Nursing Documentation and Client Care Protocols, Exams of Nursing

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VERSION A

A nurse is caring for a client who has a prescription for a 24 hour urine collection. Which of the following actions should the nurse take?

A. Discard the first void B. Keep the urine in a single container at room temperature C. Ask the client to urinate and pour the urine into a specimen container D. Ask the client to urinate into the toilet, stop midstream, and then finish urinating into a specimen container

A. Discard the first void

A nurse is reviewing the factors that increase risk of UTIs with a client who has reoccurring UTIs. Which of the following factors to the nurse include? Select all that apply

A. Frequent sexual intercourse B. Lowering of testosterone levels C. Wiping from front to back D. Location of the urethra in relation to the anus E. Frequent catheterization

A. Frequent sexual intercourse D. Location of the urethra in relation to the anus E. Frequent catheterization

A nurse is preparing to initiate a bladder training program for a client who has incontinence. Which of the following actions should the nurse take? Select all that apply

A. Establish a schedule of urinating prior to meal times B. Have the client record urination times C. Gradually increased urination intervals D. Remind the client to hold the urine until the next scheduled urination times E. Provide a sterile container for urine

B. Have the client record urination times C. Gradually increased urination intervals D. Remind the client to hold the urine until the next scheduled urination times

A nurse is determining a clients ability to learn self monitoring of blood glucose using a glucometer. Which of the following abilities should the nurse confirm that the client has down before proceeding with the instruction? Select all that apply

A. Finger dexterity B. Visual acuity C. Color vision D. Basic literacy E. Demonstration of the ability

A. Finger dexterity B. Visual acuity E. Demonstration of the ability

A nurse is providing education on how to check blood glucose levels to a client who has a new diagnosis of type one diabetes mellitus. The nurse should include which of the following instructions about transferring blood onto the reagent portion of the test strip?

A. Smear the blood onto the strip B. Squeeze the blood onto the strap C. Touch the puncture to stimulate bleeding D. Hold the test strip next to the blood on the fingertip

D. Hold the test strip next to the blood on the fingertip

A nurse attempts to collect a capillary blood specimen via fingerstick for a blood glucose monitoring from a client who has diabetes mellitus. The nurse is unable to obtain an adequate drop of blood for the reagent strip. Which of the following actions should the nurse take?

A. Puncture another finger to obtain a capillary specimen

C. Pharmacist D. Registered nurse E. Respiratory therapist

A. Provider B. Certified nursing assistant D. Registered nurse

A client who has had a CVA has persistent problems with dysphasia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team?

A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech language pathologist

D. Speech language pathologist

A nurse is acquainting a group of newly licensed nurses with the roles of various members of the healthcare team that they will encounter on a medical surgical unit. When she gives examples of types of tasks certified nursing assistant may perform, which of the following activities should be included? Select all that apply

A. Bathing B. Ambulating C. Toileting D. Determining level of pain E. Measuring vital signs

A. Bathing B. Ambulating C. Toileting E. Measuring vital signs

A nurse is caring for a client who decides to not have surgery despite significant blockages in his coronary arteries. The nurse understands that this clients choice is an example of which of the following ethical principles?

A. Fidelity B. Autonomy C. Justice D. Non-maleficence

B. Autonomy

A nurse offers pain medication to a client who is postoperative prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

A. Fidelity B. Autonomy C. Justice D. Beneficence

D. Beneficence

A nurse is instructing a group of nursing students about the responsibilities organ donation and procurement involve. When the nurse explains that all clients waiting for a kidney transplant have to meet certain qualifications, the students should understand that this aspect of care delivery is an example of which of the following ethical principles?

A. Fidelity B. Autonomy C. Justice D. Beneficence

C. Justice

A nurse questions a medication prescription that is too extreme in light of the clients advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?

A. Fidelity B. Autonomy C. Justice D. Beneficence

D. Nonmaleficence

A nurse is instructing a group of nursing students about how to know what to expect when ethical dilemmas arise. Which of the following situations should the students identify as an ethical dilemma?

