Riverside City College

NURSING MISC

1)A nurse is evaluating a newly licensed nurse who is administering a vitamin K injection to a newborn. Which of the following actions by the newly licensed nurse indicates understanding of the teaching? (SATA)

1. 1. Applies gentle pressure at the site after injection
   2. Aspirates the syringe for blood return after needle insertion
   3. Selects the dorsogluteal site to administer the injection
   4. Inserts the needle at a 45° angle - IM should be 90
   5. Cleans the injection site with alcohol

2. A nurse manager is reviewing guidelines for informed consent with the nursing staff. Which of the following statements by a staff nurse indicates that the teaching was effective?
   1. “Guardian consent is required for an emancipated minor.”
   2. “Consent can be given by a durable power of attorney.”
   3. “The nurse can answer any questions the client has about the procedure.”
   4. “A family member can interpret to obtain informed consent from a client who is deaf.”
3. A nurse is teaching a client how to use a finger-stick glucometer at home. Which of the following instructions should the nurse include?
   1. Obtain the blood sample from the finger pads.
   2. Elevate the arm for 1 min before taking the blood sample.
   3. Cap the lancet prior to putting it in the trash.
   4. Warm the hands prior to piercing the skin
4. A client is admitted with COPD. Which of the following findings should the nurse report to the provider?
   1. Report of dyspnea on exertion
   2. Oxygen saturation 89% on room air
   3. White blood cell count 9,000/mm3
   4. Bilateral crackles on auscultation of lungs
5. A client schedule for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
   1. “You shouldn’t be worried because the procedure is very safe.”
   2. “This won’t take long and it will be over before you know it.”
   3. “Why did you make the decision to have this procedure?”
   4. “It’s not too late to cancel the surgery if you want to.”
6. A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following?
   1. Libel
   2. False imprisonment
   3. Battery
   4. Assault
7. A nurse manager overhears a provider and a staff nurse talking about a client’s diagnosis in the cafeteria. Which of the following actions should the nurse take first?
   1. Provide a staff inservice about client confidentiality.
   2. Fill out an incident report regarding the situation.
   3. Remind them that client information is confidential.
   4. Report the incident to the nursing supervisor.
8. A nurse is serving on a committee that is revising the protocol for discharging clients. After developing an initial plan, in which order should the nurse take the following steps?

• Determine goals
• Implement recommended strategies
• Revise the plan.
• Evaluate the results

9. A nurse is orienting to an emergency department. The nurse is asked to assist with suturing of a laceration on a

client’s hand. Which of the following is the best resource for this nurse?

9. 1. The preceptor on the clinical unit
   2. The provider suturing the client’s injury
   3. The nursing supervisor
   4. The information on the suture package
10. A client is brought to the emergency department (ED) following a motor-vehicle crash. Drug use is suspected in the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen. Which of the following is the appropriate action by the nurse?
    1. Assess the client for urinary retention.
    2. Obtain a provider’s prescription for a blood alcohol level.
    3. Tell the client that a catheter will be inserted.
    4. Document the client’s refusal in the chart.
11. While auditing the medical records of clients currently on an oncology unit, the nurse manager finds that six of the 15 records lack documentation regarding advance directives. Which of the following is the priority action for the nurse to take?
    1. Ask nurses who are caring for clients without this information in the medical record to obtain it.
    2. Remind nurses to obtain this information during the admission process.
    3. Meet with nursing staff to review the policy regarding advance directives.
    4. Reinforce the potential consequences of not having this information on record to the nursing staff.
12. A nurse who is precepting a newly licensed nurse is discussing the client assignment for the shift. Which of the following actions should the nurse preceptor take first to demonstrate appropriate time management?
    1. Determine client care goals.
    2. Review the client’s new laboratory values.
    3. Complete required tasks.
    4. Document assessment data.
13. A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?
    1. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min.
    2. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.
    3. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better.
    4. A nurse explains to a client’s family that a DNR includes withholding comfort measures.
14. A nurse is caring for a client who is unconscious and whose partner is his health care proxy. The partner has spoken with the provider and wishes to discontinue the client’s feeding tube. The provider states to the nurse, “I will not discontinue this client’s treatment. His partner has no right to make decisions regarding the client’s care.” Which of the following responses by the nurse is appropriate?
    1. “We’ll need to have the nursing supervisor review the client’s advance directives.”
    2. “You should consider speaking with the facility’s ethics committee before making your decision.”
    3. “You have the right to make that decision, even if the partner is the client’s health care proxy.”
    4. “The client has designated his partner as health care proxy in his advance directives.”
15. A parish nurse is making a referral to a community meal delivery program for a member of the congregation. This is an example of which of the following functions of the parish nurse?
    1. Health educator
    2. Liaison
    3. Pastoral care provider
    4. Personal health counselor
16. A nurse is preparing to discharge a client back to a long-term care facility after he was admitted to an acute care facility 2 days ago for pneumonia. Which of the following information should the nurse include in the verbal transfer report?
    1. Laboratory results within the expected reference range
    2. Level of consciousness

