Which best describes the nurse’s role in social justice when caring for a client?

In the profession of nursing, what does “non maleficence” mean regarding the ethical treatment of clients?

One of the ANA’s standards of professional performance is collaboration in nursing practice. Which of the following best describes how this standard would be demonstrated?

A nurse uses critical thinking and decides to not give a medication because it is contraindicated. This is known as which of the following?

The ethical concept of respecting the client and allowing the client to make his or her own healthcare decisions is which of the following?

An older adult who has fallen at home is brought in to the hospital for treatment and is in pain. Which action of the nurse best demonstrates beneficence in this situation? Select all that apply.

According to standards set by the United Nations Educational, Cultural and Scientific Organization (UNESCO), which of the following is an example of a bioethical principle?

A client wants to leave the healthcare facility against the advice of the provider and the nurse. Which of the following situations constitutes a time when a client can legally be forced to stay in a healthcare facility against his or her will?

The nurse is assisting a newly admitted client to the hospital room. As the client gets up from the stretcher and takes a few steps, he becomes short of breath. What should the nurse do to maintain client safety?

Which of the following describes the American Nursing Association’s Code of Ethics? Select all that apply.

Studies have shown that although care planning and advance directives are available to clients, only a small percentage have actually completed them. Which of the following has been shown to be associated with a greater likelihood of completing an advance directive? Select all that apply.

A client with advanced kidney disease and diabetes wants to sign an advance directive stating that he or she does not want dialysis if it is eventually needed. Which response from the nurse is accurate in this situation?

A nurse is admitting a client to the long-term care facility. During the admission process, the nurse asks the client if they have an advance directive and the client says no. How should the nurse respond?

A client is being admitted to the hospital for surgery. Which best describes an example of an assessment parameter used by the nurse to determine if the client has an advance directive?

An older adult client who has been diagnosed with lymphoma does not have a living will in place, but has filled out a values history. Which of the following is associated with this type of directive? Select all that apply.

Which of the following best describes a healthcare proxy as part of an advance directive?

Which best describes a psychiatric advance directive?

Which of the following is a role of the registered nurse when working with older adults regarding advance directives? Select all that apply.

A client is admitted to the hospital for surgery and the nurse discovers that the client has a living will. In addition to placing a copy of the document on the client’s chart, what would be a priority action for the nurse?

A client in the hospital has just expired. Which of the following personnel must the nurse notify in the event of a client’s death? Select all that apply.

Which best describes the functional nursing model?

A group of nurses on the joint disorders unit practice team nursing in order to care for their clients. The nurses have six clients to care for. Which has been described as a disadvantage to using team nursing as part of providing client care?

A nurse works in a medical-surgical unit that is almost always short-staffed. The unit has hired several nurses, but the turnover remains high. Which of the following could the nurse consider as a valid form of retention in this situation?

A nursing unit practices primary nursing as their model of nursing care delivery. Which best describes how work allocation and patient assignments are determined with this model?

The nurse is working on a unit which practices the total patient care delivery model of nursing. One of the assigned clients requires vital signs every 4 hours, blood sugars AC/HS, turned every 2 hours, assistance with feeding for every meal, and has 4 simple dressing changes. Which of the following team members should complete these tasks?

The nurse is working in a clinic and is completing an admission for a client who is new to the practice. Which of the following questions would align with the principles of the Health Promotion Model? Select all that apply.

A client who has been diagnosed with chronic kidney disease is talking to the nurse about his overall health. Which best describes the difference between health promotion and disease management in this situation?

A nurse is evaluating a client who needs surgery for an acoustic neuroma. Which of the following is an example of a health promotion based action for this client? Select all that apply.

A nurse is caring for a client who is obese and with low activity tolerance. The client tells the nurse about a desire to lose weight in order to train for a half-marathon next year. Which best describes the nurse’s role in wellness promotion for this client?

A 67-year-old client is being seen following an arm fracture. The client was diagnosed with osteoporosis last year and has been making lifestyle changes to manage the condition. The physician now wants to start the client on medication to control the disease. Which type of medication would most likely be prescribed to prevent the breakdown of bone tissue in the body?

A client recently diagnosed with a seizure disorder says, “I’m so afraid I’m going to have a seizure again. How do I prevent them from happening?” Which lifestyle changes would decrease the risk of seizures? Select all that apply.

A nurse is talking with a client who is a smoker. The nurse wants to provide some information to the client about smoking cessation. Which situation would describe the client as being in the pre-contemplation phase of change?

During an initial assessment of a client with coronary artery disease, the nurse wants to assess the client’s dietary intake to determine if diet is contributing to his health condition. Which question would most likely give the nurse an idea of the client’s everyday diet?

A nurse is teaching a group in the community about the importance of routine screenings for significant health conditions. Which information would the nurse present that is related to the link between ethnicity and the development of certain types of health conditions?

A client is being seen for control of weight and management of heart disease. The client leads a sedentary lifestyle and consumes a high fat, energy dense diet. Which best describes how these lifestyle factors contribute to heart disease?

A nurse is assessing blood pressures at a health fair. Which of the following categories of prevention does this include?

Which action of the nurse best describes tertiary prevention of an infectious outbreak of pertussis?

A client has come to the primary care provider for a flu vaccination. Which level of prevention is this?

