Exam 1 Past Paper QA1 PDF

1\. An eight-year-old child is eating hotdog and begins coughing. What is the priority action of the nurse? a\) Begin the Heimlich maneuver quickly b\) Tell the child to put his hands by his neck to signify that he is choking c\) promote coughing d\) leave the child alone to find a phone 2\. A...

1\. An eight-year-old child is eating hotdog and begins coughing. What is the priority action of the nurse? a\) Begin the Heimlich maneuver quickly b\) Tell the child to put his hands by his neck to signify that he is choking c\) promote coughing d\) leave the child alone to find a phone 2\. A client with dementia is being admitted to the medical surgical unit after a period of syncope. The charge nurse should place the nighttime safety and decrease the risk of falling? a\) In a room close to the nurses' station, and with tightly applied posey restraint b\) In a room close to the nurses' station with quite atmosphere. c\) In a room away from nurses' station so that the client can sleep better. d\) In a room with television for distraction 3\. A nurse from a predominately Latino culture works in a hospital serving a large population. What action by the nurse best demonstrates cultural competency? a\) The nurse asks the client what matters most to them in their illness and treatment. b\) The nurse the client that they should not continue taking herbs. c\) The nurse asks the client if they utilize shaman d\) the nurse tells the client that they should follow the provider 's orders. 4\. A client states that they are experiencing pain. What question should the nurse asks in performing a focused pain assessment (select all that apply) a\) What does the pain feel like? b\) when did your pain start? c\) why didn't you tell someone sooner? d\) Is it really painful? e\) How does the pain affect your sleep? 5\. A client states that he is a Muslim. The client has type two diabetes mellitus and has been prescribed along-acting insulin. The client says that he fasts for Ramadan. What intervention is most appropriate for this client? a\) Educate the client that fasting is not an option. b\) Tell the client not to take his insulin the night before. c) Inform the client he will need to change his lifestyle completely. d\) Collaborate with the client and provider to develop a client-centered plan of care. 6\. What would be the best education for a nurse to give a client to prevent poisoning a child at home? a\) Take only prescription medications as prescribed. b\) Never share your prescription drugs. C\) Keep cleaning liquids in a locked cabinet. d\) Follow directions on the label when taking medications and read all warnings. 7\. A nurse is teaching a community group about poisoning prevention. Which of the following statements from an attendee would indicate the need for further teaching? a\) "I should take prescription medication only as they are prescribed". b\) "I should never share my prescription medication with anyone". c\) "I should immediately induce vomiting if I suspect poisoning". d\) "I should take the phone number of for the poison control center easily accessible". 8\. Which of the following responses by the nurse could create a barrier to communication? a\) "What you did was wrong. You shouldn't do that." b\) "Good morning Mrs. Nightingela. Is there anything I can do to make you more comfortable?" c\) "Let's see what we can do to find a solution." d\) Is it a good time to discuss your new diagnosis?" 9\. What is not a standard practice in the North American Healthcare system? a\) Punctuality b\) Folk medicine c\) Handwashing d\) Annual exams 10\. Which of the following statements creates a barrier to communication? a\) Do you Know how to change your dressing? b\) What did your healthcare provider tell you about your need for this hospitalization? c\) You mention your dad earlier. Did he develop complications related to high blood pressure? d\) How do you manage pain at home? 11\. What complication may be a result of decreased mobility? a\) Pressure injuries b\) Diarrhea c\) Euphoria d\) Increased energy 12\. accepting pauses or silences that may extend for some time without interjecting a verbal response is consider which of the following? a\) Rude behavior b\) A barrier to communication c\) Therapeutic communication d\) A form of a verbal communication 13\. A fire is found in a client room during a routine medication pass. What is the nurse's first action? a\) Activate the fire alarm b\) Contain the fire c\) Notify the supervisor d\) Remove the client from the room 14\. Using A Maslow's Hierarchy of needs to prioritize, what client should the nurse see first? a\) The client with temperature 101F b\) The homeless client c\) The client who is depressed d\) The client the Alzheimer's disease. 