as you visualize each option. If you had difficulty with this
question, review the principles of good body mechanics.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
801). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
3.
3.ID: 383718180
View video. A nurse, preparing a sterile field on which to perform a dressing
change, places the sterile drape on the overbed table. Which of these actions on
the part of the nurse indicate correct understanding of the principles of aseptic
technique? Select all that apply.
A.

Holding the pair of sterile forceps below waist level area

B.

Positioning the sterile field so that it remains in full view Correct

C.

Reaching across the sterile field to pick up a sterile gauze

D.

Leaving the room to obtain a bottle of sterile normal saline

solution

E.

Picking up a pair of sterile scissors from the sterile field with a

sterile gloved hand Correct

F.

Pouring sterile wound cleansing solution into a sterile cup

before donning sterile gloves Correct
Rationale: View video. The principles of surgical asepsis must be followed in the
preparation of a sterile field. Among these principles: A sterile object remains
sterile only when touched by other sterile objects; only sterile objects may be
placed on a sterile field; a sterile object or field out of the range of vision or an
object held below the nurses waist is to be considered contaminated; a sterile
object or field becomes contaminated with prolonged exposure to air; when a
sterile surface comes in contact with a wet, contaminated surface, the sterile
object or field becomes contaminated by way of capillary action; fluid flows in the
direction of gravity; a 1-inch edge of a sterile field or container is to be
considered contaminated.
Test-Taking Strategy: Focus on the subject, use of the principles of aseptic
technique. Reading each option carefully and recalling the principles of aseptic
technique will direct you to the correct options. Review aseptic technique and the
procedure for preparing a sterile field if you had difficulty with this question.
References: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
670-672). St. Louis: Mosby.
Video/animation: Preparing a sterile field: L001_preparing_a_sterile_field.flv
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 0.0 points out of 1.0 possible points.
4.
4.ID: 383717499
Which of the following actions are means of maintaining medical asepsis to
reduce and prevent the spread of microorganisms? Select all that apply.
A.

Practicing hand hygiene Correct

B.

Reapplying a sterile dressing

C.

Sterilizing contaminated items

D.

Applying a sterile gown and gloves

E.

Routinely cleaning the hospital environment Correct

F.

Wearing clean gloves to prevent direct contact with blood or

body fluids Correct

Rationale: Medical asepsis, or clean technique, involves procedures to reduce

and prevent the spread of microorganisms. Practicing hand hygiene, wearing
clean gloves to prevent direct contact with blood or body fluids, and routinely
cleaning the hospital environment are examples of medical asepsis. Surgical
asepsis involves the use of sterile technique. Examples of surgical asepsis
include reapplying a sterile dressing, sterilizing contaminated items, and applying
a sterile gown and gloves.
Test-Taking Strategy: Focus on the subject, medical asepsis. Recalling the
definition of medical asepsis and remembering that it involves clean techniques
will help you answer this question. Also note the words sterile and sterilizing
in the incorrect options; these words refer to surgical asepsis. Review the
difference between medical and surgical asepsis if you had difficulty with this
question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
655). St. Louis: Mosby.
Level of Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
5.
5.ID: 383717431
A physician writes a prescription for the application of a heating pad to a clients
back. Which of the following actions should the nurse take when implementing
this prescription? Select all that apply.
A.

Placing the heating pad under the client

B.

Adjusting the heating pad to the high setting

C.

Frequently assessing the clients skin for signs of burns Correct

D.

Assessing the clients medical history and risk factors for

burns Correct

E.

Assessing the heating pad periodically for proper electrical

function Correct
Rationale: The nurse should first assess the clients medical history, including risk
factors for burns. The heating pad should never be placed under a client; instead,
it should be placed lightly against or on top of the involved area. Burns may
result when a client lies on a heating pad. The heating pad is adjusted to the low
setting; the high setting can cause burns. Assessing the client for altered skin
integrity and checking for proper electrical function are appropriate measures for
the use of a heating pad.
Test-Taking Strategy: Focus on the subject, the correct use of a heating pad for a

client. Thinking about the hazards or risks to the client will assist you in selecting
the correct options. Placing the heating pad under the client or adjusting the
heating pad to the high setting could result in a burn. If you had difficulty with
this question, review the principles of safe use of a heating pad.
References: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., pp. 1047, 1048). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
6.
6.ID: 383717439
A post office employee with suspected skin anthrax asks the emergency
department nurse whether the infection is curable. What is the appropriate
response by the nurse?
A.

You really need to ask your doctor about that.

B.

Thats hard to say. We wont know for a week or two.

C.

Antibiotic therapy is usually prescribed and will cure the

infection. Correct

D.

It is not curable, but fortunately, unlike inhalation anthrax, it is

not deadly.
Rationale: Skin anthrax starts with an itchy bump (papule) that looks like a
mosquito bite. It progresses to a small fluid-filled sac that becomes a painless
ulcer with an area of dead black tissue in the middle. (Toxins from the anthrax
spores destroy surrounding tissue.) Antibiotic treatment cures this infection, but
untreated skin anthrax can result in overwhelming septicemia and death.
Replying, You really need to ask your physician about that or Thats hard to
say. We wont know for a week or two is nontherapeutic and places the clients
question on hold. Stating, It is not curable, but fortunately, unlike inhalation
anthrax, it is not deadly is incorrect.
Test-Taking Strategy: Use your knowledge of therapeutic communication
techniques to eliminate the options that place the clients question on hold. To
select from the remaining options, note that the correct option is the only one
that directly addresses the clients question. Review skin anthrax and therapeutic
communication techniques if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patientcentered collaborative care (6th ed., pp. 166, 167). St. Louis:
Saunders.

Cognitive Ability: Applying

Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Biological/chemical warfare
Awarded 1.0 points out of 1.0 possible points.
7.
7.ID: 383719723
A nurse is attending an inservice program on disaster preparedness. Which of the
following events is described as an example of a natural disaster?
A.

Drought Correct

B.

Bus accident

C.

Terrorist attack

D.
Toxic waste spill
Rationale: A disaster is any human-made or natural event that results in
destruction and devastation that cannot be alleviated without assistance (i.e.,
medical, local, or federal government assistance). A natural disaster usually
cannot be prevented, whereas a human-made disaster can be prevented. A
drought is the only natural disaster identified in the options. Bus accidents,
terrorist attacks, and toxic waste spills are all human-made disasters.
Test-Taking Strategy: Focus on the subject, a natural disaster. Recalling that this
type of disaster is one that usually cannot be prevented will direct you to the
correct option. Review the types of disasters if you had difficulty with this
question.
Reference: McEwen, M., & Pullis, B. (2009). Community-based nursing: An
introduction (3rd ed., p. 149). Philadelphia: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Disasters
Awarded 1.0 points out of 1.0 possible points.
8.
8.ID: 383717497

The nurse plans to wear this protective mask (see figure) when caring for clients
with certain disorders. What are these disorders? Select all that apply.
A.

Scabies Incorrect

B.

Hepatitis A

C.

Tuberculosis

D.

Pharyngeal diphtheria Correct

E.

Streptococcal pharyngitis Correct

F.
Meningococcal pneumonia Correct
Rationale: A standard mask is used as part of droplet precautions to protect the
nurse from acquiring the clients infection. Droplet precautions are those
precautions used to help prevent the spread of organisms that can spread
through the air but are unable to remain in the air farther than 3 feet from the
source. Many respiratory viral infections require the use of a standard mask
during client care. Some of the disorders requiring the use of a standard mask
are pharyngeal diphtheria; rubella; streptococcal pharyngitis; pertussis; mumps;
pneumonia, including meningococcal pneumonia; and pneumonic plague.
Scabies and hepatitis A, transmitted by way of direct contact with an infected
person, require the use of contact precautions for protection. Tuberculosis
requires airborne precautions and the use of an individually fitted particulate
filter mask. A standard mask would not protect the nurse from Mycobacterium
tuberculosis.
Test-Taking Strategy: Focus on the figure and note that it depicts a nurse donning
a standard mask. This indicates the need for the nurse to protect himself or
herself from inhaling an organism. You can eliminate tuberculosis by recalling
that tuberculosis requires the use of an individually fitted particulate filter mask.
Next eliminate the options that are comparable or alike (i.e., scabies and
hepatitis A virus) in that these disorders are not transmitted by way of the
respiratory route. Also note that the correct options are respiratory infections.
Review the indications for the use of a standard mask if you had difficulty with

this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
662, 663, 645, 666). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 0.0 points out of 1.0 possible points.
9.
9.ID: 383718817
A community health nurse working in a school setting is concerned because
parents are not participating in health activities designed to promote child safety.
In this situation, the most appropriate initial action is:
A.

Implementing a child safety program

B.

Planning a focused child safety program

C.

Performing an analysis of health problems related to child

safety

D.

Determining the appropriateness of the planned health

activity Correct
Rationale: In this situation, the best initial action would be to determine the
appropriateness of the planned health activities. This would be followed by
analysis, planning, and implementation.
Test-Taking Strategy: Use the steps of the nursing process to answer the
question. Note that the correct option involves the process of assessment, the
first step of the nursing process. Review the procedure for planning health
activities to provide safety if you had difficulty with this question.
Reference: Maurer, F., & Smith, C. (2009). Community/public health nursing
practices: Health for families and populations (4th ed., p. 445). Philadelphia:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
10.
10.ID: 383718879

Place in order of priority the actions that the nurse should take to perform handwashing procedure.
Incorrect
A.
Obtain 3 to 5 mL of soap from the dispenser.
B.
Wet the hands and wrists, keeping the hands lower than the
elbows.
C.
Wash all surfaces for 15 to 30 seconds.
D.
Rinse the hands and wrists.
E.
Dry the hands.
F.
Turn off the water faucet.
The correct order is:
G.
Wet the hands and wrists, keeping the hands lower than the
elbows.
H.
Obtain 3 to 5 mL of soap from the dispenser.
I.
Wash all surfaces for 15 to 30 seconds.
J.
Rinse the hands and wrists.
K.
Dry the hands.
L.
Turn off the water faucet.
Rationale: Proper handwashing procedure involves wetting the hands and wrists
and keeping the hands lower than the forearms so that water flows toward the
fingertips. The nurse uses 3 to 5 mL of soap and washes all surfaces for 15 to 30
seconds, using a rubbing circular motion. Moving from the fingers to the
forearms, the nurse next rinses and then dries the hands. The paper towel is then
discarded and a second one is used to turn off the faucet to help prevent hand
contamination.
Test-Taking Strategy: Focus on the subject, the order of the actions that the nurse
takes in correct handwashing procedure. Visualizing this procedure will help you
determine the correct order of action. Review the procedure for performing hand
hygiene if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
656-658). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 0.0 points out of 1.0 possible points.
2. 11.ID: 383719725
A nurse who is preparing to leave the room of a client who is under airborne
precautions needs to remove the following protective items: gloves, gown, mask,
and goggles. Place in order of priority the items that need to be removed.
Incorrect

A.
Gloves
B.
Goggles
C.
Mask
D.
Gown
The correct order is:
E.
Gloves
F.
Goggles
G.
Gown
H.
Mask
Rationale: The gloves are removed first, because they are considered the dirtiest
item. The goggles are then removed to help prevent contamination of the eyes
by other dirty items. Next the nurse removes the gown by untying it and turning
it inside out as it is removed. Because protective garb is removed before the staff
member leaves the room of a client under airborne precautions, the mask is
removed last to help prevent exposure to airborne particles. Hand hygiene is
performed after the protective garb is removed.
Test-Taking Strategy: Focus on the data in the question and note that the client is
under airborne precautions. This will help you determine that the mask is the last
item to be removed. Recalling that the gloves are the dirtiest item will help you
determine that they need to be removed first. To select the order of the
remaining items, recall that the goggles should be removed from the face with
clean hands. If you had difficulty with this question, review the procedure for
removing protective garb.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
670). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 0.0 points out of 1.0 possible points.
3. 12.ID: 383719749
An emergency department (ED) nurse is triaging victims of an explosion at a
nearby manufacturing plant. To which victims should the nurse assign the
emergent (priority 1) designation? Select all that apply.
A.

A victim with a limb amputation Correct

B.

A victim who is alert but complaining of loss of vision Correct

C.
D.

A victim who is bleeding profusely from a head

laceration Correct
A victim who is dazed and staggering around the other victims

E.

A victim who has sustained minor bruising of an arm and the

lower legs
Rationale: The emergent designation (a.k.a. red or priority 1), the highest
priority, is assigned to the victim who has sustained life-threatening injuries and
requires immediate attention and continuous evaluation yet has a high
probability of survival once his or her condition has been stabilized. In this
scenario, emergent status should be assigned to the victim with a limb
amputation, the victim with vision loss, and the victim who is bleeding profusely.
The urgent designation (a.k.a. yellow or priority 2) is given to the victim who
requires treatment but whose injuries and their complications are not life
threatening, provided that they are treated within 1 to 2 hours. The victim who is
dazed and staggering around the other victims may be assigned to this category
because it is possible that the client has sustained a head injury. The nonurgent
(a.k.a. green or priority 3) designation is given to the victim with local injuries
who does not exhibit immediate complications and who will be able to wait
several hours for medical treatment; such victims require evaluation every 1 to 2
hours thereafter. In this scenario, the victim who has sustained minor bruises of
the arm and lower legs would be assigned to this category.
Test-Taking Strategy: Focus on the subject, the victims that would be assigned to
the emergent category. Use the ABCs airway, breathing, and circulation to
identify the victim with a limb amputation and the victim bleeding profusely from
a head laceration as belonging in the emergent category. Noting that another
victim has lost vision will help you determine that this victim requires emergency
care. Review the triage classification system used in the ED if you had difficulty
with this question.
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 2194). St. Louis: Saunders.
Maurer, F., & Smith, C. (2009). Community/public health nursing practices: Health
for families and populations (4th ed., p. 567). Philadelphia: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
B. 13.ID: 383718887
Which of the following events would require a nurse to complete and file an
incident report?
A.
B.

A client has a seizure.

The nurse determines that a client would benefit from the use
of a walker to ambulate.

C.

The nurse, preparing an intravenous infusion, notes that the

battery of an intravenous infusion pump is not working. Incorrect

D.

When a visitor suddenly becomes weak and dizzy, the nurse

checks the visitors blood pressure and takes the visitor to the
emergency department for treatment. Correct
Rationale: An incident is any event that is not consistent with the routine
operation of a healthcare unit or routine care of a client. Examples of incidents
include client falls, needlestick injuries, a visitor having symptoms of illness,
medication administration errors, accidental omission of prescribed therapies,
and circumstances leading to injury or a risk for injury. An incident report does
not need to be filed if a client has a seizure unless the client sustains injury as a
result of the seizure. If the nurse determines that a client would benefit from the
use of a walker to ambulate, he or she should take the appropriate action to
obtain one. If the nurse notes that the battery of an intravenous infusion pump is
not working, he or she should obtain a functioning pump and send the
nonfunctioning pump to the appropriate department for repair.
Test-Taking Strategy: Use the process of elimination and read each option
carefully. Recalling that an incident is any event that is not consistent with the
routine operation of a healthcare unit or routine care of a client will direct you to
the correct option. Review the reasons for filing an incident report if you had
difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
336, 337, 403). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
C. 14.ID: 383719743
A nurse educator is providing an inservice program to emergency department
nurses about the signs of inhalation anthrax. The nurse educator tells the nurses
that one early indication of inhalation anthrax is:
A.

Hemorrhage Incorrect

B.

Signs of shock

C.

Flulike symptoms Correct

D.
Respiratory distress
Rationale: Inhalation anthrax is caused by the inhalation of spores from Bacillus
anthracis, which multiply in the alveoli. This form of anthrax begins with the
same symptoms as the flu, including fever, muscle aches, and fatigue. Symptoms

suddenly become more severe with the development of breathing problems and
shock. Toxins from the anthrax spores cause hemorrhage and destruction of lung
tissue.
Test-Taking Strategy: Focus on the data in the question and note the strategic
word inhalation. This will assist you in eliminating the options that indicate
hemorrhage and signs of shock. To select from the remaining options, note the
word early, which will direct you to the correct option. Review the signs of
inhalation anthrax if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., pp. 672, 673). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Biological/Chemical Warfare
Awarded 0.0 points out of 1.0 possible points.
D. 15.ID: 383718103
The nursing staff in an emergency department is reviewing and updating the
disaster preparedness plan. The staff members, discussing ways to help prevent
the transmission of smallpox, know that this infection is transmitted by which
route?
A.

Enteric

B.

Inhalation Correct

C.

Gastrointestinal

D.
Through open wounds
Rationale: Smallpox, transmitted in air droplets and in the handling of
contaminated materials, is highly contagious. Symptoms include fever, back
pain, vomiting, malaise, and headache, followed 2 days later by the appearance
of papules that progress to pustular vesicles, which are initially abundant on the
face and extremities. Enteric, gastrointestinal, and open wounds are not routes of
smallpox transmission.
Test-Taking Strategy: Specific knowledge regarding the route of transmission of
smallpox is necessary to answer this question. Remember that smallpox is
transmitted in air droplets and through the handling of contaminated materials.
Review the characteristics of smallpox if you had difficulty with this question.
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 338). St. Louis: Saunders.
McEwen, M., & Pullis, B. (2009). Community-based nursing: An introduction (3rd

ed., pp. 411, 412). Philadelphia: Saunders.

Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
E. 16.ID: 383718843
A nurse employed in a physicians office hears a client in the waiting room call
out, Help! Fire! The nurse rushes to the waiting room and finds that the
wastebasket is on fire. The nurse immediately:
A.

Confines the fire

B.

Extinguishes the fire

C.

Activates the fire alarm

D.
Removes the clients from the waiting room Correct
Rationale: The immediate priority in the event of a fire is removing any clients in
immediate danger. The next step is activating the fire alarm. The nurse would
then confine the fire by closing all of the doors and, finally, extinguish the fire.
Test-Taking Strategy: Remember the mnemonic RACE to prioritize actions in the
event of a fire: Rescue clients in immediate danger, sound the alarm, confine the
fire by closing all doors, and extinguish. If you had difficulty with this question,
review the principles of fire safety.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7the ed., pp.
839, 840). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
F. 17.ID: 383718140
A nurse hears someone calling, Help! My bed is on fire! On entering the room,
the nurse finds a client trying to beat out the flames with a pillow. Place in order
of priority the actions that the nurse should take:
Correct
A.
Removing the client from the room
B.
Pulling the nearest fire alarm
C.
Closing the door to the room

D.
Running to get the nearest fire extinguisher
Rationale: A nurse who encounters a fire emergency should think of the
mnemonic RACE. The first step is to remove the client from the room, after which
the nurse should activatethe fire alarm, contain the fire, and extinguish the fire.
This is a universal standard that may be applied to any type of fire emergency.
Removing the client from the room is the first step. Pulling the nearest fire alarm
is the second step (alarm). Closing the door to the room to contain the fire is the
third action. Obtaining the nearest fire extinguisher to put out the fire is the
fourth action.
Test-Taking Strategy: Focus on the subject, the steps to take in a fire emergency.
With this in mind, sequence the actions, using the RACE mnemonic. Review fire
safety if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
839, 840). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
2. 18.ID: 383717465
A nurse is questioning a client about hazards in the home environment. Which of
the following items in the home is an indication that the client requires
instruction about safety? Select all that apply.
A.

Untacked rugs on the stairs Correct

B.

Small rugs in the living room Correct

C.

Carpet on stairs secured with tacks

D.

Clothes hamper at the end of the hallway Incorrect

E.

Cereal boxes, canned foods, and infrequently used cooking

utensils stored on top of the refrigerator Correct
Rationale: Area rugs and runners should not be used on or near stairs. Injuries in
the home are frequently the result of loose objects, including small rugs on the
stairs or floor, wet spots on the floor, or clutter on bedside tables, closet shelves,
the top of the refrigerator, and bookshelves. Care should also be taken to ensure
that end tables are secure and have stable straight legs. Nonessential items
should be placed in drawers to eliminate clutter. If the stairs must be carpeted,
carpeting should be secured with the use of tacks.
Test-Taking Strategy: Note the strategic words requires instruction. These words
indicate a negative event query and the need to identify safety hazards in the
environment. Reading each option carefully will assist you in answering correctly.

Review safety hazards in the home if you had difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 1062). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
B. 19.ID: 383717481
A home health nurse is visiting a client with tuberculosis (TB). Which action by
the client tells the nurse that the client understands the necessary respiratory
precautions to be taken at home?
A.

Staying secluded in the bedroom

B.

Wearing an oxygen mask at all times

C.

Keeping the house closed up to minimize the spread of disease

D.

Disposing of contaminated tissues in a container with a leakproof bag Correct

Rationale: The client under respiratory precautions at home does not need to
remain secluded; the client would not be at home if he or she were infectious.
However, proper respiratory precautions are necessary. The house should be
properly ventilated, and the windows should be opened as much as possible.
Wearing an oxygen mask at all times is not a respiratory precaution, and there is
no information in the question to indicate that oxygen is necessary.
Contaminated tissues should be discarded in container with a leak-proof bag and
then placed in an outdoor trash bin. Tissues should not be left lying around.
Test-Taking Strategy: Use the process of elimination. Focus on the clients
diagnosis and the subject, respiratory precautions at home. Recalling the mode
of transmission and home care measures for TB will direct you to the correct
option. Also note the words secluded, all times, and closed up in the
incorrect options. If you had difficulty answering this question, review the
precautions that should be taken by the client with TB who has been discharged
home.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 670). St. Louis: Saunders.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Evaluation

Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
C. 20.ID: 383718184
A client undergoing chemotherapy is found to have an extremely low white blood
cell count, and neutropenic precautions, including a low-bacteria diet, are
immediately instituted. Which of these food items will the client be allowed to
consume? Select all that apply.
A.

Fresh apple

B.

Raw celery

C.

Italian bread Correct

D.

Tossed salad

E.

Baked chicken Correct

F.
Well-cooked cheeseburger Correct
Rationale: An extremely low white blood cell count puts the client at risk for
infection, necessitating the implementation of a low-bacteria diet. The client
must avoid fresh fruits and vegetables, which may harbor microorganisms that
could cause infection, and ensure that meat is thoroughly cooked. Italian bread,
baked chicken, and a well-done cheeseburger are all acceptable foods for the
client.
Test-Taking Strategy: Focus on the subject of the question, a low-bacteria diet.
Read each option carefully and think about the foods that harbor bacteria.
Recalling that fresh fruits and vegetables are restricted in a low-bacteria diet will
help you select the correct items. Review interventions for the client on a lowbacteria diet if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patientcentered collaborative care (6th ed., p. 427). St. Louis:
Saunders.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 0.0 points out of 1.0 possible points.
D. 21.ID: 383718813
A nurse is assigned to care for a client with an infection caused by methicillinresistant Staphylococcus aureus (MRSA). The client has an abdominal wound that
requires irrigation and has a tracheostomy attached to a mechanical ventilator
that requires frequent suctioning. While gathering the needed supplies before

entering the clients room, which necessary protective items does the nurse
obtain? Select all that apply.
A.

Mask

B.

Gown Correct

C.

Gloves Correct

D.

Face shield Correct

E.
Shoe protectors
Rationale: Infection caused by MRSA necessitates contact precautions. The care
of this client requires the use of gown, gloves, and a face shield. The face shield
is worn to protect the face and the mucous membranes of the mouth, nose, and
eyes during interventions that could produce splashes of blood, body fluids,
secretions, and excretions (e.g., wound irrigation and suctioning). Contact
precautions also require the use of gloves and a gown if direct client contact is
anticipated. A mask does not provide adequate protection. Shoe protectors are
not necessary.
Test-Taking Strategy: Focus on the data in the question and think about the
events that might occur during a wound irrigation and suctioning. This will help
you determine the necessary items for the care of this client. If you had difficulty
with this question, review standard and contact precautions.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
655, 663). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 0.0 points out of 1.0 possible points.
E. 22.ID: 383718178
A nurse is preparing to initiate a continuous tube feeding, using a tube-feeding
pump. On bringing the pump to the bedside and preparing to plug the pump in,
the nurse discovers that there is no available plug in the wall socket. What should
the nurse do?
A.

Plug in the pump cord into an available plug above the sink

B.

Ask the physician to change the prescription to intermittent

feedings

C.

Determine the need for the appliances now plugged into the
needed wall socket Correct

D.

Use a regular extension cord to allow the use of more than one
electrical appliance

Rationale: It is most appropriate for the nurse to assess the situation and
determine the need for the appliances already plugged into the needed wall
socket. The use of electrical appliances near a sink presents a hazard. It is not
appropriate (and is premature) to ask the physician to change the prescription,
because the prescription is based on the clients needs. A regular extension cord
should not be used, because it poses a risk of fire.
Test-Taking Strategy: Use the process of elimination and the steps of the nursing
process to answer the question. The only option that addresses assessment is
the one that involves determining the need for the appliances currently plugged
into the needed wall socket. Review electrical safety procedures if you had
difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 323). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
F. 23.ID: 383718114
An older client in a long-term care facility is at risk for injury because of
confusion. Which of the following devices would be the best choice to help
prevent injury while the client is in bed?

A.

B.

C.

D.
Correct
Rationale: If the client is confused, the least intrusive method of restraint is the
use of a bed alarm such as the Bed-Check bed exit alarm device. It consists of a
weight-sensitive mat, placed on the clients mattress, that sounds an alarm when
the sensor detects the removal of pressure. A belt restraint secures the client to
the bed or stretcher. It restrains the center of gravity and prevents the client from
sitting up on or rolling off a stretcher or falling out of bed. The extremity (ankle or
wrist) restraint is used to immobilize an extremity as a means of protecting the
client from injury resulting from a fall or the accidental removal of a therapeutic
device such as a Foley catheter. The mitten restraint is a thumbless mitten
device that is used to restrain the clients hand. It prevents the client from
dislodging invasive equipment, removing dressings, or scratching him- or herself.
Test-Taking Strategy: Use the process of elimination and knowledge of the various
restraint methods and the ethical and legal ramifications of using a restraint. The
use of the words best choice will guide you to the correct option. Also recall
that the least invasive method of restraint should be used; this will help you
answer correctly. Review the guidelines for the use of restraints if you had
difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
834, 835, 837-839). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation

Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
G. 24.ID: 383717469
A nurse is preparing a continuous intravenous (IV) infusion at the medication
cart. As the nurse goes to attach the IV tubing port to the solution bag, the
tubing drops, hitting the top of the medication cart. Which action should the
nurse take to maintain asepsis?
A.

Obtaining new IV tubing Correct

B.

Obtaining a new IV solution bag

C.

Scrubbing the tubing port with an alcohol swab

D.
Wiping the tubing port with povidone-iodine solution (Betadine)
Rationale: If IV tubing becomes contaminated as a result of coming into contact
with some nonsterile object, the nurse should obtain new IV tubing.
Contaminated tubing could cause systemic infection in the client. The IV solution
bag has not been contaminated and does not need replacement. Wiping the
tubing port with Betadine or scrubbing it with alcohol is insufficient and would be
contraindicated regardless, because the tubing will be attached directly to a
catheter in the clients vein.
Test-Taking Strategy: Visualize the situation as you read the question. Use your
knowledge of basic infection control measures and IV therapy to answer this
question. Also, focus on the data in the question and note that the IV tubing has
become contaminated. Review aseptic technique if you had difficulty with this
question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., pp. 179, 188). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
H. 25.ID: 383719753
A registered nurse is instructing a group of nursing assistants in the principles of
body mechanics. Which of these observations tell the nurse that a student is
using the principles appropriately? Select all that apply.
A.

The assistant leans forward when turning a client in

bed. Incorrect

B.

The assistant positions a box that is to be lifted between his

knees. Correct

C.

The assistant turns his back to change position while moving a

client.

D.

The assistant keeps the object to be moved as close to his body

as possible. Correct

E.

The assistant helps a client requiring total care into a chair

without additional assistance.
Rationale: When moving an object, the nursing assistant should position the
object between his knees. The assistant should keep the client or object to be
moved as close to his body as possible. When turning a client, the assistant
should keep his back straight and take small steps with the feet. The assistant
should turn his feet, rather than twisting his back, if a change in direction is
necessary when carrying an object or a client. The assistant should seek out
assistance when transferring a client who requires total care.
Test-Taking Strategy: Use the process of elimination and your knowledge of body
mechanics to answer the question. Visualize each of the items in the options to
determine which actions could result in injury. Review the principles of body
mechanics if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
797, 800). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning

I.

Content Area: Leadership/Management

Awarded 0.0 points out of 1.0 possible points.
26.ID: 383717495
An adolescent client asks the nurse questions about the transmission of the
Epstein-Barr virus (infectious mononucleosis). By which route should the nurse
tell the client that the disease is transmitted?
A.

Fecal-oral

B.

Airborne particles

C.

Respiratory droplets

D.
Close intimate contact Correct
Rationale: Epstein-Barr virus is transmitted by way of contact with infectious
saliva, close intimate contact with an infectious individual, or contact with
infected blood. The infectious period is unknown, but the virus is commonly shed
from before clinical onset of disease until 6 months or longer after recovery. It is
not transmitted by way of the fecal-oral route, in airborne particles, or in

respiratory droplets.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike (i.e., airborne particles and respiratory droplets). To
select from the remaining options, it is necessary to know the route of
transmission of infectious mononucleosis. If you are unfamiliar with transmission
of the Epstein-Barr virus, review this content.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternalchild nursing (3rd ed., p. 1025). St. Louis: Elsevier.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning

J.

Content Area: Infection Control

Awarded 1.0 points out of 1.0 possible points.
27.ID: 383719704
The nurse administers a dose of ramipril (Altace) 2.5 mg to a client at 9 am.
While documenting administration of the medication, the nurse discovers that
1.25 mg, not 2.5 mg, was the prescribed dose. The nurse assesses the client,
completes an incident report, and notifies the physician and nursing supervisor of
the error. What statement does the nurse add to the clients record?
A.

An incident report was completed and filed.

B.

Ramipril (Altace) 2.5 mg was administered at 9 am. Correct

C.

Twice the amount of the prescribed ramipril was administered

at 9 am.

D.

Clients blood pressure was 128/82 mm Hg after the

administration of the incorrect dose of ramipril.
Rationale: After an incident, the nurse would document a concise and objective
description of what occurred and any follow-up actions taken in the clients
record. The nurse would not document in the clients record that an incident
report was completed. Nor would the nurse document that twice the prescribed
dose was given or that an incorrect dose was given.
Test-Taking Strategy: Focus on the data in the question. Recall that notes made in
a clients record must be objective. Eliminate the options that are comparable or
alike in that they indicate that an incorrect dose of medication was administered.
Next note that the correct option clearly and accurately describes the incident in
an objective manner. Review documentation of a medication error or other
incident if you had difficulty with this question.
References: Huber, D. (2010). Leadership and nursing care management (4th
ed., pp. 557, 558). St. Louis: Saunders.

Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 704, 705). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
K. 28.ID: 383718828
A home health nurse is performing an assessment of a clients skin. The nurse,
noting multiple threadlike lines, both straight and wavy, beneath the skin,
recognizes the presence of scabies. Which of the following precautions should the
nurse institute before completing the assessment of the client?
A.

Putting on a pair of gloves

B.

Donning a mask and gloves

C.

Putting on a gown and gloves Correct

D.
Avoiding sitting on the clients furniture
Rationale: Scabies is usually transmitted from person to person by way of direct
skin contact. The Centers for Disease Control and Prevention recommends the
wearing of gowns and gloves for close contact with a person infested with
scabies. Masks are not necessary. Transmission by way of clothing and other
inanimate objects is uncommon. Everyone with whom the client has had contact
should be treated for scabies at the same time.
Test-Taking Strategy: Consider the mode of transmission of scabies and use the
process of elimination in answering the question. Knowing that scabies is
transmitted by way of direct skin contact will assist you in answering correctly. If
you had difficulty with this question, review standard precautions and the
transmission of scabies.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patientcentered collaborative care (6th ed., pp. 446, 447, 504). St.
Louis: Saunders.
Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 179).
St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control

Awarded 1.0 points out of 1.0 possible points.

L. 29.ID: 383718157
A sedated client is being transported to the radiology department on a stretcher.
Which type of restraint should the nurse suggest applying to help ensure the
clients safety?
A.

Belt Correct

B.

Wrist Incorrect

C.

Elbow

D.
Mitten
Rationale: A belt restraint is a device that is wrapped around the clients waist to
secure the client to bed or to a stretcher. An elbow restraint consists of a piece of
fabric with slots into which tongue blades are inserted; the device is wrapped
around the elbow area to keep it immobile. A mitten restraint is a thumbless
device that covers the clients hand and is used to restrain the clients hand,
preventing the client from dislodging invasive equipment (e.g., an intravenous
line). A wrist restraint is a device used to immobilize an arm that does not allow
movement as a mitten restraint would.
Test Taking Strategy: Focus on the data in the question and note the strategic
word best. Noting the words sedated and on a stretcher will help direct you
to the correct option. Review the types of restraints and their uses if you had
difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
834, 838). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
M. 30.ID: 383718188
A nurse employed on a medical care unit is administering medications. She tells
a client that she is going to administer his furosemide (Lasix) through his
intravenous (IV) line. The client tells the nurse that he takes this medication
orally at home every day and is concerned that it is being administered by way of
a different route. The nurse should take which most appropriate action?
A.

Verifying the physicians prescription Correct

B.

Sitting and talking to the client to alleviate his concern

C.

Explaining to the client that the oral route will not permit the
medication to exert an adequate effect

D.

Letting the client know that most medications are administered

by way of the IV route when a client is hospitalized
Rationale: If the client questions a physician's prescription, the nurse must verify
the prescription. This is the most appropriate action. Although it is appropriate to
talk to the client and alleviate concerns, this is not the most appropriate action of
those provided. Although in some client situations the IV route of administration
of certain medications is more effective than the oral route, providing the client
with this information is not the most appropriate action of the options provided.
Critical care units in the hospital may administer most medications by way the IV
route, but this is not necessarily the situation in a medical care unit.
Test-Taking Strategy: Use the process of elimination, focusing on the data in the
question. Noting that the client is questioning the route of administration of the
medication will direct you to the correct option. Remember to always verify a
prescription if the client questions it. If you had difficulty with this question,
review nursing responsibilities related to the administration of medications.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
336). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
N. 31.ID: 383717467
A home care nurse is instructing a client in the use of ice packs to treat an eye
injury. The nurse instructs the client to:
A.

Place the ice pack directly on the eye

B.

Avoid the use of commercially prepared ice bags

C.

Keep the ice pack on the eye continuously for 24 hours

D.

Wrap a plastic bag filled with ice in a pillowcase and place it on

the eye Correct

Rationale: An ice pack placed directly against the skin or left in place for an
extended period carries a risk of tissue damage similar to that of a hot water
bottle. To help prevent tissue damage resulting from excessive cold exposure, the
ice pack should be removed in most cases after 30 minutes; after a short time it
may be reapplied. An ice pack should never be placed directly against the skin;
instead, it should be covered with a pillowcase or towel. Commercially prepared
ice bags are appropriate for use as ice packs.
Test-Taking Strategy: Use the process of elimination to answer the question.
Eliminate the options that include the words directly and continuously. From

the remaining options, recall that the use of commercially prepared ice bags for
the purpose described in the question is acceptable. Review safety measures for
the use of ice packs if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
1339). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
O. 32.ID: 383718129
A nursing instructor is observing a nursing student who is practicing the use of
standard precautions in the nursing laboratory. Which of the following
observations by the instructor indicates a need for further teaching?
A.

The nursing student changes gloves between tasks and

procedures.

B.

The nursing student washes hands before making contact with

the client.

C.

The nursing student wears a gown to change the bed of an

incontinent client.

D.

The nursing student washes her hands before glove removal

after emptying a Foley bag. Correct
Rationale: Standard precautions require that gloves be removed promptly after
use and before the wearer touches noncontaminated surfaces or other clients.
Gloves are not washed before removal, because splashing of contaminated
material may result. Changing gloves between tasks and procedures, washing
the hands before making contact with the client, and wearing a gown to change
the bed of an incontinent client reflect correct understanding of the principles of
standard precautions.
Test-Taking Strategy: Note the strategic words need for further teaching. These
words indicate a negative event query and the need to select the incorrect
action. Use the process of elimination, visualizing each of the procedures
described in the options. Thinking about the principles of standard precautions
will direct you to the correct option. Review the principles associated with
standard precautions if you had difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., pp. 178, 179). St. Louis: Mosby.
Cognitive Ability: Evaluating

Client Needs: Safe and Effective Care Environment

Integrated Process: Teaching and Learning
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
P. 33.ID: 383717483
A nurse provides instruction to a new nursing assistant regarding the application
of a restraint to a client. The nurse watches as the nursing assistant applies the
restraint. What observation tells the nurse that the nursing assistant is using
correct procedure?
A.

The assistant applies a tie knot in the restraint strap.

B.

The assistant attaches the restraint straps securely to the

siderails.

C.

The assistant applies the restraint so that the strap does not
tighten when force is applied against it. Correct

D.

The assistant secures the restraint in such a way that it is

impossible to slip a finger between the restraint and the clients skin.
Rationale: A half-bow or safety knot should be used to apply a restraint, because
it does not tighten when force is applied against it and because it allows quick,
easy removal of the restraint in the event of an emergency. The restraint strap is
secured to the bed frame, never to the side rails, to help prevent accidental
injury in the event that the siderail is released. A restraint should be secured in
such a way that one or two fingers can be easily slipped between the restraint
and the clients skin.
Test-Taking Strategy: Note the strategic words correct procedure in the query.
This indicates that you are looking for an option that involves an accurate
measure of how a restraint is applied. Use the process of elimination and your
knowledge of safety measures and the use of restraints to answer the question.
Noting the words tie knot, siderails, and impossible to slip will assist you in
eliminating these options. Review guidelines for the application of restraints if
you had difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 337). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.

Q. 34.ID: 383719731
A home care nurse visits a client who lives in a small apartment to perform an
admission assessment. During the home safety assessment, the client asks the
nurse whether it is safe to use a space heater. What is the appropriate response
by the nurse?
A.

A space heater should never be used in an apartment.

B.

A space heater can be used as long as it is kept at a low

setting at all times.

C.

A space heater can be used as long as it is kept in the

bedroom at night in case a fire occurs.

D.

A space heater can be used as long as its placed at least 3

feet from anything that may ignite. Correct
Rationale: Space heaters must be used appropriately because of the risk of fire. A
space heater should be placed at least 3 feet from anything that may ignite. A
space heater may be used in an apartment if there is ample space and safety
precautions are followed. A low setting does not reduce the risk of fire. Placing a
heater in a bedroom does not guarantee that it will be 3 feet from anything that
may ignite.
Test-Taking Strategy: Use the process of elimination, keeping in mind the
subject, fire safety. Eliminate the options that include the closed-ended words
never and all. To select from the remaining options, note that the correct
option is the only one that specifically defines a safety measure involving the use
of a space heater. Review fire safety measures in the home if you had difficulty
with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 1066). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
R. 35.ID: 383719739
An industrial nurse at a large factory provides information to the employees in
the mailroom and shipping department about the signs of skin (cutaneous)
anthrax. For which early sign of cutaneous anthrax does the nurse tell the
employees to check their skin?
A.

An open ulcer

B.

An itchy bump Correct

C.

A weeping blister

D.
A black skin area of skin Incorrect
Rationale: Skin anthrax starts with an itchy bump (papule) that looks like a
mosquito bite. It progresses to a small fluid-filled sac that becomes a painless
ulcer with an area of dead black tissue in the middle. (Toxins from the anthrax
spores destroy the surrounding tissue.)
Test-Taking Strategy: Focus on the data in the question. Noting the strategic word
early will direct you to the correct option. Review the early signs of cutaneous
anthrax if you had difficulty with this question.
References:Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 338). St. Louis: Saunders.
Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient
centered collaborative care (6th ed., p. 454). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Biological/Chemical Warfare
Awarded 0.0 points out of 1.0 possible points.
S. 36.ID: 383718809
A client with an infection is receiving antibiotics by way of intramuscular (IM)
injection. The client is also receiving subcutaneous (SC) injections of heparin.
Which precaution does the nurse understand is most appropriate to help ensure
the safety of this client?
A.

Doubling the dose of anticoagulant

B.

Applying a pressure bandage to the site after each IM injection

C.

Applying prolonged pressure to the sites of the IM and SC

sites Correct

D.

Decreasing the sizes of the needles used for the IM and SC

injections Incorrect
Rationale: The use of anticoagulants puts the client at risk for bleeding.
Prolonged pressure over the site of an IM injection will help prevent bleeding into
the tissues surrounding the injection site. Doubling the dose of anticoagulants is
incorrect. Decreasing the needle sizes may be helpful but is not necessary. A
pressure bandage is not an appropriate measure and is also unnecessary.
Test-Taking Strategy: Use the process of elimination and note the strategic words
most appropriate. Eliminate the option that involves doubling the dose. Next
recall the principles of medication administration, then eliminate the option
involving a decrease in needle size. To select from the remaining options,
visualize each. It is inappropriate and unnecessary to apply a pressure bandage
after each injection. Review safety measures for the client receiving injections

and taking an anticoagulant if you had difficulty with this question.

References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing:Patient-centered collaborative care (6th ed., p. 683). St. Louis: Saunders.
Lehne, R. (2010). Pharmacology for nursing care (7th ed., p. 616). St. Louis:
Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
T. 37.ID: 383717487
A nurse manager tells the nursing staff that the agencys disaster preparedness
plan will be distributed to all employees for review. The nurse manager states
that the plan is an important component of disaster readiness because it
primarily:
A.

Identifies the location of healthcare supplies

B.

Identifies the types of disasters that may occur

C.

Aids determination of how victims will be triaged

D.

Describes a formal plan of action for the coordination of a

response Correct
Rationale: A disaster preparedness plan is a formal plan of action for coordinating
the response of a healthcare agencys staff in the event of a disaster in the
agency itself or in the surrounding community. Depending on the agency, the
disaster preparedness plan may be specific and may include other information
such as the location of health care supplies, instructions for the triage of victims,
and the types of disasters that may occur.
Test-Taking Strategy: Use the process of elimination and note the strategic word
primarily. Note that the correct option is the umbrella option. Review the
description of a disaster preparedness plan if you had difficulty with this
question.
Reference: McEwen, M., & Pullis, B. (2009). Community-based nursing: An
introduction (3rd ed., pp. 154-156). Philadelphia: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning

Content Area: Disasters

Awarded 1.0 points out of 1.0 possible points.
U. 38.ID: 383717461
A nurse caring for a client with leukemia who is undergoing chemotherapy
reviews the latest laboratory results and notes that the neutrophil count is below
500 cells/mm3. Which of the following interventions does the nurse implement on
the basis of this finding? Select all that apply.
A.

Providing a soft toothbrush for oral care

B.

Monitoring the clients oral temperature Correct

C.

Maintaining sterile occlusion of intravenous (IV)

catheters Correct

D.

Requiring the client to use an electric shaver rather than a

razor

E.

Performing meticulous skin decontamination before

venipuncture Correct

F.

Avoiding overinflation of the blood pressure cuff and rotating

the cuff among several sites when measuring the blood pressure
Rationale: When the neutrophil count falls below 500 cells/mm3, the client is at
risk for infection. Monitoring of the oral temperature, maintaining sterile
occlusion of IV and central venous catheters, and meticulous skin
decontamination before venipuncture are critical nursing interventions for the
client at risk for infection. The remaining options are interventions that are
necessary for the client who has a low platelet count and is at risk for bleeding.
Test-Taking Strategy: Focus on the information in the question and note that the
clients neutrophil count is low. Recalling the relationship between a low
neutrophil count and the risk for infection will direct you to the correct options. If
you had difficulty with this question, review the nursing plan of care for a client
with leukemia who has a low neutrophil count.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., pp. 2121. 2122). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
V. 39.ID: 383717453

A client with a new diagnosis of tuberculosis (TB) is being admitted to the

hospital. During the collection of data from the client, which of the following
considerations is especially important?
A.

The religious affiliation or church of preference

B.

The names of close friends and family members Correct

C.

What medications have been prescribed and what the client

knows about their side effects Incorrect

D.

The name of the person from whom the client contracted TB, so
that the person may be reported for follow-up care
Rationale: TB is a contagious disease that is spread in respiratory droplets. The
nurse needs to elicit the names of close friends and family members so that
these individuals may be tested for exposure to TB. The clients religious
affiliation or church of preference is a component of the data collection process
but is not the primary consideration of the options provided. It is premature to
determine knowledge regarding medications, because treatment measures may
not yet have been prescribed. The client may not know the name of the person
from whom the disease was contracted.
Test-Taking Strategy: Use the process of elimination and note the strategic words
especially important. Recalling the route of transmission of TB will direct you to
the correct option. Review data collection techniques for the client with a new
diagnosis of TB if you had difficulty with this question.
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 1605). St. Louis: Saunders.
Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patientcentered collaborative care (6th ed., p. 668). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Assessment
Content Area: Infection Control
Awarded 0.0 points out of 1.0 possible points.
W. 40.ID: 383717435
A nurse is preparing a chemotherapy infusion to be administered to a client with
a diagnosis of Hodgkins disease. Which of the following precautions should the
nurse take while working with this intravenous (IV) infusion?
A.

Wearing gloves and a mask Incorrect

B.

Wearing gloves and a gown

C.

Wearing gloves, a mask, and eye protection Correct

D.

Wearing gloves, a mask, and a head covering

Rationale: When handling chemotherapeutic agents, the nurse should wear

disposable latex gloves, a mask that covers the nose and mouth, and eye
protection, especially if a biological hood is not available. Wearing gloves and a
mask or gloves and a gown will not provide adequate protection. A head covering
is not necessary.
Test-Taking Strategy: Knowledge regarding the precautions for handling
chemotherapeutic agents is necessary to answer this question. Think about the
effects and cytotoxic nature of chemotherapy to answer the question. Select the
option that will provide the greatest degree of protection to the nurse handling
chemotherapeutic agents. If you had difficulty with this question, review the
precautions for preparing a chemotherapy infusion.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 423). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
X. 41.ID: 383717459
A nurse is assisting with disaster relief after a tornado. The nurses goal with the
overall community is to prevent as much injury and death resulting from the
uncontrollable event as possible. Finding safe housing for survivors, providing
support to families, organizing counseling sessions, and securing physical care
when needed are all examples of which level of prevention?
A.

Initial

B.

Primary

C.

Tertiary Correct

D.
Secondary
Rationale: Tertiary prevention involves the reduction of the amount and degree of
disability, injury, and damage after a crisis. Primary prevention is aimed at
keeping a crisis from ever occurring, and secondary prevention is focused on
reducing the intensity and duration of the crisis during the actual crisis. There is
no such thing as the initial prevention level.
Test-Taking Strategy: Focus on the data in the question and the nurses goal.
Note that the goals of care involve activities undertaken after the disaster. This
will assist you in identifying the correct level of prevention. If you had difficulty
with this question, review the levels of prevention.
Reference: Maurer, F., & Smith, C. (2009). Community/public health nursing

practices: Health for families and populations (4th ed., pp. 264, 265).
Philadelphia: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Disasters
Awarded 1.0 points out of 1.0 possible points.
Y. 42.ID: 383718176

In which of the following situations would the nurse use this type of restraint (see
figure)? Select all that apply.
A.

To secure the shoulders and the waist

B.

To immobilize a clients arm and shoulders

C.

To prevent the client from getting out of bed Incorrect

D.

To prevent dislodgment of an intravenous line Correct

E.

To prevent the client from turning from side to side

F.

To prevent the use of the hands while allowing free arm

movement Correct
Rationale: A mitten restraint is a thumbless device used to restrain the hands. It
prevents the use of the hands while allowing free arm movement. Mitten
restraints are useful for the client who must be prevented from dislodging an
intravenous line, indwelling urinary catheter, nasogastric tube, other types of
tubes, or wound dressings. A belt restraint prevents the client from falling out of
a bed, a chair, or a stretcher. A mitten restraint does not secure the shoulders
and the waist and is not used to prevent the client from turning side to side.

Test-Taking Strategy: Focus on the figure and note that the device covers the
clients hand. Visualizing this device will help you determine its uses. Review the
uses of a mitten restraint if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
835). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
Z. 43.ID: 383717433
A home health nurse has been called to the home of an older postoperative
cardiovascular client by the clients son. The son tells the nurse, Were using a
hospital bed here at home, but my mother has fallen out of bed three times.
Which observation by the nurse reflects an increased risk of this clients falling
out of bed?
A.

The clients bed is in a low position.

B.

The client is oriented to person, place, and time.

C.

The caregiver uses the overbed table for feedings.

D.

The caregiver leaves both siderails down while the client is in

bed. Correct
Rationale: Leaving the siderails of older clients bed down may increase the
clients risk of falling. The aging process also increases this clients potential for
falls; therefore, evaluating the safety of the environment is a necessity. Keeping
the clients bed in a low position, orientating the client to the environment, and
using the overbed table for feedings are all ways to help ensure the clients
safety.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, a
observation of an unsafe practice. Noting that the question indicates that the bed
is in the low position and that the client is oriented will assist you in eliminating
these options. To select from the remaining options, choose the one that
identifies an unsafe practice. Review the causes of falls in an older client if you
had difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 329). St. Louis: Mosby.
Cognitive Ability: Evaluating

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Assessment
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
AA.44.ID: 383718192
A nurse leading an educational session about terrorism for members of the
community is discussing anthrax. Which of the following pieces of information
should the nurse provide to the group attending the session? Select all that
apply.
A.

Anthrax is never fatal.

B.

No vaccine to prevent anthrax is available.

C.

Anthrax can be transmitted from person to person. Incorrect

D.

A blood test is available for the detection of anthrax. Correct

E.

One way that anthrax can be contracted is through the

skin. Correct
Rationale: Anthrax, which is caused by Bacillus anthracis, can be contracted
through the digestive system or abrasions in the skin or by way of inhalation. In
the lungs, anthrax can cause a buildup of fluid, tissue decay, and death;
untreated pulmonary anthrax is fatal. A blood test performed to detect anthrax
magnifies DNA from the blood sample and matches it to anthrax DNA. A vaccine
exists, but its availability is limited. Anthrax is usually treated with ciprofloxacin
(Cipro), doxycycline, or penicillin.
Test-Taking Strategy: Knowledge regarding the ways of contracting anthrax is
needed to answer this question. Recalling that there are three modes of entry
into the body will assist in eliminating the option that indicates that anthrax can
be transmitted person to person. Next eliminate the options using the closed
ended words never and no. Review information related to anthrax infection if
you had difficulty with this question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 338). St. Louis: Saunders.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Biological/chemical warfare
Awarded 0.0 points out of 1.0 possible points.
AB.45.ID: 383718120

A home health nurse teaches a client about home modifications to reduce the
risk of falls. Which statements by the client indicate a need for further
teaching? Select all that apply.
A.

I need to use night lights.

B.

I need to remove my wall-to-wall carpeting. Correct

C.

I need to get handrails put up in the bathroom.

D.

I need to use the staircase handrails when I go up the stairs.

E.

I should walk barefoot as much as possible so that Ill know

about any wet spots on the floor. Correct
Rationale: Home modifications to reduce the risk of falls include ensuring ample
lighting, removing scatter rugs, placing handrails in bathrooms, and using
handrails on all staircases. The client should wear flat rubber-soled shoes to
prevent slips and falls. Walking barefoot will not reduce the risk of injury; in fact,
it could actually increase the risk of foot injury and of slipping and falling.
Removal of wall-to-wall carpeting is not necessary.
Test-Taking Strategy: Note the strategic words need for further teaching. These
words indicate a negative event query and the need to select the incorrect
options. Answer this question by eliminating the options that involve providing
physical support for the client and that you know are needed in this situation
(e.g., night lights, handrails). Review home care measures to ensure safety and
prevent falls if you had difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 1062). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
AC.46.ID: 383718893
Which of the following actions are in keeping with the principles of standard
precautions? Select all that apply.
A.

Handwashing between client contacts Correct

B.

Cleaning of blood spills with soap and warm water

C.

Discarding needles in puncture-resistant containers Correct

D.

Handwashing before removal of a pair of soiled gloves

E.

Wearing a face shield as a part of the protective garb during a

wound irrigation Correct

F.

Wearing a gown and gloves when changing the linens on the

bed of a client with a draining lesion of the leg Correct
Rationale: Standard precautions must be practiced with all clients in every
setting. These precautions involve handwashing and the use of gloves, masks,
eye protection, and gowns, as well as other protective devices, when they are
appropriate for client contact. These precautions apply to contact with blood,
body fluids, nonintact skin, and mucous membranes. The hands are always
washed between client contacts and after (not before) gloves are removed.
Needles are not recapped (unless the agency provides special and agencyapproved recapping devices for healthcare providers) and are discarded in
puncture-resistant containers. Spills of blood or body fluids are cleaned up with a
solution of bleach and water (diluted 1:10) or other agency-approved
disinfectant. A mask, eye protection, or face shield is worn if client care activities
have the potential to result in splashes or spraying of blood or body fluid. A gown
is worn if soiling of clothing is likely.
Test Taking Strategy: Focus on the subject, standard precautions. Think about the
purpose of standard precautions and visualize each of the options. This will help
you answer correctly. Review the principles of standard precautions if you had
difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
655). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
AD.
47.ID: 383717429
A nurse receives a telephone call from the admissions office and is told that a
client scheduled for an internal radiation implant will be admitted to the nursing
unit. Which of the following precautions does the nurse include in the clients
plan of care?
A.

Wearing gloves when emptying the clients bedpan Correct

B.

Allowing the client to ambulate in the hall only once a day

C.

Placing the client in a semiprivate room at the end of a hallway

D.

Placing used linen in double bags and sending a bag to the

laundry room every evening
Rationale: A primary goal of care for the client with an internal radiation implant
is to prevent exposure of others to radiation. Therefore, a client with an internal
radiation implant is required to remain in a private room to prevent accidental
exposure of other clients, staff, and visitors to radiation. For this reason, a private

room with a private bath is essential. All client linens should be kept in the
clients room until the implant is removed. Wearing gloves when emptying the
clients bedpan is the only appropriate intervention, of those provided, for a client
with an internal radiation implant.
Test-Taking Strategy: Use the process of elimination. Eliminate the option that
includes the closed-ended word only. Also eliminate the option involving the
use of a semiprivate room. To select from the remaining options, use your
knowledge of standard precautions and precautions for a client with an internal
radiation implant. This will direct you to the correct option. Review radiation
safety principles if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 420). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
AE.48.ID: 383719747
Which actions should the nurse take in the event of an accidental
poisoning? Select all that apply.
A.

Saving vomitus for laboratory analysis Correct

B.

Placing the client in the supine position

C.

Determining the type and amount of substance

ingested Correct

D.
E.
F.

Removing any visible materials from the nose and

mouth Correct
Inducing vomiting if a household cleaner has been ingested

Assessing the clients airway patency, breathing, and

circulation Correct
Rationale: In the event of accidental poisoning, the poison center is called before
any attempt at interventions is made. Additional interventions in an accidental
poisoning include assessing the clients airway patency, breathing, and
circulation; removing any visible materials from the nose and mouth to terminate
exposure; determining the type and amount of substance ingested, if possible, to
identify an antidote; saving vomitus for laboratory analysis, which may aid
further treatment; and positioning the victim with the head to the side to prevent
aspiration of vomitus and help keep the airway open. Because of the risk of
aspiration, vomiting is never induced in an unconscious client or in a client who is
experiencing seizures. Additionally, vomiting is not induced if lye, a household

cleaner, a hair care product, grease, a petroleum product, or furniture polish has
been ingested, because of the risk of internal burns.
Test-Taking Strategy: Focus on the subject, interventions in the event of
accidental poisoning. Visualize each of the interventions and how they might be
helpful in treating the poisoning. Use of the ABCs (airway, breathing, and
circulation) will also help you determine the correct interventions. Remember,
too, that caustic substances may cause further injury to the client if vomiting is
induced. If you had difficulty with this question, review the interventions for a
victim of accidental poisoning.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
840-842). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
AF. 49.ID: 383717445
A teenage client returns to the gynecological (GYN) clinic for a follow-up visit
after diagnosis and initial treatment of a sexually transmitted infection (STI).
Which statement by the client indicates the need for further teaching?
A.

I finished all the antibiotic, just like you said.

B.

I know you wont tell my parents that Im sick.

C.

I always make sure my boyfriend uses a condom.

D.
My boyfriend doesnt have to come in for treatment. Correct
Rationale: In the treatment of STIs, all sexual contacts must be alerted and
treated with medication. Any treatment at a GYN clinic for teenagers is
confidential, and parents will not be contacted even if the client is under 18
years. The client should always finish the medication prescribed by the
healthcare provider. Every client who is being treated for an STI or is at risk for an
STI should use a condom for any sexual contact
Test-Taking Strategy: Note the strategic words need for further teaching. These
words indicate a negative event query and the need to select the incorrect client
statement. Read each option carefully. Using knowledge of safe sex practices and
the treatment of STIs will help you answer this question. Review content related
to the transmission of STIs if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternalchild nursing (3rd ed., p. 1034). St. Louis: Elsevier.

Cognitive Ability: Evaluating

Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
AG.
50.ID: 383717489
A nurse is performing sterile wound irrigation for an assigned client. A nursing
assistant enters the clients room and tells the nurse that a physician has
telephoned and has asked to speak to the nurse. What is the appropriate action
by the nurse?
A.

Asking the nursing assistant to take a message

B.

Covering the client and answering the telephone call

C.

Finishing the wound irrigation while the physician waits on the

telephone Incorrect

D.

Asking the nursing assistant to obtain a telephone number from

the physician so that the nurse may return the call after the wound
irrigation is complete Correct
Rationale: Because wound irrigation is a sterile procedure and a risk for infection
exists with any open wound, the nurse should ask the nursing assistant to obtain
a telephone number from the physician so that the call may be returned after the
wound irrigation is complete. It is not appropriate to ask a physician to wait while
a procedure is being completed. It is best to return the call. It is not the
responsibility of the nursing assistant to take a message.
Test-Taking Strategy: Note the strategic word appropriate and use your
knowledge of the priorities of care. Recalling that a wound irrigation is a sterile
procedure and that a risk for infection exists with any open wound will direct you
to the correct option. Remember that the client is the priority and must be
protected from the risk of infection. With that in mind, you must select the option
of returning the call to the physician once the irrigation is complete. Review the
principles of priorities of care if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 5,
822, 823). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 0.0 points out of 1.0 possible points.

AH.
51.ID: 383718172
A nurse in a long-term care facility recognizes the need to place wrist restraints
on a client, but the client does not want the restraints applied. The appropriate
nursing action would be to:
A.

Contact the physician Correct

B.

Apply the restraints anyway

C.

Medicate the client with a sedative, then apply the restraints

D.

Compromise with the client and use only one wrist restraint
instead of two Incorrect
Rationale: The use of restraints must be avoided if possible. If it is determined
that a restraint is necessary, the nurse should discuss the issue with the family
and obtain a prescription from the physician. The nurse should explain carefully
to the client and family the reasons that the restraint is necessary, the type of
restraint that has been selected, and the anticipated duration of use of the
restraint. If a client refuses restraints, the nurse must contact the physician.
Therefore the other options are incorrect.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike in that they involve the application of restraints. Noting
the strategic word appropriate will also assist you in answering correctly.
Review the ethical and legal guidelines for the use of restraints if you had
difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 336). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
AI. 52.ID: 383717477
A nurse is providing instructions to a nursing assistant who will be caring for a
client in hand restraints. The nurse instructs the nursing assistant to release the
restraints to permit muscle exercise:
A.

Every 2 hours Correct

B.

Every 3 hours

C.

Every 4 hours

D.
Every 30 minutes
Rationale: The nurse should instruct the nursing assistant to assess the restraints
and the clients circulatory status and skin integrity every 30 minutes. Restraints
must be released at least every 2 hours to permit muscle exercise and promote

circulation. Agency guidelines regarding the use of restraints should always be

followed.
Test-Taking Strategy: Knowledge regarding the use of restraints is necessary to
answer this question. Noting the strategic words release the restraints will help
direct you to the correct option. Review nursing responsibilities regarding the use
of restraints if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
837). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
AJ. 53.ID: 383717441
A nurse has provided instructions to a mother regarding the use of safety seats in
car travel for her newborn infant. Which statement by the mother indicates
understanding of the instructions?
A.

Ill put the babys car seat in the front seat, facing forward and
reclined a little.

B.

Ill put the babys car seat in the front seat, facing backward
and reclined a little.

C.

Ill put the babys car seat in the middle back seat, facing
forward and reclined a little.

D.

Ill put the babys car seat in the middle back seat, facing
backward and reclined a little. Correct
Rationale: The infant should be restrained in a car seat in a semireclined, rearfacing position to allow the seat and infants spine to bear the forces of impact
should a collision occur. The infant should never face forward or ride in the front
seat.
Test-Taking Strategy: Use the process of elimination. Visualize each of the
descriptions in the options with safety in mind. Recalling that an infant should not
be placed in the front seat or in a forward-facing position will direct you to the
correct option. If you had difficulty with this question, review car safety measures
for the infant.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternalchild nursing (3rd ed., p. 119). St. Louis: Elsevier.
http://www.healthychildren.org/English/safety-prevention/on-the-go/pages/CarSafety-Seats-Information-for-Families-2010.aspx

Cognitive Ability: Evaluating

Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
AK.54.ID: 383718891
A community health nurse is providing an educational session on childhood
poisoning at a local school. The nurse tells the group that when an accidental
poisoning occurs the first action is to:
A.

Induce vomiting

B.

Call an ambulance

C.

