1. The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

1. A postoperative client preparing for discharge with a new medication

2. A client requiring daily dressing changes of a recent surgical incision

3. A client scheduled for a chest x-ray after insertion of a nasogastric tube

4. A client with asthma who requested a breathing treatment during the previous shift

2. The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

1. A client complaining of muscle aches, a headache, and history of seizures

2. A client who twisted her ankle when rollerblading and is requesting medication for pain

3. A client with a minor laceration on the index finger sustained while cutting an eggplant

4. A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

3. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?

1. Each staff member is assigned a specific task for a group of clients.

2. A staff member is assigned to determine the client’s needs at home and begin discharge planning.

3. A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an assistive personnel (AP).

4. An RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients.

4. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?

1. A client who is ambulatory demonstrating steady gait

2. A postoperative client who has just received an opioid pain medication

3. A client scheduled for physical therapy for the first crutch walking session

4. A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C

5. The nurse is giving a bed bath to an assigned client when an assistive personnel (AP) enters the client’s room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

1. Finish the bed bath and then administer the pain medication to the other client.

2. Ask the AP to find out when the last pain medication was given to the client.

3. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete.

4. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client.

6. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An Assistive personnel (AP) is resistant to the change and is not taking an active part in facilitating the process of change. Which is the best approach in dealing with the AP?

1. Ignore the resistance.

2. Exert coercion on the AP. 3. Provide a positive reward system for the AP.

4. Confront the AP to encourage verbalization of feelings regarding the change.

7. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an assistive personnel (AP)?

1. A client requiring a colostomy irrigation

2. A client receiving continuous tube feedings

3. A client who requires urine specimen collections

4. A client with difficulty swallowing food and fluids

8. The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply.

1. Open doors to client rooms.

2. Move beds away from windows.

3. Close window shades and curtains.

4. Place blankets over clients who are confined to bed.

5. Relocate ambulatory clients from the hallways back into their rooms.

9. The nurse employed in a long-term care facility is planning assignments for the clients on a nursing unit. The nurse needs to assign four clients and has a licensed practical nurse and 3 assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse?

1. A client who requires a bed bath

2. An older client requiring frequent ambulation

3. A client who requires hourly vital sign measurements

4. A client requiring abdominal wound irrigations and dressing changes every 3 hours

10. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.

1. The acuity level of the clients

2. Specific requests from the staff

3. The clustering of the rooms on the unit

4. The number of anticipated client discharges

5. Client needs and workers’ needs and abilities

11. Professional Standards in Nursing: Care of Special Populations. A nurse is caring for a pediatric patient with a chronic illness. Which action by the nurse demonstrates understanding of the principles of care for special populations?

A) Providing standardized care based on adult protocols.

B) Communicating directly with the child without involving the parents.

C) Adjusting care plans to accommodate the child’s developmental stage.

D) Avoiding use of play therapy due to its potential to disrupt the child’s routine.

12. Professional Standards in Nursing: Ethical and Legal Issues. While caring for a terminally ill patient, the nurse overhears the family discussing withdrawing life support against the patient’s wishes. What should the nurse do first?

A) Respect the family’s autonomy and let them make the decision.

B) Report the situation to the hospital’s ethics committee.

C) Confront the family about their intentions.

D) Inform the attending physician immediately.

13. Professional Standards in Nursing: Prioritizing Client Care – Leadership, Delegation, and Emergency Response Planning. During a natural disaster, a nurse is assigned to triage patients in the emergency department. Which patient should the nurse prioritize for care?

A) A 30-year-old with a minor laceration on the arm.

B) A 50-year-old with chest pain and shortness of breath.

C) A 20-year-old with a sprained ankle.

D) A 40-year-old with a headache and dizziness.

14. Professional Standards in Nursing: Care of Special Populations. The nurse is caring for an elderly patient with dementia. Which intervention is most appropriate to ensure patient safety?

A) Keeping the patient isolated in a quiet room to prevent overstimulation.

B) Using restraints to prevent the patient from wandering.

C) Encouraging the patient to engage in physical activities to improve memory.

D) Implementing fall prevention measures and providing a familiar environment.

15. Professional Standards in Nursing: Ethical and Legal Issues. A nurse is caring for a patient who refuses a blood transfusion due to religious beliefs, but the physician orders it anyway. What should the nurse do?

A) Administer the blood transfusion as ordered.

B) Respect the patient’s wishes and refuse to administer the transfusion.

C) Seek clarification from the physician about the order.

D) Convince the patient to accept the transfusion for their own good.

