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?

The nurse is assigned a diabetic client and has delegated a blood glucose re-check to the certified nursing assistant (CNA). The CNA was urgently called into another client’s room and did not complete the task. The nurse failed to follow up with the CNA, and discovered later that the client’s skin was cool and clammy, with a blood glucose level of 42 mg/dL. Out of the following choices, who is ultimately accountable for this hypoglycemic episode?

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

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

In regards to the individual client decision making, what does “autonomy” mean?

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?

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?

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

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

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.

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.

The nurse is caring for a 70-year-old client diagnosed with pneumonia. The treatment plan includes antibiotics, breathing treatments, and incentive spirometer use. The client is alert and oriented to person, place, time, and situation. They are on 2L nasal cannula without any signs or symptoms of distress. The client states, “I do not want to have any antibiotics, I just want this to run its course.” The nurse knows this client has a durable power of attorney. Which of the following should the nurse do?

A nurse is filling out paperwork with a client who is being admitted to the hospital. The nurse asks the client if he has an advance directive. Which response from the client indicates understanding of a power of attorney document?

In the event that a client becomes incompetent to make his or her own decisions, the healthcare power of attorney can authorize which of the following?

The nurse is caring for a client who just arrived on the unit from PACU after a craniotomy for tumor debulking. After completing the initial assessment, the nurse administers morphine for pain. The client is groggy, but oriented and compliant. The client’s daughter is outside of the room and asks, “Can you just knock him out? He is agitated and getting on my nerves. He’s probably in pain and just needs to sleep off the rest of the day. I’m his health care power of attorney as you can see in the chart.” What is the most appropriate response?

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?

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 nurse is performing postmortem care on a client who has just died. Which of the following actions should be included as part of postmortem care? Select all that apply.

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.

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 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?

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?

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?

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?

Which best describes the functional nursing model?

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 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?

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 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 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 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?

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 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?

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

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?

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 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 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 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?

Which of the following situations best describes a breach of duty to act?

Which of the following best describes the concept of a compact state for nursing licensure?

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

A nurse is being accused of defamation against a client’s family member. Which of the following is a true statement regarding defamation in the healthcare environment? Select all that apply.

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 client is upset about the treatment received while in the hospital, and wants to leave AMA. The nurse should inform the client that it is within the client’s right to leave the hospital but should also include what information when care is refused? 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 individuals would be considered an emancipated minor?

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?

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

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?

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.

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.

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?

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

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

Which best explains the difference between confidentiality and privacy?

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?

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.

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 care team must initiate cardiopulmonary resuscitation on a client who is on a ventilator. The nurse knows to set the ventilator at which of the following breathing rates?

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.

Which of the following are components of effective cardio-pulmonary resuscitation (CPR)? 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 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 nurse calls the charge nurse and asks for a vial of Epinephrine 1:10,000 to be brought to a client’s room STAT. The charge nurse knows that what situation is likely occurring in the client’s room?

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?

A nurse is working on a team performing CPR on a client who has coded in the hospital. The nurse sets up the monitor and notes that the client has a pulseless electrical activity (PEA) rhythm. The provider tells the nurse to set up for a shock. Which response from the nurse is correct?

Select the location on the client’s body where the second AED pad should be placed.

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 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 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?

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 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?

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?

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

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 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 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.

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 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?

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 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 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.

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?

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.

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.

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 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 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.

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

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?

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

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?

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.

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 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?

A nurse is working with a client who has smoked for 14 years. The client has mentioned wanting to quit but does not show any desire to move forward with quitting. Which intervention from the nurse would be most helpful in this situation?

When assessing a client’s level of nutrition risk, the nurse uses the DETERMINE scale to determine if the client is at high risk of malnutrition or poor intake. Which best describes how the nurse would assess the D (disease) portion of the assessment?

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 diabetic client is talking with a nurse about diet and what foods to avoid. The client asks the nurse about drinking alcohol. Which response from the nurse would be correct?

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 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 has smoked cigarettes for 30 years is discussing health issues with a nurse. The nurse is advising the client about how quitting smoking can reduce the risk of certain types of cancer. Smoking is related to an increased risk of which of the following types of cancer?

A client who has been abusing heroin is brought in to the hospital by a friend for treatment. The nurse gives the client a nursing diagnosis of Denial because of the client’s lack of concern about his condition and his delay in seeking care. Select all of the following appropriate interventions for this nursing diagnosis.

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 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.

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 nurse is caring for a client who has dementia as a result of Alzheimer’s disease. The provider writes an order for bilateral wrist bands for restraints PRN. Which action of the nurse is most appropriate regarding this order?

A client is becoming violent toward the staff. The nurse considers behavioral health restraints and seclusion to protect the client and staff. Which principles must the nurse consider before implementing this type of restraint? Select all that apply.

A nurse is caring for a client who has become confused following surgery. The client makes multiple attempts to crawl out of bed. Which action should the nurse perform before placing restraints on this client? Select all that apply.

The nurse is caring for a client who is confused. This client has multiple cardiac IV drips, sequential compression devices, and a Foley catheter. The client is becoming increasingly agitated and is pulling at the IV lines and Foley catheter tubing. Which of the following is an appropriate intervention?

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 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 90-year old client is admitted for dehydration. The client is combative, confused, yells at the staff and attempts to climb out of bed. Before applying restraints, what alternatives should be considered? Select all that apply.