Call the poison control center Correct

D.
Bring the child to the emergency department (ED)
Rationale: When a poisoning occurs, a poison control center should be contacted
immediately and any directions given regarding treatment followed. The poison
control center will provide directions regarding the inducement of vomiting.
However, vomiting should not be induced if the victim is unconscious or if the
substance ingested is a strong corrosive or petroleum product. The poison control
center may advise the mother to bring the child to the ED; if this is the case, the
mother should call an ambulance. Neither bringing the child to the ED nor calling
an ambulance would be the immediate actions, because either tactic would delay
treatment.
Test-Taking Strategy: Note the strategic word first in the query of the question.
Eliminate the options that are comparable or alike in that they involve a delay in
starting treatment (calling an ambulance and bringing the victim to the
emergency department). Recalling that vomiting should not be induced in certain
types of poisoning will help you eliminate this option. Review immediate poison
control measures if you had difficulty with this question.
Reference: Maurer, F., & Smith, C. (2009). Community/public health nursing
practices: Health for families and populations (4th ed., pp. 246, 247).
Philadelphia: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.

AL. 55.ID: 383718190

A nurse educator is providing inservice sessions to the nursing staff regarding
employee safety and the prevention of occupationally acquired HIV infection.
Which of the following precautions does the nurse instruct the nursing staff to
take as a means of preventing accidental needlesticks? Select all that apply.
A.

The use of latex gloves

B.

The use of shielded needles Correct

C.

The use of recessed needles Correct

D.

The use of needleless devices Correct

E.

Disposal of needles in special puncture-resistant

containers Correct
Rationale: Although strict adherence to universal or standard precautions can
reduce significantly the incidence of exposure to blood or body fluid, latex gloves
cannot prevent a needlestick. The use of recessed needles, needleless devices,
shielded needles, and puncture-resistant containers for the disposal of needles
are all of significant benefit in the prevention of accidental needlesticks.
Test-Taking Strategy: Focus on the subject, preventing accidental needlesticks, to
answer the question. Visualize each of the options and how the action might or
might not prevent a needlestick. This will help you answer correctly. Review
standard precautions if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., pp. 368, 369). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Infection Control
Awarded 0.0 points out of 1.0 possible points.
AM.
56.ID: 383718874
A nurse preparing a sterile field is placing sterile items on the field. The nurse
understands that the border of the sterile drape is considered contaminated. How
many inch(es) is the contaminated border? Type your answer in the box
provided.
_____ inch(es)
Correct

Correct Responses: "1"

<i>Rationale: </i>Because the edge of a sterile drape touches a nonsterile
surface such as a table, 1-inch (2.5-cm) border around the drape is considered
contaminated. Objects placed on the sterile field must be within this

border.<i></i><i></i><i></i><sup></SUP><i></i><i></i><i></i><i></i>
<br><i></i><i></i><i></i><i></i><sup></SUP><i></i><i></i><i></i><i
></i><br><i></i><i>Test-Taking Strategy: </i>Specific knowledge of the
principles of aseptic technique is needed to answer this question. It is important
to remember that a 1-inch border around a drape is to be considered
contaminated. If you had difficulty with this question, review the principles of
aseptic
technique.<i></i><i></i><sup></SUP><i></i><i></i><i></i><i></i><br>
<i></i><i></i><i></i><i></i><sup></SUP><i></i><i></i><i></i><i></i
><br><i></i><i></i><i>Reference: </i>Potter, P., & Perry, A. (2009).
<i>Fundamentals of nursing</i> (7th<sup> </SUP>ed., p. 669). St. Louis:
Mosby.<i></i><i></i><i></i><i></i><br><i></i><i></i><i></i><i></i><
sup></SUP><i></i><i></i><i></i><i></i><br><i></i><i></i><i></i><i>
</i><sup></SUP><i>Cognitive Ability:
</i>Understanding<i></i><i></i><i></i><br><i></i><i></i><i></i><i></
i><sup></SUP><i></i><i></i><i></i><i></i><br><i></i><i></i><i></i>
<i></i><sup></SUP><i></i><i>Client Needs: </i>Safe and Effective Care
Environment<i></i><i></i><br><i></i><i></i><i></i><i></i><sup></SU
P><i></i><i></i><i></i><i></i><br><i></i><i></i><i></i><i></i><sup
></SUP><i></i><i></i><i>Integrated Process: </i>Nursing
Process/Implementation<i></i><br><i></i><i></i><i></i><i></i><sup></
SUP><i></i><i></i><i></i><i></i><br><i></i><i></i><i></i><i></i><s
up></SUP><i></i><i></i><i></i><i>Content Area:</i> Infection Control
Awarded 1.0 out of 1.0 possible points.
AN.
57.ID: 383717451
A nurse preparing to perform a sterile dressing change notes that the covering of
a package of sterile 4 4 gauze pads has a small tear. Which action should the
nurse take?
A.

Discarding the package Correct

B.

Using the gauze pads, because the tear was small

C.

Examining the gauze pads and using them as long as they

appear untouched

D.

Discarding the gauze pad closest to the outside of the package

and using the others
Rationale: When performing a surgically aseptic procedure, the nurse must follow
certain principles of aseptic technique to ensure maintenance of asepsis. A sterile
object remains sterile only when touched by other sterile objects. If the sterile
state of an object is questionable (e.g., if there is a tear or break in the covering
of a sterile object), the nurse must discard the object, because it is considered
contaminated. Therefore the nurse in this situation would not use the gauze
pads.
Test-Taking Strategy: Focus on the data in the question and note that the
package of sterile gauze is torn. Also note that the incorrect options are
comparable or alike in that they indicate that it is acceptable to use the gauze in
the package. If you had difficulty with this question, review the principles of

aseptic technique.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
669). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
AO.
58.ID: 383718811
A nurse responds to an external disaster that occurred in a large city when a
building collapsed. Numerous victims require treatment. Which victim should the
nurse attend to first?
A.

A victim who has died of multiple serious injuries

B.

A hysterical victim who has sustained a head injury

C.

An alert victim who has numerous bruises on the arms and legs

D.

A victim with a partial amputation of a leg who is bleeding

profusely Correct
Rationale: The nurse determines which victim will be attended to first on the
basis of the severity of injury of each of the victims of the disaster. An injury that
threatens life, limb, or vision without immediate attention is categorized as
emergent and is the priority (in this case, the victim with a partial amputation
who is bleeding profusely). A victim who requires treatment but whose life, limbs,
and vision are not threatened if care can be provided within 1 to 2 hours is
considered to represent an urgent case and is the second priority (here, the
hysterical victim who has sustained a head injury). Local injuries that require
evaluation and possibly treatment but for which time is not critical are
categorized as nonurgent and represent the third priority (here, the victim with
numerous bruises on the arms and legs). Caring for a victim who is already dead
is the final priority.
Test-Taking Strategy: Note the strategic word first and use your knowledge of
the principles of to triage. Note the words bleeding profusely in the correct
option. Review the principles of triage if you had difficulty with this question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 2194). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation

Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
AP. 59.ID: 383719751
A nurse, charting the administration of medications to an assigned client at 9 pm,
notes that atenolol (Tenormin) was prescribed to be administered at 9 am instead
of 9 pm. The nurse checks the clients vital signs, completes an incident report,
and calls the physician to report the error. The physician tells the nurse that an
incident report is not needed but instructs her to monitor the client during the
night for hypotension. What action should the nurse take?
A.

Notifying the nursing supervisor Incorrect

B.

Tearing up and discarding the incident report

C.

Telling the physician that the error warrants the completion of

an incident report Correct

D.

Telling the nursing supervisor that the physician did not want
an incident report completed and filed
Rationale: Incident reports are an important part of a healthcare agencys quality
improvement program. An incident is any event that is not consistent with the
routine operation of a healthcare unit or routine care of a client. An example of
an incident is administering a medication at a time at which it is not prescribed to
be given. Whenever an incident occurs, an incident report is completed and filed
in accordance with agency guidelines. The nursing supervisor would be notified
of the incident; however, on the basis of the data in the question, the nurse
should tell the physician that the error warrants completion and follow-through
with an incident report. Therefore, the other options are incorrect.
Test-Taking Strategy: Focus on the subject of the question, the physicians telling
the nurse that an incident report is not needed. Eliminate the options that are
comparable or alike in that they involve notifying the nursing supervisor. To select
from the remaining options, recall the purpose of an incident report to select the
correct option. Review the procedures involved in completing and filing incident
reports if you had difficulty with this question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 557, 558). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
AQ.
60.ID: 383718170

A nurse prepares to teach a client with chronic vertigo about safety measures to
help prevent exacerbation of symptoms and injury. Which instructions should the
nurse provide to the client? Select all that apply.
A.

Change positions slowly. Correct

B.

Remove clutter from your home. Correct

C.

Use public transportation as much as possible. Incorrect

D.

Drive your car only if youre not feeling dizzy.

E.

Turn your head slowly when someone speaks to

you. Incorrect
Rationale: Any sudden movement could precipitate a vertigo attack, so, to help
prevent vertigo attacks, the client should avoid such movements. The client with
chronic vertigo should avoid driving; the use of public transportation should also
be avoided because of the sudden movements that occur with this mode of
transport. The client should also change position slowly and should turn the
entire body, not just the head, when spoken to. If vertigo does occur, the client
should immediately sit down or grasp the nearest piece of stable furniture. The
client should maintain the home in a state free of clutter and remove throw rugs,
because the effort of trying to regain balance after slipping could trigger the
onset of vertigo.
Test-Taking Strategy: Focus on the subject, safety measures for a client with
chronic vertigo. Read each option carefully. Thinking about general safety
principles and those that are important for a client with chronic vertigo will help
you answer correctly. Review safety measures for the client with chronic vertigo if
you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 1127). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
AR.61.ID: 383717493
A licensed practical nurse (LPN) tells the registered nurse (RN) that she
administered acetaminophen (Tylenol) to a client by way of the rectal route
rather than the prescribed oral route because the client was extremely
nauseated. The RN most appropriately:
A.

Asks the LPN to complete and file an incident report Correct

B.

Asks the LPN to check the client in 30 minutes to see whether

the nausea has subsided

C.

Tells the LPN that she made a sound judgment in administering

the medication by way of the rectal route

D.

Instructs the LPN to write pr (per rectum) on the medication

record next to the time at which the medication was administered
Rationale: If a medication is prescribed to be administered by way of the oral
route, the nurse may not use an alternate route to administer the medication
unless the change is prescribed by the physician. The nurse would ask the LPN to
complete and file an incident report because the LPN, legally speaking, made a
medication error. Telling the LPN that she made a sound judgment in
administering the medication by way of the rectal route is incorrect. Although the
client must be reassessed and the LPN would document administration of the
medication by way of the rectal route in the clients record, the most appropriate
option given is having the LPN complete and file an incident report.
Test-Taking Strategy: Use the process of elimination and note the strategic words
most appropriately. Focusing on the data indicates that the LPN made a
medication error. This will direct you to the correct option. Review the appropriate
actions in the event of a medication error if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
403, 704, 705). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
AS.62.ID: 383746219
Contact precautions are initiated for a client with methicillinresistant Staphylococcus aureus (MRSA) infection. The nurse, providing
instructions to a nursing assistant about caring for the client, tells the assistant:
A.

To transfer the client to a semiprivate room

B.

That gloves only are needed to care for the client

C.

To wear gloves and a gown when changing the client's bed

linen. Correct

D.

To wear a gown when caring for the client and remove the
gown immediately after leaving the clients room
Rationale: Contact precautions require the use of gloves, gown, and goggles if
direct client contact is anticipated. Goggles are worn to protect the mucous
membranes of the eye during interventions that may produce splashes of blood

or body fluids, secretions, or excretions. The client should be placed in a private

room or, if a private room is not available, in a semiprivate room with another
client who has active infection with the same microorganism but no other
infection. The nursing assistant would remove the protective gear before leaving
the clients room.
Test-Taking Strategy: Use the process of elimination. Eliminate the option that
includes the closed-ended word only. Next eliminate the option that involves
removal of the gown after leaving the clients room. To select from the remaining
options, read each carefully and visualize the procedure instituted for contact
precautions, which will direct you to the correct option. If you had difficulty with
this question, review contact precautions.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
655, 663). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
AT. 63.ID: 383718174
A nurse is admitting a postoperative client from the postanesthesia care unit to
the surgical nursing unit. Which of the following measures should the nurse take
for the safety of the client?
A.

Asking the client to slide from the stretcher to the bed

B.

Quickly moving the client from the stretcher to the bed

C.

Putting the siderails up after moving the client from the

stretcher Correct

D.

Uncovering the client before making the transfer from the

stretcher to the bed
Rationale: Because the client may be experiencing residual effects of anesthesia,
the nurse should raise the siderails after transferring the client from the stretcher
to the bed. Agency policy for the use of siderails is always followed; some
agencies policies set forth the number of siderails that may be used. Because of
the effects of anesthesia and postoperative pain, it is not realistic to ask the
client to slide from the stretcher to the bed. Hurried movements and rapid
changes in position should be avoided because they may trigger orthostatic
hypotension. The nurse should avoid exposing the postoperative client during
transfer because of the potential for heat loss, respiratory infection, and shock.
Test-Taking Strategy: Use the process of elimination. First eliminate the options
that are not standard nursing interventions. Choose from the remaining options

knowing that the subject of the question is client safety. Noting the words asking
the client to slide, quickly, and uncover will help you eliminate these
options. Review care of the postsurgical client if you had difficulty with this
question.
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 218). St. Louis: Saunders.
Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th ed., p. 456).
St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
AU.
64.ID: 383718869
A community health nurse is providing information to local residents about the
transmission of anthrax. Through which body systems does the nurse tell the
residents that anthrax can be contracted? Select all that apply.
A.

Skin Correct

B.

Lungs Correct

C.

Immune

D.

Urinary

E.

Lymphatic

F.
Gastrointestinal Correct
Rationale: Anthrax, caused by Bacillus anthracis, can be contracted through the
gastrointestinal system, abrasions in the skin, or inhalation. It is not contracted
through the immune system, urinary tract, or lymphatic system.
Test-Taking Strategy: Specific knowledge of the routes of infection with B.
anthracis is needed to answer this question. Remember that anthrax can be
contracted through the gastrointestinal system, skin, or lungs. Review content on
anthrax and its modes of transmission if you had difficulty with this question.
Reference: McEwen, M., & Pullis, B. (2009). Community-based nursing: An
introduction (3rd ed., p. 410). Philadelphia: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning

Content Area: Biological/chemical warfare

Awarded 1.0 points out of 1.0 possible points.
AV. 65.ID: 383718865
A nurse is reading the history and physical examination findings of an older client
who has just been admitted to the hospital. Which findings documented in the
history indicate an increased risk for accidents? Select all that apply.
A.

The clients range of motion is limited. Correct

B.

Transmission of hot impulses is delayed. Correct

C.

The clients peripheral vision is decreased. Correct

D.

The client complaints of frequent nocturia. Correct

E.

High-frequency hearing tones are perceptible.

F.
Voluntary and autonomic reflexes are slowed. Correct
Rationale: The physiologic changes that occur during the aging process increase
the clients risk for accidents. Musculoskeletal changes include diminished
muscle strength and function, lessening of joint mobility, and limited range of
motion. Nervous system changes include slowed voluntary and autonomic
reflexes. Sensory changes include reduced peripheral vision and lens
accommodation, delayed transmission of hot and cold impulses, and impaired
hearing as high-frequency tones become less perceptible. Genitourinary changes
include nocturia and incontinence.
Test-Taking Strategy: Focus on the subject, the findings that increase the older
clients risk for accidents. Reading each option carefully and keeping in mind the
factors that affect client safety will help you answer the question. Review the
factors that put an older client at risk for accidents if you had difficulty with this
question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
198-200, 208, 816). St. Louis: Mosby.
Level of Cognitive Ability:Understanding
Client Needs:Safe and Effective Care Environment
Integrated Process:Nursing Process/Assessment
Content Area:Safety
Awarded 0.0 points out of 1.0 possible points.
AW.
66.ID: 383716392
The safety department is providing a yearly educational session on fire safety
and the use of fire extinguishers. A nurse is asked to demonstrate the use of a
fire extinguisher after the session. The nurse demonstrates appropriate use of
the fire extinguisher by first:
A.

Aiming at the base of the fire

B.

Pulling the pin on the fire extinguisher Correct

C.

Squeezing the handle of the extinguisher

D.

Sweeping from the top to the bottom of the fire with the
extinguisher
Rationale: To use a fire extinguisher, pull the pin first. Next, aim the extinguisher
at the base of the fire. Squeeze the handle of the extinguisher, then extinguish
the fire by sweeping from side to side to coat the area evenly.
Test-Taking Strategy: Use the mnemonic PASS to remember the steps in the use
of a fire extinguisher: Pull the pin, aim at the base of the fire, squeeze the handle,
and sweep from side to side to coat the area evenly. If you had difficulty with this
question, review the appropriate use of a fire extinguisher.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
840, 841). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
AX.67.ID: 383717475
A nurse manager of an emergency department (ED) arrives at work and is told
that four registered nurses scheduled to work will not be reporting to work
because they are ill. Every trauma room is busy, and emergency medical services
(EMS) has just called to report that several victims involved in a 10-car wreck on
the interstate will be brought to the ED. The nurse manager initially manages this
situation by:
A.

Telling EMS to take the victims to another hospital

B.

Closing the emergency department temporarily to incoming

clients

C.
D.

Calling the nursing supervisor to discuss activation of the

disaster plan Correct

Demanding that the nurses from the night shift stay until all of
the victims have been treated
Rationale: External disasters occur in the community, and many victims of such
events are brought to the ED for care. In this situation, the nurse manager would
initially call the nursing supervisor to discuss the need for additional staffing and
activation of the disaster plan. The nurse manager would not ask EMS to take the
victims to another hospital or temporarily close the ED to incoming clients; such
decisions are made by hospital administrators. The nurse manager should ask,
not demand, that nurses from the night shift stay until all of the victims have

been treated.
Test-Taking Strategy: Use the process of elimination, noting the strategic word
initially in the query of the question. First eliminate the option containing the
word demanding. Next eliminate the options that are comparable or alike in
that they indicate that the victims will not be admitted to the ED. Review the
procedures for management in times of disaster if you had difficulty with this
question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., pp. 76, 2213, 2214). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
AY. 68.ID: 383717455
A hurricane is forecast to make landfall in 48 hours, and the staff of the
emergency department of an area hospital is advised to prepare for causalities.
Which action should the nurse manager who receives the telephone call
regarding this warning take first?
A.

Activating the agency disaster plan Correct

B.

Supplying the triage rooms with additional equipment

C.

Increasing the number of nursing staff for the day on which the
hurricane is expected

D.

Calling the hospital maintenance department to secure the

building against the storm
Rationale: In an external disaster, many people may be brought to the
emergency department for treatment. Although increasing the nursing staff and
supplying the triage rooms with additional equipment may be steps in preparing
for casualties, the initial action by the nurse manager must be activation of the
disaster plan. Calling the hospital maintenance department to secure the building
from the storm is not a responsibility that falls within the scope of nursing
management.
Test-Taking Strategy: Note the strategic word first in the query of the question.
Use the process of elimination in determining the priority action. Note that the
correct option is the umbrella option. Also remember that other necessary
activities will be initiated once the agency disaster plan has been activated.
Review procedures related to management in times of disaster if you had
difficulty with this question.

Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical

management for positive outcomes (8th ed., pp. 76, 2213, 2214). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Disasters
Awarded 1.0 points out of 1.0 possible points.
AZ.69.ID: 383717416
A nurse performs an evaluation to determine whether a clients home is
electrically safe. Which finding indicates the need for further investigation and
intervention?
A.

Wiring for the television runs under the carpet. Correct

B.

Electrical cords are free of frayed and damaged wires.

C.

Electrical kitchen appliances are located away from the sink.

D.

A safety-type extension cord is secured to the floor with

electrical tape.
Rationale: Electrical safety guidelines must be followed to help prevent fires and
injuries. These guidelines include the maintaining of electrical equipment in good
working order with proper grounding; periodically checking electrical cords and
outlets for exposed, frayed, or damage wires and loose or missing parts; avoiding
overload of electrical circuits; reading warning labels on all equipment; never
operating unfamiliar equipment; using safety-style extension cords and using
such cords only when absolutely necessary, securing them to the floor with
electrical tape; never running electrical wiring under a carpet; never pulling a
plug by the cord; never using electrical appliances near sinks, bathtubs, or other
water sources; and disconnecting a plug from the outlet before cleaning the
equipment or appliance to which it is attached.
Test-Taking Strategy: Note the strategic words need for further investigation and
intervention. These words indicate a negative event query and the need to
select the unsafe finding. Note the words runs under the carpet in the correct
option. If you had difficulty with this question, review electrical safety guidelines.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
842). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Evaluation

Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
BA.70.ID: 383717447
A nurse caring for a client who is under airborne precautions notes that the client
is scheduled for a nuclear scan. Which action on the part of the nurse is
appropriate?
A.

Planning to have the nuclear scan performed at the bedside

B.

Asking the technicians in the nuclear scan department to wear

masks

C.

Placing a surgical mask on the client for transport and for

contact with other individuals Correct

D.

Calling the nuclear medicine department and telling the

technician that the test will have to be delayed until airborne
precautions have been discontinued
Rationale: If the client is under airborne precautions, client movement and
transport should be limited as much as possible. If transport or movement is
necessary, the nurse can minimize the dispersal of droplet nuclei from the client
by placing a surgical mask on the client. Having the scan performed at the
bedside is unreasonable. Asking the technicians in the nuclear medicine
department to wear masks would not prevent the dispersal of droplet nuclei from
the client. The physician is the individual who would prescribe the cancellation or
delay of a diagnostic test. Additionally, delaying the test until airborne
precautions have been discontinued is not within the role of the nurse.
Test-Taking Strategy: Use the process of elimination and focus on the subject of
the question, airborne precautions. Knowing that a nurse should not delay a
prescribed test will help you eliminate this option. Eliminate the option of having
the scan at the bedside, because this action is unreasonable. To select from the
remaining options, recall the route and mode of transmission of an airborne
infection. This should direct you to the correct option. Review airborne
precautions if you had difficulty with this question.
Reference: Ackley, B., Ladwig, G., Swan, B., & Tucker, S. (2008). Evidence-based
nursing care guidelines: Medical-surgical interventions (p. 475). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
BB.71.ID: 383717425

At the beginning of the 7 am3 pm shift, the nurse checks her assigned clients
and notes that a client with diabetes mellitus has an intravenous (IV) bag of 5%
dextrose in water hanging and infusing instead of the prescribed 0.9% normal
saline. The nurse verifies the prescription and changes the IV solution to the
correct one. The nurse assesses the client noting that the blood glucose level at
7:15 am was 149 mg/dL, notifies the physician, and completes an incident report.
Which information about the event is appropriate for inclusion on the incident
report? Select all that apply.
INCIDENT REPORT
Events that Occurred
A.

The physician was contacted. Correct

B.

The blood glucose level at 7:15 am was 149 mg/dL. Correct

C.

An IV solution of 5% dextrose in water was infusing at 7

am. Correct

D.

A solution of 5% dextrose in water was infusing instead of the

prescribed 0.9% normal saline solution.

E.

A 5% dextrose in water solution is not usually prescribed for

clients with diabetes, and the solution was changed immediately on its
discovery.
Rationale: The incident report should contain the clients name, age, and
diagnosis. The report should contain a factual description of the incident, any
injuries sustained by those involved, and the outcome of the situation. The nurse
should avoid the use of subjective data, instead documenting objective data. The
nurse also avoids any implication that an accident occurred or an error was
made. The statement that a 5% dextrose in water solution was infusing instead
of the prescribed 0.9% normal saline solution implies that an accident occurred
or an error was made. Likewise, the statement that 5% dextrose in water is not
usually prescribed for clients with diabetes and that the solution was changed
immediately on its discovery makes an implication. The remaining statements
identify factual and observable data without making implications.
Test-Taking Strategy: Read each statement carefully. Recalling the guidelines for
completing an incident report form and remembering that factual, observable
information without implications is the goal will direct you to the correct options.
Remember to focus on factual information when documenting, and avoid
including interpretations. Review the principles of documentation for incident
reports if you had difficulty with this question.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., pp. 171. 172). St. Louis: Mosby.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 336, 337). St.
Louis: Mosby.
Level of Cognitive Ability: Applying

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
BC.72.ID: 383718194
A nurse, assessing a clients readiness for discharge, is performing a home safety
assessment to determine whether there are any environmental hazards in the
home. Which of the following statements, if made by the client, would prompt the
nurse to investigate further? Select all that apply.
A.

I live in a single-story house.

B.

I dont have any nightlights in the house. Correct

C.

Ive removed the scatter rugs from the house.

D.

I keep my personal items within reach when I sit in my easy

chair.

E.

I havent changed the batteries in the smoke detectors in my

home for quite a few years now. Correct
Rationale: If the client tells the nurse that there are no nightlights in the home,
the nurse should further investigate the situation. Nightlights help prevent falls
by the client who may need to get up during the night. The batteries in smoke
detectors should be changed at least once a year, so the nurse must investigate
further if the client indicates that this has not been done for quite a few years.
The other statements by the client do not reflect environmental hazards in the
home.
Test-Taking Strategy: Note the strategic words investigate further. These words
indicate a negative event query and the need to select the statements by the
client that indicate the presence of environmental hazards. Reading each option
carefully will direct you to the correct options. Review environmental hazards in
the home if you had difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 1062). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
BD.
73.ID: 383718112

A triage nurse in an emergency department (ED) is attending to the victims of a

train crash. All victims are alert. Which of these clients does the nurse assign to
the emergent category? Select all that apply.
A.

A victim with respiratory distress Correct

B.

A victim with a fractured humerus

C.

A victim with partial amputation of the foot Correct

D.

A victim with a forehead laceration that is not bleeding

E.
A victim with multiple nonbleeding bruises of the arms and legs
Rationale: One rating system commonly used in the ED consists of three tiers
emergent, urgent, and nonurgent with the categories sometimes identified
with color coding or numbers. The emergent classification (a.k.a. red or priority
1) is given to clients with life-threatening injuries (here, the clients with
respiratory distress [airway] and partial amputation of the foot
[bleeding/circulation]) who require immediate attention and continuous
evaluation but have a high chance of survival once their conditions have been
stabilized. The urgent (a.k.a. yellow or priority 2) classification is given to clients
whose injuries and complications are not life threatening (here, the client with
the fractured humerus), provided that they are treated within 1 to 2 hours; such
clients require evaluation every 30 to 60 minutes thereafter. The nonurgent
(a.k.a. green or priority 3) classification is given to clients with local injuries
(here, the clients with the forehead laceration and bruises of the arms and legs)
who do not have immediate complications and can wait several hours for medical
treatment; these clients require evaluation every 1 to 2 hours thereafter.
Test-Taking Strategy: Use the ABCs airway, breathing, and circulation which
will easily direct you to the correct options. Respiratory distress involves the
airway, and the victim with amputation is at risk for bleeding (i.e., circulation).
Review the triage system and priorities of care if you had difficulty with this
question.
References: Maurer, F., & Smith, C. (2009). Community/public health nursing
practices: Health for families and populations (4th ed., p. 567). Philadelphia:
Saunders.
McEwen, M., & Pullis, B. (2009). Community-based nursing: An introduction (3rd
ed., p. 157). Philadelphia: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Disasters
Awarded 1.0 points out of 1.0 possible points.
BE.74.ID: 383717443

A nurse is preparing a disaster preparedness checklist, identifying emergency

plans and supplies that will be needed in the event of a disaster, for a community
group. Which instructions should be included on the list? Select all that apply.
A.

Have a first aid kit available. Correct

B.

Have a firearm or other weapon available.

C.

Plan a meeting place for family members. Correct

D.

Obtain a 1-day supply of water (1 gallon per person).

E.

Have an adequate supply of prescription medications. Correct

F.

Have a battery-operated radio and a flashlight and batteries

available. Correct
Rationale: Personal preparedness for a disaster includes planning a meeting
place for family members, identifying safe spots in the home for each type of
disaster; having a 3-day supply of water (1 gallon per person per day) and a 3day supply of nonperishable food; and having clothing and blankets, a first aid
kit, a battery-operated radio, a flashlight, and batteries available. For safety
reasons, the nurse would not recommend that a weapon be kept.
Test-Taking Strategy: Focus on the subject, a disaster preparedness checklist.
Thinking about necessities in the event of a disaster and about safety will assist
you in identifying the items needed. Review the items needed in the event of a
disaster if you had difficulty with this question.
Reference: McEwen, M., & Pullis, B. (2009). Community-based nursing: An
introduction (3rd ed., p. 159). Philadelphia: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Disasters
Awarded 1.0 points out of 1.0 possible points.
BF. 75.ID: 383718186
A home care nurse is visiting an older client who has been recovering from a mild
brain attack (stroke) affecting her left side. The client lives alone but receives
regular assistance from her daughter and son, who both live within 10 miles.
Which of the following actions should the nurse take to assess the clients safety
risk? Select all that apply.
A.

Assessing the clients visual acuity Correct

B.

Observing the clients gait and posture Correct

C.

Evaluating the clients muscle strength Correct

D.

Looking for any hazards in the home environment Correct

E.

Asking a family member to move in with the client until her

recovery is complete

F.

Requesting that the client transfer to an assisted living

environment for at least 1 month
Rationale:To conduct a thorough client assessment, the nurse looks for risk
factors related to safety. The assessment should include the assessment of visual
acuity, gait and posture, and muscle strength, because alterations in these areas
increase the clients risk for falls and injury. The nurse should also assess the
home environment, looking for any hazards or obstacles that might affect safety.
Asking a family member to move in with the client until recovery is complete and
requesting that the client transfer to an assisted living environment for at least 1
month are not assessment activities. Additionally, nothing in the question
indicates that these actions are necessary; therefore, these options are
unrealistic and unreasonable.
Test-Taking Strategy: Focus on the subject, an assessment for risk factors related
to safety. Read each option carefully and note that the incorrect options are
unrelated to the subject of the question. Review the items that should be
included in a safety assessment if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
198-200, 208, 813, 816). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Assessment
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
BG.
76.ID: 383717471
A client with osteoporosis is at risk for falls. Which statement by the client
indicates the need for instruction regarding measures to prevent falls?
A.

I took the bathmat out of my tub. Correct

B.

I use a shower chair when I bathe.

C.

Ive placed nightlights in my hallway.

D.
The railings on my stairs are sturdy and secure.
Rationale: Home modifications to reduce the risk for falls include use of sturdy,
secure railings on all staircases and ample lighting, including nightlights.
Bathroom safety equipment includes a shower chair, handrails in the shower and
near the toilet, and a mat in the tub to prevent slipping.
Test-Taking Strategy: Note the strategic words need for instruction. These
words indicate a negative event query and the need to select the incorrect client

statement. Begin to answer this question by eliminating the options that involve
the provision of physical support to the client, because these measures are
needed. Use of a nightlight, which will enhance vision for the client getting up at
night to use the bathroom, is also warranted. The only remaining option, which is
the correct answer, is removing the bathmat. Remember that mats prevent slips
and falls. Review the basic measures for the prevention of falls if you had
difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 1061). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
BH.
77.ID: 383718197
A nurse is preparing to clean up a blood spill on the clients bedside table that
occurred when a blood tube containing a specimen from the client broke. What
steps should the nurse take to clean up the blood spill? Select all that apply.
A.