16. 3. List of regularly prescribed medications
    4. Date of last bowel movement
17. A charge nurse on a postpartum unit is teaching a client who gave birth 2 hr ago about the facility’s protocols for preventing newborn abduction. Which of the following instructions should the nurse include?
    1. “Carry your baby snugly in your arms whenever you leave your room.”
    2. “Make sure to leave your baby in the bassinet by your bed when you use the bathroom.”
    3. “Keep your baby next to you in your bed if you think you might fall asleep.”
    4. “Check the photo identification badge of staff members who care for you and your baby.”
18. A nurse is assigned the following four clients for the current shift. Which of the following clients should the nurse assess first?
    1. A client who has diabetes mellitus and a stage 2 pressure ulcer on his foot
    2. A client who has a hip fracture and is in Buck’s traction
    3. A client who has aspiration pneumonia and a respiratory rate 28/min ABC
    4. A client who has a Clostridium difficile infection and needs a stool specimen collected
19. A nurse should recognize that an incident report is required when
    1. A visitor pinches his finger in the client’s bed frame.
    2. A nurse gives a medication 30 min late.
    3. A client throws a box of tissues at a nurse.
    4. A client refuses to attend physical therapy.
20. A charge nurse is delegating tasks to the staff on the unit. Which of the following tasks is appropriate to delegate to a licensed practical nurse?
    1. Referring a client to social services for assistance with transportation
    2. Providing the first oral feeding to a client following a stroke
    3. Instructing a client who is obese about a low-fat diet
    4. Changing the dressing on a postoperative wound
21. A nurse is precepting a newly licensed nurse who is caring for a client who is confused and has an IV infusion. The newly licensed nurse has placed the client in wrist restraints to prevent dislodging the IV catheter. Which of the following questions should the precepting nurse ask?
    1. “Are you removing the client’s restraints every 4 hours?”
    2. “Are you able to insert two fingers between the restraints and the client’s skin?”
    3. “Did you tie the restraints using a double knot?”
    4. “Did you secure the restraints to the side rails of the bed?”
22. A nurse observes a paper bag at the bedside of a client. This finding suggests that the client is receiving treatment for which of the following respiratory disorders?
    1. Stridor
    2. Asthma
    3. Hyperventilation
    4. Atelectasis
23. Which of the following observations requires a charge nurse to intervene and demonstrate safe handling techniques?
    1. A nurse uses goggles to perform tracheostomy suctioning.
    2. A nurse places a mask on a client with tuberculosis before transport to the radiology department.
    3. A nurse cleans up a blood spill with a 1:10 bleach solution.
    4. A nurse disconnects an indwelling urinary catheter from the drainage bag to collect a specimen.
24. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a sterile procedure. Which of the following actions indicates the nurse is maintain sterile technique? (SATA)
    1. Opens the sterile pack by first unfolding the flap farthest from her body
    2. Holds a bottle of sterile solution 15 cm (6 inches) above the sterile field
    3. Places sterile items within a 1.25-cm (0.5-inch) border around the edges of the sterile field
    4. Removes the outside packaging of a sterile instrument before dropping it onto the sterile field
    5. Rests the cap of a solution container upside down on the sterile field
25. A nurse working on a medical-surgical unit is receiving shift report regarding four clients. Which of the following client should the nurse see first?
    1. A 75-year-old man who has pneumonia and has a O2 saturation of 92%
    2. A 80-year-old woman who has a urinary tract infection and a temperature of 38.2° C (100.8° F)