A nurse is working in a care clinic during an outbreak of an infectious disease. The goal of interventions during secondary prevention would be which of the following?

A 46-year-old male client is being seen for a health check-up and the nurse is providing information to him about prevention of coronary artery disease. Which best describes an appropriate goal for this client that would be applied after teaching?

A nurse is teaching a community group about disaster planning and preparedness. Which is an example of primary prevention for water shortage in a potential disaster?

A nurse is giving information to expectant parents about how to install a car seat into the back seat of the car correctly. Which type of prevention measure does this situation best describe?

A nurse who works in a healthcare clinic is utilizing primary crisis prevention with her clients. Which actions demonstrate this level of crisis intervention? Select all that apply.

A 12-year-old client needs to have treatment that involves a surgical procedure that will save the child’s life. The parents refuse to give consent for the procedure based on their personal convictions. Which of the following is allowable for the healthcare team in response?

A nurse works in a busy and crowded clinic where there is little privacy for clients or the nursing staff. The nurse needs to discuss a client’s condition with another nurse but does not want to breach the client’s privacy. Which best describes how the nurse would best uphold client privacy in this environment?

After finishing a shift, a nurse uses the public restroom and encounters a colleague with a syringe and needle. The nurse remembers that this colleague has had odd behavior for the past three months and has become much more irresponsible and sloppy with work. The nurse is considering reporting the situation. Which best describes the action the nurse should take first?

A law enforcement officer arrives to the emergency department and requests information on your client, a suspect in a crime. Which information can the nurse legally disclose to law enforcement?

A nurse is taking care of a client at the beginning of a shift. Upon walking into the room, the nurse finds the client and the wife very upset. The wife says, “That last nurse was terrible! She reprimanded my husband for not taking his medication on time!” The client wants to leave against medical advice (AMA). Which response from the nurse best demonstrates conflict resolution between the client and the organization?

A registered nurse is asked to administer a drug that is considered an anesthesia induction agent. The nurse is not sure if this is within her scope of practice. Which of the following describes the nursing scope of practice? Select all that apply.

A nurse who works in the emergency department has been caring for a client who is angry and complains about the care given. Before leaving the room, the client tells the nurse, “I’m going to sue this hospital. This has been terrible!” What actions could the nurse take that would best prevent litigation? Select all that apply

Which of the following are examples of nursing malpractice? Select all that apply.

Which of the following individuals would be considered an emancipated minor?

Which of the following are examples of negligence on the part of the nurse? Select all that apply.

A nurse wants to ensure that a breach the client’s privacy and confidentiality does not occur. Which situation of disclosure of protected health information is allowed under HIPAA? Select all that apply.

Which of the following individuals has an automatic right to view a client’s medical record without the consent of the patient?

Which best explains the difference between confidentiality and privacy?

A client is being admitted to the hospital for medical care and upon admission, he signs a general release of medical information. Which of the following entities can receive client information from signing this release?

A nurse was upset about a client’s behavior and feels very angry. The nurse wants to discuss it with someone but doesn’t know what to do. Which of the following potential responses from the nurse constitutes a HIPAA violation? Select all that apply.

The nurse is caring for a male client with several supportive family members. The client’s sister from out of state calls the unit to ask how he fared overnight. Which of the following responses by the nurse is appropriate?

Which of the following is not part of HIPAA provision for protection of confidentiality?

Despite HIPAA regulations regarding confidentiality, there are some situations in which confidentiality can be breached and information reported to other entities. This includes which of the following? Select all that apply.

The charge nurse on a healthcare unit walks into the conference room and finds another nurse looking up private health information on the computer for a client that the nurse is not assigned to. The charge nurse knows that protecting health information, according to HIPAA, is designed for which of the following?

A nurse is caring for a client who recently had blood testing for HIV. The results of the test came back as HIV positive. According to standards set by HIPAA, which of the actions of the nurse is most appropriate?

A nurse is discussing a client’s upcoming surgical procedure with the client and family. Which best describes an expected client outcome after providing pre-operative education?

The nurse is providing discharge teaching to a new mother regarding the newborn baby and car seat use. The nurse identifies a need for more education when the mother says which of the following?

The nurse is educating a client who has been diagnosed with aplastic anemia. Which of the following teaching points are true of the disease? Select all that apply.

The nurse is educating a client on managing gout. Which of the following statements by the client indicates more education is necessary? Select all that apply.

The nurse is on a rapid response team that has responded to a code blue. The victim is a visitor who has fallen down a flight of stairs and is unresponsive. A cervical spine injury is suspected. In order to perform CPR safely, what is the best initial intervention?

A client in the ICU has gone into cardiac arrest. The code team has arrived and begun compressions. The nurse brings in the crash cart and sets up the defibrillator. Which of the following would be a shockable rhythm for defibrillation? Select all that apply.

A client is in the hospital after having cardiac surgery. The client’s family tells the nurse that the client does not want CPR if the client’s heart were to stop. During recovery from surgery, the client goes into cardiac arrest. Which action of the nurse is most appropriate?

The charge nurse is called to the bedside of a 6-month-old that has experienced cardiac arrest. When the charge nurse arrives, two nurses are providing CPR. Which action by these nurses would require the charge nurse to intervene immediately?

The nurse prepares the client for defibrillation due to sustained and pulseless ventricular tachycardia. Which of the following measures should the nurse ensure before delivering the shock?