15\. What statement by the student nurse educating a client on food safety is a cause for concern? a\) "It is acceptable to eat food at any time that has been sitting out for a potluck." b\) "Make sure to wash your hands with soap and water before eating." c\) "Make sure to wash produce." d\) It is acceptable to report the suspected foodborne illness to your health department." 16\) You have immigrated from the United States to Mexico. Over time you begin to eat more local foods and learnt Spanish. What is this an example of? a\) Socialization b\) acculturation c\) assimilation d\) Ethnocentrism 17\) A person who recently migrated from Mexico to the United States and lived in a Spanish-speaking community with other relatives is taken to the ER following a fall at work. He is admitted to the hospital for observation. This client is at risk for which of the following? a\) Cultural assimilation b\) Cultural imposition c\) cultural shock d\) cultural blindness 18\. A client states "I don't know what to do. My life is a mess." What is the appropriate response by the nurse? a\) Place the client on a 72-hour hold immediately b\) Remain attentive but silent c\) Leave the room immediately d\) Tell the client that everything will be fine 19\. Which organization publishes the National Patient Safety Goals? a\) Medicare b\) The American Nurses Association c\) The Joint Commission d\) The Institute of Medicine 20\. Nursing personnel are consistently listed in the top 10 occupations for work related musculoskeletal disorders. Which of the following would not help reduce musculoskeletal disorders in nurses? a\) Reporting hazards b\) Frequent bending and twisting c\) Learning about body mechanics d\) Safe moving programs 21\. A new mother asks for advice to keep her infant safe. Which of the these are true? (Select all that apply). a\) The infant should be put to bed on their back b\) The infant's car seat should be rear-facing in the back seat. c) The infant should remain in the car seat while in the vehicle d\) Do not warm formula in the microwave e\) children do not need sunscreen at this age. 22\. A nurse is caring for an elderly client living at home. What intervention can the nurse implement to reduce the client's risk of falling? (select that all apply) a\. Keep the stairs well-lit b\. use shower chairs and raised toilet seats c\. Keep stairs free of clutter d\. Go upstairs swiftly while holding the side rail e\. Encourage the use of non-slip socks or shoes 23\. The client states that they are experiencing diarrhea. What statement by the client about discharge instructions requires further teaching? a\. "I will make sure to drink water" b "I will add orange to my diet c\. "I will weigh myself every day d\. "I will wash my buttock area every other day 24\. A nurse is discharging a client who is unsteady on his feet at night. Which of the following statement by the client requires further education? a\. "I will take my water pill in the morning, rather than in the evening" b\. "I will turn on my hallway lights at night" c\. "I will place several throw rugs throughout my house" d\. "My wife helps me to bathroom at night" 25\. What is the most reliable source used to measure pain? a\. The family b\. The provider c\. The client d\. A drug reference app 26\. Which herbal product is correctly matched to its effect? (Select all that apply) a\. Gingko Biloba causes fibrin clot formation b\. Echinacea enhances immunityc. Ginseng increases physical endurance d\. chamomile enhances the immune response to influenza A e\. Aloe promotes wound healing 27\. What expected physiological changes of the older adult put the at risk of the falls? (select all that apply) a\. Reduce muscle strength b\. Sensory losses like vision and hearing c\. Slowing of reflexes d\. Dementia e\. Inability to adapt 28\. A client has decreased mobility. What nursing intervention would be inappropriate to promote mobility? a\. Teach the client active range of motion (AROM) exercises every 2 hours b\. Evaluate the client's need for ambulatory aids c\. Keep skin clean and dry d\. Encourage ambulation 29\. A client has insomnia. What is not appropriate client education for a client experiencing insomnia? a\. Take naps when drowsy. b\. exercise regularly c\. Limit fluids 2-4 hours before bedtime d\. Limit alcohol at least 