25. 3. A 45-year-old man who has new onset of confusion 24 hr after a total hip arthroplasty
    4. A 50-year-old woman reporting abdominal pain of 7 on a scale of 0 to 10
26. An RN is planning client assignments for a licensed practical nurse (LPN) and three assistive personnel. The RN should assign the LPN to the client who requires
    1. Recording of daily intake and output
    2. Assistance with meals
    3. A complete bed bath
    4. Frequent dressing changes
27. A client has a new permanent pacemaker inserted. Which of the following home care instructions should the nurse include?
    1. Swimming could cause the unit to have an electrical short.
    2. The client should avoid using remote control devices to prevent dysrhythmias.
    3. Regular programming evaluations can be conducted by telephone.
    4. The client should avoid using a microwave oven to heat food.
28. According to HIPAA regulations, which of the following is a violation of client confidentiality?
    1. Reporting a client’s disposition to the referring provider
    2. Informing housekeeping staff that the client is in the dialysis unit
    3. Providing a copy of the record to the transporting paramedic
    4. Telephoning the pharmacy with a prescription for the spouse to pick up
29. A nurse is preparing discharge planning for a client who has a newly placed tracheostomy tube. The nurse should assess the client’s need for which of the following to manage the tracheostomy at home? (SATA)
    1. Pipe cleaners
    2. Cotton balls
    3. Petroleum jelly
    4. Oxygen tank
    5. Obturator
30. A nurse manager is preparing to institute a new system for scheduling staff. Several nurses have verbalized their concern over the possible changes that will occur. Which of the following is an appropriate method to facilitate the adoption of the new scheduling system?
    1. Provide a brief overview of the new scheduling system immediately before its implementation.
    2. Offer to reassign staff who do not support the change to another unit.
    3. Identify nurses who accept the change to help influence other staff nurses.
    4. Introduce the new scheduling system by describing how it will save the institution money.
31. A nurse enters a client’s room and observes a fire in the trash can. Identify the sequence of actions the nurse should take.
    1. Remove the client from the are
    2. Activate the first alarm system.
    3. Confine the fire by closing doors and windows.
    4. Extinguish the fire if possible.
32. A nurse enters the room of a client who is unconscious and finds that the client’s son is reading her electronic medical records from a monitor located at the bedside. Which of the following actions should the nurse take first?
    1. Complete an incident report regarding the breach of the client’s confidentiality.
    2. Report the possible violation of client confidentiality to the nurse manager.
    3. Log out the computer so that the client’s son is unable to view his mother’s information.
    4. Recommend the son meet with the provider to get information about his mother’s condition.
33. Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following is appropriate to include in the cost-containment plan?
    1. Return unused supplies from the bedside to the unit’s supply stock.
    2. Use clean gloves rather than sterile gloves for colostomy care.
    3. Wait to dispose of sharps containers until they are completely full.
    4. Store opened bottles of normal saline in a refrigerator for up to 48 hr.
34. Which of the following puts a hospital at the highest risk for infringement of client record confidentiality?
    1. Paper-based charts are stored at the nurses’’ station.
    2. A provider and nurse access client information using once access code.
    3. A nurse performs electronic documentation outside a client’s room.