A client has gone into ventricular fibrillation. Two nurses run into the room and one nurse tries unsuccessfully to find a pulse. The other nurse immediately begins CPR while the first nurse calls a code and grabs the ambu bag. What is the most important aspect of this attempted resuscitation?

The nurse is helping a conscious 9-month old client with an upper airway obstruction. What techniques will the nurse implement to help this client? Select all that apply.

The nurse is caring for a client who verbally expresses his wish to not be resuscitated. Later in the nurses shift the client codes. The nurse looks at the chart and notes that the client is listed as full code. What should the nurse do?

A nurse responds to an adult who is lying in the hallway and unresponsive. What actions by the nurse are most appropriate? Select all that apply.

What are the main findings in a cardiopulmonary arrest? Select all that apply.

A nurse is caring for clients during the day shift when the fire alarm goes off. The nurse remembers the RACE acronym for fires, and does which of the following actions for E in RACE in the event there is a small fire?

The nurse is caring for a medically stable client who states that he is extremely busy at work. The client has multiple electronic devices in the room. What is the nurse’s priority?

A fire breaks out in a long-term care facility and a nurse is in a client’s room. The nurse and the client cannot get out. Which of the following actions should the nurse perform to keep the two of them as safe as possible?

A nurse walks into a client’s room and realizes that there is a fire in the bathroom. Which actions should the nurse do in response? Select all that apply.

A school nurse participates in monthly fire drills in which all students are to file out of the building. What best describes the nurse’s role during a fire drill?

The nurse is working on a busy hospital unit. A small fire has started in a trashcan in the nurse’s break room, away from clients, and a colleague has pulled the fire alarm. What is the next priority action?

A nurse walks into the dirty utility area of the unit and finds a small fire burning in the corner. The nurse is able to quickly put it out with a nearby fire extinguisher before it activates the fire alarm. Which of the following should be the next step of the nurse?

Using bones and muscles to maintain proper alignment and body posture while performing a task is known as which of the following?

A client has undergone external beam radiation to the chest for treatment of lung cancer and is back in their room following the procedure. Which of the following interventions is most appropriate in this situation?

A client with a diagnosis of thyroid cancer has recently had internal radiation through brachytherapy. What should the nurse tell the client about visitors when this type of therapy is in place?

A 59-year-old client is undergoing radiation treatment for uterine cancer. Which of the following best describes an acute adverse effect following external radiation therapy to this area?

Following radiation treatment for cancer, a client returns to the room and a sign is placed on the door that says, “Caution: Radioactive Material”. Choose the option that best describes how visitors should respond to this sign.

The nurse is caring for a client who is receiving internal radiation therapy. The client’s implant was placed two days ago and is active. Which of the following actions is appropriate for the nurse to limit exposure to the implant?

A 48-year-old client is undergoing internal radiation for the treatment of kidney cancer. The nurse caring for this client would best protect the client, others, and himself or herself from contamination by which of the following actions? Select all that apply.

A client with throat cancer is receiving radiation treatment to the head and neck and has developed xerostomia as a result. Which of the following interventions should the nurse suggest to this client?

The nurse is caring for a client who underwent external beam radiation for breast cancer. The client complains of skin irritation at the site. Which of the following recommendations is appropriate for the nurse to make?

A nurse is caring for a client the morning after internal radiation therapy for treatment of uterine cancer in which an implant was placed. Which of the following actions demonstrate safe practice by the nurse? Select all that apply.

A home care nurse is working with a client who has been diagnosed with diabetes. The nurse is providing instructions to the client about how to dispose of used items that can puncture the skin. Which of the following describes a sharps disposal system that should be in this client’s home? Select all that apply.

While working in the recovery room, a nurse is caring for a client who has a dressing that is wet with serosanguinous fluid. Choose the action that is most appropriate for this nurse to handle regulated waste.

The client has been given an IM injection. What is the proper way for the nurse to handle the needle for disposal?

A nurse who works in a medical clinic comes into contact with client care materials and numerous other supplies and equipment that are used as part of client care. The nurse knows that biohazardous waste materials must be disposed of properly. Which of the following items would be considered a form of biohazardous waste? Select all that apply.

A client who was recently diagnosed with diabetes and who requires exogenous insulin at home has asked the nurse about the best method of disposing of needles. The client tells the nurse, “I know I’m supposed to use those red containers to put my needles in, but I do not always have one.” Which response from the nurse is most appropriate?

A nurse is changing a dressing on a client’s wound. When the soiled dressing is removed, it is saturated with blood. Which of the following best describes the most appropriate method of disposal?

A client is being discharged home after being evaluated for a fall. Which of the following should the nurse include in discharge instructions for the client? Select all that apply.

A client who is exhibiting behavioral and psychological symptoms should be medically cleared to rule out which of the following?

While admitting a client, the nurse has determined the client is a fall risk. What is a priority nursing intervention?

A nurse is working in the surgical unit and is assigned the following clients. Client A, a 78-year-old male client who recently had a hip fracture and who suffers from Parkinson’s disease. Client B, a 60-year-old client who is visually impaired and who is post-op day three after hernia surgery. Client C, a 56-year-old client who has a prescription for ketorolac and who had shoulder surgery. In which order would the nurse categorize these patients’ fall risk from greatest risk to least risk?

