Practice Questions
When caring for a patient with Crohn's disease who is on a low residue diet, which of the following should be given as a snack?
1 cup of pasta
Which of the following situations is an example of horizontal violence?
A nurse blames a peer for her error
A newly licensed nurse is orientating to a facility's documentation system. The facility requires staff to only document variations from an expected set of findings when performing a physical assessment. The nurse should identify which of the following documentation methods?
Charting by exception
To prevent aspiration:
Elevate the head of the client's bed to 45 degrees during meals
A novice nurse demonstrates which behavior?
Inflexibility
When taking a rectal temperature:
Insert the probe about 2.5 cm (1 to 1.5 in) into the client's anus
A nurse holds a single state nursing license and is preparing to move to another state. For the nurse to apply for reciprocity, which actions should the nurse take?
Present a current and valid nursing license Submit an application Pay the fees for new license
Which of the following relates to the concept of caring in professional nursing?
Promoting role excellence
How should a nurse react with a client who begins to fall?
Protect the client's extremities while lowering them to the floor
Which of the following is a component of biculturalism?
Evaluation of personal values
When should PROM exercises be performed?
For clients who are weak and otherwise unable to perform active ROM PROM does not allow for muscle contraction but can help with flexibility
A client has a CVA, resulting in flaccidity of the right side with aphasia. For this client, which intervention constitutes tertiary prevention?
Gait training and speech therapy
A client is learning to use crutches. What advice should the nurse administer to the patient?
"Hold the crutches on your unaffected side when preparing to sit in a chair"
A nurse receives a phone call from a client who was discharged yesterday. The client asks the nurse to email them a copy of their discharge instructions. Which of the following responses should the nurse make?
"I am unable to send your discharge instructions via email due to the HIPAA Privacy Act"
A staff nurse is evaluating a newly licensed nurse's understanding of telephone prescriptions. Which of the following statements by the newly licensed nurse indicates an understanding of the information?
"I can take a telephone prescription if a provider is directing a code for an unresponsive client"
A nurse is teaching a client about advance directives. Which of the following client statements indicates an understanding of the teaching?
"My health care surrogate will make health care decisions for me if I am unable"
A nurse is reviewing the documentation of a newly licensed nurse. Which of the following entries should the nurse identify as meeting the American Nurses Association (ANA) standards for documentation?
"The client vomited 240 mL of clear emesis but denies pain or nausea"
A nurse is reviewing standards of care with a group of newly hired nurses. The nurse should include which of the following incidents as an example of a breach of standards of care?
A nurse did not read back a verbal medication prescription to a provider
Which of the following actions represents the professional value of altruism?
A nurse mentoring a colleague in professional growth
Which six trends in health care reflect the Institute of Medicine's (IOM) focus?
A safe, effective, efficient, patient-centered, timely, and equitable system
A 32 year old construction worker is admitted to the emergency department after suffering a heat stroke. Which of the following IV solutions would the nurse expect the physician would order?
A solution of normal saline
A nurse is caring for a client who has been hospitalized and is performing active range-of-motion exercises. Which of the following body movements should indicate to the nurse that the client has full range of motion of the shoulder?
Adducting the arm so that it lies next to the client's side
A nurse is obtaining a client's vital signs. The client has a new onset of a temperature of 39 degrees Celsius or 102 degrees Fahrenheit. Which of the following other vital signs should the nurse expect?
An elevated pulse rate
What should be assessed when ambulating a client who has previously been immobile?
Assess the client's activity tolerance, strength, coordination, and baseline vital signs
A nurse is caring for a client who is alone and has just received a serious diagnosis. The client asks the nurse if they can pray together, and the nurse agrees. The nurse is demonstrating which of the following ethical principles?
Beneficence
Which of the following is an evidence-based documentation tool for effective communication between health care professionals?
Clinical pathway
The NPA
Contains current laws and regulations for nursing practice Contains standards and scope of practice The nurse is responsible to know current roles and responsibilities as defined by the NPA
A nurse is planning a health fair in the community to highlight promotion and prevention of the leading cause of death in the US. Which disease process should the nurse address?
Coronary artery disease
A hospice nurse is caring for a client who states that they want to have their last rites before they die. The nurse recognizes that which of the following factors is influencing the client's request?
Cultural factor
Client health records include:
Demographics Vital signs Medical history Medications Allergies and immunizations etc They allow health care providers to follow a client's care from one facility to another - enhance communication between providers Medical and prescription errors reduce more reliable coding and billing Most important goal is to improve client care and provide for better health outcomes
A nurse is planning teaching for a client about wound care. which of the following actions should the nurse take
Ensure the client is wearing their glasses during teaching
What should the nurse ensure while dressing a client with stockings?
Ensure the client's toes are visible after placing the stockings on the client
A nurse is instructing a client regarding heart-healthy activities. This action represents which of the following phases of the nurse-client relationship?
Exploitation
Which are examples of implied consent?