16. Professional Standards in Nursing: Prioritizing Client Care – Leadership, Delegation, and Emergency Response Planning.

During a mass casualty event, which task can the nurse delegate to unlicensed assistive personnel (UAP)?

A) Assessing a patient’s respiratory status.

B) Administering intravenous medications.

C) Providing emotional support to family members.

D) Assisting with patient transportation.

17. Professional Standards in Nursing: Care of Special Populations A nurse is caring for a pregnant teenager. Which action is most important for the nurse to take to support the teenager’s health during pregnancy?

A) Providing education about contraception to prevent future pregnancies.

B) Encouraging the teenager to continue her education.

C) Ensuring the teenager receives adequate prenatal care and nutrition.

D) Advising the teenager to consider adoption for the baby.

18. Professional Standards in Nursing: Ethical and Legal Issues A nurse discovers that a colleague has been diverting medications for personal use. What should the nurse do first?

A) Report the colleague to the nursing supervisor.

B) Confront the colleague privately about the behavior.

C) Ignore the behavior as it’s not the nurse’s responsibility.

D) Document the incident in the colleague’s file for future reference.

19. Professional Standards in Nursing: Prioritizing Client Care – Leadership, Delegation, and Emergency Response Planning. The nurse is leading a team during a disaster response. Which action by the nurse demonstrates effective leadership?

A) Micromanaging team members to ensure tasks are completed correctly.

B) Making all decisions independently without input from the team.

C) Providing clear directions and support to team members.

D) Avoiding communication with other healthcare teams to prevent confusion.

20. Professional Standards in Nursing: Care of Special Populations A nurse is caring for a client who is visually impaired. Which action is most important for the nurse to take to ensure effective communication?

A) Speak loudly to ensure the client can hear clearly.

B) Provide written instructions for all procedures.

C) Orient the client to the environment and location of items.

D) Avoid touching the client to respect their personal space.

21. Professional Standards in Nursing: Care of Special Populations A nurse is caring for a patient with limited English proficiency. Which action by the nurse best promotes effective communication?

A) Speaking loudly and using hand gestures to convey messages.

B) Using medical jargon to ensure accuracy in communication.

C) Providing written instructions only.

D) Using a qualified interpreter to facilitate communication.

22. Professional Standards in Nursing: Ethical and Legal Issues A nurse witnesses a colleague making a medication error. The colleague asks the nurse not to report it. What should the nurse do?

A) Respect the colleague’s request for confidentiality.

B) Report the error to the charge nurse immediately.

C) Document the incident and inform the colleague’s supervisor.

D) Confront the colleague privately and discuss the error.

23. Professional Standards in Nursing: Prioritizing Client Care – Leadership, Delegation, and Emergency Response Planning. During a code blue situation, which task is most appropriate for the charge nurse to delegate to a newly licensed nurse?

A) Administering intravenous medications.

B) Leading the resuscitation efforts.

C) Documenting the events and interventions.

D) Notifying the family members about the situation.

24. Professional Standards in Nursing: Care of Special Populations A nurse is caring for a patient from a different cultural background. Which action by the nurse demonstrates cultural competence?

A) Avoiding discussing the patient’s cultural beliefs and practices.

B) Assuming that the patient adheres to Western medical practices.

C) Asking the patient about their cultural preferences and beliefs.

D) Refusing to provide care to patients from different cultures.

25. Professional Standards in Nursing: Ethical and Legal Issues A patient expresses suicidal ideation to the nurse. What is the nurse’s priority action?

A) Reassure the patient that everything will be fine.

B) Inform the patient’s family about the situation.

C) Keep the patient under constant observation.

D) Contact the mental health team for evaluation.

26. Professional Standards in Nursing: Prioritizing Client Care – Leadership, Delegation, and Emergency Response Planning. The nurse is leading a disaster preparedness training session for a group of newly hired nurses. Which statement by a nurse indicates a need for further education?

A) “During a disaster, we should prioritize care based on the severity of injuries.”

B) “Delegating tasks to unlicensed personnel can help manage a surge of patients.”

C) “Communication among healthcare teams is crucial for effective disaster response.”

D) “We should focus on addressing non-emergency issues during a disaster.”

27. Professional Standards in Nursing: Care of Special Populations A nurse is caring for a patient with a hearing impairment. Which action by the nurse promotes effective communication?

A) Speaking rapidly to ensure the patient receives information quickly.

B) Using complex medical terminology to ensure accuracy.

C) Facing the patient and speaking clearly while providing visual cues.

D) Providing written instructions without verbal communication.