A nurse is filling out a fall risk assessment on a client who is considered to be at high risk of injury due to falls. Which of the following information is documented as part of the fall risk assessment?

The emergency room has four clients that have had a fall. Which of the following types of falls is the priority for the nurse to see first?

A nurse is caring for a 9-year-old client who is considered a fall risk because of a history of seizures. Which of the following interventions should be implemented to prevent falls in a pediatric client? Select all that apply.

The risk management nurse at a long-term care facility is reviewing the facility’s data related to recent client falls. The nurse should consider which of the following as a risk factor for client falls? Select all that apply.

A client has admitted to a potential problem with alcohol when talking to the nurse. The nurse talks with the client about substance abuse and the negative effects of alcoholism. Which describes how personal engagement with a client is effective as a method of change?

A nurse suspects that her 80-year-old client has an alcohol use disorder. Which of the following nursing actions should the nurse take if the client is intoxicated? Select all that apply.

A nurse is performing a clinic intake assessment on a 16-year-old client. When the nurse asks the client about alcohol consumption, the client admits that he sometimes drinks to excess with his friends. Which response should the nurse utilize to talk about this topic?

A client with alcohol use disorder is refusing to take his medication for treatment. He tells the nurse, “There is nothing wrong with me! I do not have a problem and I am fine!” The nurse understands that the client is most likely exhibiting which of the following?

A 21-year-old college student is being seen at the healthcare clinic for symptoms of a sexually transmitted infection. Which information should the nurse provide that would best teach this client about the consequences of the likely behavior that led to this condition?

An 86-year-old client has developed protein energy malnutrition as a result of poor eating habits and difficulties with chewing and swallowing. Which best describes how poor nutrition contributes to skin breakdown in an elderly client?

A nurse has developed a plan of behavior modification with a client who has been trying to quit smoking. Select all of the following nursing considerations to use when carrying out this plan.

A client who is undergoing treatment for alcoholism is an inpatient in a rehabilitation facility. The nurse is talking to the client’s family, who is concerned about the client’s health. Which information would the nurse give to the family that would best help them to care for their family member?

A 56-year-old client is being seen for injuries incurred while the client was intoxicated. The nurse utilizes the CAGE questionnaire during the assessment. What distinguishes this test from other alcohol abuse assessments?

A 35-year-old client in the care clinic tells the nurse that he thinks he has a problem with alcohol abuse. The nurse talks with the client more about his behavior and drinking patterns. Which assessment components would most likely suggest that the client has an alcohol abuse disorder? Select all that apply.

The Joint Commission has issued a sentinel event alert on restraint use, citing an increased risk of harm to clients when restraints are used inappropriately. Which of the following is a risk associated with using restraints? Select all that apply.

A nurse had to place physical restraints on a client who had been pulling out the IV line and tearing at the surgical incision. Which elements must the nurse include as part of monitoring while the client is in restraints? Select all that apply.

An 86-year-old client receiving enteral nutrition through a nasogastric (NG) tube. The client continues to pull at the NG tube. The client has had intermittent wrist restraints for the past two days and the nurse is considering what options could be implemented instead of the wrist restraints. Which of the following should the nurse consider as an alternative to using wrist restraints?

A client with schizophrenia has become very angry and is throwing items at the nursing staff. The nurses have tried other forms of calming the client, but nothing has worked. Which of the following accurately describes the staff’s ability to use restraints in this situation?

A client who is cognitively impaired has become agitated and upset with the nursing staff. The nurse does not want to use restraints with the client but is struggling to keep her calm. Which is an example of an appropriate intervention that would be an alternative to using restraints?

When a client is restrained to prevent pulling at medical equipment, the placement of the restraint and the condition of the client should be assessed at what intervals?

A client with upper arm restrains has a pale and cold hand. The client is complaining that the restraint hurts. What is the first thing the nurse should do?

A nurse is caring for a client who is acting out and threatening to harm the staff. After calling security, the nurse discusses with the provider the need for restraints. Which of the following does the nurse need to verify before placing restraints on the client?

A nurse is caring for a client who becomes combative and is restrained. What principles should be considered in the plan of care? Select all that apply.

Despite trying multiple interventions to manage a client’s behavior, the nurse has decided to use restraints through an order from the provider. In which situation would the client most likely need mitt restraints?

A client presents for care at a primary care facility. The client is coughing and has a fever of 102 F. Which statement from the nurse regarding protective equipment is most appropriate in preventing the potential spread of this client’s infection?

The nurse is caring for a client diagnosed with influenza. Which of the following personal protective equipment (PPE) MUST the nurse wear when entering this client’s room?

A 31-year-old client has developed meningococcal meningitis after recently traveling out of the United States. Which type of precautions would the nurse most likely implement in this situation?

Which of the following principles of using personal protective equipment (PPE) is correct?

A 60-year-old client has been admitted to the hospital with Creutzfeldt-Jakob disease. Which type of isolation precautions must the nurse use while caring for this client?

The nurse is caring for a client with watery diarrhea following a course of clindamycin. The nurse suspects clostridium dificile. Which of the following isolation precautions are necessary for this client? Select all that apply.

A 50-year-old client with measles has been admitted to the hospital and is in isolation. The client’s daughter asks the nurse, “How can I keep from catching this myself if I have been vaccinated?” Which answer from the nurse is most appropriate?