A. A nurse on a medical surgical unit demonstrates signs of chemical impairment B. A nurse overhears another nurse telling an older adult client that if he does stay in bed, she will apply for restraints C. A family has conflicting feelings about the initiation of internal tube feedings for their father, who is terminally ill D. A client who is terminally ill hesitates to name her spouse on her durable power of attorney

C. A family has conflicting feelings about the initiation of internal tube feedings for their father, who is terminally ill

A nurse observes an assistive personnel reprimanding a client for not using the urinal properly. The AP tells him that she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?

A. Assault

A. Alert the American nurses Association B. Fill out an incident report C. Report the observations to the nurse manager on the unit D. Leave the nurse alone to sleep

C. Report the observation to the nurse manager on the unit

A nurse is preparing information for change of shift report. Which of the following information should the nurse include in the report?

A. Input and output for the shift B. Blood pressure from the previous day C. A bone scan scheduled for today D. Medication routine from the medication administration record

C. A bone scan scheduled for today

A nurse is discussing the HIPAA privacy rule with nurses during a new employee orientation. Which of the following information should the nurse include in the teaching? Select all that apply

A. A single electronic record password is provided for all nurses on the same unit B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station D. A client may request a copy of their medical record E. A nurse made a photocopy a clients medical record for transferred to another facility

B. Family members should provide a code prior to receiving client health information C. Communication of client information can occur at the nurses station D. A client may request a copy of their medical record E. A nurse made a photocopy a clients medical record for transferred to another facility

A nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting a clients record? Select all that apply

A. Cover errors with correction fluid, and write in the corrected information B. Put dates and times on all entries C. Document objective data leaving out opinions D. Use as many abbreviations as possible E. Wait until the end of your shift to document

B. Put dates and times on all entries C. Document objective data leaving out opinions

A nurse is discussing occurrences that require completion of an incident report with a newly licensed nurse. Which of the following should the nurse include in her teaching? Select all that apply

A. Medication errors

B. Needle sticks C. Conflict with provider and staff D. Omission of prescription order E. Missed specimen collection of prescribed laboratory test

A. Medication errors B. Needle sticks D. Omission of prescription order

A nurse is receiving a providers prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all that apply

A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the providers signature within 24 hours of the prescription D. Decline verbal prescription because it is not an emergency E. Tell the charge nurse that the provider has prescribed morphine via phone

A. Repeat the details of the prescription back to the provider B. Have another nurse listen to the telephone prescription C. Obtain the providers signature within 24 hours of the prescription

By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, in order to follow the nursing process?

A. Reassess the client to determine the reasons for inadequate pain relief B. Wait to see whether the pain lessons over the next 24 hours C. Change the plan of care to provide different pain relief interventions D. Teach the client about the plan of care for managing his pain

A. Re-assess the client to determine the reasons for inadequate pain relief

A newly licensed nurse is reporting to the charge nurse about the care she gave to a client. She states, "the clients at his leg pain was back, so I checked his medical record, the last received his pain medication six hours ago. The prescription reads every four hours PRN for pain, so I decided that he needs it. I asked the unit nurse to observe me preparing and administering it. I checked back with a client 40 minutes later, he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps and the nursing process?

A. Assessment B. Planning C. Intervention D. Evaluation

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the nurse identify as objective data? Select all that apply

A. 0905

B. 0825

C. 1000

D. 0840

E. 0935

A. 0905

D. 0840

**time must be within 30min of scheduled dose

A nurse is working with a newly licensed nurse who is administering medications to clients. Which of the following actions should the nurse identify as an indication that the newly hired nurse understands medication error prevention?