Using tongs to collect any broken glass Correct

B.

Wearing gloves for the cleanup procedure Correct

C.

Placing the pieces of broken glass in a plastic bag

D.

Blotting up the spill with a face cloth or cloth towel

E.

Disinfecting the area of the blood spill with a dilute bleach

solution Correct
Rationale: The nurse should blot the spill with an absorbent disposable material
such as disposable paper towels or terry wipes, not a face cloth or towel. Tongs
are used to pick up any broken glass, and gloves are worn for the procedure. The
broken glass is disposed of in a puncture-resistant container. The area is
disinfected with a dilute bleach solution or other agency-accepted product.
Test-Taking Strategy: Read each option carefully. Visualizing the actions identified
in each option and recalling the principles associated with standard precautions
will direct you to the correct options. Review the procedure for cleaning up blood
spills if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
668). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation

Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
BI. 78.ID: 383718867
A nurse is reading an article about the role of the American Red Cross (ARC) in a
disaster. Which of the following responsibilities does the article ascribe to the
ARC?
A.

Declaring a disaster

B.

Providing disaster relief Correct

C.

Activating disaster medical assistant teams

D.
Developing a federal disaster response plan
Rationale: The ARC has been given authority by the federal government to
provide disaster relief. This organization works with the government in
developing and testing community disaster plans, identifying and training
personnel for disaster response, working with businesses and labor organizations
to identify resources and people for disaster work, and educating the public
about ways to prepare for disasters. Other responsibilities include operating
shelters, providing assistance to meet immediate emergency needs, and
providing disaster health services. Declaring a disaster, developing a federal
disaster response plan, and activating disaster medical assistant teams are
responsibilities of the Federal Emergency Management Agency.
Test-Taking Strategy: Focus on the subject, the roles and responsibilities of the
ARC. Read each option carefully and think about the parties involved in each
action in the options; this will direct you to the correct option. Review the roles of
the ARC in a disaster if you had difficulty with this question.
Reference: Maurer, F., & Smith, C. (2009). Community/public health nursing
practices: Health for families and populations (4th ed., p. 565). Philadelphia:
Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Disasters
Awarded 1.0 points out of 1.0 possible points.
BJ. 79.ID: 383717406
A nurse in a postanesthesia care unit (PACU) receives a client from the operating
room. For what finding should the PACU nurse assess the client first?
A.

Airway patency Correct

B.

Active bowel sounds

C.

Adequate urine output

D.
Orientation to surroundings
Rationale: After a clients transfer from the operating room, the PACU nurse
performs an assessment, assessing airway patency first. The client may not have
active bowel sounds at this time as a result of the effects of anesthesia. Urine
output and orientation to surroundings may also be assessed, but these are not
the first priorities.
Test-Taking Strategy: Note the strategic word first. Use your knowledge of the
ABCs airway, breathing, and circulation to identify the correct option.
Review the initial actions to be taken in the care of a postoperative client if you
had difficulty with this question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 214). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
BK.80.ID: 383747027
A registered nurse (RN) is watching as a new licensed practical nurse (LPN)
suctions a client with a diagnosis of acquired immunodeficiency syndrome (AIDS).
Which of the following protective devices worn by the LPN would cause the RN to
determine that the LPN was performing the procedure safely?
A.

Gloves and mask

B.

Gloves and gown

C.

Gloves, gown, and face shield. Correct

D.
Gown and protective eyewear
Rationale: The RN is responsible for supervising procedures performed by a new
LPN to ensure that safety is maintained and that policies and procedural
guidelines are followed. Standard precautions include use of gloves whenever
there will be actual contact with blood or body fluids or the potential for contact
exists. Therefore the LPN must wear gloves. The LPN also needs to protect the
eyes, nose, and mouth from contact with the clients respiratory secretions; a
face shield will provide this protection. A mask or protective eyewear does not
provide adequate protection. Gowns are worn in those instances when it is
anticipated that there will be contact with body fluid or blood.
Test-Taking Strategy: Note that the question addresses suctioning, so remember

that airborne secretions and possibly airborne particles of blood are a possibility
with this procedure. Basic knowledge of standard precautions should guide you to
look for an option that includes adequate protection during this procedure. This
will direct you to the option that includes a face shield as one of the necessary
protective items. If you had difficulty with this question, review standard
precautions and the procedure for suctioning.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., pp. 368, 369, 446). St.
Louis: Saunders.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
BL. 81.ID: 383717427
Which of these interventions does a nurse manager, reviewing infection control
interventions with the nursing staff, tell the staff will reduce reservoirs of
infection? Select all that apply.
A.

Keeping bedside table surfaces clean and dry Correct

B.

Placing tissues and soiled dressings in paper bags

C.

Changing dressings that become wet or soiled Correct

D.

Placing capped needles and syringes in puncture-resistant

containers

E.

Using soap and water to remove drainage, dried secretions, or

excess perspiration from a clients skin Correct

F.

Emptying urinary drainage systems (Foley catheter drainage)

on each shift unless prescribed otherwise by a physician Correct
Rationale: Measures to reduce reservoirs of infection include keeping bedside
table surfaces clean and dry; placing tissues, soiled dressings, and soiled linens
in moisture resistant bags (not paper bags); changing dressings that become wet
or soiled; placing syringes and uncapped (not capped) needles in punctureresistant containers; using soap and water to remove drainage, dried secretions,
or excess perspiration from a clients skin; and emptying all drainage systems on
each shift unless prescribed otherwise by a physician.
Test-Taking Strategy: Focus on the subject, interventions to reduce reservoirs of
infection. Read each option carefully; note the words paper and capped in
the incorrect options. Review interventions that will reduce reservoirs of infection
if you had difficulty with this question.

Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
660, 661). St. Louis: Mosby.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
BM.
82.ID: 383718101
Acccording to the Federal Emergency Management Agency (FEMA) description of
the phases of disaster management, in which phase are the available resources
for the care of infants, older clients, the disabled, and people with chronic health
problems addressed?
A.

Response

B.

Recovery

C.

Mitigation Correct

D.
Preparedness Incorrect
Rationale: The mitigation phase consists of actions or measures that can either
prevent the occurrence of a disaster or reduce a disasters damaging effects. The
task of determining the resources available for the care of infants, older clients,
the disabled, and people with chronic health problems is addressed in this phase.
The preparedness phase involves actions that plan for rescue, evacuation, and
care of disaster victims. The response phase involves putting disaster-planning
services into action and enumerating the actions needed to save lives and
prevent further damage. The recovery phase includes actions taken to return to
normal after the disaster.
Test-Taking Strategy: Focus on the subject, available resources. Think about the
definition of each item in the options. This will help you determine the correct
phase. Review the phases of disaster management if you had difficulty with this
question.
Reference: Maurer, F., & Smith, C. (2009). Community/public health nursing
practices: Health for families and populations (4th ed., pp. 566, 567).
Philadelphia: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Biological/Chemical Warfare

Awarded 0.0 points out of 1.0 possible points.

BN.
83.ID: 383719735
Which of the following statements reflect the principles of sterile
technique? Select all that apply.
A.

The edge of a sterile field and a border 1 inch inward is

unsterile. Correct

B.

If a package is not labeled as sterile, it should be considered

unsterile. Correct

C.

Sterile objects that come in contact with unsterile objects are

to be considered contaminated. Correct

D.

Any part of a sterile field that hangs below the top of the table
is sterile as long as it is not touched.

E.

When a sterile field becomes wet, it remains sterile as long as

the items on the field are not touched.

F.

Items in a sterile package must be used immediately once the

package has been opened; otherwise they are considered
contaminated. Correct
Rationale: The term sterile means the absence of all microorganisms. To maintain
sterile technique, the nurse must follow several principles. Among these
principles: The edge of a sterile field and 1 inch inward is unsterile; sterile
packages are labeled as sterile and, if the package is not so labeled, it is
considered unsterile; sterile objects that come in contact with unsterile objects
are considered contaminated; any part of a sterile field that falls or hangs below
the top of the table is unsterile; a sterile field that becomes wet will draw
microorganisms from the surface beneath, contaminating the field; and items in
a sterile package must be used immediately once the package has been opened,
or they will be considered contaminated.
Test-Taking Strategy: Focus on the subject, the accurate principles of sterile
technique. Visualize each of the options and think about the principles of sterility
to assist in answering the question. Note the words hangs below the top of the
table and becomes wet in the incorrect options. Review these principles if you
had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
669, 670). St. Louis: Mosby.
Level of Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.

BO.
84.ID: 383718105
A nurse enters the laundry room to empty a bag of dirty linen and discovers a fire
in a laundry basket. What action should the nurse take first?
A.

Confining the fire

B.

Extinguishing the fire

C.

Activating the fire alarm Correct

D.
Running for the fire extinguisher
Rationale: The immediate priority in the event of a fire is rescuing the clients in
immediate danger. In this situation, no clients are in immediate danger. The next
step is to activate the fire alarm. The nurse then confines the fire by closing all
doors and, finally, extinguishes the fire.
Test-Taking Strategy: Use the mnemonic RACE to remember priorities in the
event of a fire: rescue clients in immediate danger, sound the alarm, confine the
fire by closing all doors, and extinguish. If you had difficulty with this question,
review the principles of fire safety.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
840). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
BP. 85.ID: 383717485
The unit supervisor of an emergency department (ED) is called at home and told
by an emergency department nurse who is on duty that an airplane crash has
occurred and numerous casualties will be arriving at the ED. What should the
initial response by the unit supervisor be?
A.

Has the disaster plan been activated? Correct

B.

Call as many nursing staff as you can to come in to work.

C.

Make sure all of the rooms are well stocked with supplies.

D.

Be sure that the nursing staff finds as many stretchers as they

can.
Rationale: In an external disaster, many people will be brought to the ED for
treatment. Although ensuring that rooms are well stocked with supplies, calling
nursing staff to come to work, and finding stretchers are components of
preparing for the casualties, the initial nursing action must be activation of the
disaster plan. Therefore the initial response by the unit supervisor should be Has
the disaster plan been activated?

Test-Taking Strategy: Note the strategic words initial response in the query.
Focus on the data in the question and note that the correct option is the umbrella
response. Review procedures related to management of a disaster if you had
difficulty with this question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., pp. 76, 2213, 2214). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Disasters
Awarded 1.0 points out of 1.0 possible points.
BQ.
86.ID: 383719741
A nurse giving a client a bed bath drops the towel on the floor. The nurse should:
A.

Use a bath blanket as a towel

B.

Borrow a towel from the clients roommate

C.

Wash her hands, pick up the towel, and shake the towel out

D.

Wash her hands and go to the linen room to obtain another

towel Correct
Rationale: To avoid spreading the clients germs, the nurse must wash her hands
before leaving the clients room. Therefore the nurse should cover the client and
ensure that the client is safe, wash her hands, and go to the linen room to obtain
another towel. It is not appropriate to use a bath blanket as a towel. It is never
appropriate to borrow other clients supplies, because this is inconsistent with the
principles of infection control. The nurse would never use linen that had been
dropped on the floor. Also, shaking linen spreads germs.
Test-Taking Strategy: Focus on the data in the question and note that the nurse
has dropped the towel on the floor. Read each option carefully and use your
knowledge of infection control and the principles of bathing a client to direct you
to the correct option. Review the principles of infection control if you had
difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
874-877). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation

Content Area: Infection Control

Awarded 1.0 points out of 1.0 possible points.
BR.87.ID: 383719737
A staff nurse caring for a client with a head injury notes that the client is restless
and pulling at the intravenous (IV) line. The clients physician does not want to
prescribe sedation, and the family has requested that the client not be
restrained. Which action by the nurse is appropriate?
A.

Asking a family member to sit with the client

B.

Asking a nursing assistant to monitor the client

C.

Staying with the client and consulting with the nurse manager
about the situation Correct

D.

Telling the family that the application of wrist restraints is

critical in preventing injury to the client Incorrect
Rationale: The nurse must stay with the client and consult with the nurse
manager about the situation. It may be necessary for the nurse manager to call
the supervisor to request an additional staff member to care for the client.
Because the client has a head injury, the development of increased intracranial
pressure (ICP) is a major concern. A nursing assistant is not trained to monitor
the client for increased ICP. It is inappropriate to ask a family member to sit with
the client. The application of restraints may agitate the client, causing further
restlessness and thus increasing ICP.
Test-Taking Strategy: Use the process of elimination, noting the strategic word
appropriate. Focus on the data in the question, noting that the client has
sustained a head injury, and remember that the client with a head injury is at risk
for increased ICP. Eliminate the options that are comparable or alike (i.e., asking
a family member or the nursing assistant to stay with the client). To select from
the remaining options, recall that the application of restraints could agitate the
client. Review the guidelines for the use of restraints and nursing responsibilities
when a client requires continuous monitoring if you had difficulty with this
question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., pp. 141, 1932). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
BS.88.ID: 383717437

A client with paraplegia has spasticity of the leg muscles. Which interventions
should be included in the plan of care for this client? Select all that apply.
A.

The use of restraints to immobilize the limbs

B.

Range-of-motion exercises of the affected limbs Correct

C.

An as-needed prescription for a muscle relaxant Correct

D.

Removal of potentially harmful objects near the client Correct

E.

The use of padding against the clients legs when the client is
sitting in a wheelchair Correct
Rationale: The use of limb restraints will not alleviate spasticity and could harm
the client, so restraints should be avoided. Range-of-motion exercises are
beneficial in stretching the muscles, which may diminish spasticity. The use of
muscle relaxants may be helpful if spasms are causing discomfort for the client
or pose a risk to the clients safety. Removing potentially harmful objects from
the vicinity of the client is a good basic safety measure. Padding will prevent
injury to the clients legs while the client is in the wheelchair.
Test-Taking Strategy: Use the process of elimination and note the client has
spasticity of the leg muscles. Read each option carefully and remember that
restraints could cause harm to the client. If this question was difficult, review the
care of the client with leg spasticity.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 1960). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
BT. 89.ID: 383718118
Which of the following safety guidelines should the nurse include in the plan of
care for a client with an internal radiation implant? Select all that apply.
A.

Wear a lead shield when in the clients room. Correct

B.

Limit visits from family to 60 minutes per day.

C.

Wear a dosimeter film badge when in the clients room. Correct

D.
E.

Allow children to visit the client as long as they are at least 12

years old.

Keep all bed linens and dressings in the clients room until the
implant is removed. Correct
Rationale: Nursing responsibilities in the care of a client with an internal radiation
implant, which involve preventing exposure to the radiation, include placing the
client in a private room with a private bath; rotating nursing assignments and

organizing nursing tasks to minimize exposure to the radiation source; limiting

time to 30 minutes per care provider per shift; wearing a dosimeter film badge to
measure radiation exposure; wearing a lead shield to reduce the transmission of
radiation; not allowing pregnant women or children younger than 16 years to visit
the client; limiting visitors to 30 minutes per day (visitors should stay at least 6
feet from the source); keeping all bed linens and dressings in the clients room
until the implant is removed; keeping a lead container in the clients room for
housing the implant if it should be dislodged; and avoiding touching a dislodged
radiation source (long-handled forceps are used to place the source in the lead
container).
Test-Taking Strategy: Focus on the subject, safety guidelines for the client with an
internal radiation implant. Recalling that the goal of care is to prevent exposure
to the radiation will direct you to the correct options. If you had difficulty with this
question, review radiation safety guidelines.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 420). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
BU.
90.ID: 383719733
A hospitalized client, experiencing confusion, is at risk of falling because she
continually tries to climb out of bed. Which of these safety devices that the nurse
might suggest is the least restrictive?
A.

Belt

B.

Wrist

C.

Elbow

D.
Ambularm Correct
Rationale: The Ambularm device, worn on the leg, signals when the clients leg is
in a dependent position. It is used for clients who climb out of bed and are at risk
for falling. Ambularm devices that may be attached to the bed or chair or to the
client's mattress or nightgown are also available. A belt restraint is a device that
is wrapped around the clients waist to secure the client to bed or to a stretcher.
A wrist restraint is a device used to immobilize an arm. An elbow restraint
consists of a piece of fabric with slots into which tongue blades are inserted, after
which the device is wrapped around the elbow area to immobilize it. Of the
options provided, the Ambularm is the least restrictive safety device.
Test-Taking Strategy: Note the strategic words least restrictive. Read each

option and think about where it would be applied to the client and how it might
affect the clients mobility; this will direct you to the correct option. If you had
difficulty with this question, review the various types of security devices and how
they affect a clients movement.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
834, 838). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
BV. 91.ID: 383719755
A home health nurse has instructed a client about safety measures during the
use of an oxygen concentrator in the home. Which statement by the client
indicates to the nurse that the client has understood the directions? Select all
that apply.
A.

I need to follow the oxygen prescription exactly. Correct

B.

I can use my electric razor while Im using oxygen.

C.

I have to keep the oxygen concentrator out of direct

sunlight. Correct

D.

I need to keep the oxygen concentrator as close to the wall as

possible or put it in a corner.

E.

I have to tell everyone that they cant smoke or have an open

flame within 10 feet of the oxygen concentrator. Correct
Rationale: The client should follow the oxygen prescription exactly. The use of
electric razors or other equipment that could emit sparks should be avoided while
oxygen is in use, because fire and injury to the client could result. The oxygen
concentrator is kept out of direct sunlight and slightly away from walls and
corners to permit adequate air flow. The client should not allow smoking or any
type of flame within 10 feet of the oxygen source. Other measures include having
telephone numbers for the physician, nurse, and oxygen vendor available and
teaching the client signs and symptoms requiring emergency care.
Test-Taking Strategy: Recall that one hazard associated with oxygen is ignition,
which could result from heat in the form of flames or sparks. Evaluating the
question from this perspective, eliminate the options that are unsafe. Review
oxygen safety measures if you had difficulty with this question.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 631). St. Louis: Mosby.

Cognitive Ability: Evaluating

Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
BW.
92.ID: 383717449
After discussing the use of restraints with a client and family, a physician has
written a prescription for wrist restraints to be applied to a client. The nurse
instructs the nursing assistant to apply the restraints. Which of the following
observations by the nurse indicates that the nursing assistant is using the
restraints safely and correctly? Select all that apply.
A.

The restraints are applied tightly.

B.

The restraints are being released every 2 hours. Correct

C.

A safety knot has been used to secure the restraints. Correct

D.

The restraints have been tied to the siderails of the bed.

E.
The call light has been placed within reach of the client. Correct
Rationale: Restraints should never be applied tightly, because this could impair
circulation. They should be tied to the bed frame (not the siderail) with the use of
a safety knot. The client could sustain injury if the siderail were lowered with a
restraint attached to it. A safety knot is used because it can easily be released in
an emergency. Restraints must be released every 2 hours to facilitate inspection
of the skin, help ensure good circulation, and permit movement of the joint
through its range of motion. The call light must always be within reach of the
client in case he or she needs assistance.
Test-Taking Strategy: Focus on the subject, the delivery of safe care by the
nursing assistant. Think about the guidelines for the use of restraints. Note the
word tightly and tied to the siderails in the incorrect options. Review the
guidelines for the use of restraints if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
837). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
BX.93.ID: 383718889

An older client is extremely anxious after admission, having never been

hospitalized before. To help provide a safe environment and minimize the stress
of hospitalization on the client, what does the nurse plan to do? Select all that
apply.
A.

Keep visitors to a minimum

B.

Acknowledge the clients feelings Correct

C.

Provide information about hospital routines Correct

D.

Put the client in a room far from the nurses station

E.

Keep the door open and the room lights on at all times Incorrect

F.

Allow the client to have as many choices regarding his care as

possible Correct
Rationale: Several general interventions can be used to minimize stress in the
hospitalized client. These include acknowledging the clients feelings, providing
information, providing social support, and giving the client control, when
possible, over choices related to care. Admitting the client to a room far from the
nurses station and limiting visitors would both serve to increase the clients
anxiety. Keeping the door open and the room lights on at all times could cause
further disruption in the clients sleep pattern in addition to the disruption
created by the hospitalization.
Test-Taking Strategy: The strategic words are safe and minimize the stress.
This tells you that the correct option(s) allay(s) the clients fears and anxiety after
sudden placement in a foreign environment. Use your knowledge of the
principles of safety and stress reduction to answer the question and review these
principles if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., pp. 17, 18). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
BY. 94.ID: 383718109
A fever develops in a client who has been hospitalized for 2 months and is
receiving parenteral nutrition by way of a central venous line, and central venous
linerelated sepsis is diagnosed. The nurse interprets this finding as meaning that
this infection is:
A.

An iatrogenic infection

B.

A result of bacterial colonization

C.

A community-acquired infection

D.
A healthcare-associated infection Correct
Rationale: Infections that occur during hospitalization, or are a result of
hospitalization, are referred to as healthcare-associated infections, hospitalacquired infections, or nosocomial infections. Colonization is defined as a
condition in which microorganisms are present in body tissues; there is no
damage to the tissues, and no local signs or symptoms of infection are evident.
Iatrogenic infections are infections that involve the clients normal flora. A
community-acquired infection is an infection that the person is admitted with or
is incubating on admission to the hospital.
Test-Taking Strategy: Focus on the data in the question. Noting that the fever and
sepsis developed while the client was hospitalized will direct you to the correct
option. Review the various types of infection and the definition of colonization if
you had difficulty answering this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
648). St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Assessment
Content Area: Infection Control
Awarded 1.0 points out of 1.0 possible points.
BZ.95.ID: 383718182
Which of the following points should the nurse include when documenting
information about a client who is wearing wrist restraints? Select all that apply.
A.

The clients temperature

B.

The clients 24-hour urine output

C.

Skin integrity of the restrained body part Correct

D.

The procedure used in applying the restraint Correct

E.

The date and time of application of the restraint Correct

F.

Circulatory and neurovascular status of the restrained

extremities Correct
Rationale: The nurse is responsible for documenting specific information about
the client who is wearing any type of restraint. The points that must be included
in such documentation are the reason for the restraint; alternatives to the
restraint that were used; the method of restraint; the procedure used in applying
the restraint; date and time of application of the restraint; client's response to
application of the restraint; condition of the restrained body part; assessment of
circulatory, neurovascular, and skin integrity; periodic release from restraint with
movement or range-of-motion exercise; assessment of the need for continued

use of the restraint; the duration of use of the restraint; and the client's response
on removal of the restraint.
Test-Taking Strategy: Focus on the subject, documentation points for a client with
restraints. Read each option carefully to determine its association with the use of
restraints. Also note that the correct options make specific reference to
restraints. Review documentation of the use of restraints if you had difficulty with
this question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 1809). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 832, 838). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
CA.96.ID: 383718107
A community health nurse is asked to assist in developing a community disaster
plan. The nurse determines that this responsibility is a component of which
disaster management phase identified by the Federal Emergency Management
Agency (FEMA)?
A.

Response

B.

Recovery

C.

Mitigation

D.
Preparedness Correct
Rationale: The preparedness phase has many functions, including planning for
rescue, evacuation, and caring for disaster victims; the training of disaster
personnel and gathering of resources, equipment, and other materials needed in
dealing with a disaster; identifying specific responsibilities for various disaster
response personnel; establishing a community disaster plan and an effective
public communication system; setting up an emergency medical system and a
plan for its activation; checking for proper function of emergency equipment;
making anticipatory provisions and setting up a location for food, water, clothing,
medication, shelter, and other supplies; checking supplies on a regular basis and
replenishing outdated materials; and practicing community disaster plans (mockdisaster drills). The mitigation phase refers to actions or measures to either
prevent the occurrence of a disaster or reduce the damaging effects of a disaster.
The response phase includes putting disaster planning services into action and
the actions taken to save lives and prevent further damage. The recovery phase

includes actions taken to return to a normal situation after the disaster.

Test-Taking Strategy: Use the process of elimination. Note the relationship
between the subject, developing a community disaster plan, and the correct
option, preparedness. Review the four disaster management phases if you had
difficulty with this question.
Reference: McEwen, M., & Pullis, B. (2009). Community-based nursing: An
introduction (3rd ed., p. 159). Philadelphia: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Disasters
Awarded 1.0 points out of 1.0 possible points.
CB.97.ID: 383717491
A nurse caring for a 9-month-old who has undergone repair of a cleft palate
applies elbow restraints to the child. The mother visits her child and asks the
nurse to remove the restraints. According to the guidelines for the use of
restraints, what should the nurse do in response to the mothers request?
A.

Remove both restraints Incorrect

B.

Remove a restraint from one extremity Correct

C.

Tell the mother that the restraints may not be removed

D.

Loosen the restraints after telling the mother that they may not
be removed
Rationale: Elbow restraints are used after cleft palate repair to prevent the child
from touching the repair site, which could cause rupture or tearing of the sutures.
The restraints may be removed one at a time only with a parent or nurse in
constant attendance. Removing both restraints, telling the mother that the
restraints may not be removed, and loosening the restraints are all incorrect
nursing actions.
Test-Taking Strategy: Eliminate the options that are comparable or alike in that
they indicate that the restraints may not be removed. To select from the
remaining options, recall the purpose of the restraints after this surgical
procedure. This will direct you to the correct option, the safe nursing action. Also
note the word both in the incorrect option. Review nursing interventions after
cleft palate repair if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternalchild nursing (3rd ed., p. 1095). St. Louis: Elsevier.
Cognitive Ability: Applying

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 0.0 points out of 1.0 possible points.
CC.
98.ID: 383717457
A nurse is discussing accident prevention with the family of an older client who is
being discharged from the hospital after hip surgery. Which items in the home
increase the clients risk for injury? Select all that apply.
A.

A nightlight in the bathroom

B.

Elevated toilet seat with armrests Incorrect

C.

Cooking equipment such as a stove Correct

D.

Smoke and carbon monoxide detectors

E.

Common household objects such as doormats Correct

F.
A water heater thermostat adjusted to a low setting
Rationale: Physical hazards in the environment place the client at risk for
accidental injury and death. Adequate lighting, such as nightlights in dark
hallways and bathrooms, reduces the physical hazard by illuminating areas in
which a person moves about. An elevated toilet seat with armrests and nonslip
strips on the floor in front of the toilet are useful in reducing the incidence of falls
in the bathroom. Cooking equipment and appliances, particularly stoves, are a
major cause of fires and related injuries in the home. Smoke and carbon
monoxide detectors should be placed throughout the home to alert members of
the household to danger. A low thermostat setting on the water heater reduces
the risk of burns during the use of hot water (e.g., bathing or showering). Injuries
in the home are often the result of tripping over or coming into contact with such
common household objects as a doormats, small rugs on the floor or stairs, and
clutter around the house.
Test-Taking Strategy: Read each option carefully. Focus on the subject of the
question, the physical factors that put the client at risk for injury at home. Next
think about whether the factor is safe or presents a potential for injury; this will
help you answer the question. Review the physical factors that increase a clients
risk for injury at home if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
813). St. Louis: Mosby.
Level of Cognitive Ability:Applying
Client Needs:Safe and Effective Care Environment
Integrated Process:Teaching and Learning

Content Area:Safety
Awarded 0.0 points out of 1.0 possible points.
CD.
99.ID: 383717479
The mother of a 3-year-old calls a neighbor who is a nurse and reports that her
child just drank some window cleaner that had been stored in a cabinet. The
nurse should instruct the mother to immediately:
A.

Call a poison control center Correct

B.

Administer an excessive amount of fluids to induce vomiting

C.
D.

Call an ambulance to bring the child to the emergency

department
Leave a message at the physician answering service about the

incident
Rationale: When a poisoning occurs, a poison center should be called
immediately. Vomiting should not be induced if the victim is unconscious or if the
substance ingested was a strong corrosive or petroleum product. Also, vomiting
should not be induced unless a healthcare provider has given specific
instructions to induce vomiting. Neither calling an ambulance nor calling the
physicians answering service is the immediate action, because either would
delay treatment. Additionally, the physician would immediately make a referral to
the poison control center. The poison control center may advise the mother to
bring the child to the emergency department; if this is the case, the mother
should then call an ambulance.
Test-Taking Strategy: Note the strategic word immediately in the query of the
question. First, recalling that vomiting should not be induced without appropriate
advice to do so will help you eliminate the option that involves inducing vomiting.
Next eliminate the options that will delay treatment (i.e., calling an ambulance
and leaving a message with the answering service). Review immediate poison
control measures if you had difficulty with this question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternalchild nursing (3rd ed., pp. 120, 121). St. Louis: Elsevier.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
CE.100.ID: 383717463
A military nurse who is in charge of planning a vaccination clinic to administer
the smallpox vaccine to military personnel is preparing a pamphlet that sets forth

guidelines for care of the vaccination site. Which guideline should the nurse
include in the pamphlet?
A.

Soak the scab that forms with warm water every day.

B.

Keep the vaccination site open to air as much as

possible. Incorrect

C.

Apply an antihistamine ointment to the scab to prevent itching.

D.

Avoid sharing towels or other items that have come in contact

with the vaccination site. Correct
Rationale: A scab will form in the spot where the vaccination was administered.
This scab should be left alone so that the vaccinia virus in the vaccine doesnt
spread to other parts of the body. The site is loosely covered with a gauze
bandage; this bandage, in turn, is covered with a waterproof bandage during
bathing. Clothing is worn over the vaccination site as an extra precaution. The
hands must be washed frequently, including whenever the site is touched or the
bandage is changed; the vaccinee should not touch the eyes or any other part of
the body after changing the bandage or touching the vaccination site. The
vaccinee must avoid scratching or putting ointment on the vaccination site. The
vaccinee is told to avoid sharing towels and to launder items that have touched
the vaccination site because of the risk of spread of the vaccina virus.
Test-Taking Strategy: Use the process of elimination. Recalling that the scab
should be left alone so that the vaccinia virus in the vaccine doesnt spread to
other parts of the body will direct you to the correct option. Review care of the
vaccination site after a smallpox vaccination if you had difficulty with this
question.

MODULE 5
Questions
1.

1.ID: 383694005
A client whose right leg is in skeletal traction complains of pain in the leg. Which
action should the nurse take first?
A.

Realigning the client Correct

B.

Asking the client to wiggle her toes

C.

Removing some of the traction weights

D.
Medicating the client with the prescribed analgesic
Rationale: A client who complains of severe pain may need realignment or may
have traction weights that are too heavy. The nurse would first realign the client
and then, if this is ineffective, call the physician. Asking the client to wiggle her
toes serves no useful purpose. The nurse never removes traction weights unless
this has been specifically prescribed by the physician. The client should be
medicated only after an effort has been made to determine and treat the cause
of her pain.