A mother has brought her 5-year-old son into the healthcare clinic for a physical to prepare for kindergarten. The nurse is reviewing the child’s immunization history and notes that the child has had one prior MMR vaccine. Which response from the nurse is most appropriate?

A 6-month-old child has just received the 6 month scheduled immunizations. Which type of immunity does this process best describe?

A healthcare office provides immunizations for children and adults in the community. The nurse is preparing vaccine information sheets (VIS) to give to clients about the vaccines. Another nurse says, “Those forms are optional. You do not have to give those out if you do not want to.” Which response from the nurse is accurate?

The nurse is administering a pneumococcal conjugate vaccine to a client. Which of the following is true regarding this type of vaccine? Select all that apply.

According to the Centers for Disease Control and Prevention, which of the following best describes the recommended ages to administer the measles, mumps, and rubella vaccine?

The nurse is caring for a client who stepped on a rusty nail. The client does not want to receive medications if possible. The nurse educates the client on which of the following important medications to receive?

The parents of a 6-month-old infant have brought the child in for a routine well-child check. The parents want to know what immunizations their child should get at this visit. According to the Centers for Disease Control and Prevention recommendations, which vaccines should the child get at this age? Select all that apply.

A nurse mistakenly administered heparin after reading the order incorrectly, and the client started bleeding uncontrollably. The nurse is documenting the occurrence. Which elements should be included as part of documentation in this situation? Select all that apply.

A nurse walks into a client’s room and discovers him lying on the floor next to his bed. The nurse must fill out an incident report. Which of the following is most appropriate for documenting the information?

The nursing staff at a local hospital have complained about the changes in computerized documentation in their unit. The nurse manager tries to explain why electronic documentation can be beneficial. Which of the following best describe benefits of using computerized nursing documentation? Select all that apply.

A nurse is performing chart checks on the evening shift at the hospital and notes that one of the clients has an error in the way the order was transcribed. Which of the following is an example of an error of transcription in documentation? Select all that apply.

A client who received a unit of packed red cells suffered a transfusion reaction. The nurse followed the appropriate steps to manage the reaction. What information is required for the nurse to document in the client’s chart? Select all that apply.

A diabetic client is being transferred to a long-term care facility following hospitalization. The nurse who is transferring the client is reporting to the receiving facility about skin care interventions the facility has been utilizing. Which of the following information should be included as part of the report?

At the end of the shift, a nurse is giving report to the oncoming nurse. The nurse uses the SBAR format to relay appropriate information. The nurse knows that the A in SBAR stands for which of the following?

A nurse is preparing a change-of-shift report by recording the report for the nurses on the next shift. Which of the following best describes the primary purpose of change-of-shift report?

A nurse is caring for a client who will be transferred to another hospital that is closer to the client’s home. The nurse calls ahead to the facility to report to staff about the client. What information would the nurse include as part of this report? Select all that apply.

A client is being transferred to another facility and the nurse calls ahead to give the receiving facility a report about the client’s condition. The nurse uses the SBAR method of communicating pertinent information. Which of the following information would be included in the R portion of the SBAR format?

A nurse who is going home at the end of the shift is giving report to the oncoming nurse. The report is on a 53-year-old client who is being treated for hypovolemic shock secondary to chronic vomiting and diarrhea. Which information should the nurse present first during this client handoff?

What should be included in a transfer report from the post-anesthesia care unit (PACU) to the floor? Select all that apply.

Which of the following best describes a barrier to an appropriate client handoff within the healthcare facility? Select all that apply.

What is the main advantage of a face-to-face change of shift report?

It is nearing the end of a shift and the nurse is preparing to give bedside report to the oncoming nurse. Which of the following items would NOT be included in the bedside shift report?

The nurse knows to make clinical priority decisions based on which hierarchy of needs?

Which is an example of a first-order priority need when providing client care?

The nurse is going over discharge paperwork with a client. While educating the client on decreasing risks of falls such as removing rugs and keeping walkways clear of clutter, the client starts to cry. The nurse discovers that the client is homeless. Which of the following should the nurse do for the client?

A float nurse comes to help in the emergency room and is triaging clients with an experienced nurse. The experienced nurse helps the float nurse understand that the client with which of the following is the priority?

A nurse is starting a shift in the morning. After receiving report on the clients, the nurse reviews what needs to be done and starts to prioritize tasks. The nurse has the following clients: A: A 68-year-old client who must take his medication with breakfast whose tray has just arrived B: A 42-year-old client who has become unresponsive in the last 5 minutes C: A 51-year-old client who is complaining of pain when he moves his shoulder D: A 38-year-old client who wants to take a shower right away In which order should the nurse prioritize activities?

What is the highest order of Maslow’s Hierarchy of needs?

A client with post-traumatic stress disorder has been brought into the emergency department after attempting suicide by carbon monoxide poisoning. The nurse assesses the client and finds that the client is short of breath, with a respiratory rate of 30/min, HR 98 bpm, and a blood pressure 110/80 mmHg. The client is irritable and withdrawn and his wife is at his side. Which intervention is the highest priority in this situation?

A client’s respiratory rate is at 8 breaths per minute and the client is cyanotic. The nurse knows this client’s needs fall into which level of Maslow’s hierarchy of needs?