A. Taking all medications out of the unit dose wrappers before entering the clients room B. Checking with the provider when a single dose requires administration of multiple tablets C. Administering a medication, then looking up the usual dose range D. Relying on another nurse to clarify the medication prescription

B. Checking with the provider when a single dose requires administration of multiple tablets

*This is an indication that prescription or transcription errors may have occurred

A nurse educator is teaching a module about safe medication administration to newly licensed nurses. Which of the following statements should the nurse identify as an indication that one of the groups understands how to implement medication therapy? (Select all that apply)

A. " I will observe for side effects" B. " I will monitor for therapeutic effects" C. " I will prescribe the appropriate dose" D. " I will change the dose if adverse effects occur" E. " I will refuse to give a medication if I believe that it is unsafe"

A. " I will observe for side effects" B. " I will monitor for therapeutic effects" E. " I will refuse to give a medication if I believe that it is unsafe"

*other options are outside of your scope of practice

A nurse is preparing to administer digoxin to a client who states " I don't want to take that medication. I do not want one more pill." Which of the following responses should the nurse make?

A. " your physician prescribed it for you, so you really should take it." B. " well, let's get it over with quickly then"

C. " OK I will just give you your other medications" D. " tell me about your concerns with taking this medication"

D. Tell me your concerns with taking this medication

A nurse is caring for a client diagnosed with severe respiratory syndrome. The nurse is aware that healthcare professionals are required to report communicable and infectious diseases. Which of the following illustrates the rationale for reporting? (Select all that apply)

A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment D. Identifying endemic disease E. Monitoring for common source outbreaks

A. Planning and evaluating control and prevention strategies B. Determining public health priorities C. Ensuring proper medical treatment E. Monitoring for common source outbreaks

A nurse is caring for a client who presents with linear clusters of fluid containing vesicles with some crustings. The nurse should identify the client has manifestations of what following condition?

A. Allergic reaction B. Ringworm C. Systemic lupus erythematosus D. Herpes zoster

D. Herpes zoster

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?

A. Prodromal B. Incubation C. Convalescence D. Illness

D. Illness

A nurse educator is reviewing with a newly hired nurse the difference in manifestation of a localized versus a systemic infection. The nurse indicates understanding when she states which of the following are manifestations of a systemic infection? (Select all that apply)

A. Fever B. Malaise C. Edema

B. " I will go to the nurses station for assistance"

*When a client is having a seizure you should stay with him and use the call light to summon additional assistance

A nurse observes smoke coming from under the door of the staff lounge. Which of the following actions is the nurses priority?

A. Extinguish the fire B. Activate the fire alarm C. Move clients who are nearby D. Close all open doors of the unit

C. Move clients who are nearby

The nurse is caring for a client who has a history of falls. Which of the following actions is the nurses priority?

A. Complete a fall risk assessment B. Educate the client and family about fall risk C. Eliminate safety hazards from the clients environment D. Make sure the client uses assistive aids in his possession

A. Complete a fall risk assessment

• it is important to do this first to determine the clients fall risk. After determining the risk you are then able to implement appropriate safety measures

A charge nurse is assigning rooms for the clients to be admitted to the unit. To prevent falls, which of the following clients should the nurse assigned to the room closest to the station?

A. A middle adult who is post operative following a laparoscopic cholecystectomy B. A middle-aged adult who requires telemetry for a possible myocardial infraction C. A young adult who is post operative following an open reduction internal fixation of the ankle D. An older adult who is postoperative following a below the knee amputation

D. An older adult who is postoperative following a below the knee amputation

A nurse in a providers office is preparing to access adult males musculoskeletal system as a part of a comprehensive physical examination. Which of the following findings should the nurse expect? (Select all that apply)

A. Concave thoracic spine posteriorly B. Exaggerated lumbar curvature C. Concave lumbar spine posteriorly D. Exaggerated thoracic curvature E. Muscles slightly larger on his dominant side

C. Concave lumbar spine posteriorly E. Muscles slightly larger on his dominant side

A nurse is assessing a clients neurosensory system. To evaluate stereognosis, the nurse should ask the client to close his eyes and identify which of the following items?