Insertion of a urinary catheter Initiation of an IV site Administration of pain medication
A nurse notifies their supervisor that they accidentally administered the wrong medication to a client. The nurse is demonstrating with of the following professional values?
Integrity
What is true of the second diastolic pressure sound?
It might not follow with a fifth Korotkoff sound
A nurse is observing an assistive personal (AP) who is using a mechanical lift with a hammock sling to transfer a client. For which of the following actions by the AP should the nurse intervene?
Leaves the bed in the lowest position throughout the procedure
Which of the following abbreviations should not be included on the Joint Commission's Do Not Use List?
MSO4 IU qhs
A nurse in a long-term care facility is caring for a client who is on bed rest and requires frequent linen changes. Which of the following should the nurse identify as the priority rationale for frequent linen changes?
Moisture from excessive diaphoresis can cause skin breakdown
A nurse is assessing a client who came to the emergency department reporting chest pain. The client tells the nurse that they have hearing loss and forgot to bring their hearing aid with them. Which of the following actions should the nurse take to improve communication with the client?
Move the client to a quiet area or private room Speak at a slower pace Avoid using medical terminology
How can the PMI be located?
Overt the fifth intercostal space at the left midclavicular line
Which of the following is a characteristic of the advanced beginner nurse?
Performs at an acceptable level Bases actions on principles and experience
A nurse is measuring a client's temperature orally. Which of the following actions should the nurse take?
Place the probe in the posterior lingual pocket lateral to the midline
Which of the following will assist the new graduate nurse with the development of knowledge and skills necessary for the nursing role?
Preceptor
A nurse is caring for a client who has a new prescription for dialysis three times a week. The client avoids eye contact while talking to the nurse and explains that they work two jobs to support their partner and two children. The client also states, "I don't know how I am going to have time for dialysis." Which of the following factors are influencing the client's communication?
Psychosocial factors Situational factors
A charge nurse is reviewing characteristics of electronic documentation with staff at a provider's office. Which of the following characteristics should the charge nurse plan to include?
Reduces medical errors Makes client medical history more easily available Increases accuracy of coding procedures
How do ventilation, diffusion, and perfusion differ?
Respiration encompasses ventilation - a mechanical process involving the movement of gases into and out of the lungs Diffusion is the movement of oxygen and carbon dioxide between the alveoli and the red blood cells Perfusion is the process of blood distribution (pulmonary circulation) to and from the blood-gas barrier in the pulmonary capillaries where gas exchange occurs
Which are examples of informed consent?
Scheduled cesarean section Colonoscopy to screen for colon cancer Effective cosmetic surgery
A nurse manager is reviewing the documentation of four newly licensed nurses. Which of the following medication entries should the nurse identify as being written correctly?
Synthroid 100 mg PO every morning ac
A nurse refers an HIV-positive client to a local support group. This is an example of what level of preventative care?
Tertiary
A nurse is documenting information in a client's chart and makes the entry "client reports abdominal pain on external region." Which of the following documentation formats describes this entry?
The "S" in SOAP
Which model is most useful in examining the cause of disease in an individual, based upon external factors?
The Agent-Host-Environment Model
A nurse is discussing the history of electronic health records (EHRs) during a staff in-service. The nurse should identify that which of the following agencies advocated for nationwide use of EHRs?
The Institute of Medicine
A nurse is caring for a client following a stroke. The nurse should recognize that which of the following can view the medical record without obtaining special consent from the client first?
The admitting provider The charge nurse on the unit The client
The fourth Korotkoff sound reflects what?
The first diastolic pressure
A standard of care is defined as
The level of care a nurse provides that is the same for all nurses who have comparable education, competency, and experience
A nurse is taking an admission history from a client who is concerned about the facility using an electronic documentation system. Which of the following information should the nurse include as a benefit of electronic documentation?
The system alerts providers of possible actions that could cause client harm
What have the models of health promotion and illness prevention been used for?
To help health care providers understand health-related behaviors
A nurse in the PACU is determining if a client has pain. The client is drowsy and opens their eyes to verbal stimuli but is unable to communicate their pain level. Which of the following actions should the nurse take?
Use an alternative method for determining the client's pain level
A nurse is planning to teach new assistive personnel (AP) how to use a bedside glucose monitor to check a client's blood glucose level. The nurse will include a 30 min face-to-face lecture and a written copy of the step-by-step procedure. Which of the following modes of communication is the nurse using in the teaching plan?
Verbal Written Nonverbal
A graduate nurse is offered a position in the emergency department upon the granting of initial licensure. Which of the following information should the graduate nurse identify as a requirement during the initial licensure process?
Verification of graduation Criminal background check in certain states Passing score on NCLEX exam Self-disclosure of any substance use in the past 5 years
Which of the following questions would be appropriate to ask the client before you reassess blood pressure?
What is your usual blood pressure reading? Did you drink any tea, coffee, or soda within the last hour? Are you currently experiencing any emotional stress such as fear or anxiety? Have you smoked within the last 15 to 30 minutes?
Teaching a woman about breast self-examination is an example of what broad aim of nursing?
preventing illness