A nurse is caring for a client in the ICU who has been severely burned. According to Maslow’s hierarchy of needs, which of the following actions demonstrates that the nurse is meeting the client’s highest priority needs? Select all that apply.

The nurse is caring for a client who began to cough and became short of breath while eating a meal. What is the nurse’s priority?

The nurse is caring for a client in the emergency department. The client needs vital signs, a urine sample, triage, an assessment, and pain medication. Which interventions can the nurse delegate to the nursing assistant? Select all that apply.

After receiving report, the nurse is planning client tasks. Which of the following tasks can be delegated to the nursing assistant?

The nurse is working on a busy unit with an unlicensed assistive personnel (UAP). Which of the following tasks is outside of the scope of practice for the UAP? Select all that apply.

The nursing assistant in the busy emergency room is helping with tasks. Which of the following task is appropriate?

The nurses on a busy unit are all needing help so a nurse assistant is asked to assist them. Which of the following tasks should the nurse assign to the nursing assistant?

A nurse is delegating client assignments. Which task is most appropriate to delegate to the unlicensed assistive personnel (UAP)?

The nurse is caring for a client who is having chest pain. Which of the following interventions can be appropriately delegated to the certified nursing assistant? Select all that apply.

A 16-year-old client needs to get up to ambulate after having knee surgery. A nurse assigns a nursing assistant to ambulate the client. Which of the following should the nurse consider when delegating this task to the nursing assistant?

The nursing staff on a critical care unit must routinely check the crash cart each shift to ensure that all supplies are in place. The RN wants to delegate the task of checking the crash cart to a nursing assistant who is working with her. Which of the following is true regarding this action?

A nursing student is practicing delegation with other students. The nursing students would be correct in saying which of the following tasks is not appropriate to delegate to a nursing assistant?

The night shift nurse gives report to the charge nurse. After reviewing the diagnosis and symptoms the charge nurse should see which of the following clients first?

A student nurse assesses four clients in the emergency room and reports to the nurse with the client’s symptoms. The nurse would be most concerned with which of the following findings?

A nurse is called in for an on call shift in the Emergency Department and is quickly trying to prioritize the clients that need to be seen. The client with which of the following should be seen first?

A nurse is reviewing the needs of four clients and trying to prioritize their care. The nurse should see which of the following clients first?

The nurse receives a client in the emergency room with an obvious deformity of the left leg. What is the first thing the nurse should do?

The nurse is prioritizing tasks at the beginning of the shift. The client with which of the following should be the priority?

A student nurse is trying to understand how to prioritize the following four clients. The nurse is helping the student understand the order of priority. Which of the following client symptoms should be the top priority?

There are four clients in the emergency room with different lacerations. The nurse knows that which of the following is the priority?

During a busy shift at the hospital, a nurse continually gets bogged down with extra tasks and is unable to keep up with the workload. Which of the following is an example of a barrier to setting priorities? Select all that apply.

Four clients are waiting to be seen in the emergency room. The nurse knows to first see the client with which of the following?

After receiving report on four clients the emergency room nurse should see the client with which of the following diagnosis first?

The triage nurse is working in the emergency department. Which of the following clients would the nurse classify as priority 2, or urgent? Select all that apply.

There are 4 pediatric clients sitting in the waiting room of the emergency department. A bed becomes available and the triage nurse knows to take back the client with which of the following first?

There are four clients that the nurse is prioritizing in order of importance. Of the following clients, which client should the nurse see first?

The following four clients are brought to the emergency room by ambulance. The triage nurse is assigning clients to a room and should prioritize which of the following symptoms?

The triage nurse has one bed available in the ED. Which of the following clients waiting to be seen is the priority?

A client presents to the emergency department after being struck in the head with a baseball bat. The client complains of headaches and pain in the deltoid region. The triage nurse knows to perform which of the following first?

A nurse is performing triage on clients who are brought to the hospital after a nearby train accident. Which nursing assessments or actions occur during the primary triage survey? Select all that apply.

The nurse knows that common mechanisms of injury involved in penetrating trauma include all of the following except which of the following?

A client is brought into the trauma bay after being stabbed in the abdomen with a 12 inch knife. The blade is still present in the client. The client is complaining of severe abdominal pain and is restless. After completing the initial survey, which of the following is the next thing the nurse should do?

A nurse is not sure if the provider should be contacted about a client’s condition. What elements of the problem-solving method should the nurse consider that would help with this decision? Select all that apply.

A patient calls the nurse and complains about his IV site. The nurse assesses the site and notes that the skin is red and warm and the client states that the pain travels up his arm. Which of the following potential complications of IV therapy has most likely occurred?

A nurse is assessing a 37-year-old client prior to administration of packed red blood cells for post-op hemorrhage. The nurse must use a pressure infusion device to rapidly administer the blood products. The nurse notes that the client has a 24-gauge catheter in her antecubital fossa. Which action of the nurse is correct?

Prior to a client’s surgery, a nurse is assessing whether a PCA would be appropriate during the post-op period. Which factors would the nurse assess that would help determine that the use of a PCA is appropriate? Select all that apply.

A nurse is caring for a client who is at high risk of dehydration. Which parameter would the nurse use to assess whether this patient is dehydrated?

A nurse is assessing a client’s ability to perform activities of daily living. Which action would the nurse have the client perform as part of this assessment process?