34. 4. A nurse clusters documentation of care for multiple clients.
35. A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
    1. Review the chart for non-restrain alternatives for agitation.
    2. Speak with the AP about the incident.
    3. Remove the restraints from the client’s wrists.
    4. Inform the unit manager of the incident.
36. A nurse is providing change-of-shift report for an oncoming nurse. Which of the following information should the nurse include in the report?
    1. “The client’s partner came to visit him 2 hours ago and smelled of alcohol.”
    2. “The client is currently in the radiology department for a chest x-ray.”
    3. “The client will need vital signs every 4 hours.”
    4. “The client is the president of a local bank.”
37. A client who has substance use disorder is admitted to the mental health unit and reports that he has been depressed lately. When preparing for discharge the next day, the client states, “It’s okay. Soon everything will be just fine.” Which of the following is the nurse’s priority action?
    1. Ask the client if he has considered hurting himself.
    2. Provide the client with information about Alcoholics Anonymous.
    3. Encourage the client to participate in physical activities.
    4. Reinforce the need to follow up with discharge referral.
38. A charge nurse is addressing conflict between two nurses who are having a disagreement at the nurses’ station. Which of the following strategies should the charge nurse use to assist with negotiations? (SATA)
    1. Continue negotiations until a resolution is made.
    2. Have the nurses move the discussion to a private location.
    3. Begin negotiations with minimal demands from each nurse.
    4. Address the nurses using assertive communication techniques.
    5. Use active listening when obtaining each nurse’s perception of the situation.
39. A nurse is providing care for four postoperative clients. The nurse should first assess the client
    1. Who is reporting nausea after the prescribed antiemetic was administered.
    2. Whose pulse has been steadily increasing during the past shift.
    3. Whose urine output has averaged 32 mL/hr for the past 24 hr.
    4. Who is reporting a pain level of 8 on a scale of 0 to 10.
40. A nurse finds a client sitting on the floor holding her right forearm. She tells the nurse that she slipped and hit her arm. Which of the following actions should the nurse take first?
    1. Submit an incident report.
    2. Alert the client’s provider of the incident.
    3. Reposition the client to prevent further injury.
    4. Check the client for injuries.
41. A nurse in an acute care unit is assessing a group of clients. Which of the following clients is the nurse’s priority?
    1. A client who has pneumonia and has an oxygen saturation of 95%
    2. A client who has atrial fibrillation and reports chest pain of 5 on a scale from 0 to 10
    3. A client who has peripheral vascular disease and has +1 pedal pulses bilaterally
    4. A client who has inflammatory bowel syndrome and reports two loose stools
42. A nurse is caring for a client who fell and is reporting pain in the left hip with external rotation of the left leg. The nurse has been unable to reach the provider despite several attempts over the past 30 min. Which of the following actions should the nurse take?
    1. Reposition the client for comfort.
    2. Notify the nursing supervisor about the issue.
    3. Contact the client’s physical therapist.
    4. Apply a warm compress to the hip.
43. Which of the following should lead a nurse to suspect abuse that must be reported?
    1. A school-age child has several bruises on her lower legs.
    2. A preschool child who was previously trained now requires diapers in the hospital.
    3. A toddler cries whenever his parent enters the hospital room.