Test-Taking Strategy: Note the strategic word first. Recall the causes of pain in
a client with skeletal traction and remember that the nurse first determines and
treats the cause. Review care of the client in traction if you had difficulty with this
question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 1190). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
2.
2.ID: 383692448
A nurse preparing a client for a bronchoscopy notes that the client is wearing a
gold necklace. What should the nurse do to safeguard the clients necklace?
A.

Ask the client whether the necklace is gold

B.

Ask the client for permission to lock the necklace in the hospital
safe Correct

C.

Ask the client to remove the necklace and place it in the top
drawer of the bedside table Incorrect

D.

Ask the client to sign a release to free the hospital of

responsibility if the necklace is damaged or lost during the procedure
Rationale: When a client has valuables, the nurse should give them to a family
member or secure them for safekeeping. Most healthcare institutions require that
a client sign a release form that frees the institution of responsibility if a valuable
item (e.g., jewelry, money) is lost, but this does not safeguard the clients
necklace. Valuables may be locked in a designated location such as the hospitals
safe. Removing the necklace and putting it in a drawer does not safeguard it.
Asking the client whether the necklace is gold is inappropriate and unrelated to
the subject.
Test-Taking Strategy: Use the process of elimination and focus on the subject,
safeguarding the clients necklace. Focusing on the subject and noting the word
lock in the correct option will help you answer correctly. Review the procedures
for safeguarding a clients valuables if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
1387). St. Louis: Mosby.
Cognitive Ability: Applying

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
3.
3.ID: 383691781
A nurse manager asks a nurse to work overtime because of a short-staffing
problem. The nurse has made plans to do her Christmas shopping after work and
does not want to work overtime. What is the most assertive response by the
nurse to her nurse manager?
A.

Im not working overtime today.

B.

You know how I hate to work overtime.

C.

I will if you need me, but I am not happy about this.

D.

I have plans after work and will not be able to work

overtime. Correct
Rationale: The most assertive response in dealing with this conflict is the one
that is direct and conveys a clear message in a positive manner. The nurse
responds aggressively by stating, I'm not working overtime today or You know
how I hate to work overtime. The statement I will if you need me, but I am not
happy about this is a passive-aggressive response.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, the
most assertive response. Note the relationship between the data in the question
and the correct option. Review assertive communication techniques if you had
difficulty with this question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
p. 262). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
4.
4.ID: 383691755
A nurse working the 7 amto3 pm shift is assigned to care for four clients. List
the clients in order of priority for the nurse.
Correct
A. A client with pneumonia who is receiving oxygen
B.
A client with diabetes mellitus who requires the administration of
NPH insulin before breakfast

C.

A client with a wound requiring dressing changes at 10 am and 2

pm

D.
A client preparing for discharge after surgery
Rationale: Airway is always the priority, so the nurse would assess the client with
pneumonia who is receiving oxygen first. The nurse would next care for the client
with diabetes mellitus who requires the administration of NPH insulin before
breakfast, because the client will not be allowed to consume food or caloric fluids
until insulin has been received. Because the client with the wound requires two
dressing changes during the shift, this client would be cared for next; the nurse
would want to ensure that the changes are done on time. Although the client
preparing for discharge would have needs, including education, they are not of
immediate importance.
Test-Taking Strategy: Use the ABCs airway, breathing, and circulation to
determine that the client with pneumonia who is receiving oxygen is the priority.
Next, read the remaining client descriptions and think about each clients needs
to determine the order of priority for the remaining clients. Review principles
related to prioritization if you had difficulty with this question.
References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patientcentered collaborative care (6th ed., pp. 663, 664). St. Louis:
Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 374, 375). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
2. 5.ID: 383694054
A client with leukemia is being considered for a bone marrow transplant. The
healthcare team is discussing the risks and benefits of this treatment and other
possible treatments with the goal of inflicting the least possible harm on the
client. Which principle of healthcare ethics is the team practicing?
A.

Justice

B.

Fidelity

C.

Autonomy

D.
Nonmaleficence Correct
Rationale: Nonmaleficence is the avoidance of hurt or harm. Remember that in
healthcare ethics, ethical practice involves not only the will to do good but also
the equal commitment to do no harm. Healthcare professionals try to balance the
risks and benefits of a plan of care while striving to do the least possible harm.

Justice refers to fairness and equity and ensuring fair allocation of resources,
such as nursing care for all clients. Fidelity is the keeping of promises made to
clients, families, and other healthcare professionals. Autonomy refers to a
persons independence and represents an agreement to respect anothers right
to determine his or her course of action.
Test-Taking Strategy: Use the process of elimination and think about the
definition of each item in the options. Note the relationship of the words least
possible harm in the question and the definition of nonmaleficence. Review the
principles of healthcare ethics if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
314). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
B. 6.ID: 383692403
A nurse leader in a medical-surgical unit overhears the nursing staff openly
discussing a client and stating that the client is uncooperative and a real pain to
care for. The nurse leader would most appropriately manage this issue by:
A.

Discouraging the judgmental comments Correct

B.

Ignoring the comments made about the client

C.

Reporting the nurses comments to administration Incorrect

D.

Leaving articles about judgmental opinions in the nurses report

room
Rationale: Nurses must discuss clients in a professional manner and avoid using
judgmental language such as uncooperative or difficult. When such
comments and language are discouraged, fewer comments will be made.
Ignoring the comments is an inappropriate option because the concern will not
addressed. Leaving articles about judgmental opinions in the nurses report room
indirectly addresses the issue. Additionally, the nurse manager cannot ensure
that the nursing staff will read the articles. Likewise, reporting the nurses
comments to administration does not directly address the issue. The best
approach that the nurse manager can take is to directly discuss the issue with
the staff members. This action is not identified in the options. Therefore, of the
options presented, discouraging judgmental comments is the most appropriate
way to manage this concern.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike in that they do not directly address the staffs

unprofessional behavior. Review methods of discouraging judgmental comments

if you had difficulty with this question.
References: Marriner-Tomey, A. (2009). Guide to nursing management and
leadership (8th ed., pp 306, 307). St. Louis: Mosby.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 242). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 0.0 points out of 1.0 possible points.
C. 7.ID: 383692456
A physician asks the nurse who is caring for a client with a new colostomy to ask
the hospitals stoma nurse to visit the client and assist the client with care of the
colostomy. The nurse initiates the consultation, understanding that the stoma
nurse will be able to influence the client because of his:
A.

Expert power Correct

B.

Reward power

C.

Referent power

D.
Coercive power
Rationale: Power is the ability to influence others to achieve goals. Expert power
results from knowledge and skills that one possesses that is needed by others.
Reward power is based on the ability to be able to grant rewards and favors.
Coercive power is based on fear and the ability to punish. Referent power results
from followers desire to identify with a powerful person.
Test-Taking Strategy: Focus on the data in the question and note that a
consultation is being sought from another healthcare team member in the care of
a client. This will direct you to the correct option. Review the types of power and
the purpose of consultations if you had difficulty with this question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
p. 263). St. Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management

Awarded 1.0 points out of 1.0 possible points.

D. 8.ID: 383693570
Which of the following situations is an example of the use of evidence-based
practice in the delivery of client care?
A.

Encouraging a client who has had a stroke to consume thin

liquids and foods

B.

Blowing on a fingerstick site to dry it after cleaning the site with

an alcohol swab

C.

Immediately picking up a dislodged radiation implant with

gloved hands and placing it in a lead container

D.

Pouring 1 to 2 mL of sterile solution that will be used for wound

cleansing into a plastic-lined waste receptacle before pouring the solution into
a sterile basin Correct
Rationale: Evidence-based practice is an approach to client care in which the
nurse integrates the clients preferences, clinical expertise, and the best research
evidence to deliver quality care. Pouring 1 to 2 mL of sterile solution that will be
used for wound cleansing into a plastic-lined waste receptacle before pouring the
solution into the sterile basin reflects evidence-based practice because this
action cleans the lip of the bottle, thus preventing the entrance of harmful
bacteria into the wound. The remaining options do not reflect evidence-based
practice. Encouraging a client with a stroke to consume thin liquids and foods
could cause harm because of the risk for choking; instead, such a client should
receive thickened liquids. A dislodged radiation implant should be picked up with
the use of long-handled forceps, not gloved hands, to be placed in a lead
container to minimize radiation exposure. Blowing on a fingerstick site to dry it
after cleaning the site with an alcohol swab recontaminates the stick site.
Test-Taking Strategy: Read each option carefully, focusing on the subject,
evidence-based practice. Recall the definition of evidence-based practice and
note that the correct option prevents the entrance of harmful bacteria into the
wound. Review the concept of evidence-based practice if you had difficulty with
this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 5460, 674). St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
E. 9.ID: 383692485

A case manager is serving on a community task force on violence in schools. The

members of the task force are planning to develop interventions to help prevent
violence. According to the nursing process, the first activity that the nurse would
suggest to the task force is:
A.
B.

Teaching schoolchildren about the dangers of school violence

Looking at what other communities are doing about school

violence
C.

Distributing fliers that identify the causes of school violence to

families in the community

D.

Conducting a community survey to assess community

perceptions regarding school violence Correct
Rationale: An assessment activity is always the first step in the nursing process.
Conducting a community survey on school violence addresses assessment of
community perceptions. Teaching schoolchildren about the dangers of violence
and distributing fliers that identify the cause of school violence are
implementation measures. Looking at what other communities are doing is part
of the analysis of a variety of assessment data but is not specific to the subject of
the question.
Test-Taking Strategy: Use the steps of the nursing process to answer the
question. Eliminate the options that are implementation actions. To select from
the remaining options, note the word assess in the correct option. Review the
various roles of the nurse and the process of assessment if you had difficulty with
this question.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., pp. 350, 351). St. Louis: Mosby.
Maurer, F., & Smith, C. (2009). Community/public health nursing practices: Health
for families and populations (4th ed., pp. 772, 773). Philadelphia: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
F. 10.ID: 383694020
A nurse manager discusses staff empowerment with the nursing team. The nurse
manager explains that staff empowerment:
A.
B.

Allows the staff to make every decision regarding employee

scheduling
Fosters the growth of others so that they are less dependent on

the leader Correct

C.

Means that the staff has the power to reprimand and punish
any individual who is not meeting the standards of care delivery

D.

Indicates that the nurse leader will make decisions regarding

the nursing unit and expects that the staff will comply with the changes
Rationale: Staff empowerment fosters the growth of others and facilitates their
development so that they are less dependent on their leader. Staff do not have
the power to reprimand and punish or make decisions regarding scheduling or
the nursing unit.
Test-Taking Strategy: Think about the definition of the term empowerment and
use the process of elimination. Note the relationship of this definition and its
relationship to the information in the correct option. Review the description of
empowerment if you had difficulty with this question.
References: Huber, D. (2010). Leadership and nursing care management (4th
ed., pp. 261, 262). St. Louis: Saunders.
Marriner-Tomey, A. (2009). Guide to nursing management and leadership (8th
ed., p. 123). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
G. 11.ID: 383692438
A nurse and a nursing assistant enter a clients room to provide care and find the
client lying on the floor. The nurse should first:
A.

Ask the nursing assistant to complete an incident report

B.

Check the clients level of consciousness and vital signs Correct

C.

Ask the nursing assistant to assist in getting the client back to

bed Incorrect

D.

Contact the unit secretary on the intercom and ask that the
clients physician be called
Rationale: When a client sustains a fall, the nurse must first assess the client. The
nurse should check the clients level of consciousness and vital signs and look for
any bruises or injuries sustained in the fall. If the nurse determines that the client
has not sustained any injuries and that it is safe to move the client, the nurse
should ask the nursing assistant to assist in getting the client into bed. The nurse
should then contact the physician and file an incident report.
Test-Taking Strategy: Note the strategic word first. Use the steps of the nursing
process to answer the question. The correct option is the only one that addresses

assessment. Remember to always assess the client first if a client sustains a fall.
Review client injuries and procedures for filing incident reports if you had
difficulty with this question.
References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patientcentered collaborative care (6th ed., p. 180). St. Louis:
Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 403). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
H. 12.ID: 383693536
A new nurse employed at a community hospital is reading the organizations
mission statement. The new nurse understands that this statement:
A.

Describes the benefits available to employees

B.

Outlines what the organization plans to accomplish Correct

C.

Identifies the policies and procedures of the organization

D.

Defines the rules of the organization that the employees must

follow
Rationale: All organizations have a purpose or reason for existing. This purpose is
often expressed in the form of a mission statement. The mission statement
outlines what the organization plans to accomplish. Sometimes mission
statements incorporate statements of philosophy (beliefs), purpose, and goals or
objectives into a single statement; other times the philosophy, purposes, and
goals are addressed in addition to the mission statement. These statements
serve as a benchmark against which an organizations performance may be
evaluated. The mission statement does not describe the benefits available to the
client; this is usually done by the human resources department. The rules of the
organization are identified in policies and procedures, which are usually
maintained in manuals kept in the nursing units or online.
Test-Taking Strategy: Use the process of elimination, focusing on the subject, a
mission statement. Note the relationship between the definition of a mission
statement and the correct option. Review the description of an organizations
mission statement if you had difficulty with this question.
Reference: Marriner-Tomey, A. (2009). Guide to nursing management and
leadership (8th ed., pp. 225, 226). St. Louis: Mosby.

Cognitive Ability: Understanding

Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning

I.

Content Area: Leadership/Management

Awarded 1.0 points out of 1.0 possible points.
13.ID: 383693562
A nurse discovers that another nurse has administered an enema to a client even
though the client told the nurse that he did not want one. The most appropriate
action for the nurse is to:
A.

Contact the clients physician

B.

Report the incident to the nursing supervisor Correct

C.

Tell the client that the nurse did the right thing in giving the
enema

D.

Confront the nurse who gave the enema and tell the nurse that
she is going to be charged with battery
Rationale: Battery is any intentional touching of a client without the clients
consent. Such contact may be harmful to the client or it may merely be offensive
to the clients dignity. If a nurse discovers that battery of a client has occurred,
the nurse should report the situation to the nursing supervisor. Telling the client
that the nurse did the right thing in giving the enema is incorrect, because the
other nurse has violated the clients rights. Confronting the nurse and telling her
that she is going to be charged with battery would likely result in unnecessary
conflict. Although the physician may need to be notified, the nurse should first
report the situation to the nursing supervisor.
Test-Taking Strategy: Use the process of elimination and note the strategic words
most appropriate. Next, focus on the subject, client rights. Recalling that any
situation that constitutes a violation of a clients rights needs to be reported and
remembering the organizational channels of reporting will direct you to the
correct option. Review the issues surrounding violation of client rights and
nursing responsibilities when a clients rights have been violated if you had
difficulty with this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., pp. 172, 173). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal

J.

Awarded 1.0 points out of 1.0 possible points.

14.ID: 383691773
A nurse employed at a hospital is asked by a nurse manager to review the
organizational chart. The nurse reviews the chart so that he will:
A.

Understand the organizations reason for existence

B.

Be familiar with the organizations line of authority Correct

C.

Be familiar with the beliefs and values of the organization

D.
Be aware of the geographical area that the organization serves
Rationale: An organizational chart depicts and communicates how activities are
arranged, how authority relationships are defined, and how communication
channels are established. Understanding the organizations reason for existence,
geographical area, and the beliefs and values of the organization are all
components of the organizations mission statement.
Test-Taking Strategy: Use the process of elimination and your knowledge of the
components of an organizational chart to answer this question. Note the
relationship of the words organizational in the question and lines of authority
in the correct option. Review the purpose of an organizational chart if you had
difficulty with this question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 415, 427). St. Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
K. 15.ID: 383692450
A nurse working the 7 amto3 pm shift is reviewing the records of her assigned
clients. Which client should the nurse assess first?
A.

A client scheduled for hemodialysis at 10 am Correct

B.

A client scheduled for a nuclear scanning procedure at 10 am

C.

A client scheduled for contrast computed tomography (CT) at

noon

D.

A client scheduled for hydrotherapy for treatment of a burn

injury at 10:30 am Incorrect
Rationale: A client scheduled for hemodialysis has needs that must be met
before the procedure. The nurse must ensure that the client is physically and
emotionally ready for the treatment, which may take as long as 5 hours. Before
the treatment, the nurse must assess the client, including looking for fluid
overload by checking the clients weight and lung sounds. The nurse must also

assess the clients predialysis vital signs and the results of laboratory tests for
comparison in the postdialysis period. Although the clients described in the other
options have needs, they are not immediate. A client scheduled for a nuclear
scanning procedure at 10 am may require reinforcement of information about the
procedure and will need to increase fluid intake before the procedure. A client
scheduled for hydrotherapy for treatment of a burn injury at 10:30 am may
require pain medication, but the medication should be administered
approximately 30 minutes before the hydrotherapy. A client scheduled for
contrast CT at noon may require reinforcement of information about the
procedure and may need to drink a special contrast preparation just before the
procedure.
Test-Taking Strategy: Use Maslows Hierarchy of Needs theory and think about
the needs of each client and what pretesting or preprocedure preparation
involves. Although all of the clients have physiological needs, the client
scheduled for hemodialysis has the priority need, that being the risk of fluid
overload. Review the principles of prioritizing if you had difficulty with this
question.
References: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
374, 375). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
L. 16.ID: 383691797
A case manager is reviewing the records of the clients in the nursing unit. Which
note(s) in a clients record indicate an unexpected outcome and the need for
follow-up?Select all that apply.
A.
B.

A client is performing his own colostomy irrigations.

A client with a central venous catheter has a temperature of

100.6 F. Correct
C.

A client with a new diagnosis of diabetes mellitus is selfadministering insulin. Incorrect

D.

A client who has just undergone surgery has a urine output of

more than 30 mL/hr. Incorrect

E.

A client who has just undergone surgery is getting relief from

the prescribed pain medication.
Rationale: A case manager is a nurse who assumes responsibility for coordinating
a client's care from the point of admission through, and after, discharge. This
nurse initiates a plan of nursing care, care map, or clinical pathway as

appropriate to guide care and evaluates and updates the plan of care as needed.
The case manager monitors the client for expected and unexpected outcomes
and provides follow-up and revises the plan of care if an unexpected outcome is
noted. A temperature of 100.6 F in a client with a central venous catheter is an
unexpected and unwanted outcome requiring the need for follow-up, because it
may indicate the development of an infection. The other options all represent
expected outcomes.
Test-Taking Strategy: Think about the role of the case manager and read each
client description carefully. Next, focus on the subject, an unexpected outcome
and the need for follow-up. This will direct you to the outcome that is unexpected
or unwanted. An increased temperature is a concern because it is a sign of
infection. Review the role of the nurse manager and information on these
expected and unexpected outcomes if you had difficulty with this question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 468, 469). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 397). St. Louis:
Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Leadership/Management
Awarded 0.0 points out of 1.0 possible points.
M. 17.ID: 383692460
A registered nurse (RN) who has a licensed practical nurse (LPN) and a nursing
assistant on the nursing team is planning client assignments for the day. Which
of the following clients should the RN assign to the LPN?
A.
B.
C.
D.

A client on bedrest who needs assistance with feeding

A client who must be turned and repositioned every 2 hours

A client receiving oxygen who requires frequent pulse oximetry

monitoring and respiratory treatments Correct

A client with retinal detachment who is wearing eye patches

and requires assistance with hygiene measures
Rationale: When a nurse delegates aspects of a clients care to another staff
member, he or she is responsible for appropriately assigning tasks on the basis of
the educational level and competency of the staff member. A client receiving
oxygen who requires pulse oximetry monitoring and respiratory treatments
should be assigned to the LPN, because this staff member can perform these
tasks and is competent to note changes in the clients condition. Feeding a client,
turning and repositioning a client, and assisting with hygiene measures, all
noninvasive interventions, may be assigned to a nursing assistant.

Test-Taking Strategy: Use the process of elimination, focusing on the subject of

the question, assignment of tasks to an LPN. Think about the activities that the
LPN is able to perform. Next, eliminate the options that are comparable or alike in
that they are noninvasive procedures. Review the principles of delegating tasks if
you had difficulty with this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., pp. 406, 407). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
N. 18.ID: 383693542
A nurse calls a physician to report that a client with congestive heart failure
(CHF) is exhibiting dyspnea and worsening of wheezing. The physician, who is in
a hurry because of a situation in the emergency department, gives the nurse a
telephone prescription for furosemide (Lasix) but does not specify the route of
administration. What is the appropriate action on the part of the nurse?
A.

Calling the physician who gave the telephone prescription to

clarify the prescription Correct

B.

Calling the nursing supervisor for assistance in determining the

route of administration

C.

Administering the medication intravenously, because this route

is generally used for clients with CHF

D.

Administering the medication orally and clarifying the

prescription once the physician has finished caring for the client in the
emergency department
Rationale: Telephone prescriptions involve a physicians dictating a prescribed
therapy over the telephone to the nurse. The nurse must clarify the prescription
by repeating the prescription clearly and precisely to the physician. The nurse
then writes the prescription on the physicians prescription sheet. Under no
circumstances should the nurse try to interpret an unclear prescription or
administer a medication by a route that has not been expressly prescribed. The
nurse must call the physician who gave the telephone prescription and clarify the
prescription.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike in that they indicate that the nurse should administer the
medication without clarifying the physicians prescription. Review the procedures
for accepting telephone prescriptions if you had difficulty with this question.

Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
699, 700). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
O. 19.ID: 383693568
A nurse manager arrives at work and is immediately faced with several activities
that require his attention. Which activity will the nurse manager attend to first?
A.

Stocking the medication closet

B.

Client assignments for the day Correct

C.

A phone message from a clients wife

D.
A phone message from employee health services
Rationale: The nurse manager must attend to client assignments first, because
client care is the priority. Also, the nursing staff need their assignments so that
they may begin client assessments and start delivering client care. The nurse
manager should next check the medication supply to ensure that needed
medications are available. The nurse manager could also delegate this task to
another registered nurse while client assignments are being planned. The nurse
manager would next return the phone calls.
Test-Taking Strategy: Note the strategic word first and use the process of
elimination and prioritization skills. Remember that the client is the priority.
Eliminate the options that are not directly related to immediate client needs. This
will direct you to the correct option. Review the principles of prioritization and
time management if you had difficulty with this question.
References: Huber, D. (2010). Leadership and nursing care management (4th
ed., p. 243). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 308, 309). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.

P. 20.ID: 383692428
The nurse manager of a quality improvement program asks a nurse in the
neurological unit to conduct a retrospective audit. Which of the following actions
should the auditing nurse plan to perform in this type of audit?
A.

Checking the documentation written by a new nursing graduate

on her assigned clients at the end of the shift

B.

Checking the crash cart to ensure that all needed supplies are
readily available should an emergency arise

C.

Reviewing neurological assessment checklists for all clients on

the unit to ensure that these assessments are being conducted as prescribed

D.

Obtaining the assigned medical record from the hospitals

medical record room to review documentation made during a clients hospital
stay Correct
Rationale: Quality improvement, also known as performance improvement, is
focused on processes or systems that significantly contribute to client safety and
effective client care outcomes. Criteria are used to assess outcomes of care and
determine the need for changes improve the quality of care. In a retrospective, or
looking back, audit, the medical record is inspected after the clients discharge
for documentation of compliance with standards. In a concurrent, or at the same
time, audit, the nursing staffs compliance with predetermined standards and
criteria is assessed as the nurses are providing care during the clients stay. In
this type of audit, a peer review approach in which members of the nursing staff
are involved in data collection may be implemented. Obtaining the a clients
medical record from the medical record room for the purpose of reviewing
documentation made during the clients hospital stay is an example of a
retrospective audit. The incorrect options are examples of concurrent audits.
Test-Taking Strategy: Focus on the subject, a retrospective audit. Note the
relationship of the word retrospective in the question and the description in the
correct option. Review the procedures for quality improvement and retrospective
and concurrent audits if you have difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
64, 65). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
Q. 21.ID: 383692435

A nurse is assisting a new nursing graduate with organizational skills in delivering

client care. The nurse determines that the new nursing graduate needs
assistance with time management if he:
A.

Allows time for unexpected tasks

B.

Prioritizes client needs and daily tasks

C.

Gathers supplies before beginning a task

D.

Documents task completion and client information at the end of

the day Correct
Rationale: The nurse should document task completion and client information
throughout the day. Allowing time for unexpected tasks, prioritizing needs and
tasks, and gathering supplies before beginning a task are all components of time
management.
Test-Taking Strategy: Note the strategic words needs assistance. These words
indicate a negative event query and the need to select the incorrect action by
the nursing graduate. Read each option carefully and recall the guidelines for
time management to answer the question. If you had difficulty with this question,
review the principles of time management and documentation.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., p. 529). St. Louis: Mosby.
Huber, D. (2010). Leadership and nursing care management (4th ed., pp. 128130). St. Louis: Saunders.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
R. 22.ID: 383693558
A nurse manager notes that an employee is constantly calling in sick. Which
action should the nurse manager take initially to handle this problem?
A.

Reporting the employee to administration

B.

Documenting the employees behavior in the personnel file

C.

Telling the employee that she will be fired if she calls in sick
again

D.

Reminding the employee of the employment standards of the

agency Correct
Rationale: When an employee demonstrates an unacceptable level of
absenteeism, the nurse must first remind the employee of the employment
standards of the agency. Sometimes an employee does not know or has forgotten
the existing standards, and a reminder with no threats or discipline is all that is

needed. When the oral reminder does not result in a change in behavior, the
reminder should be placed in writing. If the written reminder fails, the employee
should be granted a day of decision to determine whether to accept the
standards for work attendance. Pay may be given for this day (depending on the
agency protocol) so that it is not interpreted as punishment, and the employee
must return to work with a written decision. If the employee decides not to
adhere to standards, her employment with the agency is terminated. Reporting
the employee to administration, documenting the employees behavior in her
personnel file, and telling the employee that she will be fired if she calls in sick
again are not appropriate initial actions.
Test-Taking Strategy: Use the process of elimination, noting the strategic word
"initially." Focusing on the data in the question and noting that there is no
information to indicate that this employee has been approached about his or her
behavior in the past will direct you to the correct option. Review the procedure
for handling unacceptable behavior related to employment standards if you had
difficulty with this question.
Reference: Marriner-Tomey, A. (2009). Guide to nursing management and
leadership (8th ed., pp. 447, 448). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
S. 23.ID: 383694038
A client has signed the informed consent for mastectomy of the left breast. On
the morning of the surgical procedure, the client asks the nurse several questions
about the procedure that make it obvious that she has does not have an
adequate comprehension of the procedure. What is the most appropriate
response by the nurse?
A.

Telling the client that it is her surgeons responsibility to explain

the procedure

B.

Contacting the surgeon and requesting that she visit the client
to answer her questions Correct

C.

Informing the client that she has the right to cancel the surgical
procedure if she wishes

D.

Telling the client that she needed to ask these questions before
signing the informed consent for surgery
Rationale: Informed consent is the authorization by a client or a clients legal
representative to do something to the client. The surgeon is primarily responsible
for explaining the surgical procedure and obtaining informed consent. If the client

asks questions that alert the nurse to an inadequacy of comprehension on the

clients part, the nurse has the obligation to contact the surgeon. Telling the
client that she needs to ask questions before signing the consent for surgery is
incorrect. Although the client should be thoroughly informed before signing
consent, the client has the right to ask questions thereafter. It is the surgeons
responsibility to explain the procedure, and, if the client wishes, she has the right
to cancel the surgical procedure. Although these are correct statements, they are
not the most appropriate and do not address the clients concerns. Additionally,
they do not address the legal ramifications associated with informed consent.
Test-Taking Strategy: Use the process of elimination. Noting the strategic words
does not have an adequate comprehension of the procedure and recalling that
the physician is primarily responsible for explaining the surgical procedure to the
client will direct you to the correct option. Review the issues surrounding
informed consent if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patientcentered collaborative care (6th ed., pp. 252, 254). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
T. 24.ID: 383691771
A client admitted to the hospital has a do-not-resuscitate (DNR) order in his
medical record. The nurse understands that:
A.

The DNR order may not be changed once it is in effect

B.

The DNR order requires frequent review as specified by state or

agency policy Correct

C.

The only people who may change the DNR order are members
of the clients immediate family

D.

The DNR order, as written on admission, must remain in effect

for the duration of the clients hospitalization
Rationale: If the clients condition changes, the DNR order may need to be
changed. For this reason, DNR orders require frequent review as specified by
state or agency policy. A DNR order may be changed at any time and does not
remain in effect for the duration of the clients hospitalization. The clients
request regarding DNR status is the priority.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that
use the closed-ended words may not and only. To select from the remaining

options, recall that a DNR status may be changed at any time. Review the ethical
and legal issues regarding DNR orders if you had difficulty with this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., p. 177). St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
U. 25.ID: 383694046
A client with a left arm fracture complains of severe diffuse pain that is
unrelieved by pain medication. On further assessment, the nurse notes that the
client experiences increased pain during passive motion, compared with active
motion, of the left arm. On the basis of these assessment findings, which action
should the nurse take first?
A.

Contacting the physician Correct

B.

Reassessing the client in 30 minutes

C.

Checking to see whether it is time for more pain medication

D.

Encouraging the client to continue active range of motion

exercises of the left arm
Rationale: The client with early acute compartment syndrome typically complains
of severe diffuse pain that is unrelieved by pain medication. The affected client
also complains that pain during passive motion is greater than that during active
motion. The nurse must notify the physician immediately. The other options are
incorrect because they delay necessary interventions.
Test-Taking Strategy: Focus on the assessment data presented in the question.
Recall that these signs indicate early acute compartment syndrome. Remember,
if this is suspected, the physician needs to be notified. Also note that the
incorrect options are comparable or alike in that they delay necessary
intervention. Review the complications associated with a fracture of an extremity
and the associated priority nursing interventions if you had difficulty with this
question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patientcentered collaborative care (6th ed., p. 1181). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation

Content Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
V. 26.ID: 383691785
Which action by the nurse represents the ethical principle of beneficence?
A.

The nurse upholds a clients decision to refuse chemotherapy

for lung cancer.

B.

The nurse follows a plan of care designed to relieve pain in a

client with cancer.

C.

The nurse administers an immunization to a child even though

it may cause discomfort. Correct

D.

The nurse provides equal amounts of care to all assigned

clients on the basis of illness acuity.
Rationale: Beneficence is taking action to help others. Although administration of
a childs immunization might cause discomfort, the benefits of protection from
disease outweigh the temporary discomfort. Fidelity is keeping promises made to
clients, families, and other healthcare professionals. Autonomy is a persons
independence. Respecting anothers autonomy means that you are agreeing to
respect that persons right to determine his or her course of action. Justice refers
to fairness and equity, including fair allocation of resources, such as nursing care
for all clients.
Test-Taking Strategy: Focus on the subject, beneficence. Recalling that
beneficence refers to taking action to help others will direct you to the correct
option. Review the principles of healthcare ethics if you had difficulty with this
question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
314). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
W. 27.ID: 383691783
A nurse educator describes the standards of care formulated by the American
Nurses Association to a group of new nursing graduates hired by the hospital.
Which of the following options are accurate descriptions of these standards of
care? Select all that apply.
A.

Are specific guidelines Incorrect

B.