4 hours before bedtime 30\. Parents enter the emergency with their 5-year-old child, crying and holding his stomach. The parents are visible distressed. What is an example of false reassurance in this scenario? a\. "Your child will receive prompt care" b\. "Don't worry. I'm sure he will be fine" c\. "We care for many 5-year-olds here" d\. "I have been a pediatric nurse for ten years" 31.The nurse provides education on the long-term physiological consequences of malnutrition. What complication should be included in this education? a\. Constipationb. b\. Osteoporosis c\. Arthritis d\. irritable bowel syndrome 32\. Client states. "I am worried about my insulin. I have no money and my insurance doesn't cover the insulin. I can't control my sugar." The nurse response by stating. "You are worried about affording insulin." What type of Therepuutic communication is this an example of? a\. Establishing trust b\. Using silence c\. Restating d\. Reassuring 33\. Time orientation within culture can vary quite a bit. The client receiving a transplant will need to maintain a stick schedule of antirejection medications. The client states that he has never used a watch before and his people do things when the know they should be done. An appropriate response by the nurse would be which of the following? a\. "You have to take this a certain time, or you will die" b\. "Well that's your prerogative. Here is the schedule. If you adhere to it you will be healthier." c\. "Tell me more about that. Let's talk about finding a method that will work for you." d\. "Here I the schedule. Here is a watch. You take these three medications at 8am, these four at noon and these three again at 5pm. At 10pm you have these five pills, and you will take them at 3pm." 34\. What factor may interfere with sleep? (Select all that apply) a\. A large meal right before bedtime. b\. A stressful job c\. Anxiety d\. Similar routine each night e\. Medication 35\. What is the primary response of an incident report? a\. A tool used for a disciplinary action b\. To eliminate unforeseen errors c\. A device used in identifying opportunities for improvement d\. To hold persons accountable for their errors 36\. A client is diagnosed with narcolepsy. What is the nurse's priority interventiona. a\. Encourage the client to stop drinking caffeine after 6pm b\. To inform the client to drink two cups of regular coffee c\. Encourage the client to participate in normal activities d\. Inform the client that driving will be dangerous 37\. The nurse is caring for a 65-years-old client and notes a temperature of 96.8\*. How does the nurse interpret this finding? a\. Hypothermia b\. Hyperthermia c\. Normal d\. A cold environment 38\. Therapeutic communication techniques by the nurse include which of the following? (select all that apply) a\. Asking clarifying questions b\. Giving all clients a hug c\. Encouraging the client on social media d\. Expressing advice that will be best for the client e\. Being attentive and listening f\. Restating what the client said 39\. An ambulatory and oriented client who gets out off bed at night to void will be at a lower risk for injury when the nurse implements which of the following interventaions? a\. Limit fluids intake after 6pm b\. illuminating the path to the bathroom c\. Awaken the client every hour to use the bathroom d\. Arriving immediately when the bed alarm sounds 40\. The nurse knows which of the following is a "never event" a\. No blood compatibility occurs during blood transfusion b\. A surgical spongy is left in a client incision c\. A client falls in his own home d\. Inserting a urinary catheter before surgery 41\. A client just received a diagnosis of cancer. Which statement by the nurse best demonstrates empathy? a\. "Tomorrow will be better" b\. "This must be hard news to hear. Tell me more about it." c\. "What is your biggest fear about this diagnosis?" d\. "I believe you can overcome this because I've seen how strong you are" 42\. A nurse and a client work on strategies to reduce weight. What phase of the therapeutic relationship are the nurse and the client in? a\. pre-interaction b\. Orientation. c\. Working d\. Termination 43\. What is the mission of the Occupational Safety and Health Administration (OSHA)? a\. Protect the client b\. prevents work-related injuries and deaths c\. Prevent Injuries a nurse may incur at home d\. Reduce client falls and provides emotional support 44\. What client should be seen by the nurse first? a\. a client with acute diarrhea b\. A client who is anxious c\. A women who feels isolated d\. An elderly man with a fractured hip 45\. A client arrives speaking only Cambodian The daughter is interpreting for her. What is the priority responsibility of the nurse? a\. Call the Champlain for support b\. Allow the unlicensed assistive personnel to interpret c\. Call for a Cambodian interpreter d\. Continue to work with the daughter for interpretation 46\. What question is considered culturally sensitive? a\. Are you required to pray in a certain way at a certain time b\. What types of food do you eat for meals and between meals c\. Are you familiar with the way we prepare meals? Policy d\. Are you okay with not having kosher meals? 