A 69-year-old client has been diagnosed with cardiomyopathy. The nurse gives the client a nursing diagnosis of powerlessness because the client has said that she feels sad and angry about what she will miss out on with her diagnosis. Which nursing intervention is most appropriate for this nursing diagnosis?

A nurse has given a client a nursing diagnosis of Ineffective Coping because of her response to an injury. The nurse helps the client to recognize individual strengths in this situation. Which outcome would most likely be expected as a result of these interventions?

A patient has been given a nursing diagnosis of Alteration in Comfort related to a back injury. Which nursing intervention would be most appropriate in this situation?

A nurse has arrived at the healthcare center to work the day shift and is getting ready for report. In order to best organize the day, which of the following is most important to consider while planning tasks?

A nurse case manager is working with a diabetic client to ensure that the client has the supplies needed to manage the condition at home. The case manager has developed a plan of care for the client and is listing appropriate outcomes related to the client’s self-care skills at home. Which of the following examples is most applicable in this situation?

The nurse is caring for a client with cancer. The client has discussed treatment options with the provider and agreed upon a plan that involves chemotherapy. The client tells the nurse that he is nervous about the side effects of the chemotherapy. Which of the following responses from the nurse is most appropriate?

The nurse is caring for a client with a neutrophil count of 490. Which of the following actions should the nurse implement? Select all that apply.

A nurse is working as part of an interdisciplinary team to make decisions for a client’s plan of care. Which of the following would the nurse utilize as part of collaboration with the interdisciplinary team? Select all that apply.

When planning nursing care for a client, objectives should be SMART. Specific, measurable, action-oriented, realistic, and timely. Which example best describes an outcome that is measurable?

The nurse is speaking with the family members about a client’s plan of care. The client’s daughter states, “Her living will stated she did not want to be intubated.” Which of the following actions by the nurse are the most appropriate? Select all that apply.

The nurse is caring for a client who was informed yesterday that amputation of the left leg is recommended. When the nurse attempts to discuss this with the client, he says the provider informed him that the leg was fine and he will go home any day now. What is most helpful in facilitating this client’s plan of care?

A nurse works in a medical rehabilitation facility and is developing a plan of care for a 68-year-old client who has been admitted to the facility. Which best describes an appropriate goal in providing healthcare for a client in this age group? Select all that apply.

A 40-year-old woman is talking to a home care nurse about her husband’s infidelity and their subsequent divorce. The woman asks the nurse about providing for her children after her husband moves out. Which is an example of the nurse utilizing the planning portion of this client’s plan of care?

While caring for a patient who is dying of cancer, the nurse tries to control the patient’s pain. The nurse uses the WHO ladder to determine how much pain medicine to give. Which best describes implementation of this ladder?

A nurse is caring for a 12-month old child who is recovering from surgery. Which of the following principles should the nurse implement when managing pain in a patient who cannot communicate with words? Select all that apply.

The nurse is caring for a client who has returned to the floor from the PACU after an appendectomy. Based on this surgical procedure, the nurse knows to implement which of the following interventions for this client?

A nurse is discharging a client to home following abdominal surgery. The client has a history of diabetic neuropathy and the nurse is providing discharge instructions. Which of the following instructions should the nurse give to this client to best prevent an injury at home as a result of peripheral neuropathy symptoms?

A nurse started working in an ethnically diverse clinic. Which actions could the nurse implement to deliver culturally competent care? Select all that apply.

A nurse is administering medication to a client in the hospital. Which best describes an example of a nursing consideration during the evaluation phase of medication administration?

The nurse has a discharge order for your postoperative client who is verbally expressing their want to be discharged as soon as possible. The client needs to be evaluated to see if they are ready for discharge. The nurse knows that all except which of the following assessment findings would indicate it is safe for discharge the client?

A client has been hospitalized for symptoms of abdominal pain and diarrhea following exacerbation of stress. The nurse is teaching the client about ways to minimize environmental stress in her life. Which statement from the client indicates that teaching has been effective?

A nurse has implemented a screening program for members of a neighborhood to screen for diabetes. Which best describes the process the nurse would use to evaluate the success of this program?

A client with stress incontinence is undergoing treatment through rehabilitation of the pelvic floor muscles. Which statement by the client suggests that the treatment is effective?

A nurse is working with a diabetic client in the primary care clinic. Which factor regarding the client’s health would most likely warrant a referral to a diabetic educator for further teaching?

A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which tasks can be delegated? Select all that apply.

A nurse has just completed client education prior to discharging a two-year-old who was just diagnosed with Hemophilia A. Which of the following statements from the parents indicate that the teaching was effective? Select all that apply.

A nurse is working in a community that has a low rate of birth control use and high birth rate among its population. The nurse wants to provide information to community members about birth control. Which factor would the nurse most likely consider when evaluating outcomes of this education program?

A nurse is caring for a client complaining of pain. Which of the following critical thinking steps would the nurse utilize to respond to this situation? Select all that apply.

The nurse is assigned to 4 clients who all have labetalol ordered. Which client will need labetalol first?

The nurse is caring for a client with high blood pressure. After starting drug therapy for this condition, the client complains of dizziness and weakness. The nurse takes a set of vital signs and notes the client’s blood pressure is 85/55. Which of the following interventions are appropriate for the nurse to perform for these side effects? Select all that apply.