Define professional practice Correct

C.

Have some similarity to policies and procedures Correct

D.

Are statements that relate only to the agency in which the

nurse is employed

E.

Are authoritative statements that describe a common or

acceptable level of client care or performance Correct
Rationale: Standards of care are authoritative statements that describe a
common or acceptable level of client care or performance. They bear some
similarity to policies and procedures. Therefore standards of care define
professional practice. The American Nurses Association has formulated general
standards and guidelines for nursing practice. They are general in nature and
apply across the nation.
Test-Taking Strategy: Focus on the subject, standards of care formulated by the
American Nurses Association. Note that the incorrect options are comparable or
alike in that they contain the words specific or only. Review the standards of
care set forth by the American Nurses Association if you had difficulty with this
question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 627, 628). St. Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
X. 28.ID: 383693556
A nurse is taking a morning break with the unit secretary in the nurses lounge.
The unit secretary says to the nurse, I read in Mr. Gages medical record that he
has gonorrhea. How should the nurse respond to the secretary?
A.

Oh, really? I didnt see that!

B.

We cant discuss a clients medical condition. Correct

C.

Yes, thats why weve imposed contact precautions.

D.
Yes, he does, but be sure not to discuss this with anyone else.
Rationale: A clients medical condition is confidential and should never be
discussed with anyone other than the client and the clients healthcare provider.
Therefore the nurse must tell the unit secretary that the clients condition is not
to be discussed. The statements Yes, he does, but be sure not to discuss this
with anyone else and Yes, thats why weve imposed contact precautions both
confirm the clients disease and are therefore inappropriate. Responding, Oh,
really? I didnt see that! promotes further discussion of the clients condition and

is inappropriate.
Test-Taking Strategy: Use the process of elimination and recall the issues
surrounding confidentiality. This will help you eliminate the option that promotes
further discussion of the clients condition. Next, eliminate the options that are
comparable or alike in that they confirm the clients illness. Review the issues
surrounding confidentiality if you had difficulty with this question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 156, 157). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
Y. 29.ID: 383694024
A nurse on the day shift receives her client assignments for the day. List the
clients in order of their priority for assessment.
Correct
A. A client with heart failure whose condition has been stable since the
administration of furosemide (Lasix)
B.
A client with gastroenteritis and diarrhea
C.
A client with suspected gallbladder disease who is scheduled for an
ultrasound of the abdomen
D.
A client with a herniated disc who is scheduled to be discharged
today
Rationale: The nurse would first assess the client with a cardiac problem. Even
though the clients condition is stable, this client has received medication for
stabilization and requires continued close monitoring. After this assessment, the
nurse would assess the client with gastroenteritis for signs of fluid volume deficit
(dehydration). The nurse would next assess the client scheduled for the
ultrasound to ensure that this client understands the reason for the test. Finally
the nurse would assess the client preparing for discharge to determine the need
for reinforcement of home care instructions.
Test-Taking Strategy: Use the process of elimination and the ABCs airway,
breathing, and circulation. This will direct you to the client with a cardiac problem
(circulation) as the priority. Next use Maslows Hierarchy of Needs theory to direct
you to the client with gastroenteritis and diarrhea, who has the highest priority
physiological need of the remaining clients. To determine the order of priority for
the last two clients, the nurse would assess the client scheduled for the
ultrasound to determine the presence of gallbladder pain, because this client
could be experiencing pain. Review the guidelines for prioritization if you had

difficulty with this question.

Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
220, 221). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
2. 30.ID: 383693552
A nurse is planning the client assignments for the shift. Which client should the
nurse assign to the nursing assistant?
A.
B.

A client who needs a blood transfusion

A client with diarrhea on whom contact precautions have been

imposed Correct
C.

A client with angina who needs to be ambulated for the first

time since admission

D.

A client with a draining abdominal wound that requires frequent

dressing changes
Rationale: Assignment of tasks must be based the job description of the nursing
assistant, the assistants level of clinical competence, and state law. Blood
transfusions, dressing changes, and ambulation of a client with angina require
the skill of a licensed nurse. A client under contact precautions is the most
appropriate assignment for the nursing assistant because the nursing assistant is
trained to provide hygiene care and to care for clients under specific precautions.
Test-Taking Strategy: Use the process of elimination and knowledge regarding
tasks that may be safely delegated to the nursing assistant. Read each client
description and think about the needs of the client. Recalling that clients
requiring invasive procedures or close monitoring must be assigned to a licensed
nurse will assist you in answering correctly. Review the principles of delegation
and assignment-making if you had difficulty with this question.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., pp. 405, 406). St. Louis: Mosby.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 287). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Planning

Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
B. 31.ID: 383694048
A man who is visiting his wife in a long-term care facility for people with
Alzheimers disease collapses and is transported to a hospital. The client remains
unconscious, and testing reveals that he has cancer that has metastasized to
bone, brain, and liver. The nursing staff at the wifes care facility report to the
hospital physician that the client has no other family members and that his wife
is mentally incompetent. What information regarding do-not-resuscitate (DNR)
orders does the nurse remember?
A.
B.

That a DNR order may be written by a clients physician Correct

That everything possible must be done if the client stops

breathing Incorrect
C.

That medications only may be given to the client if the client

stops breathing

D.

That life support measures will have to be implemented if the

client stops breathing
Rationale: In a situation in which a client has no family members who can provide
permission for treatment, the physician may write a DNR order if he or she is
reasonably and medically certain that resuscitation would be futile. Therefore the
other options are inaccurate.
Test-Taking Strategy: Focus on the information in the question and note that the
client is terminally ill and has no family members other than a wife who is
mentally incompetent. Eliminate the options that are comparable or alike in that
they indicate that resuscitation measures will be instituted. Next eliminate the
option containing the closed-ended word only. Review the ethical and legal
issues related to DNR orders if you had difficulty with this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., p. 177). St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
C. 32.ID: 383692491
A nurse preparing a client to go to the radiology department for a chest x-ray
notes that the client is wearing a religious medal on a chain around the neck. The

client, a Catholic, expresses a concern about removing the medal. What is the
most appropriate action for the nurse to take?
A.

Asking the client to remove the medal until the x-ray has been
completed

B.

Assisting the client in pinning the medal and chain to the

waistband of the clients pajama bottoms Correct

C.

Asking the client to place the medal in the top drawer of the
bedside stand just before leaving for the radiology department

D.

Telling the client that the medal and chain will be kept at the
nurses station for safekeeping while the client is undergoing the x-ray
Rationale: A client undergoing a chest x-ray must remove all metal objects to
help prevent artifacts on the x-ray. If the client expresses concern about
removing the medal, the nurse should help the client pin the medal and chain to
the hospital gown or in another area where it will not appear on the x-ray image.
The nurse should also alert staff in the radiology department that this has been
done. If the client is expressing concern about removing the medal, asking the
client to remove it or leave it with the nurse or in the bedside stand is
inappropriate. Each of these actions also increases the likelihood that the medal
and chain will be lost.
Test-Taking Strategy: Use the process of elimination and note that the client is
expressing concern about removing the religious medal. Eliminate the options
that are comparable or alike in that they indicate that the client should remove
the medal. Also note that the correct option is the only option that addresses the
clients concern. Review care of clients valuables if you had difficulty with this
question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
1387). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Safety
Awarded 1.0 points out of 1.0 possible points.
D. 33.ID: 383692411
A charge nurse on the 11 pmto7 am shift is gathering the nursing staff together
to listen to the 3-to-11 pm intershift report. The charge nurse notes that a staff
member has an odor of alcohol on her breath, slurred speech, and an unsteady
gait and suspects alcohol intoxication. The charge nurse would most
appropriately:
A.

Send the staff member home Correct

B.

Ask the staff member how much alcohol she has consumed

C.

Tell the staff member that she is not allowed to administer

medications

D.

Ask the staff member to rest in the nurses lounge until the
effects of the alcohol wear off
Rationale: When a staff member reports to work in a state of alcohol intoxication,
the nurse notes the signs objectively and asks a second person to validate these
observations. The nurse also contacts the nursing supervisor. An odor of alcohol,
slurred speech, unsteady gait, and errors in judgment are symptoms of
intoxication. Client safety is the primary concern. The intoxicated nurse is
removed from the situation, confronted briefly and firmly about the behavior, and
sent home to rest and recuperate. The incident is recorded and the nurse
describes the observations, states the action taken, indicates future plans, and
has the staff member sign and date the memo of the recorded incident after
returning to work. Refusal to sign and date the memo should be noted by the
charge nurse and a witness. Neither asking the staff member to rest in the
nurses lounge until the effects of the alcohol wear off nor telling the staff
member that he or she will not be allowed to administer medications removes
the staff member from the client care area, jeopardizing the clients safety.
Asking the staff member how much alcohol she has consumed is confrontational
and irrelevant.
Test-Taking Strategy: Use the process of elimination, keeping in mind that client
safety is the priority. Asking the staff member how much alcohol she has
consumed is irrelevant, so eliminate this option. Next eliminate the options that
are comparable or alike in that they do not involve removal of the staff member
from the client care area. Review nursing responsibilities when substance abuse
is suspected in a staff member if you had difficulty with this question.
Reference: Marriner-Tomey, A. (2009). Guide to nursing management and
leadership (8th ed., pp. 445, 446). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
E. 34.ID: 383694036
A nurse is assisting a physician in assessing a hospitalized client. During the
assessment, the physician is paged to report to the recovery room. The physician
leaves the clients bedside after giving the nurse a verbal prescription to change
the solution and rate of the intravenous (IV) fluid being administered. What is the
appropriate nursing action in this situation?

A.

Calling the nursing supervisor to obtain permission to accept

the verbal prescription

B.

Changing the solution and rate of the IV fluid per the

physicians verbal prescription Incorrect

C.

Asking the physician to write the prescription in the clients

record before leaving the nursing unit Correct

D.

Telling the physician that the prescription will not be

implemented until it is documented in the clients record
Rationale: The physician should write all prescriptions. Verbal prescriptions are
not recommended, because they increase the risk for error. If a verbal
prescription is necessary, such as during an emergency, it should be written and
signed by the physician as soon as possible, usually within 24 hours. The nurse
must follow agency policies and procedures regarding verbal prescriptions. The
appropriate nursing action would be to ask the physician to write the prescription
in the clients record before leaving the nursing unit. Changing the solution in
keeping with the verbal prescription and contacting the supervisor to obtain
permission to accept the verbal prescription each imply that the nurse accepts
the verbal prescription. Telling the physician that the prescription will not be
implemented until it is documented in the clients record delays necessary
treatment.
Test-Taking Strategy: Use the process of elimination and note the strategic word
appropriate. Eliminate the options that are comparable or alike in that they
imply acceptance of the verbal prescription by the nurse. To select from the
remaining options, recall the guidelines and principles for implementing
physician prescriptions. This will direct you to the correct option. Review nursing
responsibilities related to verbal prescriptions if you had difficulty with this
question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
699, 700). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
F. 35.ID: 383692496
The nurse reviewing a clients record sees that the following medications are
prescribed. Which medication should the nurse plan to administer first?

Client Medications

1. Atorvastatin (Lipitor) 10 mg orally

2. Zolpidem (Ambien) 5 mg orally daily
3. Ferrous sulfate (Feosol) 1 tablet orally
4. Levothyroxine (Synthroid) 137 mg orally
A.

B.

C.

D.
4 Correct
Rationale: For adequate absorption, levothyroxine must be administered with
water on an empty stomach as soon as the client awakens and at least 1 hour
apart from other fluids (e.g., coffee or tea), food, and other medications.
Therefore this medication should be administered first. Atorvastatin (Lipitor), an
HMGCoA reductase inhibitor used to lower cholesterol, is administered at
bedtime because cholesterol synthesis is increased during the night. Zolpidem, a
benzodiazepine-like medication used to enhance sleep, is administered at
bedtime. Ferrous sulfate is an iron supplement that is administered with water
between meals.
Test-Taking Strategy: Note the strategic word first. Think about the
classification of each medication to determine its action. This will help you
answer correctly. Also note that atorvastatin and zolpidem are comparable or
alike in that they are administered at bedtime. Next, recalling the action of
levothyroxine will direct you to this option. Review the medications in the options
and their method of administration if you had difficulty with this question.
References: Lehne, R. (2010). Pharmacology for nursing care (7th ed., pp. 380,
570, 694). St. Louis: Saunders.
Hodgson, B., & Kizior, R. (2009). Saunders nursing drug handbook 2009 (p. 476).
St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
G. 36.ID: 383692481
A nurse monitoring a client with a chest tube notes that there is no tidaling of
fluid in the water seal chamber. After further assessment, the nurse suspects that
the clients lung has reexpanded and notifies the physician. The physician
verifies with the use of a chest x-ray that the lung has reexpanded, then calls the
nurse to asks that the chest tube be removed. The nurse should first:

A.
B.

Call the nursing supervisor

Explain the procedure to the client, then remove the chest

tube Incorrect
C.

Inform the physician that removal of a chest tube is not a

nursing procedure Correct

D.

Obtain petrolatum-impregnated gauze and ask another nurse

to assist in removing the chest tube
Rationale: Actual removal of a chest tube is the duty of a physician. Therefore the
nurse would first inform the physician that this is not a nursing procedure. If the
physician insists that the nurse remove the tube, the nurse must contact the
nursing supervisor. Some agencys policies and procedures may permit an
advanced practice nurse (a nurse with a masters degree in a specialized area of
nursing) to remove a chest tube. However, there is no information in the question
to indicate that the nurse is an advanced practice nurse.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike in that they indicate that the nurse would remove the
chest tube. To select from the remaining options, note the strategic word first.
The nurse should discuss the prescription with the physician. Review nursing
responsibilities with regard to removal of a chest tube if you had difficulty with
this question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 1624). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
H. 37.ID: 383694060
A registered nurse (RN) is watching as a new licensed practical nurse (LPN)
administer an intramuscular (IM) injection in a clients deltoid muscle. The RN
determines that the LPN is performing the procedure correctly if the LPN:
A.

Administers the injection in the thigh

B.

Places the client in the Sims position

C.

Positions the client in a prone toe-in position

D.

Administers the injection 2 inches below the acromion

process Correct
Rationale: The RN is responsible for supervising certain procedures performed by
an LPN to ensure that client safety is maintained. The deltoid muscle is located in
the upper arm area. Administration of an injection into this muscle is done 2

inches below the acromion process (the bony structure on top of the shoulder
blade). Therefore the injection is not given in the thigh (vastus lateralis or rectus
femoris muscle). The Sims position is not the correct position for an injection into
the deltoid muscle. A prone toe-in position is used for injection into the
dorsogluteal site or gluteus medius muscle because it will promote internal
rotation of the hips, which relaxes the muscle and makes the injection less
painful.
Test-Taking Strategy: Note the strategic words deltoid muscle. Visualize each
description in the options and use your knowledge of the anatomical locations of
the various muscles to find the correct option. If you are unfamiliar with the
administration of IM medications in the deltoid muscle, review the correct
procedure.
Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., p. 600). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation

I.

Content Area: Leadership/Management

Awarded 1.0 points out of 1.0 possible points.
38.ID: 383694042
A registered nurse (RN) is supervising a nursing assistant ambulating a client
with right-sided weakness. The RN would conclude that the nursing assistant is
performing the procedure incorrectly after observing that the nursing assistant:
A.

Stands behind the client Correct

B.

Stands on the right side of the client

C.

Positions the free hand on the clients shoulder

D.

Grasps the security belt in the midspine area of the small of the

clients back
Rationale: When walking with a client, the nurse should stand on the affected
side and grasp the security belt in the midspine area of the small of the clients
back. The nurse should position the free hand at the shoulder area so that the
client may be pulled toward the nurse in the event that there is a forward fall.
The client is instructed to look up and outward rather than at his or her feet.
Test-Taking Strategy: Note the strategic word incorrectly. This word indicates a
negative event query and the need to select the unsafe action by the nursing
assistant. Visualizing the action in each option will direct you to the unsafe and
incorrect action. Review the procedure for assisting ambulation of a client with
weakness if you had difficulty with this question.

Reference: Perry, A., & Potter, P. (2010). Clinical nursing skills & techniques (7th
ed., pp. 250, 253). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning

J.

Content Area: Leadership/Management

Awarded 1.0 points out of 1.0 possible points.
39.ID: 383692458
A nursing student is assigned to care for a client who requires a total bed bath.
When the student explains to the client that she is going to gather supplies to
administer the bath, the client states, I dont want a bath. Ive been up all night,
and Im clean enough. The student reports the clients refusal to the nurse in
charge. Which action by the nurse in charge is appropriate?
A.
B.

Telling the nursing student to allow the client to rest Correct

Telling the nursing student to give the client the bath anyway

C.

Telling the client that the physician will be informed of the

refusal of care

D.

Telling the nursing student to persuade the client to have a

bath so that the evening shift staff will not have to do it
Rationale: The client has the right to refuse a treatment or procedure, and if the
client does refuse, the nurse must respect the clients decision. Therefore the
nurse would allow the client to rest. Persuading the client to have a bath and
giving the bath anyway are both inappropriate and represent violations of the
clients rights. Telling the client that the physician will be informed of the refusal
of care is a threatening action on the nurses part.
Test-Taking Strategy: Use the process of elimination and your knowledge of client
rights. Eliminate the options that present a threat to the client or indicate that
the bath will be given regardless of the clients wishes. Review client rights if you
had difficulty with this question.
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 79). St. Louis: Saunders.
Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., pp. 176-181). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation

Content Area: Ethical/Legal

Awarded 1.0 points out of 1.0 possible points.
K. 40.ID: 383694052
A nurse is preparing to administer medications to a client by way of a nasogastric
(NG) tube. Before administering the medication, the nurse must first:
A.

Check the clients apical pulse

B.

Check the placement of the tube Correct

C.

Check when the last feeding was given

D.
Check when the last medications were given
Rationale: To help prevent aspiration, the nurse checks the placement of the tube
by aspirating gastric contents and measuring the pH. Checking when a feeding or
medication was last given and checking the clients apical pulse are not directly
related to the subject of the question.
Test-Taking Strategy: Note the strategic word first. Use the ABCs airway,
breathing, and circulation. To help prevent the complication of aspiration when
administering medications to a client with an NG tube, the nurse must first
assess accurate placement of the tube. Review the principles of administering
medications through an NG tube if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patientcentered collaborative care (6th ed., p. 1276). St. Louis:
Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
L. 41.ID: 383692415
A case manager is reviewing progress notes in a clients medical record. Which
notation indicates the need for follow-up?

S. No

Client Condition

Notation

1.

Client 1
Status postmastectomy:18 hours

Five milliliters of bloody drainage was emptied from

drain.

2.

Client 2

Crackles were heard in the lower lung lobes bilater

Heart Failure

3.

Client 3
Status postappendectomy: 24 hours

The surgical dressing is clean and dry.

4.

Client 4
Diabetes mellitus

Blood glucose level is124 mg/dL.

A.

B.

2 Correct

C.

3 Incorrect

D.
4
Rationale: A case manager is a nurse who assumes responsibility for coordinating
a client's care from the point of admission through, and after, discharge. This
nurse initiates a nursing plan of care, care map, or clinical pathway as
appropriate to guide care, evaluating and updating the plan of care as needed.
The case manager monitors the client for expected and unexpected outcomes
and provides follow-up and revises the plan of care if an unexpected outcome is
noted. Crackles heard in the lower lobes of the lungs in a client with heart failure
are an unexpected and unwanted outcome requiring follow-up because they
could indicate the development of pulmonary edema. The notations made for the
other clients listed represent expected outcomes.
Test-Taking Strategy: Think about the role of the case manager and read each
notation carefully. Next, focus on the subject, the need for follow-up. This will
direct you to the notation that represents an unexpected or unwanted outcome.
Crackles heard in the lower lobes of the lungs on auscultation are a matter of
concern. Review the role of the nurse manager and the expected and unexpected
findings for the client conditions noted in the options if you had difficulty with this
question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 468-469). St. Louis: Saunders.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Leadership/Management
Awarded 0.0 points out of 1.0 possible points.
M. 42.ID: 383691763

A registered nurse (RN) is planning client assignments for the day. Which clients
should the nurse assign to a nursing assistant (unlicensed assistive
personnel)? Select all that apply.
A.

A client with a permanent tracheostomy

B.

A client requiring a gastrostomy tube dressing change

C.

A client who requires transport to the radiology department in a

wheelchair Correct

D.

A client with a Foley catheter for whom a 24-hour urine

collection is in progress Correct

E.

A client who underwent surgery an hour earlier and has a

nasogastric tube and a Foley catheter
Rationale: The nurse must base assignments on the basis of the skills of the staff
member and the needs of the client. The nursing assistant is capable of caring
for the client with a Foley catheter for whom a 24-hour urine collection is in
progress and the client who requires transport to the radiology department in a
wheelchair. The nursing assistant is skilled in such tasks. The client who has just
undergone surgery will require specific monitoring in addition to recording of vital
signs. Dressing changes and tracheostomy care are not performed by unlicensed
personnel.
Test-Taking Strategy: Focus on the subject, assignments for the nursing assistant.
Think about the skills that the nursing assistant can perform and remember that
the nursing assistant may perform tasks that are noninvasive. Review the
principles of delegation and assignment-making if you had difficulty with this
question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 244-246, 250). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
N. 43.ID: 383694030
A nurse on the day shift is assigned to care for four clients. List the clients in
order of priority for nurse.
Correct
A.
A client with asthma who had shortness of breath during the night
B.
A client scheduled to have a chest x-ray at 9 am
C.
A client scheduled for an echocardiogram at 10 am
D.
A client with pneumonia who is scheduled for discharge home

Rationale: Airway is always the priority, so the nurse would first assess the client
with asthma who had shortness of breath during the night. The nurse would next
assess the client scheduled for a chest x-ray, because the x-ray is scheduled at 9
am and the nurse would want to gather data about the client before the client
leaves the nursing unit. Next the nurse would assess the client scheduled for an
echocardiogram at 10 am, and finally the nurse would care for the client
scheduled for discharge. The client being discharged will have needs that must
be addressed, but there is nothing in the question to indicate that the client must
have his or her discharge needs addressed by a specific time.
Test-Taking Strategy: Use the ABCs airway, breathing, and circulation and
note that the first priority is the client who had difficulty breathing. Next note the
scheduled times in the options to assist in determining your second and third
priority. Review the guidelines for prioritizing if you had difficulty with this
question.
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., pp. 1574, 1575). St. Louis:
Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 374, 375). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
2. 44.ID: 383692452
A registered nurse (RN) in charge of a long-term care facility who is working with
a nursing assistant on the night shift prepares to take her break. To ensure client
safety during her break, which of the following actions should the nurse
take? Select all that apply.
A.
B.

Conducting client rounds before taking the break Correct

Taking the break in the staff lounge located on the nursing

unit Correct
C.

Asking the nursing assistant to administer a medication placed

at the clients bedside if the client awakens

D.

Asking the nursing assistant to monitor a clients tube feeding

and to contact the nurse when the feeding bag is empty

E.

Asking the nursing assistant to contact the physician during the

nurses break if a clients pain medication is not effective

F.

Informing the nursing assistant that she is leaving the nursing

unit to get a cup of coffee from a vending machine in the lobby Incorrect
Rationale: The RN is responsible for ensuring client safety at all times and must
not leave the nursing unit for any reason during the shift. The nurses break
should be taken in a designated area located on the nursing unit. Before taking
the break, the nurse should check all clients to ensure that they are safe and
comfortable and that their needs have been met. A nursing assistant should
never be asked to perform any activity that he or she is not trained for. This
includes such activities as administering medications; assessing, monitoring, or
evaluating the client; and making decisions about contacting a physician.
Test-Taking Strategy: Think about the roles and responsibilities of the RN and the
tasks or activities that the nursing assistant may legally perform and focus on the
subject, safety. Remember that the registered nurse is responsible for
administering medications; assessing, monitoring, and evaluating the client; and
making decisions about contacting a physician. Review the role of the RN and the
tasks and activities that may be delegated to a nursing assistant if you had
difficulty with this question.
References: Huber, D. (2010). Leadership and nursing care management (4th
ed., pp. 242, 243). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 400-402). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
B. 45.ID: 383691795
A registered nurse (RN) is planning client assignments for the day. Which of the
following clients should the RN assign to the nursing assistant?
A.

A client who requires periodic suctioning

B.

A client who needs a colostomy irrigation

C.

A client who needs frequent ambulation with a walker Correct

D.

A client who has undergone an arteriogram and requires close

monitoring
Rationale: When a nurse delegates aspects of a clients care to another staff
member, he or she is responsible for appropriately assigning tasks on the basis of
the educational level and competency of the staff member. Noninvasive
interventions such as ambulating a client with a walker may be assigned to a
nursing assistant. A client who requires suctioning or one who needs a colostomy
irrigation should be assigned to a licensed practical nurse (LPN) because these

staff members can perform certain invasive procedures. The client who has
undergone an arteriogram should be assigned to either an LPN or an RN because
these personnel have the knowledge and education to detect changes in the
clients status that require attention.
Test-Taking Strategy: Use the process of elimination, focusing on the subject of
the question, assignment to a nursing assistant. Eliminate the options that are
comparable or alike in that they involve invasive procedures. To select from the
remaining options, think about the education that a nursing assistant receives.
The nursing assistant is trained to ambulate a client with an assistive device but
does not have the knowledge and education to detect changes in a clients
status. Review the guidelines for delegation of tasks if you had difficulty with this
question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., pp. 406, 407). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
C. 46.ID: 383692444
A nurse who has been employed in a hospital for 8 weeks is consistently taking
extended lunch breaks. The nurses behavior has caused problems with client
care during lunch hours. What is the appropriate way for the nurse manager to
deal with this situation?
A.

Ignoring the situation

B.

Asking other staff members to cover for the nurse

C.

Documenting the problem in the nurses personnel file

D.

Confronting the nurse to discuss the behavior and initiate

problem-solving measures Correct
Rationale: Taking extended lunch breaks is an unacceptable behavior, mainly
because the behavior affects client care. The nurse manager must confront the
nurse, discuss the behavior, and initiate problem-solving measures to ensure that
the behavior does not continue. Ignoring the situation, asking other staff
members to cover for the nurse, and documenting the problem in the nurses
personnel file are all inappropriate because none of these actions will resolve the
problem.
Test-Taking Strategy: Use the process of elimination and your knowledge of the
principles of dealing with conflict and unacceptable behavior. Remember that it is
most appropriate to confront and address a problem when it occurs. Also note

that the incorrect options are comparable or alike in that they avoid the problem.
Review the principles of dealing with conflict if you had difficulty with this
question.
References: Huber, D. (2010). Leadership and nursing care management (4th
ed., p. 287). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 355). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
D. 47.ID: 383693544
A nurse is supervising a new nursing graduate in various procedures. Which of
the following actions by the new nursing graduate constitutes a negligent act?
A.

Giving a verbal report to the nurse on the oncoming shift

B.

Checking neurological signs in a client with a head injury

C.

Using clean gloves to change a gastrostomy tube

dressing Correct

D.

Contacting a physician about a change in a clients blood

pressure
Rationale: Common negligent acts include medication errors that result in injury
to the client; intravenous therapy errors resulting in infiltrations or phlebitis;
burns caused by equipment, bathing, or spills of hot liquids and foods; falls
resulting in an injury; failure to use aseptic technique where required; failure to
give report or giving an incomplete report to an oncoming shift; failure to
adequately monitor a clients condition; and failure to notify a physician of a
significant change in a clients condition. Using clean gloves is a negligent act.
The nurse would use sterile gloves to change a dressing over broken skin.
Test-Taking Strategy: Use the process of elimination and focus on the subject, a
negligent act. Read each option carefully; note the word clean in the correct
option. Review the concept of negligence if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
332). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment

Integrated Process: Teaching and Learning

Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
E. 48.ID: 383692442
A registered nurse is in charge of the emergency department (ED) during the
night shift. A client arrives at the ED for treatment after a sexual assault. The
nurse has never cared for anyone who has been raped. To determine the
necessary actions in regard to this clients injury, the nurse should:
A.

Ask a licensed practical nurse

B.

Call the nurse in charge of the day shift

C.

Ask the police officers who brought the client to the ED

D.

Check the unit policy for the protocol for the care of clients who
have been sexually assaulted Correct
Rationale: A policy or procedure is a designated plan or course of action to be
taken in a specific situation. Written copies of all policies are usually placed in a
policy manual that is available in each department or may be available online.
Specific unit policies are sometimes referred to as protocols. The policy or
protocol for a client who has been raped will describe the physical, psychosocial,
and legal responsibilities of the nurse. Calling the nurse in charge during the day
shift or asking an LPN or the police officers who brought the client into the ED is
inappropriate. If the nurse needs additional information after reviewing the policy
or protocol, it would be most appropriate to contact the agency nursing
supervisor of the night shift.
Test-Taking Strategy: Use the process of elimination, recalling the legal
implications related to providing care. Note that the incorrect options are
comparable or alike in that they suggest obtaining information from other
individuals. Review the purpose of organizational policies, procedures, or
protocols if you had difficulty with this question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 389, 394, 395). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
F. 49.ID: 383692430
A nurse is preparing for the admission of a client with pulmonary tuberculosis.
Which of the following actions reflects the use of evidence-based practice in the
care of the client?

A.

Keeping the door to the clients room closed Correct

B.

Using a surgical mask when entering the clients room

C.

Placing the client in a semiprivate room with a cohort client

D.

Fitting the client for an N95 or HEPA (high-efficiency particulate

air) mask to be worn at all times
Rationale: Evidence-based practice is an approach to client care in which the
nurse integrates the clients preferences, clinical expertise, and the best research
evidence to deliver quality care. Pulmonary tuberculosis is a respiratory infection
that is transmitted to others by way of the airborne route. The door to the clients
room must be kept closed to prevent the transmission of the infection via the
airborne route. The remaining options do not reflect evidence-based practice. An
N95 or HEPA respirator (not a surgical mask) must be worn by the nurse on
entering the room. It is not necessary for the client to wear a mask. Airborne
precautions require the use of a private room.
Test-Taking Strategy: Read each option carefully, focusing on the subject,
evidence-based practice. Recall the definition of evidence-based practice and
recall that tuberculosis is transmitted by way of the airborne route. This will
direct you to the correct option. Review the concept of evidence-based practice if
you had difficulty with this question.
References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing:
Patient-centered collaborative care (6th ed., p. 467 ). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 54-60, 662663, 674). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
G. 50.ID: 383692479
An 18-year-old client is brought to the emergency department (ED) by
emergency medical services after sustaining life-threatening injuries in an
automobile accident. The client is unconscious and requires an emergency
splenectomy. A nurse in the ED assists in quickly preparing the client for surgery
and tries to contact the clients parents but is unsuccessful. In regard to informed
consent for the surgery:
A.
B.

The nurse understands that consent is not needed Correct

The nurse will contact the hospital clergy to provide informed

consent

C.

The nurse will sign informed consent on behalf of the client and
ask another nurse to witness the signature

D.