28. Professional Standards in Nursing: Ethical and Legal Issues A nurse discovers that a patient’s family member has been accessing the patient’s medical records without authorization. What should the nurse do?

A) Confront the family member and request an explanation.

B) Report the incident to the hospital’s privacy officer.

C) Ignore the situation unless the patient complains.

D) Document the incident in the patient’s chart for future reference.

29. Professional Standards in Nursing: Prioritizing Client Care – Leadership, Delegation, and Emergency Response Planning. A nurse is triaging patients in the emergency department during a mass casualty event. Which patient should the nurse prioritize for immediate care?

A) A patient with a minor abrasion.

B) A patient with difficulty breathing and chest pain.

C) A patient with a fractured wrist.

D) A patient with a headache and nausea.

30. Professional Standards in Nursing: Care of Special Populations A nurse is caring for a patient who is transgender. Which action by the nurse demonstrates respect for the patient’s identity?

A) Using the patient’s previous name and pronouns.

B) Avoiding discussing gender identity to prevent discomfort.

C) Asking the patient about their preferred name and pronouns.

D) Referring to the patient by their biological sex.

31. A nurse is caring for an elderly client who is admitted with dehydration. Which intervention should the nurse prioritize when providing care for this client?

a) Encourage the client to increase fluid intake rapidly.

b) Administer intravenous fluids cautiously to prevent fluid overload.

c) Provide diuretics to promote urine output and fluid balance.

d) Limit fluid intake to prevent electrolyte imbalances.

32. A pregnant client with gestational diabetes mellitus (GDM) is admitted to the antenatal unit. Which intervention should the nurse include in the care plan for this client?

a) Encourage a high-protein, low-carbohydrate diet.

b) Administer regular insulin injections as prescribed.

c) Advise the client to avoid any physical activity to prevent complications.

d) Monitor for signs of hypoglycemia only during the third trimester.

33. A nurse is caring for a pediatric client with autism spectrum disorder (ASD). Which approach should the nurse implement when providing care to this client?

a) Use clear and concise language when communicating with the client.

b) Avoid routines to encourage flexibility and adaptability.

c) Provide unpredictable changes to the environment to promote stimulation.

d) Use physical restraints when the client exhibits aggressive behavior.

34. A client with end-stage renal disease (ESRD) is receiving hemodialysis. Which assessment finding should the nurse monitor closely during hemodialysis?

a) Decreased blood pressure

b) Increased serum potassium levels

c) Decreased serum creatinine levels

d) Increased urine output

35. A nurse is providing care to a client who is homeless and presents with multiple health issues. Which intervention should the nurse prioritize when caring for this client?

a) Refer the client to a local shelter for immediate housing.

b) Provide education on healthy lifestyle choices and disease prevention.

c) Assist the client in accessing healthcare resources and social services.

d) Administer medications to treat acute health conditions.

36. A nurse is caring for a client who has expressed a desire to refuse a blood transfusion due to religious beliefs, despite it being medically necessary. The client’s family insists that the transfusion be administered to save the client’s life. Which action should the nurse take first?

a) Administer the blood transfusion against the client’s wishes to prevent harm.

b) Seek guidance from the hospital’s ethics committee.

c) Inform the client’s family that their wishes cannot be honored.

d) Advocate for the client’s right to make decisions about their own care.

37. A nurse is working on a busy medical-surgical unit. The nurse receives report on the following four clients:

a) Client A: Newly diagnosed with type 1 diabetes mellitus and requires education on insulin administration.

b) Client B: Postoperative from abdominal surgery and requires pain management.

c) Client C: Admitted with community-acquired pneumonia and requires administration of intravenous antibiotics.

d) Client D: Experiencing chest pain and shortness of breath, with a history of coronary artery disease.

38. Which client should the nurse prioritize as needing immediate attention?

a) Client A: Newly diagnosed with type 1 diabetes mellitus and requires education on insulin administration.

b) Client B: Postoperative from abdominal surgery and requires pain management.

c) Client C: Admitted with community-acquired pneumonia and requires administration of intravenous antibiotics.

d) Client D: Experiencing chest pain and shortness of breath, with a history of coronary artery disease.

38. A nurse is caring for a client who has a history of severe allergic reactions to peanuts. The client accidentally ingests a food item containing peanuts and immediately develops hives, swelling of the face and lips, and difficulty breathing. The nurse recognizes the signs of an anaphylactic reaction. What is the priority action for the nurse?

a) Administer an antihistamine to the client.

b) Notify the healthcare provider.

c) Administer epinephrine immediately.

d) Prepare to intubate the client.