A. A word she whispers 30 cm from his ear B. A number she traces on the palm of his hand C. The vibration of a tuning fork she places on his foot D. A familiar object she places in his hand

D. A familiar objects placed in his hand

A nurse is caring for a client who reports pain with internal rotation of her shoulder. This discomfort can affect the clients ability to perform which of the following activities?

A. Mopping her floors B. Brushing the back of her hair C. Fastening her bra behind her back D. Reaching into a cabinet above the sink

C. Fastening her bra behind her back

A nurse is performing a neurosensory examination for a client. Which of the following assessments should the nurse perform to test the clients balance? (Select all that apply)

A. Romberg test B. Heel to toe walk C. Snellen test D. Spinal accessory function E. Rosenbaum test

A. Romberg test B. Heel to toe walk

A nurse is collecting data from an older adult client as part of a Neurosensory examination. Which of the following findings should the nurse expect as changes associated with aging? (Select all that apply)

A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short term memory decline E. Decreased risk of depression

A. Slower light touch sensation B. Some vision and hearing decline C. Slower fine finger movement D. Some short term memory decline

B. Encourage the client to communicate his thoughts and feelings

A nurse is caring for a school age child who is sitting in a chair. To facilitate effective communication, which of the following actions should the nurse take?

A. Touch the child's arm B. Sit at eye level with the child C. Stand facing the child D. Stand with a relaxed posture

B. Sit at eye level with the child

A nurse is caring for a client who has terminal lung cancer. The nurse observes the clients family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate with the family?

A. Allowing the client to function independently will strengthen her muscles and promote healing B. The client needs to be given privacy at times for self reflecting and organizing her life C. The clients sense of loss can be lessened through retaining control of certain areas of her life D. Performing ADLs is required prior to discharge from an acute care facility

C. The clients sense of loss can be lessened through retaining control of certain areas of her life

A nurse is caring for a client who has stage five lung cancer and his three days postoperative following a wedge resection. The client states, "I told myself I would go through with the surgery and quit smoking, if I could just live long enough to attend my daughters wedding." Based on Kubler Ross' is model which stage of grief is the client experiencing?

A. Anger B. Denial C. Bargaining D. Acceptance

C. Bargaining

A nurse is consoling the partner of a client who just expired after a long battle with liver cancer. The partner is displaying grief and states, "I hate him for leaving me here." Which of the following statements by the nurse successfully facilitates mourning for the grieving partner? (Select all that apply)

A. "Would you like me to contact the chaplain to come and speak with you?" B. "You will feel better soon. You have been expecting this for a while now." C. "Let's talk about your children and how they are going to react." D. "You know, it's quite normal to feel anger towards your husband at this time." E. "Tell me more about how you were feeling."

A. "Would you like me to contact the chaplain to come and speak with you?" D. "You know, it's quite normal to feel anger towards your husband at this time." E. "Tell me more about how you were feeling."

A nurse is caring for a client who has a terminal disease. Death is expected within 24 hours. The clients family is at bedside and asks the nurse about anticipated findings at this time. Which of the following findings should the nurse discuss?

A. Regular breathing patterns B. Warm extremities C. Increased urine output D. Decreased muscle tone

D. Decreased muscle tone

A nurse is assisting a newly licensed nurse with postmortem care of a client. The family wishes to view the body. Which of the following statements by the newly licensed nurse indicates an understanding of this procedure? (Select all that apply)

A. "I will remove the dentures from the body" B. "I will make sure the body is lying completely flat" C. "I will apply fresh linens and place a clean gown on the body" D. "I will remove all equipment from the bedside" E. " I will dim the lights in the room"

C. "I will apply fresh linens and place a clean gown on the body" D. "I will remove all equipment from the bedside" E. " I will dim the lights in the room"

A nurse on a med surgical unit has received change of shift report and will care for four clients. Which of the following needs should the nurse assigned to an assistive personnel?