A nurse who works in the emergency department is concerned that one of his clients is getting angry enough to become violent. The client has been yelling and has started to suggest threats to staff. Which of the following actions are appropriate? Select all that apply.

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 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?

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?

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

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 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?

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?

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.

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?

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?

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?

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?

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

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.

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 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 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 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?

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 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 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?

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 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?

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?

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?

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

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.

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

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

A nurse is caring for a client who will need bariatric surgery. According to Maslow’s hierarchy of Needs, which of the following client needs would be categorized in the love and belonging classification? Select all that apply.

A nurse is working in the emergency department when a client is brought in via ambulance for care. The nurse glances at the client and realizes that there are many factors to consider regarding his care and the nurse needs to focus on one area to begin. Which of the following items should the nurse consider to determine the first priority intervention?

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?

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

A nurse is starting a shift at the hospital and is considering which clients are highest priority to see first. Which of the following clients would be considered first priority? 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 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 nurse is caring for a client who has been diagnosed with lung cancer. The client tells the nurse that she has not spoken with her mother in 8 years and really wants to reconnect with her. The nurse recognizes that this need falls under which category of Maslow’s Hierarchy of Needs?

A nurse is caring for a client who has been admitted for care after being injured while cooking at home. The client is hurting because of the burns received while cooking, but also because she is upset that her spouse was not there to help. According to Maslow’s hierarchy of needs, in which of the following levels is this client most likely feeling a deficit?

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?

The nurse is working with a large client load and has many tasks to complete. Which tasks can be delegated to the nursing assistant?

A new nurse is overwhelmed by tasks that need to get done. The nurse knows that which of the following can be delegated to the nursing assistant?

A nurse works in a labor and delivery unit and has two unlicensed assistive personnel helping with tasks. Which of the following tasks is not appropriate for the nurse to delegate to unlicensed assistive personnel?

A provider has ordered the following tests for a client with chest pain. Which of these can the nurse delegate to the nursing assistant? Select all that apply.

The nurse is working with a new nursing assistant and needs to delegate a task. Which of the following tasks is inappropriate to delegate to the new nurse assistant?

Which of the following tasks can be delegated to a 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?

A nurse is providing post-mortem care for a client who died 30 minutes ago. Which of the following components of this care can the nurse delegate to unlicensed assistive personnel?

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.

A nurse in the emergency room has 4 clients that all have shortness of breath. Which of the following additional symptoms are the most concerning and should be the priority?

The nurse receives a client with altered mental status from the ambulance. What is the first thing the nurse will obtain?

A student nurse is practicing how to effectively prioritize clients and client needs. Which of the following clients should the student nurse see first?

The nurse has just clocked in to work on the medical-surgical floor and receives report on assigned clients. Which of the following clients is the highest priority at this time?

A nursing student is practicing prioritizing pediatric clients. The student would be correct in seeing the client with which of the following first?

The nurse is working in the emergency department. Which of the following clients should take priority?

The nurse is reviewing the four clients that were assigned with a nursing student. The nursing student would be correct in saying that that the client with which of the following is the priority?

The nurses in the emergency room have four clients to prioritize for the float nurse to see. The client with which of the following should be seen first by the float nurse?

Which of the following conditions is an example of a fourth-order priority for the nurse?

A nurse assistant tells the nurse that four of the clients had complaints when morning vitals were being done. Of the following four client complaints, which is the priority for the nurse to see first?

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 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?

Right at shift change, four clients arrive to the emergency room and the nurse is putting them on the board in order of priority. The client with which of the following should be the first priority?

Four clients have just walked into the emergency room. There is one bed available. The triage nurse should assign which client to this bed?

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?

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 has been a bombing at the convention center downtown. The nurse is working in the emergency department and has been notified that approximately 58 clients are on the way to the hospital facility. Which clients will be given the highest priority?

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

A nurse is working in a pediatric emergency room and has 4 clients that need assessment. The nurse would be accurate in seeing which client first?

Four clients arrive to the emergency room triage with the following conditions. Which client should be seen first?

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 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 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?

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 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?

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 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?

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?

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?

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.

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 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 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.

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?

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 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?

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

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 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 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.

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 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 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 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 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?

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 nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which tasks can be delegated? 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?

Which of the following is the best example of a nurse utilizing critical thinking and judgment when making delegation decisions?

A client has been brought into the recovery room after undergoing abdominal surgery. Several minutes after arrival, the nurse notes that the client’s hands and feet are cool, capillary refill is 6 seconds, and the client’s blood pressure is dropping. Which response from the nurse is most appropriate?

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?

The nurse is caring for 4 clients. All the clients have IV heparin ordered. Which client should receive heparin first?

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.

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

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

A nurse manager who works on the medical-surgical unit makes decisions several times a day to ensure that the appropriate staff members on the unit care for clients based on their skill mix, number, and experience level. This is best described as:

A palliative care nurse works in the medical-surgical unit of the hospital to provide holistic care to clients who are critically ill. The nurse is facing significant stress due to a larger than normal number of deaths and is not coping well. Which of the following is the most appropriate self-care action for the nurse?

The nurse is caring for an elderly client who had an unwitnessed fall out of bed and is complaining of hip pain. What is the nurse’s priority?

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.

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

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 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 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?

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

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

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?

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 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.

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 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?

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

Which of the following situations best describes acute grief?

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?

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?

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 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?

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?

Which best describes disenfranchised 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 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.

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