43. 4. An adolescent admitted to the emergency department won’t speak to his parents.
44. A home health nurse is assessing the home environment of a client who is on continuous oxygen therapy. Which of the following findings requires the nurse to intervene?
    1. The client is covered with a woolen blanket.
    2. The oxygen machine has a grounded plug.
    3. The family keeps a spare oxygen tank in the room.
    4. The windows of the client’s room are open.
45. A nurse is caring for a client who has increased intracranial pressure and is receiving IV corticosteroids. Which of the following information is most important for the nurse to report at shift change?
    1. Reddened area on the coccyx
    2. Most recent blood glucose reading
    3. Glasgow Coma Scale score
    4. Laboratory tests scheduled for next shift
46. A nurse in the emergency department is caring for a group of four clients. Which of the following clients should the nurse recommend for transfer to the ICU?
    1. A client who has chronic atrial fibrillation and a digoxin level of 0.3 ng/mL
    2. A client who has bleeding esophageal varices and a blood pressure of 90/50 mm Hg
    3. A client who has a head injury and Glasgow Coma Scale score of 10
    4. A client who has chronic kidney disease and a creatinine level of 15 mg/dL
47. A nurse tells the unit manager, “I am tired of all the changes on the unit. If things don’t get better, I’m going to quit.” Which of the following responses by the unit manager is appropriate?
    1. “Just stick with it a little longer. Things will get better soon.”
    2. “So you are upset about all the changes on the unit?”
    3. “You should file a written complaint with hospital administration.”
    4. “I think you have a right to be upset. I am tired of the changes, too.”
48. An older adult client is awaiting surgery for a fractured right hip. The nurse should recognize that which of the following can be delegated to assistive personnel?
    1. Recording the client’s vital signs
    2. Determining the client’s pain level
    3. Checking the pulses of the client’s right foot
    4. Turning the client
49. A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel?
    1. Assessing a client who just returned from hemodialysis
    2. Reviewing dietary instructions for a client with kidney stones
    3. Monitoring a client with a fluid restriction
    4. Obtaining a stool sample from a client with renal failure
50. A nurse is providing teaching to a client who has a new diagnosis of diabetes mellitus. The client expresses concern about the cost of blood glucose monitoring supplies. Which of the following referrals should the nurse make to address the client’s concern?
    1. Case manager
    2. Dietitian
    3. Chaplain
    4. House supervisor
51. A nurse manager is providing orientation to a group of newly licensed nurses. The nurse manager should communicate that which of the following actions is the responsibility of the nurse when responding to a disaster?
    1. Assume leadership for directing the emergency plan.
    2. Use the chain-of-command for communication.
    3. Act as a spokesperson between the facility and the community.
    4. Coordinate the activities of emergency medical services.
52. A client who is febrile is admitted to the hospital for treatment of pneumonia. In accordance with the care pathway, antibiotic therapy is prescribed. Which of the following situations requires the nurse to complete a variance report with regard to the care pathway?
    1. A blood culture was obtained after antibiotic therapy had been initiated.
    2. The route of antibiotic therapy on the care pathway was changed from IV to PO.
    3. An allergy to penicillin required an alternative antibiotic to be prescribed.
    4. Antibiotic therapy was initiated 2 hr after implementation of the care pathway.

53. A nurse is working on a quality improvement team that is assessing an increase in client falls at a facility. After problem identification, which of the following actions should the nurse plan to take first as part of the quality improvement process?
    1. Review current literature regarding client falls.
    2. Identify clients who are at risk for falls.
    3. Notify staff of the increased fall rate.
    4. Implement a fall prevention plan.
54. To receive a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict-resolution strategies is the nurse manager using?
    1. Compromising
    2. Cooperating
    3. Competing
    4. Collaborating
55. A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?
    1. Ask other staff members to take over some of his tasks.
    2. Advise him to complete less time-consuming tasks first.
    3. Recommend that he take time to plan at the beginning of his shift.
    4. Offer to provide care for his clients while he takes a break.
56. Client satisfaction surveys from a surgical unit indicate that pain is not being adequately relieved during the first 12 hr postoperatively. The unit manager decides to identify postoperative pain as a quality indicator. Which of the following data sources will be helpful in determining the reason why clients are not receiving adequate pain management after surgery?
    1. Prospective chart audit
    2. Pain assessment policy
    3. Postoperative care policy
    4. Retrospective chart audit
57. The mother of a client with breast cancer states, “It’s been hard for her, especially after losing her hair. And it has been difficult to pay for all the treatments.” Which of the following actions is appropriate client advocacy?
    1. The nurse suggests counseling for the client’s body image issues.
    2. The nurse investigates potential resources to help the client purchase a wig.
    3. The nurse informs the next shift nurse regarding the mother’s concerns.
    4. The nurse explains to the mother that most clients with cancer lose their hair.
58. A nurse performing triage during a mass casualty incident should recognize that which of the following clients should be transported to the hospital first?
    1. A client who has a 4-inch laceration on the forearm
    2. A client who has an open fracture of the femur
    3. A client who reports substernal chest pain radiating to the neck
    4. A client who has a penetrating head injury and fixed and dilated pupils
59. A nurse is caring for an older adult client who has a Stage III pressure ulcer. The nurse requests a consultation with the wound care specialist. Which of the following actions by the nurse is appropriate when working with a consultant?
    1. Request the consultation after several wound care treatments are tried.
    2. Arrange the consultation for a time when the nurse caring for the client is able to be present for the consultation.
    3. Provide the consultant with subjective opinions and beliefs about the client’s wound care.
    4. Arrange for the wound care nurse specialist to see the client daily to provide the recommended treatment.
60. Which of the following items must be discarded in a biohazard waste receptacle?
    1. A bedsheet from a client with bacterial pneumonia
    2. An empty IV bag removed from a client who has HIV
    3. A urinary catheter drainage bag from a client who is postoperative
    4. A peripheral pad from a client who is 24-hr post-vaginal delivery