47\. What Is not a sign of inadequate perfusion? a\. Bounding pulses b\. Cyanosis c\. Pallor d\. Coolness 48\. What client should the nurse asses first? a\. A client needing to void b\. A recently divorced client c\. A client who has recently lost their job d\. A client who is homeless 49\. For which of the following reasons is a client's culture important to their health care? a\. Culture defines values, dimension factors and disparities b\. Culture cannot be modified c\. Culture is the main focus of all interventions d\. Culture is transparent in healthcare 50\. What contributes to needlesticks injuries for healthcare workers? a\. Recapping needles b\. Working in low-stress environment c\. Protective equipment d\. Working 4-hour shifts 51\. What is not a type of pollution? a\. Cross-contamination b\. Air pollution c\. Noise pollution d\. Hazardous waste 52\. Which of these is the greatest danger to toddlers? a\. Mistletoe tightly secured to the celling b\. Medication locked in a cabinet c\. large toys with large parts d\. Unattended pools 53\. A client states that they will schedule massages as well as take their prescribed medication for pain control. What is this an example of? a\. pain therapy b\. Nociceptive pain control c\. non-therapeutic communication d\. Complementary therapy 54\. What is an example of non-verbal communication by a nurse? a\. Sending an email b\. Speaking with an accent c\. Eye contact d\. Receiving a text message 55\. What suggestion by the nurse is an example of alternative therapy? a\. Including appointments with the massage therapies while continuing medical treatments for the chronic leg pain b\. Initiating "cupping" While also taking antibiotics for pneumonia c\. Utilizing lavender in addition to the use of lorazepam for anxiety d\. Using garlic to manage clotting disorder 56\. When assessing the client's bowel elimination. The nurse understands that which is not a factor? a\. Age b\. Diet c\. Fluid intake d\. Gender 57\. A nurse is assisting with a transfer from the bed to a wheelchair. Which of the following is a priority the action of the nurse to ensure client safety? a\. Encourage the client to push up from the wheelchair b\. Ensure the client is bathed before getting into the wheelchair c\. Lock the wheels of the wheelchair d\. Place the bed in the lithotomy position 58\. a client has a reddened area on his right heel. What is the best intervention by the nurse to prevent further skin and tissue breakdown? a\. Document the reddened of the area b\. Ask the client how the area became reddened c\. Assess the client's diet d\. Relieve pressure from the right heel 59\. According to Maslow's Hierarchy of needs. What do all people have? a\. The same needs at the same time b\. The risk of becoming ill c\. A desire to be the best d\. Basic human needs 60\. Which of the following non-pharmacological interventions for pain management include which of the following? (Select all that apply) a\. Transcutaneous electrical nerve stimulation b\. Deep breathing c\. Acupuncture d\. cold therapy e\. Patient-controlled analgesia (PCA) 61\. Motor vehicle accidents are the leading cause of accidental death in the United States. What should the nurse teach the client to avoid motor vehicle injuries? (Select all that apply) a\. Do not change the music while driving b\. Do not drive over the speed limit c\. Be cautious when bicycling on the roadway d\. It is safe to eat while driving e\. It is safe to drive if you have had one alcoholic drink 62\. The nurse is providing discharge instructions for a client with visual impairment. What are appropriate interventions for the client with visual impairment? (Select all that apply) a\. Identify yourself b\. Ensure adequate lighting c\. Speak louder d\. Talk to other people in the room e\. Provide discharge instructions in a larger font 63\. Which set of vital signs taken on