The nurse will prepare the client to undergo mechanical

ventilation until the clients parents can be contacted
Rationale: In an emergency situation, if it is impossible to obtain consent from
the client or an authorized person, the procedure required to benefit the client or
save his or her life may be undertaken without informed consent. In such cases
the law assumes that the client would wish to be treated. Contacting the hospital
clergy to provide the informed consent and having the nurse sign on behalf of the
client with another nurse to witness the signature are both incorrect. Also, having
the client undergo mechanical ventilation until his parents can be contacted will
delay treatment of a life-threatening injury.
Test-Taking Strategy: Use the process of elimination. Noting the strategic words
life-threatening injuries will direct you to the correct option. Review the issues
regarding informed consent if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
332, 333). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
H. 51.ID: 383692487
A nurse providing preoperative care to a client who is scheduled for a left
mastectomy and axillary lymph node dissection notes that the client is wearing a
wedding band on her left ring finger. The nurse should:
A.
B.

Tape the wedding band in place Incorrect

Explain to the client why the wedding band must be

removed Correct
C.
D.

Ask the client whether she would like to remove the wedding
band or wear it to surgery

Ask the client to sign a release to free the hospital of

responsibility if the wedding band is lost during surgery
Rationale: In most situations a wedding band may be taped in place and worn
during a surgical procedure. However, if the possibility exists that the client will
experience swelling of the hand or fingers, the wedding band should be removed.
On admission to a healthcare facility, the client is asked to sign a form that frees
the agency from responsibility if a clients valuable is lost. After mastectomy with
axillary lymph node dissection, the client is at risk for lymphedema, which results

in swelling of the arm and hand on the affected side. Therefore the appropriate
nursing action is to ask the client to remove the wedding band and explain why.
Test-Taking Strategy: Use the process of elimination and focus on the data in the
question. Eliminate the options that are comparable or alike in that they indicate
that the client may wear the wedding band during the surgical procedure. Next,
recall the complications associated with mastectomy, which will direct you to the
correct option. Review preoperative procedures for a clients valuables if you had
difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
1387). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation

I.

Content Area: Perioperative Care

Awarded 0.0 points out of 1.0 possible points.
52.ID: 383693554
A nursing staff member approaches a nurse manager and announces that
another nurse is not using alcohol swabs to clean the intravenous port when
administering intravenous push medications. What is the appropriate way for the
nurse manager to handle this situation?
A.

Telling the nurse that it is inappropriate to report other nurses

B.

Providing an in-service educational session on aseptic

technique for everyone on the nursing unit

C.

Informing the nurse who reported the occurrence that

intravenous ports do not need to be cleaned with alcohol before medication
administration

D.

Reviewing the skills checklist of the nurse who is not using

aseptic technique to determine whether the nurse has ever performed this
skill and had her technique validatedCorrect
Rationale: Intravenous ports must be cleaned with alcohol (or another antiseptic
as designated by agency policy) before access. The nurse manager should
handle this problem directly with the nurse who is using incorrect technique by
first reviewing the nurses skills checklist to determine whether this skill has ever
been performed by the nurse and validated. There is no information in the
question to indicate that an in-service educational session is needed for everyone
on the nursing unit. As a part of professional responsibility to maintain quality
care, nurses are required to report instances of clinical incompetence.
Test-Taking Strategy: Use the process of elimination and your knowledge of the
principles of ensuring quality care for clients. Remember that it is best for the

nurse manager to deal directly with the employee who is exhibiting unacceptable
behavior. Review the principles of handling clinical incompetence if you had
difficulty with this question.
References: Huber, D. (2010). Leadership and nursing care management (4th
ed., pp. 531. 532). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 658, 660). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation

J.

Content Area: Leadership/Management

Awarded 1.0 points out of 1.0 possible points.
53.ID: 383691761
An emergency department nurse is performing an assessment of a client who
has sustained circumferential burns of both legs. What should the nurse assess
first?
A.

Heart rate

B.

Radial pulse rate

C.

Peripheral pulses Correct

D.
Blood pressure (BP)
Rationale: The client who has sustained circumferential burns to the extremities
is at risk for altered peripheral circulation. The priority assessment is to check the
peripheral pulses to ensure that circulation is adequate. Although the heart rate
and BP would also be assessed, the priority with a circumferential extremity burn
is the assessment of peripheral pulses.
Test-Taking Strategy: Eliminate the options that are comparable or alike first
(heart rate and radial pulse rate). To select from the remaining options, focus on
the strategic words first and circumferential burns of both legs. If you had
difficulty with this question or are unfamiliar with the priority assessment in a
client who has sustained a circumferential burn of an extremity, review this
content.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 1252). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation

Content Area: Delegating/Prioritizing

Awarded 1.0 points out of 1.0 possible points.
K. 54.ID: 383693550
A nurse is assisting a client with a closed chest tube drainage system in bathing.
As the nurse is turning the client onto his side, the chest tube is disconnected.
What should the nurse do first?
A.

Call the physician

B.

Clamp the chest tube with a Kelly clamp

C.

Instruct the client to inhale and hold his breath

D.

Submerge the end of the chest tube in a bottle of sterile

water Correct
Rationale: If the tube becomes disconnected, it is best to immediately reattach it
to the drainage system or to submerge the end in a bottle of sterile water or
saline solution to reestablish a water seal. The physician must be notified, but
this is not the first action. The client would not be instructed to inhale, because
this would cause atmospheric air to enter the pleural space. In most situations,
clamping of chest tubes is contraindicated. When the client has a residual air
leak or pneumothorax, clamping the chest tube may precipitate a tension
pneumothorax, because the air has no escape route.
Test-Taking Strategy: Use the process of elimination, noting the strategic word
first. Thinking about the principles related to a chest tube drainage system will
direct you to the correct option. Remember that if the tube is disconnected the
water seal must be reestablished. Review the immediate nursing actions related
to the complications associated with a closed chest tube drainage system if you
had difficulty with this question.
Reference: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 1624). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
L. 55.ID: 383691767
A nurse is planning to administer an oral antibiotic to a client with a
communicable disease. The client refuses the medication and tells the nurse that
the medication causes abdominal cramping. The nurse responds, The
medication is needed to prevent the spread of infection, and if you dont take it
orally I will have to give it to you in an intramuscular injection. Which of the
following statements accurately describes the nurses response to the client?

A.

The nurse could be charged with battery.

B.

The nurse could be charged with assault. Correct

C.

The nurse is justified in administering the medication by way of

the intramuscular route, because the client has a communicable disease.

D.

The nurse will be justified in administering the medication by

the intramuscular route once a prescription has been obtained from the
physician.
Rationale: Assault is an intentional threat to bring about harmful or offensive
contact. If a nurse threatens to give a client a medication that the client refuses
or threatens to give a client an injection without the clients consent, the nurse
may be charged with assault. Therefore the nurse is not justified in administering
the medication. Battery is any intentional touching without the clients consent.
Test-Taking Strategy: Focus on the data in the question and the nurses
statement. Note that the nurse threatens the client. Next, recall the definition of
assault, which will direct you to the correct option. Review violations of client
rights if you had difficulty with this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., pp. 172, 173). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
M. 56.ID: 383691742
A client asks a nurse about the procedure for becoming an organ donor. The
nurse tells the client:
A.

That anatomical gifts must be made in writing and signed by

the client Correct

B.

To speak with the chaplain about the psychosocial aspects of

becoming a donor

C.

That this decision must be made by the next of kin at the time
of the clients death

D.

To let the physician know about the request so that it may be

documented in the clients record Incorrect
Rationale: An individual who is at least 18 years old may make an anatomical gift
of all or part of the human body. The gift must be made in writing and signed by
the donor. If the client cannot sign, the document must be signed by another
individual and two witnesses. The physician is informed of the clients wishes and
the client may wish to speak to a chaplain, but the specific procedure requires a

written document signed by the client. The family of a deceased client may be
asked about organ donation, but this is not the procedure when a living person
wishes to become a donor.
Test-Taking Strategy: Use the process of elimination and focus on the subject, a
client requesting information about organ donation. Eliminate the option using
the closed-ended word must. To select from the remaining options, remember
that an anatomical gift must be made in writing and signed by the client. Review
the procedure for organ donation if you had difficulty with this question.
Reference: Marriner-Tomey, A. (2009). Guide to nursing management and
leadership (8th ed., pp. 498, 499). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
N. 57.ID: 383692407
A graduate nurse hired to work in a medical unit of a hospital is attending an
orientation session. The nurse educator, discussing care maps, asks the graduate
nurse whether she understands how a care map is used. Which response
indicates understanding?
A.

The care map is developed by a nurse and identifies nursing

diagnoses. Incorrect

B.

The care map is a plan that is used only by the nurse to

provide client care.

C.

The care map outlines the day-to-day expected outcomes of

care and the outcomes anticipated at discharge. Correct

D.

The care map is a standard plan, rather than an individualized

one, that is developed strictly by a nurse and used for a client with a
particular diagnosis.
Rationale: The care map is a type of critical pathway that incorporates expected
day-to-day client outcomes and those anticipated at discharge or at the end of a
treatment phase. It outlines clinical assessments, treatments and procedures,
dietary interventions, activity and exercise therapies, client education, and
discharge planning. It may identify nursing diagnoses but is developed by
members of all disciplines that normally care for the particular client type and is
used by all members of the interdisciplinary team. Continuity of care can be
achieved with the use of a care map.
Test-Taking Strategy: Eliminate the options that are comparable or alike in that
they refer to the care map as a nursing tool only. Also note that the correct option

is the umbrella option. Review the purpose and use of the care map if you had
difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
304, 549). St. Louis: Mosby.
Level of Cognitive Ability: Evaluation
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Evaluation
Content Area: Leadership/Management
Awarded 0.0 points out of 1.0 possible points.
O. 58.ID: 383692493
A client who had a stroke has left-side weakness and is having difficulty holding
utensils while eating. To which of these services does the nurse suggest a
referral?
A.

Home care

B.

Social services

C.

Physical therapy

D.
Occupational therapy Correct
Rationale: An occupational therapist assists a client who experiences impairment
in performing activities of daily living such as feeding him- or herself with the use
of an adaptive device. Home care provides a variety of support services for the
client and family, but the specific assistance needed for this client would be
provided by the occupational therapist. A social worker is trained to counsel
clients in a variety of areas and may assist with the financial aspects of care. A
physical therapist assists in examining, testing, and treating the physically
disabled or handicapped through the use of exercises and other techniques.
Test-Taking Strategy: Use the process of elimination and focus on the subject, the
need for assistance in eating. Recalling the functions and roles of the
occupational therapist and the other healthcare workers in the options will help
you answer correctly. Review the roles of the various healthcare team members if
you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patientcentered collaborative care (6th ed., p. 96). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation

Content Area: Leadership/Management

Awarded 1.0 points out of 1.0 possible points.
P. 59.ID: 383692409
A nurse has delegated several nursing tasks to staff members. The nurses
primary responsibility after delegation of the tasks is:
A.
B.

Documenting completion of each task

Assigning any tasks that were not completed to the next

nursing shift
C.

Allowing each staff member to make judgments when

performing the tasks

D.

Following up with each staff member regarding the

performance of the task and the outcomes related to implementation of the
task. Correct
Rationale: The ultimate responsibility for a task lies with the person who
delegated it. Therefore it is the nurses primary responsibility to follow up with
each staff member regarding the performance of the task and the outcomes
related to implementation of the task. Not all staff members have the education,
knowledge, and ability to make judgments about the tasks being performed. The
nurse would document that the task was completed, but this would not be done
until follow-up had been conducted and outcomes identified. It is not appropriate
to assign the tasks that have not been completed to the next nursing shift; this
action does not ensure that client needs will be met and also increases the
workload for the next shift.
Test-Taking Strategy: Use the process of elimination, noting the strategic words
primary responsibility. Recalling that the ultimate responsibility for a task lies
with the person who delegated it will direct you to the correct option. Review the
guidelines for delegation if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
309-311). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
Q. 60.ID: 383691765
The nurse notes that a physician has documented the following prescription in a
clients record: Furosemide (Lasix) 40 mg stat once. What action should the nurse
take?
A.

Contacting the physician Correct

B.

Administering the medication

C.

Drawing up the medication in a syringe

D.

Planning to have the nurse on the next shift administer the

medication
Rationale: The medication prescription must include the medication name, dose,
route of administration, time, and frequency of the administration. The nurse
would contact the physician and ask about the route of the medication. The
nurse would not prepare the medication or administer it without first checking
with the physician. A stat prescription must be administered immediately.
Therefore it is inappropriate to plan to have the nurse on the next shift
administer the medication.
Test-Taking Strategy: Read the prescription and think about the procedure for
fulfilling a prescription. This will reveal that the route of administration is not
specified. Review components of a medication prescription if you had difficulty
with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
713). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Medication Administration
Awarded 1.0 points out of 1.0 possible points.
R. 61.ID: 383692405
A married couple is attending a hospital program about in vitro fertilization.
During the program, a crew from a local television station arrives to film the
proceedings because the station is publicizing a series on hospital services. The
nurse conducting the program should:
A.
B.

Allow the television crew to videotape the program

Explain to the television crew that videotaping is not

allowed Correct
C.
D.

Ask the television crew to interview the individuals attending

the program individually

Allow the television crew to videotape the program as long as

they do not publicize that the program is about in vitro fertilization
Rationale: Privacy is a clients right to be free from unwanted intrusion into his or
her private affairs. Videotaping constitutes an invasion of a clients privacy, and
written permission is required from the client for an action such as photographing
or videotaping. Therefore the nurse must explain to the television crew that
videotaping is not allowed. The other options are incorrect and constitute

invasions of client privacy.

Test-Taking Strategy: Focus on the subject, client privacy. Eliminate the options
that are comparable or alike in that they represent invasions of client privacy.
Review violations of client privacy if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
331). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
S. 62.ID: 383694058
A nurse manager tells the nursing staff that they will need to comply with the
mandatory overtime policy that the hospital has implemented. Later that day,
the nurse manager overhears a nurse complaining about the policy and telling
other nurses that she will not work the overtime if she has made other plans after
her regular shift. What is the best approach for the nurse manager to use in
dealing with the conflict?
A.
B.
C.

Ignoring the complaints

Avoiding assigning the nurse mandatory overtime

Confronting the nurse regarding her behavior regarding the

overtime policy Correct

D.

Providing a positive reward system for the nurse so that the

nurse will agree to work the mandatory overtime
Rationale: Confrontation is an important strategy for addressing resistance by a
staff member who is complaining about an agency protocol. Face-to-face
meetings to confront the issue at hand will allow verbalization of feelings and
identification of problems and issues, and give the nurse manager the
opportunity to develop strategies to solve the problem. Ignoring the complaints
and avoiding assigning the nurse mandatory overtime are inappropriate
strategies that do not address the problem. Providing a positive reward system
might provide a temporary solution to the resistance but will not specifically
address the problem.
Test-Taking Strategy: Note the strategic word best in the query of the question
and focus on the subject, dealing with conflict. Eliminate the options that ignore
the nurses complaints. To select from the remaining options, look for the option
that specifically addresses the subject and provides problem-solving measures. If
you had difficulty with this question, review the strategies associated with
dealing with conflict.

Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
p. 68). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
T. 63.ID: 383692401
A client with diabetes mellitus who takes a daily dose of NPH insulin has a hard
time drawing the insulin into a syringe because he has difficulty seeing the
markings on the syringe. To which of the following services does the nurse
suggest a referral?
A.

Home care Correct

B.

Social services

C.

Physical therapy

D.
Occupational therapy
Rationale: Home care provides a variety of support services for the client and
family, including assistance with the administration of insulin. For the client who
has difficulty drawing insulin into a syringe, the home care nurse would prefill a
weeks supply of syringes containing the required dose. These syringes would be
placed in the clients refrigerator for self-administration by the client. A social
worker is trained to counsel clients in a variety of areas and may assist with the
financial aspects of care. A physical therapist assists in examining, testing, and
treating the physically disabled or handicapped through the use of exercises and
other techniques. An occupational therapist assists a client who experiences
impairment in performing activities of daily living such as feeding him- or herself
with the use of an adaptive device.
Test-Taking Strategy: Use the process of elimination and focus on the subject, the
need for assistance with insulin administration. Recalling the functions and roles
of the home care nurse and the healthcare workers in the other options will help
you answer correctly. Review the roles of various healthcare team members if
you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patientcentered collaborative care (6th ed., p. 96). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation

Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
U. 64.ID: 383691799
A nurse is assigned to care for four clients. Which client should the nurse assess
first?
A.

A client scheduled for a colonoscopy

B.

A client preparing for discharge after surgery

C.

A client requiring a tube feeding through a gastrostomy tube

D.

A client with a tracheostomy who is receiving humidified

oxygen by way of a tracheostomy mask Correct
Rationale: Airway is always the priority, so the nurse would attend to the client
who has a condition related to airway first. The other clients do not have
conditions related to the airway and represent intermediate priorities.
Test-Taking Strategy: Use the ABCs airway, breathing, and circulation to
answer the question. The client with a tracheostomy is the only client with an
airway problem. Remember that airway is always the first priority. Review the
guidelines for prioritization if you had difficulty with this question.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., p. 510). St. Louis: Mosby.
Huber, D. (2010). Leadership and nursing care management (4th ed., p. 128). St.
Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
V. 65.ID: 383693538
The registered nurse has accepted a new position as case manager in a hospital.
Which of the following responsibilities are part of the nurses new role? Select all
that apply.
A.

Evaluating and updating the plan of care as needed Correct

B.

Prescribing treatments specific to the clients needs

C.

Assessing the clients needs for home supplies and

equipment Correct

D.

Coordinating consultations and referrals to facilitate

discharge Correct

E.

Establishing a safe and cost-effective plan of care with the

client Correct
Rationale: A case manager is a nurse who assumes responsibility for coordinating
the client's care from the point of admission through, and after, discharge.
Specific responsibilities of the case manager include establishing a safe and costeffective plan of care with the client, coordinating consultations and referrals,
and facilitating discharge; initiating a plan of nursing care, care map, or clinical
pathway as appropriate to guide care and evaluating and updating the plan of
care as needed; ensuring that the plan of care is tailored to the clients needs,
taking into account the clients diagnosis, self-care ability, and prescribed
treatments; assessing the clients need for equipment such as oxygen or wound
care supplies and exploring available resources to provide the client with these
supplies; providing resources that will assist the client in maintaining
independence as much as possible; and providing the client with information on
discharge procedures and the plan of care. The nurse does not prescribe
treatments.
Test-Taking Strategy: Focus on the subject, the responsibilities of the case
manager. Note the word prescribing in the incorrect option. It is not within the
role of the nurse to prescribe. Review the responsibilities of the case manager if
you have difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 21).
St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
W. 66.ID: 383692432
A registered nurse (RN) must determine how best to assign co-workers (another
RN and one licensed practical nurse [LPN]) to provide care to a group of clients.
Which of the following is the best assignment?
A.

The RN is assigned to care for a woman with newly diagnosed

leukemia who has a newborn at home. Correct

B.

The LPN is assigned to provide discharge teaching about

dressing changes and medications to a 35-year-old man.

C.

The LPN is assigned to care for a client with newly diagnosed

diabetes mellitus who will need to be taught how to self-administer insulin.

D.

The RN is assigned to care for a 75-year-old woman,

hospitalized for dehydration, who is being discharged home today with no
medications.

Rationale: To determine what may and may not be delegated to the various coworkers, the RN making the assignment must take into account several factors:
the level of care required by each client, both immediately and in the future; the
competencies possessed by the co-workers; and the legal limitations on the
practice of those co-workers. Self-administration of insulin and discharge
instructions on dressing changes and medications require teaching, a
professional responsibility that the RN may not delegate to anyone except
another RN. Although the RN might care for a client being discharged, the
question tells you that an LPN is available. The RN would be best used to care for
the client with more critical or complicated needs. Assigning an RN to a client
who is being discharged with no medications is, therefore, incorrect. The client
with newly diagnosed leukemia who has a newborn at home is likely to be in
need of the skills of an RN in terms of both physiological and psychosocial needs,
making this an appropriate assignment.
Test-Taking Strategy: Use the process of elimination, noting the strategic word
best. Eliminate the options in which the LPN is assigned to a client requiring
teaching. To select from the remaining options, focus on each client and think
about his or her actual and potential needs. The RN is best assigned to the client
with physiological and psychosocial needs. Review the guidelines for delegation
and assignment-making if you had difficulty with this question.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., pp. 406-408, 418). St. Louis: Mosby.
Huber, D. (2010). Leadership and nursing care management (4th ed., p. 243). St.
Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
X. 67.ID: 383692413
A nurse is preparing the client assignments for the day. One of the registered
nurses on the team has just learned that she is pregnant. Which client does the
nurse refrain from assigning to the pregnant team member?
A.
B.

A client with a solid sealed cervical radiation implant Correct

A client with diarrhea for whom enteric precautions are in effect

C.

A client with metastatic cancer who is receiving a continuous

infusion of intravenous morphine sulfate

D.

A client for whom contact precautions have been implemented

and who requires frequent wound irrigations

Rationale: Brachytherapy involves the implantation of a sealed radiation source

within the targeted tumor tissue. A client who is wearing a solid implant emits
radiation as long as the implant is in place; however, the clients excreta is not
radioactive. Pregnant nurses should not care for such clients. There are no
contraindications to having a pregnant nurse care for a client under enteric
precautions, a client with cancer who is receiving a continuous infusion of
intravenous therapy, or a client who requires frequent wound irrigation.
Test-Taking Strategy: Use the process of elimination, noting the strategic word
avoids. This word indicates a negative event query and the need to select the
client situation that could present a risk to a pregnant client. Thinking about the
risks associated with each client listed in the options will direct you to the correct
one. Review the guidelines associated with caring for a client with a sealed
radiation implant if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 420). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
Y. 68.ID: 383691789
A nurse is providing a change-of-shift report on his assigned clients, using an
audiotape. Which of the following pieces of information should the nurse include
in the report about each assigned client? Select all that apply.
A.

Family history

B.

Client needs and priorities of care Correct

C.

Current diagnosis and any secondary diagnoses Correct

D.

Results of laboratory studies conducted that day Correct

E.

Client response to treatments implemented that day Correct

F.

The steps used to perform the procedure for changing the

clients sterile dressing at the gastrostomy tube site
Rationale: A change-of-shift report ensures continuity of care among nurses
caring for a client and informs the nurse on the next shift about the client's needs
and priorities for care. It may be given written, orally, by audiotape, or while the
nurses are walking rounds at a client's bedside. The report should describe the
client's health status, current and secondary diagnoses, results of laboratory or
diagnostic studies done that day, and the clients response to treatments
implemented that day. The clients family history does not need to be described
in a change-of shift report, and doing so would take time. If such information is

needed by the oncoming nurse, it may be obtained from the clients medical
record. There is no useful reason for describing a routine procedure; this would
also take time, and the information is available in the agency procedure manual.
Test-Taking Strategy: Focus on the subject, what to include in the change-of-shift
report. Read each option carefully and eliminate family history, because it is not
directly related to the clients current status. Next eliminate the option that
involves describing the steps in performing a procedure, because this is routine
information. Also note that the correct options are client focused. Review the
components of a change-of-shift report if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp.
400-402). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
Z. 69.ID: 383694044
A nurse is reviewing the notes written by a nurse on a previous shift. Which note
in the clients record reflects the correct use of guidelines for documentation?
A.

The client seems anxious

B.

The clients intake was 360 mL Correct

C.

The clients wound is healing well

D.
The client is voiding large amounts
Rationale: Quality documentation and reporting have five important
characteristics: factual, accurate, complete, current, and organized. Using an
accurate measurement of intake is correct. The use of the word seems
indicates that the nurse did not know the facts. Using the word well is also
incorrect, because it does not provide an accurate observation. Likewise, using
the word large does not provide an accurate measurement.
Test-Taking Strategy: Recall the characteristics of quality documentation and
reporting. Also note that the correct option is the only one that is specific. Review
the guidelines for documentation if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
388). St. Louis: Mosby.
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Evaluation

Content Area: Communication and Documentation
Awarded 1.0 points out of 1.0 possible points.
AA.70.ID: 383694050
The nurse is preparing client assignments for the day. Which client should the
nurse assign to a nursing assistant?
A.

A client scheduled for a liver biopsy

B.

An unconscious client who requires oral care Correct

C.

A client who has just undergone cardiac catheterization

D.

A client who is getting up to ambulate for the first time after

surgery
Rationale: The registered nurse is legally responsible for client assignments and
must assign tasks on the basis of the guidelines of the state nursing practice act
and the job descriptions set forth by the employing agency. Oral care may be
delegated to a nursing assistant. The nurse would provide instructions to the
nursing assistant regarding the task, how to adapt the procedure for the client at
risk for aspiration, and the signs of complications that must be reported
immediately (e.g., bleeding gums, excessive coughing). A client who has just
undergone cardiac catheterization requires monitoring for complications, and a
client scheduled for liver biopsy requires preparation for the test and client
teaching. A client who is getting up to ambulate for the first time after surgery is
at risk for orthostatic hypotension and should be assisted by a licensed nurse.
Test-Taking Strategy: Note that the question asks for the assignment to be
delegated to the nursing assistant. When asked questions related to delegation,
think about the role description of the employee and the needs of the client. For
the nursing assistant, select the client who has needs that do not require a high
skill level, meaning that assessment, teaching, and monitoring are not
appropriate. Note that two of the incorrect options are comparable or alike in that
they identify clients who have undergone invasive procedures. Review the
guidelines related to delegation to a nursing assistant if you had difficulty with
this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., pp. 405-407). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.

AB.71.ID: 383691787
A nurse employed in a community hospital as a nurse manager understands that
in this position, the term authority most appropriately refers to:
A.

Being responsible for what staff members do

B.

Accepting the responsibility for the actions of others

C.

Carrying the legal responsibility for others performance of

tasks

D.

The official power to see that an organizational decision is

enforced Correct
Rationale: The term authority refers to the official power of an individual to
approve or command an action or to see that a decision is enforced. Being
responsible for what staff members do, accepting responsibility for the action of
others, and carrying legal responsibility for others are not related to the
description of a position of authority.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the
description of a position of authority. Note the relationship between the word
authority in the question and power in the correct option. Also note that the
incorrect options are comparable or alike in that they involve responsibility.
Review the description of authority if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 10).
St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
AC.72.ID: 383693540
A registered nurse (RN) has received the assignment for the day shift. Once the
RN has made initial rounds and checked all of the assigned clients, which client
will she plan to care for first?
A.

A client who is scheduled for surgery at 1 pm Correct

B.

A client scheduled for physical therapy at 11 am

C.

A client in skeletal traction who has just received pain

medication Incorrect

D.

A client who is able to perform activities of daily living

independently
Rationale: For the client assignment presented, the RN would plan to care for the
client who is scheduled for surgery at 1 pm first. Several items need to be
addressed before surgery, including client preparation (physical and emotional)

and physician prescriptions, all of which will take time. Also, many times the
operating room will make late changes in the schedule, depending on room and
physician availability, and will request an earlier surgical time. Therefore it is best
to ensure that this client is prepared. It is best to wait for pain medication to take
effect before providing care to a client. The needs of the client who is
independent and the client scheduled for physical therapy later in the morning
are not high priorities.
Test-Taking Strategy: Use the process of elimination and principles related to
prioritization. Focus on the subject, the client for whom the RN will care first.
Noting that an assigned client is scheduled for surgery and recalling the many
needs of a client about to undergo surgery will direct you to the correct option.
Review the principles of prioritizing if you had difficulty with this question.
References: Huber, D. (2010). Leadership and nursing care management (4th
ed., p. 128). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 374, 375). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
AD.
73.ID: 383692483
A 17-year-old client arrives at the clinic and asks to be examined because she
believes that she has contracted a sexually transmitted infection. In regard to
informed consent, the nurse tells the client that:
A.
B.

She will need to sign an informed consent form Correct

Her mother or father will need to be contacted for permission

to treat her
C.

Anyone over the age of 18 years may sign a consent form for
her treatment

D.

A consent form is not needed if the problem is a sexually

transmitted infection
Rationale: Informed consent is a persons agreement to allow something, such as
a treatment, to be performed. A consent form is needed if the problem is a
sexually transmitted infection. If the client is a minor, he or she may sign the
informed consent in the following situations: if the client is an emancipated
minor; if the client is seeking birth control services or is pregnant; if the client is
seeking treatment for a sexually transmitted infection, drug or substance abuse,
or psychiatric services; or if a court order or other legal authorization has been
obtained.

Test-Taking Strategy: Eliminate the options that are comparable or alike in that
they indicate that the consent form must be signed by another individual. To
select from the remaining options, recall that a consent form is required for
treatment. Review the issues related to informed consent if you had difficulty
with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 63,
333). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
AE.74.ID: 383693560
A nurse enters a clients room to administer a medication that has been
prescribed by the physician. The client asks the nurse about the medication.
Which response by the nurse is appropriate?
A.

Its to help get rid of the swelling in your feet.

B.

You need to discuss this medication with your physician.

C.

I know that its for fluid buildup, and I think youve taken it
before.

D.

Its called furosemide (Lasix), and it will promote urination and

rid your body of the excess fluid. It can cause an alteration in electrolyte
levels, so well need to increase the potassium in your diet. Correct
Rationale: A client has the right to be informed of the medication name, purpose,
action, and potential undesirable effects of a prescribed medication. The nurse
should provide adequate information to the client. Therefore, the appropriate
response is the one that is thorough and complete. Referring the client to the
physician places the clients question on hold. The remaining options are
incomplete.
Test-Taking Strategy: Note the strategic word appropriate. Eliminate the option
that refers the client to the physician, because it places the clients question on
hold. To select from the remaining choices, find the option that is most complete
and thorough. Review client rights in regard to the provision of information about
medication if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
709). St. Louis: Mosby.
Cognitive Ability: Applying

Client Needs: Safe and Effective Care Environment

Integrated Process: Teaching and Learning
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
AF. 75.ID: 383692462
A nurse manager is planning client assignments for the day. Which of the
following clients should the nurse assign to the nursing assistant (unlicensed
assistive personnel)?
A.

A client scheduled for a cardiac stress test

B.

A client who had a mastectomy 2 days ago

C.

A client scheduled for a laparoscopic cholecystectomy Incorrect

D.
A client with renal calculi whose urine must be strained Correct
Rationale: The registered nurse is legally responsible for client assignments and
must assign tasks on the basis of the guidelines of the state nursing practice act
and the job descriptions set forth by the employing agency. The nursing assistant
has been trained to collect and strain urine. The nurse manager would provide
instructions to the nursing assistant regarding the task, but the task is within the
role description of a nursing assistant. A client scheduled for a cardiac stress test
requires preparation for the test, teaching, and postprocedure monitoring. A
client scheduled for surgery will require preoperative preparation, including
teaching. A client who underwent mastectomy 2 days earlier will need both
physiological and psychosocial care, requiring the skills of a licensed nurse.
Test-Taking Strategy: Note that the question asks for the assignment to be
delegated to the nursing assistant. When asked questions related to delegation,
think about the role description of the employee and the needs of the client. For
the nursing assistant, select the client who has needs that are noninvasive and
do not require a high level skill, meaning that assessment, teaching, and
monitoring are inappropriate tasks. Review the guidelines related to delegation to
a nursing assistant if you had difficulty with this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., pp. 405-407). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
AG.
76.ID: 383692446

A nurse on the night shift is making client rounds. When the nurse checks a client
who is 97 years old and has successfully been treated for heart failure, he notes
that the client is not breathing. If the client does not have a do-not-resuscitate
(DNR) order, the nurse should:
A.