61. A client is admitted with tuberculosis and placed in a negative pressure room. Which of the following nursing actions is appropriate?
    1. Notify the local health department of the admission.
    2. Ensure that admitting staff undergo PPD skin tests.
    3. Place a sign on the client’s door with the diagnosis.
    4. Determine who had contact with the client in the last 48 hr.
62. A nurse is preparing to transcribe a client’s medication prescription in the medical record. Which of the following should the nurse recognize as containing the essential components of a medication order?
    1. Haloperidol 1 mg by mouth
    2. Multivitamin every morning by mouth
    3. Aspirin 650 mg by mouth every 4 hr
    4. NPH insulin 10 units before meals and at bedtime
63. A nurse is caring for a client who has anorexia nervosa. Which of the following interdisciplinary team members should be consulted in regard to this client’s care? (SATA)
    1. Case manager
    2. Mental health counselor
    3. Physical therapist
    4. Nutritional therapist
    5. Occupational therapist
64. A charge nurse is assessing staff knowledge about safety procedures regarding needlestick injuries. Which of the following statements by a nurse indicates appropriate understanding of these safety procedures?
    1. “An incident report should be completed if a client receives a stick from her own used needle.”
    2. “I should stop the bleeding as soon as possible following a needlestick injury.”
    3. “Prophylactic treatment should be initiated after a needlestick during preparation of an injection.”
    4. “The needle should be recapped to prevent injury during transport to the biohazard container.”
65. Which of the following actions taken by a nurse constitutes battery?
    1. Failing to put up side rails on a confused client’s bed
    2. Threatening to apply wrist restraints to control a client who is agitated
    3. Inserting a feeding tube against the wishes of a client who refuses to eat
    4. Telling a client who refused his oral medication that he will be given an injection
66. A charge nurse notices that two staff nurses are not taking meal breaks during their regular 8-hr shifts. Which of the following actions should the nurse take first?
    1. Provide coverage for the nurses’ breaks.
    2. Discuss time management strategies with the nurses.
    3. Determine the reasons the nurses are not taking scheduled breaks.
    4. Review facility policies for taking scheduled breaks.
67. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a licensed practical nurse?
    1. Determine adequacy of ventilator settings.
    2. Plan break times for assistive personnel.
    3. Administer a nasogastric tube feeding.

b.        Pick up the meal trays after lunch.

68. A nurse is an ambulatory care setting is orienting a newly licensed nurse who is preparing to return a call to a client. The nurse should explain that which of the following is an objective of telehealth?
    1. Assessing client needs
    2. Providing medication reconciliation
    3. Developing client treatment protocols
    4. Establishing communication between providers
69. A nurse manager smells alcohol on the breath of a nurse who is starting a shift. Which of the following actions should the nurse manager take first?
    1. Remove the nurse from the unit.
    2. Have a blood alcohol level drawn from the nurse.
    3. Report the situation to the director of nursing.
    4. Document a factual description of the situation.
70. A case manager working in a rehabilitation unit is discharging to home a client who has a spinal cord injury at vertebral level C-7. Which of the following is the priority action when creating the discharge plan?