A nurse is preparing to administer medication to a client who is recovering from surgery. Which of the following demonstrates that the nurse is using critical thinking skills when administering this drug? Select all that apply.

A nurse is preparing to give the first dose of an oral medication to a client. Which answer best describes how the nurse would utilize critical thinking when administering this drug?

The nurse has received report on 4 clients who all need antibiotics administered. Which of the following clients will need antibiotics first?

A tornado has hit a small community and the staff at the hospital have lost power in the facility. The nurses and other staff are working by flashlight. One of the nursing assistants becomes very upset and tells a nurse, “I can’t handle this! I feel like I don’t know what to do!” Which of the following responses by the nurse best reflects nursing leadership skills?

A client in the emergency department is displaying signs of dread and terror, has disorganized thoughts, and cannot communicate clearly with hospital staff. What takes priority when dealing with this client?

A worker in the laboratory notes that a nurse on the surgical unit of the hospital failed to report a client’s critical lab value to the provider. Which of the following actions should the healthcare staff member perform in response? Select all the apply.

A client is rushed to the emergency room after spilling hazardous material all over the face. The chemical is burning the client’s face and the client is struggling to breathe. The nurse gowns up into the hazmat suit and makes sure it is safe to enter the hazmat room. What is the nurse’s highest priority at this time?

Which best describes the role of a utilization review nurse in pediatric care?

A patient has a non-tunneled central catheter placed for intravenous administration of antibiotics. Which of the following is true regarding this type of catheter? Select all that apply.

A nurse is caring for a client who is experiencing significant anxiety and is fearful because of his diagnosis of cancer. The nurse responds by reducing distractions and loud noises in the environment and providing calm and empathic care. Which outcome would the nurse most likely expect to see from the client as a response to this intervention?

A client and her spouse are seen at the primary care clinic for assessment for infertility. The client becomes tearful as she tells the nurse that she has been trying to become pregnant for over a year without success. The client says, “I do not think I could handle it if I knew I could never start a family.” Which intervention by the nurse best demonstrates therapeutic communication to assist the client with coping with her situation?

Which of the following is a true statement regarding communication between the nurse and the client?

After a successful return demonstration, the nurse says to the client, “You are confidently using that inhaler!” This is an example of which type of therapeutic communication?

A nurse is performing an intake interview on a client who has come to the hospital for abdominal pain. Which action demonstrates that the nurse is actively listening during the client interview?

While talking to a patient about how she lost her job, the nurse utilizes clarifying techniques as therapeutic communication. Which of the following are examples of clarifying during the conversation? Select all that apply.

A 39-year-old client is talking with a nurse about the client’s sexual relationship with a committed partner. Which describes how the nurse should discuss an awkward topic with a client?

A client with lung cancer tells the nurse about how difficult it has been to go through cancer treatment. Which response from the nurse best demonstrates therapeutic communication?

Which is an example of a qualitative open-ended question that the nurse may use in therapeutic communication with the client?

A nurse is caring for a client who is experiencing severe stress associated with her family. The nurse knows that which form of non-verbal communication would most likely indicate interest in what the client is trying to say?

A nurse is working with a client who suffers from depression. The client has started taking medications and is engaged in group therapy, but still tells the nurse, “I do not like myself. I am annoying, even to me.” Which activities can the nurse suggest that would most likely increase this client’s self-concept? Select all that apply.

A client has a cancerous wound that has a significant odor. The client states, “I feel disgusting because of this”. Which nursing intervention is most appropriate in this situation?

You are caring for a patient with a disturbance in self-concept. Which of the following nursing diagnoses should you consider when planning care? Select all that apply.

A 35-year-old client is undergoing a lower limb amputation after a crushing injury. Which best describes how the nurse can support the client’s anticipated grief during this time?

A nurse is caring for a woman whose mother died six months ago and who is grieving over the loss. The nurse assesses the woman for any signs of complicated grief patterns. Based on the nurse’s understanding of this condition, the nurse knows to look for what signs that indicate complicated grief? Select all that apply.

A 58-year-old client is feeling sadness and loss after his mother died. Which best describes the difference between grief and depression?

A nurse is helping a family whose loved one died thirty minutes ago. The family exhibits sadness and crying. What kind of grief is the family experiencing?

Which of the following situations best describes acute grief?

Which best describes disenfranchised grief?

A nurse is caring for a client who lost her father to cancer last year. The client is demonstrating dysfunctional grief in that she has intense feelings of guilt over the situation. Which of the following factors would increase a person’s risk of developing dysfunctional grief?

The parents of a 1-year-old child who has been adopted from Ethiopia ask the nurse about the child’s feelings of grief. The mother tells the nurse, “I do not think the understands the loss at one year old.” Which response from the nurse is correct?

A client is suffering from feelings of loss after experiencing a miscarriage. Which action of the nurse would best support this client in working through her grief?

The parents of a 2-year-old child who died of leukemia are experiencing intense grief in the months following the death. Which of the following is a factor that would affect how these parents experience grief?

A client who has suffered a brain injury requires rehabilitation technology. Which of the following describes this type of technology? Select all that apply.

A nurse is caring for a client with a communication disorder who uses an augmentative and alternative communication device. Which of the following is an impairment for which this device can be helpful? Select all that apply.