an adult is a cause for concern and requires further evaluation? a\. Temperature 96.9\*; pulse 100 bpm; respirations 20 breaths/minute; blood pressure 120/80 mmHg b\. Temperature 97.0\*; pulse 54 bpm; respirations 14 breaths/minute; blood pressure 196/114 mmHg c\. Temperature 98\*; pulse 60 bpm; respirations 14 breaths/minute; blood pressure 110/76 mmHg d\. Temperature 99\*; pulse 72 bpm; respirations 16 breaths/minute; blood pressure 100/60 mmHg 64\. a homeless client arrives in the emergency room. The client verbalizes an inability to bathe for at least one month. What is the nurse's priority? a\. Inspect the client's skin b\. Provide a towel and show the client to the shower c\. Ask if the client has been to a homeless shelter recently d\. Call a social worker 65\. You overhear the following comments throughout the day by the coworkers. Which of these statements warrants immediate intervention? a\. "I'm turning your lights off the night. Do not turn it on when you use the bathroom. It will wake your roommate." b\. "You can have chicken for dinner. But after midnight you have restrictions for your surgery tomorrow and will not be able to have anything to eat or drink." c\. I'm placing your call light next to you. Press this button for assistance." d\. "I would like to have you participate in your discharge planning. Tell me how many stairs are in your home." 66\. A client begins to fall while the nurse is assisting with ambulation. What is the priority nursing intervention? a\. Initiate a code b\. Call the charge nurse c\. Guide the client safely to the floor d\. Call the client's doctor 67\. A nurse is telling a new mother from Africa that she should carry her baby in a sling created from a large rectangular cloth. The African woman tells the nurse that everyone in Mozambique carries babies that way. The nurse believes that bassinets are safer for infants. What is this scenario an example of? a\. Cultural imposition b\. Cultural competency c\. Stereotyping d\. Racism 68\. What is not true about side rails? a\. Split rails are not considered restrains if a client requests to feel more secure b\. A full-length side rail is a restraint when is used to prevent a client from getting out of bed c\. Siderails have not been linked to serious falls and injuries d\. Siderails should not be used routinely 69\. A nurse is orienting the client to their room. What safety measures is a priority during this orientation? a\. Explain how to use the telephone b\. Introduce the client to her roommate c\. Review hospital policy on visiting hours d\. Explain how to operate the call light 70\. A nurse enters a client's room and states. "Hello I am Joan, and I will be your nurse today. How wouldyou like me to address you while we work together today?" What phase of the therapeutic (helping) relationship does this interaction occur in? a\. Pre-interaction phase b\. Orientation Phase c\. Working phase d\. Termination phase 71\. What level of Maslow's Hierarchy of needs does food belong to? a\. Love and belonging b\. Safe and security c\. Physiological d\. Esteem 72\. A client recently had an above-the-knee amputation and complained of a pain of distal to the amputation. What type of pain is the client experiencing? a\. Nociceptive b\. Neuropathic c\. Cutaneous d\. Visceral 73\. Which of the following is an example of alternate therapy? a\. Using Garlic to manage a disorder\ b. Taking prescribed medication\ c. Undergoing physical therapy sessions\ d. Getting regular check-ups 74\. You have a pt who has nerve pain, which of the non-Pharmacological interventions could you use to manage pt's comfort? a\. Stress management b\. Non-steroid analgesic c\. Topical lidocaine d\. Acupuncture 75\. What non-pharmacological interventions can you use to help with anxiety? a\. Application of ice b\. Analgesics c\. Tylenol d\. Aromatherapy 76\. how long should you leave an ice bag on? a\. 