A. Updating a plan of care for a postoperative client B. Reinforcing teaching with a client learning how to use a quad cane C. Re-applying a condom catheter for urinary incontinence D. Applying a sterile dressing to a pressure ulcer

C. Reapplying a condom catheter for urinary incontinence

A nurse manager of a med surgical unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from a PACU following thoracic surgery. To which of the following staff members should the nurse assign this client?

A. Charge nurse B. RN C. PN D. AP

B. RN

A nurse is delegating the ambulation of a client who had knee arthroplasty five days ago to an AP. Which of the following information should the nurse share with the AP? (select all that apply)

A. " does your lack of sleep interfere with your ability to function during the day?" C. " do you drink coffee, tea, or any other caffeinated drinks? If so, how many cups per day?" D. " has anyone ever told you that you seem to stop breathing for a few seconds while you sleep?" E. " tell me about any personal stress you are experiencing"

A nurse is talking with a client about ways to make him sleep and rest. Which of the following recommendations should the nurse give to the client to promote sleep and rest? Select all that apply

A. Practice muscle relaxation techniques B. Exercise each morning C. Take an afternoon nap D. Alter the sleep environment for comfort E. Limit fluid intake at least two hours before bedtime

A. Practice muscle relaxation techniques B. Exercise each morning D. Alter the sleep environment for comfort E. Limit fluid intake at least two hours before bedtime

A nurse is caring for an older adult client who has been following the facilities routine and bathing in the morning. However, at home, she always takes a warm bath before bedtime. Now she is having difficulty sleeping at night. Which of the following actions should the nurse take first?

A. Rub the clients back for 15 minutes before bedtime B. Offer the client warm milk and crackers at 2000 C. Allow the client to take a bath in the evening D. Ask the provider for sleeping medication

C. Allow the client to take a bath in the evening

A nurse is preparing a presentation at a local community center about sleep and hygiene. When explaining rapid eye movement (REM) sleep, which of the following characteristics should the nurse include? Select all that apply

A. REM sleep provides cognitive restoration B. REM sleep last about 90 minutes C. It is difficult to awaken a person in REM sleep D. Sleepwalking occurs during REM sleep E. Vivid dreams are common during REM sleep

A. REM sleep provides cognitive restoration C. It is difficult to awaken a person in REM sleep E. Vivid dreams are common during REM sleep

A nurse is instructing a client who has newly been diagnosed of narcolepsy about measures that might help with self management. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A. I will add plenty of carbs to my meals B. I will take a short nap whenever I feel sleepy C. I will make sure I stay warm when I am at my desk at work D. It is OK for me to drink alcohol as long as I have one drink per day

B. I will take a short nap whenever I feel sleepy

A nurse is caring for a client who is one day post operative following a total knee arthroplasty. The client states that his pain level is a 10 on a scale from 0 to 10. After reviewing the clients medical administration record which of the following medications should the nurse prepare to administer?

A. Meperidine 75mg IM B. Fentanyl 50mcg/ hr via transdermal patch C. Morphine 2mg IV D. Oxycodone 10mg po

C. Morphine 2mg IV

*IV delivers sudden onset, pain is extreme

A nurse is teaching a client about taking multiple oral medications at home including time release capsules, liquid medications, enteric coded pills, and opioids. Which of the following statements should the nurse identify as an indication that the client understands the instruction?

A. " I can open the capsule with the beads in it and sprinkle them on my oatmeal" B. " if I am having difficulty swallowing, I will add the liquid medication to a batch of pudding" C. " I can crush pills with the coating on them" D. " I will eat two crackers with the pain pills"

D. I will each two crackers with the pain pills

A nurse is teaching a client how to administer medication through a jejunostomy tube. Which of the following instructions should the nurse include?

A. " Flush the tube before and after each medication" B. " mix your medications with your internal feeding" C. " push tablets through the tube slowly" D. " mix all crush medications prior to dissolving them in water"

A. " flush the tube before and after each medication"

A nurse is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the nurse take?

A. Use a 22 gauge needle B. Select a site on the clients abdomen