Call the clients physician

B.

Contact the nursing supervisor for directions

C.

Administer cardiopulmonary resuscitation (CPR) Correct

D.
Administer oxygen to the client and call the physician
Rationale: CPR is an emergency treatment that is provided without client consent
unless a DNR order is part of the clients record. Calling the nursing supervisor for
directions, administering oxygen to the client, and calling the physician are all
inappropriate actions that would delay necessary treatment.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike in that they delay necessary treatment. Review
procedures related to CPR and DNR orders if you had difficulty with this question.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., p. 177). St. Louis: Mosby.
Marriner-Tomey, A. (2009). Guide to nursing management and leadership (8th
ed., pp. 497-498). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 0.0 points out of 1.0 possible points.
AH.
77.ID: 383694098
A nursing instructor asks a nursing student to describe accountability. Which
statement(s) by the student indicate(s) an accurate description of
accountability? Select all that apply.
A.

Accountability can be delegated.

B.

You are responsible for your own actions. Correct

C.

It carries legal implications for task performance. Correct

D.
E.

You must answer for the care that you ask others to
complete. Correct
It refers to the process of answering or being responsible for

what occurs. Correct

Rationale: Accountability, the process of answering or being responsible for what
occurs, carries legal implications for task performance. Accountability cannot be
delegated; one is responsible for ones own actions and must answer for the care

given, as well as for the care one asks others to complete.

Test-Taking Strategy: Focus on the subject, the definition of accountability.
Recalling this definition will easily direct you to the correct options. Review the
definition of accountability if you had difficulty with this question.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 249, 250). St. Louis: Saunders.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
AI. 78.ID: 383693566
A client who has undergone a total hip replacement is told that she will need to
go to an extended care rehabilitation facility for therapy before going home.
Which member of the healthcare team does the nurse ask to plan the discharge
and transition from the hospital to the rehabilitation facility?
A.

Clergy

B.

Social worker Correct

C.

Physical therapist

D.
Occupational therapist
Rationale: A social worker is trained to counsel clients in a variety of areas.
Counseling services may include providing emotional support for clients and
families during severe and terminal illnesses, arranging placement in extended
care facilities, and locating financial resources. Clergy (pastoral care) offer
spiritual support and guidance to clients and families. A physical therapist assists
in examining, testing, and treating the physically disabled or handicapped
through the use of exercises and other techniques. An occupational therapist
assists a client who experiences impairment in performing activities of daily
living such as feeding him- or herself with the use of an adaptive device.
Test-Taking Strategy: Use the process of elimination and focus on the subject,
discharge planning. Recalling the functions and roles of the social worker and the
other members of the healthcare team presented in the options will direct you to
the correct option. Review the roles of the various healthcare team members if
you had difficulty with this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., p. 536). St. Louis: Mosby.
Cognitive Ability: Applying

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
AJ. 79.ID: 383694022
A nurse, newly employed by a home health agency, is told that the organizations
decision-making process is centralized. The nurse determines that this means
that the authority to make decisions is vested in:
A.

Every employee

B.

A few individuals, such as the board of directors Correct

C.

All nursing employees, pharmacists, and hospital physicians

D.

Many individuals, with decisions filtering down to the individual

employee
Rationale: Organizations may be described as having a centralized or
decentralized structure in regard to the decision-making process. An organization
is depicted as centralized when the authority to make decisions is vested in a few
individuals. Conversely, when the decision-making involves a number of
individuals, with decisions filtering down to the individual employee, the
organization is said to operate in a decentralized fashion.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike in that they indicate that several people associated with
the organization make decisions. Review the differences between centralized and
decentralized organizations if you had difficulty with this question.
Reference: Marriner-Tomey, A. (2009). Guide to nursing management and
leadership (8th ed., pp. 278-280). St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
AK.80.ID: 383692454
A nurse sees another nurse changing an intravenous (IV) solution because the
wrong solution is infusing into the client. The nurse who changed the IV solution
does not report the error. What should the nurse who observed the error do first?
A.
B.

Call the clients physician

Document the error in the clients chart

C.

Report the nurse who changed the IV solution Incorrect

D.
Ask the nurse whether she intends to report the error Correct
Rationale: The first thing the nurse who observed the error should do is ask the
nurse whether she intends to report the error. As means of helping ensure client
safety, all errors must be reported to the physician, but this is not the initial
action. The client also needs to be assessed immediately. An incident report
should be completed by the nurse who discovered the error (the nurse who
changed the intravenous solution). The appropriate documentation also must be
made in the clients record by the nurse who discovered the error. If the nurse
who discovered the error indicates that the error will not be reported, it may be
necessary for the other nurse to contact the supervisor.
Test-Taking Strategy: Use the process of elimination, noting the strategic words
do first. Eliminate the options that are comparable or alike in that they involve
reporting the error. To select from the remaining options, think about the
principles of dealing with conflict. This will direct you to the direct option. Review
nursing responsibilities when an error occurs if you had difficulty with this
question.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., pp. 405, 406). St. Louis: Mosby.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 820). St. Louis:
Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 0.0 points out of 1.0 possible points.
AL. 81.ID: 383693574
A physician repeatedly asks a nurse to write his verbal prescriptions in his clients
charts after he makes his rounds. The nurse is uncomfortable with writing the
prescriptions and explains this to the physician, but the physician tells the nurse
that she will be reported if she does not write the prescriptions. How should the
nurse manage this conflict?
A.

Fulfilling the physicians request

B.

Discussing the situation with the nurse manager Correct

C.

Reporting the physician to the chief of medicine at the hospital

D.

Stating to the physician, I dont really care whether you report

me. I am not writing your prescriptions.
Rationale: When a conflict arises, it is most appropriate to try resolving the
conflict directly. In this situation, the nurse has tried to explain why she is

uncomfortable with the physicians request but has been unable to resolve the
conflict. The nurse would then most appropriately use organizational channels of
communication and discuss the issue with the nurse manager, who would then
proceed to resolve the conflict. The nurse manager may attempt to discuss the
situation with the physician or seek assistance from the nursing supervisor.
Fulfilling the physicians request and writing the prescriptions in the clients
charts ignores the issue. Reporting the physician to the chief of medicine is
inappropriate, because the nurse should use the appropriate organizational
channels of communication to resolve the conflict. Stating, I dont care whether
you report me. I am not writing your prescriptions is an inappropriate statement
and will result in further conflict between the nurse and physician.
Test-Taking Strategy: Use the process of elimination. First eliminate the option
that ignores the subject. Next eliminate the option that will result in further
conflict between the nurse and physician. To select from the remaining options,
think about the appropriate use of the organizational channels of communication;
this will direct you to the correct option. Review the principles of managing
conflict if you had difficulty with this question.
Reference: Marriner-Tomey, A. (2009). Guide to nursing management and
leadership (8th ed., pp. 153-155). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
AM.
82.ID: 383693564
A nurse calls a physician to question a prescription written for a higher-thannormal dosage of morphine sulfate. The physician changes the prescription to a
dosage within the normal range, and the nurse documents the new telephone
prescription in accordance with the agencys guidelines in the clients record.
Which other statement does the nurse document in the nursing notes?
A.

The physician was called to clarify the prescription for

morphine sulfate. Correct

B.

The physician made an error in the written prescription for

morphine sulfate.

C.

The physician was called to correct an error in the dosage of

morphine sulfate.

D.

An incorrect dosage of morphine sulfate was prescribed and the

physician was notified.
Rationale: The nurse needs to document a factual, descriptive, and objective
statement that does not include words indicating that an individual made an

error or performed an incorrect action or procedure. If a physicians prescription

must be questioned, the nurse should record that clarification regarding the
prescription was sought.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike in that they indicate that the physician made an error in
writing a prescription. These options contain the words error or incorrect.
Review the principles of documentation if you had difficulty with this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., pp. 388-390). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
AN.
83.ID: 383693588
A client with terminal cancer is receiving a continuous intravenous infusion of
morphine sulfate. On assessment of the client, what does the nurse check first?
A.

Pulse

B.

Urine output

C.

Temperature

D.
Respiratory status Correct
Rationale: Morphine sulfate depresses respiration, so the nurse must monitor the
clients respiratory status closely. Although the incorrect options may be
components of the assessment, checking respiratory status is the priority nursing
action.
Test-Taking Strategy: Use the process of elimination, noting the strategic word
first. Use the ABCs airway, breathing, and circulation to guide you to the
correct option. Review priority nursing interventions in the care of a client
receiving morphine sulfate if you had difficulty with this question.
Reference: Gahart, B., & Nazareno, A. (2010). Intravenous medications (26th ed.,
pp. 928, 930). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation

Content Area: Leadership/Management

Awarded 1.0 points out of 1.0 possible points.
AO.
84.ID: 383691793
A physician informs a nurse that the husband of an unconscious client with
terminal cancer will not grant permission for a do-not-resuscitate (DNR) order.
The physician tells the nurse to perform a slow code and let the client rest in
peace if she stops breathing. How should the nurse respond?
A.

Telling the physician that slow codes are not

acceptable Correct

B.

Telling the physician that the client would probably want to die
in peace

C.

Telling the physician that all of the nurses on the unit agree
with this plan

D.

Telling the physician that if the client stops breathing, the

physician will be called before any other actions are taken
Rationale: The nurse may not violate a familys request regarding the clients
treatment plan. A slow code is not acceptable, and the nurse should state this
to the physician. The definition of a slow code varies among healthcare
facilities and personnel and could be interpreted as not performing resuscitative
procedures as quickly as a competent person would. Resuscitative procedures
that are performed more slowly than recommended by the American Heart
Association are below the standard of care and could therefore serve as the basis
for a lawsuit. The other options are therefore inappropriate.
Test-Taking Strategy: Focus on the information in the question specifically, that
the spouse will not grant permission for a DNR order. Recalling the procedures for
CPR and the ethical/legal guidelines for a DNR order will direct you to the correct
option. Review the nurses responsibility regarding DNR orders if you had
difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 113). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
AP. 85.ID: 383694071
A nurse is planning client assignments for the day. Which of the following
assignments is the least appropriate for the nursing assistant?
A.

Assisting a client with dysphagia in eating Correct

B.

Providing hygiene to a client with dementia

C.

Ambulating a client with Parkinsons disease

D.

Assisting a client with an above-the-knee amputation in

showering
Rationale: The nurse must determine the most appropriate assignment on the
basis of the skills of the staff member and the needs of the client. In this case,
the least appropriate assignment for a nursing assistant would be assisting a
client with dysphagia with eating because of the risk of complications such as
choking and aspiration. The remaining three situations include no data to
indicate that these tasks carry any unforeseen risk.
Test-Taking Strategy: Note the strategic words least appropriate. Use the ABCs
airway, breathing, and circulation and recall the principles of delegation and
supervision of tasks in answering the question. Remember, delegation of work
must be consistent with the individuals level of expertise and licensure or lack of
licensure. Review the principles of assignments and delegation if you had
difficulty with this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., pp. 405-407). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
AQ.
86.ID: 383691779
A nurse who works in a medical care unit is told that she must float to the
intensive care unit because of a short-staffing problem on that unit. The nurse
reports to the unit and is assigned to three clients. The nurse is angry with the
assignment because she believes that the assignment is more difficult than the
assignment delegated to other nurses on the unit and because the intensive care
unit nurses are each assigned only one client. The nurse should most
appropriately:
A.

Refuse to do the assignment

B.

Tell the nurse manager to call the nursing supervisor

C.

Ask the nurse manager of the intensive care unit to discuss the
assignment Correct

D.

Return to the medical care unit and discuss the assignment

with the nurse manager on that unit
Rationale: A nurse who feels that the assignment is more difficult than the
assignments delegated to other nurses on the unit would most appropriately

discuss the assignment with the nurse manager of the intensive care unit. This
will help the nurse identify the rationale for the assignment or determine whether
the assignment is actually more difficult. A nurse would not refuse an
assignment. The nurse would not return to the medical care unit, which would
constitute client abandonment. Additionally, this action does not address the
conflict directly. Telling the nurse manager to call the nursing supervisor is an
aggressive action that does not address the conflict directly.
Test-Taking Strategy: Focus on the subject, dealing with conflict. Refusing to
perform the assignment is unethical and could be grounds for dismissal. Leaving
the nursing unit constitutes client abandonment and could also result in
dismissal. From the remaining options, select the option in which the conflict is
dealt with directly. Review the appropriate methods of dealing with a conflict if
you had difficulty with this question.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., pp. 163, 164). St. Louis: Mosby.
Marriner-Tomey, A. (2009). Guide to nursing management and leadership (8th
ed., pp. 153, 154). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
AR.87.ID: 383693534
A nurse is performing suctioning through an adult clients tracheostomy tube.
The nurse notes that the clients oxygen saturation is 89% and terminates the
procedure. Which action would the nurse take next?
A.

Calling the physician

B.

Calling the respiratory therapist

C.

Rechecking the pulse oximetry reading

D.
Oxygenating the client with 100% oxygen Correct
Rationale: The nurse should monitor the clients heart rate and pulse oximetry
during suctioning to assess the clients tolerance of the procedure. Oxygen
desaturation to below 90% indicates hypoxemia. If hypoxia occurs during
suctioning, the nurse must terminate the procedure and oxygenate the client
with 100% oxygen. Although the nurse would monitor the clients pulse oximetry,
an improvement would not be expected until the client is reoxygenated. It is not
necessary to contact the physician or the respiratory therapist at this time.
Test-Taking Strategy: Use the ABCs airway, breathing, and circulation to
answer the question. This will direct you to the correct option. Review the

complications associated with suctioning and the appropriate nursing

interventions if you had difficulty with this question.
Reference: Ignatavicius, D., & Workman, M. (2010). Medical-surgical
nursing: Patient-centered collaborative care (6th ed., p. 584). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Delegating/Prioritizing
Awarded 1.0 points out of 1.0 possible points.
AS.88.ID: 383693506
A client with cancer is transported to the radiology department for a bone scan to
determine whether the cancer has metastasized to bone. While the client is in
the radiology department, the clients wife arrives for a visit and asks what test is
being performed on the client. What should the nurse tell the wife?
A.
B.

A bone scan is being performed.

She will have to discuss the prescribed test with the

client. Correct
C.

The radiology department is not clear as to which test has been

prescribed.

D.

She can read the clients medical record to determine what the
physician prescribed.
Rationale: Unless a client consents, a nurse may not disclose confidential
information to anyone else. Therefore the appropriate response is to tell the
clients wife that she will have to discuss the test with the client. Likewise, a
clients medical record is confidential and cannot be given to the wife for reading.
Telling the clients wife that the radiology department is unclear as to what test
has been prescribed is inappropriate. The nurse must not place the responsibility
or accountability for a prescribed test on another department.
Test-Taking Strategy: Use the process of elimination. Focusing on the subject,
confidentiality, and recalling the issues surrounding confidentiality will direct you
to the correct option. Review the issues surrounding confidentiality if you had
difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
315). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Implementation

Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
AT. 89.ID: 383691769
A nurse manager has announced a change to computerized documentation of
nursing care. A licensed practical nurse (LPN) on the team, resistant to the
change, is not taking an active part in facilitating implementation of the new
procedure. Which of the following strategies would be the best approach to
dealing with the conflict?
A.

Ignoring the resistance

B.

Telling the LPN that his noncompliance will be documented in

his personnel record

C.

Confronting the LPN and encouraging him to express his

feelings regarding the change Correct

D.

Telling the LPN that a registered nurse will perform all of the
computer documentation if he will document all intake and output and vital
signs
Rationale: Confrontation is an important strategy in dealing with resistance. Faceto-face meetings to confront the issue at hand allow verbalization of feelings,
identification of problems and issues, and development of strategies to solve the
problem. Ignoring the resistance does not address the problem. Providing a
temporary solution to the resistance by having the registered nurse do all of the
computer work and having the LPN perform only specific documentation will not
specifically address the concern. Telling the LPN that the noncompliance will be
documented in his personnel record may produce additional resistance.
Test-Taking Strategy: Focus on the subject, the best approach to dealing with a
conflict. Use the process of elimination and eliminate the options that are
comparable or alike in that they represent direct avoidance of the conflict. If you
had difficulty with this question, review the best approaches to with dealing with
conflict.
References: Huber, D. (2010). Leadership and nursing care management (4th
ed., p. 287). St. Louis: Saunders.
Marriner-Tomey, A. (2009). Guide to nursing management and leadership (8th
ed., pp. 326, 327). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.

AU.
90.ID: 383693578
The nursing instructor asks a student to name an example of false imprisonment.
Which of the following situations reflects a violation of this client right?
A.
B.

Performing a procedure without consent

Telling the client that he or she may not leave the

hospital Correct

C.

Threatening to give a client a medication against his or her will

D.

Observing the provision of care to the client without the clients

permission
Rationale: Telling a client that he or she may not leave the hospital constitutes
false imprisonment. Performing a procedure without consent is an example of
battery. Threatening to give a client a medication against his or her will is
assault. Invasion of privacy takes place with unreasonable intrusion into an
individuals private affairs. Observing the provision of care to a client without the
clients permission is an example of invasion of privacy.
Test-Taking Strategy: Focus on the subject, an example of false
imprisonment. Note the relationship of the subject and the words in the correct
option. If you had difficulty with this question, review the concept of false
imprisonment.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., pp. 175, 176). St. Louis: Mosby.
Zerwekh, J., & Claborn, J. (2009). Nursing today: Transition and trends (6th ed., p.
424).
Cognitive Ability: Evaluating
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
AV. 91.ID: 383692489
A client scheduled for surgery tells the nurse that he signed an informed consent
for the surgical procedure but was never told about the risks of the surgery. The
nurse serves as the clients advocate by:
A.
B.

Reassuring the client that the risks are minimal

Calling the surgeon and asking that the risks be explained to

the client Correct

C.

Noting in the clients record that the client was not told about
the risks of the surgery

D.

Writing a note on the front of the clients record so that the

surgeon will see it when the client arrives in the operating room

Rationale: A nurse serves as a client advocate by protecting the right of the client
to be informed and to participate in decisions regarding care. The only option
that ensures that the client will be informed of the risks of the surgery is
contacting the surgeon and asking that the risks be explained to the client.
Telling the client that the risks are minimal is false reassurance. Putting a note on
the clients chart or documenting that the client was not informed about the risks
does ensure that the client will be informed.
Test-Taking Strategy: Use the process of elimination and guidelines and principles
of obtaining informed consent. Focusing on the words never told about the risks
of the surgery will direct you to the correct option, the only option that ensures
that the client will be told about the risks. Review the role of a nurse as a client
advocate if you had difficulty with this question.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., p. 179). St. Louis: Mosby.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 352-357). St.
Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
AW.
92.ID: 383692440
A registered nurse (RN) is planning assignments for five clients on the nursing
unit. The team includes a licensed practical nurse (LPN) and a nursing assistant.
Which clients should the nurse assign to the LPN? Select all that apply.
A.
B.

A client who is confused and requires assistance with a

shower Incorrect
A client requiring a bed bath and frequent ambulation with a

cane
C.

A client who must be accompanied to physical therapy twice

during the shift

D.

A client with a colostomy who requires reinforcement regarding

the procedure for irrigation Correct

E.

A client with diabetes mellitus who requires the administration

of regular insulin in accordance with a sliding dosage scale every 4
hours Correct
Rationale: When delegating nursing assignments, the nurse must consider the
skills and educational level of the nursing staff. The nursing assistant may be
assigned the tasks of caring for a confused client, assisting with a shower or a
bed bath, ambulating a client with a cane, and accompanying a client to physical

therapy. The LPN is educated to reinforce teaching regarding the colostomy

irrigation (the RN is responsible for the initial teaching) and administering regular
insulin in accordance with a sliding scale.
Test-Taking Strategy: Focus on the subject, the client assignment for the LPN. Use
the process of elimination to eliminate the clients whose needs are noninvasive,
because a nursing assistant may perform these tasks. This will help you identify
the clients who may be assigned to the LPN. If you had difficulty with this
question, review the principles of delegation and assignment-making.
Reference: Huber, D. (2010). Leadership and nursing care management (4th ed.,
pp. 244-246, 250). St. Louis: Saunders.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Awarded 0.0 points out of 1.0 possible points.
AX.93.ID: 383692472
A nurse planning care for her assigned clients understands that the purpose of
the hospitals standards of care is to:
A.

Identify methods of treatment

B.

Provide direction for the practice of nursing Correct

C.

Provide direction for care on the basis of the clients diagnosis

D.

Identify new care methods on the basis of current medical

research
Rationale: The purpose of standards of care is to provide a broad direction for the
overall practice of nursing that applies to all nursing situations, across specialty
areas, across the country. Standards of care include the provision of competent
care on the basis of current practice. Methods of treatment are individualized to
the care of a specific client. Providing direction of care on the basis of the clients
diagnosis is a matter of medical interventions. New care methods are a matter of
research.
Test-Taking Strategy: Focus on the subject, standards of care. Note the
relationship of the subject and the information in the correct option. The correct
option is also the umbrella option. Review the purpose of standards of care if you
had difficulty with this question.
Reference: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends &
management (4th ed., p. 143). St. Louis: Mosby.
Cognitive Ability: Understanding

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Planning
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
AY. 94.ID: 383691777
In which situation is the nurse upholding the ethical principle of fidelity?
A.

Allowing a client to decide when to receive daily hygiene care

B.

Inserting a 19-gauge intravenous catheter into a client

requiring a blood transfusion

C.

Providing complete information regarding treatment options to

a client with newly diagnosed cancer

D.

Contacting the physician about the clients request to

incorporate complementary therapies for pain into the treatment plan Correct
Rationale: Fidelity is the keeping of promises made to clients, families, and other
healthcare professionals. Contacting the physician about the clients request that
complementary therapies be used to relieve pain is an example of fidelity.
Respect for a persons autonomy, or independence, involves respecting that
persons right to determine his or her own course of action. Allowing a client to
decide when he or she would like to have daily hygiene care is an example of
respecting a clients autonomy. Beneficence is taking action to help others.
Inserting a 19-gauge intravenous catheter into a client requiring a blood
transfusion is an example of beneficence. Although insertion of an intravenous
catheter might cause discomfort, the benefits of receiving the transfusion
outweigh the temporary discomfort. Justice refers to fairness and equity; in the
healthcare arena, this involves ensuring fair allocation of resources, such as
nursing care, to all clients. Providing complete information regarding treatment
options to each client with a cancer diagnosis is an example of justice.
Test-Taking Strategy: Use the process of elimination and think about the
definition of each item in the options. Note the relationship of the definition of
fidelity and the correct option. Review the principles of healthcare ethics if you
had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
314). St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal

Awarded 1.0 points out of 1.0 possible points.

AZ.95.ID: 383693548
A physician writes a medication prescription in a clients record. While
transcribing the prescription, the nurse notes that the prescribed dose is three
times higher than the recommended dose. The nurse calls the physician, who
states that this is the dose that the client takes at home and that it is acceptable
for this clients condition. What is the appropriate action for the nurse to take?
A.
B.
C.

Contacting the nursing supervisor Correct

Continuing to transcribe the prescription

Asking the nurse assigned to care for the client to administer

the medication

D.

Verifying the prescribed dose with the client before

administering the medication
Rationale: A nurse must follow a physicians prescription unless he or she
believes that the prescription is in error or that it would harm the client. If a
prescription is found to be incorrect or harmful, further clarification from the
physician is necessary. If the physician confirms the prescription and the nurse
still believes that it is inappropriate, the nurse should contact the nursing
supervisor. The nurse should not continue transcribing the prescription or ask
another nurse to implement the prescription. The nurse might ask the client
about the medication and the dose taken at home but would not administer the
medication.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that
are comparable or alike in that they indicate that the medication would be
administered. Review the nurses responsibilities in regard to a physicians
prescriptions if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p.
709). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
BA.96.ID: 383693520
A nurse is reading the nurse practice act for the state in which she is employed.
The nurse uses the information in this act to:
A.

Identify healthcare policies in her state

B.

Know how to perform certain procedures

C.

Be aware of the role of the professional nurse Correct

D.
Be aware of hospital and long-term care facilities policies
Rationale: A nurse practice act regulates the licensure and practice of nursing.
Nurse practice acts describe in general terms what constitutes nursing practice.
Actions that are considered unprofessional conduct are usually identified.
Guidelines for procedures and policies are formulated by the specific healthcare
agency. The healthcare policies of the state in question are not identified in a
nurse practice act.
Test-Taking Strategy: Use the process of elimination. Note the relationship
between the words nurse practice act in the question and role of the
professional nurse in the correct option. Review the purpose of the nurse
practice act if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 8,
9). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
BB.97.ID: 383693572
A 51-year-old client with amyotrophic lateral sclerosis (Lou Gehrigs disease) is
admitted to the hospital because his condition is deteriorating. The client tells
the nurse that he wants a do-not-resuscitate (DNR) order. The nurse should tell
the client that:
A.
B.
C.

Consent must be obtained from the family

The physician makes the final decision about a DNR request

The DNR request should be discussed with the physician, who

will write the order Correct

D.

Oral consent is sufficient and that his request will be honored

by all healthcare providers
Rationale: A client may request a DNR order after being given the appropriate
information by the physician. Therefore, if a client requests a DNR order the
nurse should contact the physician so that the physician may discuss the request
with the client. A DNR order should be written, not verbal. The pertinent agency
and state guidelines must be followed with regard to when a verbal DNR order is
acceptable. Therefore the other options are incorrect.
Test-Taking Strategy: Use the process of elimination and your knowledge of the
issues related to DNR orders. Eliminate the options that contain the closed-ended
words must and all. Next, recall that the client has the right to request a DNR
order, which will direct you to the correct option from those remaining. Review

the issues related to DNR orders if you had difficulty with this question.
Reference: Marriner-Tomey, A. (2009). Guide to nursing management and
leadership (8th ed., p. 497). St. Louis: Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Ethical/Legal
Awarded 1.0 points out of 1.0 possible points.
BC.98.ID: 383693546
A client receives cefazolin sodium (Ancef) by way of the intravenous route.
During the infusion, the client begins exhibiting signs of an allergic reaction. The
client states that his skin is itchy, and the nurse notes that the skin is warm and
flushed, with a red rash on the arms, chest, and back. The nurse immediately
discontinues the medication, further assesses the client, contacts the physician,
and begins to document the reaction in an incident report. The nurse most
accurately documents which of the following?
A.

The client had an allergy to cefazolin sodium.

B.

The physician was notified because a rash developed while the

client was receiving cefazolin sodium.

C.

The client is apparently allergic to cefazolin sodium, as

indicated by warm, flushed skin and a rash on the arms, chest, and back.

D.

During an infusion of cefazolin sodium, the client complained

that his skin was itchy. The clients skin was warm and flushed, with a red
rash on the arms, chest, and back. The physician was notified. Correct
Rationale: The nurse should document relevant information in an accurate,
complete, and objective form. Noting the client had an allergy to cefazolin
sodium does not identify objective data. Assuming that the client is allergic to
cefazolin sodium because of warm and flushed skin makes an interpretation
about the occurrence. Documenting that the physician was notified because the
client developed a rash while receiving the medication identifies accurate data,
but is incomplete.
Test-Taking Strategy: Use the process of elimination, recalling that documentation
should include relevant information in an accurate, complete, and objective form.
This will direct you to the correct option. Also note the relationship of the data in
the question and in the correct option. Review the principles related to
documentation if you had difficulty with this question.
References: Cherry, B., & Jacob, S. (2008). Contemporary nursing issues: Trends
& management (4th ed., p. 389). St. Louis: Mosby.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 709). St. Louis:

Mosby.
Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Communication and Documentation
Content Area: Leadership/Management
Awarded 1.0 points out of 1.0 possible points.
BD.
99.ID: 383691791
Which of the following actions exemplifies the use of evidence-based practice in
the delivery of client care?
A.

Donning sterile gloves to change an abdominal wound

dressing Correct

B.

Encouraging a client to take an herbal substance to treat his

insomnia

C.

Advising a client to agree to the treatment recommended by

her physician

D.

Taking a rectal temperature from a client for whom bleeding

precautions have been instituted
Rationale: Evidence-based practice is an approach to client care in which the
nurse integrates the clients preferences, clinical expertise, and the best research
evidence to deliver quality care. Donning sterile gloves to change an abdominal
wound dressing reflects evidence-based practice, because it prevents the
entrance of harmful bacteria into the wound. The remaining options do not reflect
evidence-based practice. Taking an herbal substance could be harmful to some
clients. It is nontherapeutic for a nurse to advise a client to agree to a treatment.
Because of the risk of injury to the rectal mucosa, rectal temperature-taking is
avoided in the client for whom bleeding precautions have been instituted.
Test-Taking Strategy: Read each option carefully, focusing on the subject,
evidence-based practice. Recall the definition of evidence-based practice and
note the words sterile gloves in the correct option. Review the situations that
reflect evidence-based practice if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., pp. 5460). St. Louis: Mosby.
Cognitive Ability: Understanding
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Leadership/Management

Awarded 1.0 points out of 1.0 possible points.

BE.100.ID: 383691775
A case manager is reviewing notations made in clients records. Which note
indicates an unexpected outcome and the need for immediate follow-up?
A.
B.

A client who has sustained a stroke dresses herself.

A client exhibits signs of increased intracranial pressure after a

craniotomy. Correct
C.
D.

Normal neurological findings are noted in a client with a

cerebral aneurysm.
A client with a spinal cord injury transfers himself from a bed to

a wheelchair.
Rationale: A case manager is a nurse who assumes responsibility for coordinating
a client's care from the point of admission through, and after, discharge. This
nurse initiates a plan of nursing care, care map, or clinical pathway as
appropriate to guide care and evaluates and updates the plan of care as needed.
The case manager monitors the client for expected and unexpected outcomes
and provides follow-up and revises the plan of care if an unexpected outcome is
noted. A client who exhibits signs of increased intracranial pressure after a
craniotomy, indicating a deterioration of the clients condition, requires
immediate follow-up. The descriptions in the other options are expected
outcomes.
Test-Taking Strategy: Think about the role of the case manager and read each
client description carefully. Next, focus on the subject, an unexpected outcome
and the need for immediate follow-up. This will direct you to the description that
is unexpected or unwanted. Signs of increased intracranial pressure are an
immediate concern, indicating deterioration in the clients condition. Review the
role of the nurse manager and expected and unexpected outcomes if you had
difficulty with this question.