39. A client diagnosed with heart failure is prescribed furosemide (Lasix), a loop diuretic. The nurse should monitor the client for which electrolyte imbalance commonly associated with this medication?

a) Hyperkalemia

b) Hypocalcemia

c) Hypermagnesemia

d) Hypokalemia

40. A client admitted with severe vomiting and diarrhea is at risk for which electrolyte imbalance?

a) Hypernatremia

b) Hypokalemia

c) Hypocalcemia

d) Hypercalcemia

41. The nurse is caring for a client with chronic renal failure. The nurse should assess the client for signs and symptoms of which electrolyte imbalance?

a) Hyperkalemia

b) Hypermagnesemia

c) Hypocalcemia

d) Hypokalemia

42. A client with diabetes insipidus is prescribed desmopressin (DDAVP). Which electrolyte imbalance should the nurse monitor for while the client is taking this medication?

a) Hyperkalemia

b) Hypernatremia

c) Hypokalemia

d) Hypocalcemia

43. A client with Addison’s disease is admitted to the hospital. The nurse should assess the client for which electrolyte imbalance associated with this condition?

a) Hypernatremia

b) Hyperkalemia

c) Hypocalcemia

d) Hypomagnesemia

44. A client diagnosed with celiac disease asks the nurse for advice on meal planning. Which of the following foods should the nurse instruct the client to avoid?

a) Rice

b) Oats

c) Wheat

d) Corn

45. A client with lactose intolerance is concerned about meeting their calcium needs. Which of the following non-dairy foods is a good source of calcium?

a) Yogurt

b) Cheese

c) Spinach

d) Almonds

46. A client with a history of hyperlipidemia is advised to follow a low-fat diet. Which of the following foods should the client avoid?

a) Avocado

b) Olive oil

c) Salmon

d) Fried chicken

47. A client with iron-deficiency anemia is prescribed iron supplements. The nurse should instruct the client to take the supplements with which of the following to enhance absorption?

a) Milk

b) Orange juice

c) Coffee

d) Tea

48. A client with hypertension is following a low-sodium diet. Which of the following foods should the client avoid?

a) Fresh fruits

b) Canned soups

c) Lean meats

d) Whole grains

49. A nurse is assessing a client’s vital signs. Which vital sign is considered a “fifth” vital sign?

a) Temperature

b) Blood pressure

c) Respiratory rate

d) Pain level

50. The normal range for an adult’s resting heart rate is:

a) 60-100 beats per minute

b) 80-120 beats per minute

c) 40-60 beats per minute

d) 100-140 beats per minute

51. A nurse is caring for a client with a body temperature of 101.8°F. Which action should the nurse take first?

a) Administer antipyretic medication

b) Apply a cooling blanket

c) Encourage increased fluid intake

d) Notify the healthcare provider

52. When assessing a client’s respiratory rate, the nurse should:

a) Count respirations for 30 seconds and multiply by 2

b) Count respirations for 1 minute

c) Count respirations while the client is sleeping

d) Count respirations immediately after the client eats

53. The normal range for blood pressure in adults is:

a) 90/50 to 120/80 mm Hg

b) 120/80 to 140/90 mm Hg

c) 100/60 to 130/90 mm Hg

d) 110/70 to 150/100 mm Hg

54. Which laboratory value indicates potential dehydration in a client?

a) Sodium level of 135 mEq/L

b) Potassium level of 4.5 mEq/L

c) Hemoglobin level of 14 g/dL

d) Blood urea nitrogen (BUN) level of 8 mg/dL

55. A nurse is reviewing laboratory results for a client with suspected hypothyroidism. Which laboratory value is typically elevated in hypothyroidism?

a) Thyroxine (T4)

b) Thyroid-stimulating hormone (TSH)

c) Triiodothyronine (T3)

d) Thyroid peroxidase antibodies (TPOAb)

56. A client’s serum glucose level is 180 mg/dL. The nurse recognizes this result as:

a) Within normal limits

b) Indicative of hypoglycemia

c) Indicative of hyperglycemia

d) Inconclusive and requires retesting

57. A client’s international normalized ratio (INR) is 3.5. Which action should the nurse take?

a) Administer vitamin K

b) Administer heparin

c) Administer warfarin

d) Monitor for signs of bleeding

58. A nurse is caring for a client with a platelet count of 40,000/mm³. Which precaution is appropriate for this client?

a) Contact precautions

b) Airborne precautions

c) Droplet precautions

d) Bleeding precautions