20 minutes, take off and let the skin return to room temperature before you apply it again\ b. 30 minutes continuously\ c. 10 minutes, then reapply immediately\ d. 1 hour continuously 77\. I'm teaching a client about prevention of infection. Which statement tells me that the client understood my teaching? a\. I don't need to follow the recommended immunization guidelines for an adult b\. I can use my roommate's used towel after washing my face c\. I can continue to eat as I had before because fast food is cheaper d\. I'll wash my hands at least 30 secs or use alcohol-based hand rub for 15 secs 78\. what does RICE stand for? a\. Rest, Inflammation, Compression, Elevation\ b. Rest, Ice, Compression, Elevation\ c. Rehydration, Ice, Compression, Elevation\ d. Rest, Insulation, Compression, Elevation 79\. Which one of these is the benefit of relaxation therapy? a\. A balance graceful coordinated style of movement b\. Decrease skin temp in the pt's extremities c\. decrease HR and BP d\. Exploration and resolution on consciousness psychiatric 80\. If you're taking care of a child that's experiencing pain from leukemia and you play music for them, what pain management technique are you using? a. Music therapy(distracting the child) 81\. If you're caring for a client and asked them if they're taking any herbs or vitamins and encouraged the family to bring the foods they like, maybe some things that make them safe and secure and you pray with them. What type of nursing model are you using? a\. Health Promotion b\. Trans-therapy theory c\. Health believe d\. Holistic 82\. Pain management technique using stimulation to nerve vibration directly apply to the painful area. a\. Acupressure b\. Acupuncture c\. TENS mech d\. Trans-therapy theory 83\. Which complementary and alternative therapy involves client participation and is appropriate for all levels of care? a\. Meditation b\. Yoga and palates c\. Acupuncture d\. Supplements 84\. Which of the following nursing diagnoses has the highest priority? a\. Impaired mobility b\. Impaired comm c\. Impaired nutrition d\. Impaired airway clearances 85\. if your pt has redness, swelling localized pain on the right lower extremities, during the assessment you note that the site is a warmth to touch and the patient is a-fibril(no fever), you'll document, which of the physiological a\. infection b\. inflammation c\. irritation d\. impurity 86\. You're caring for a pt whose incontinent, frequent loose diarrhea stools, what should you include in their care plan? a\. Assess the lung sounds b\. Encourage frequent amputation c\. To limit fluids to decrease the frequency of the stools d\. Apply barrier to the skin irritation 87\. You're discussing complementary therapy with a client recently diagnosed with cancer, what should the nurse include in the discussion? a\. Place all the meds with herbs b\. Complementary therapy, never interfere with traditional therapies c\. Distraction and guided imagery may decrease fever with pain meds 88\. Following an infusion of intravenous fluids, your pt develops a sudden onset SOB and wheezing. Which action would you do first? a\. Maintain bedrest with both legs elevated b\. Increase the rate of the infusion c\. Consult with a healthcare provider regarding initiation of O2 therapy d\. Place the client on a high-fowler position 89\. If you have a post-operative pt that has increasing pain in their right arm after their surgery, what's your priority action? a\. Elevate right arm on a pillow b\. Check swelling in the left arm c\. Notify the rapid response team d\. Perform a peripheral vascular assessment 90\. The nurse is preparing to initiate an intravenous (IV) line containing potassium chloride using an IV infusion pump. While preparing to plug the pump cord into the wall, the nurse finds that no outlet is available in the wall socket. The nurse would take which action? A. Initiate the IV line without the use of a pump.\ B. Contact the electrical maintenance department for assistance.\ C. Plug in the pump cord in the available plug above the room sink.\ D. Use an extension cord from the nurses' lounge for the pump plug. 91\. The nurse obtains a prescription from a primary health care provider to restrain a client and instructs assistive personnel (AP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required for the AP? A. Placing a safety knot in the safety device straps\ B. Safely securing the safety device straps to the side rails\ C. Applying safety device straps that do not tighten when force is applied against them\ D. Securing so that two fingers can slide easily between the safety device and the client's skin 92\. The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply. A. Bites from ticks or deer flies\ B. Inhalation of bacterial spores\ C. Through a cut or abrasion in the skin\ D. Direct contact with an infected individual\ E. Sexual contact with an infected individual\ F. Ingestion of contaminated undercooked meat 93\. The nurse is giving report to assistive personnel (AP) who will be caring for a client who has hand restraints (safety devices) applied. How frequently would the nurse instruct the AP to remove the restraints to allow for muscle activity? A. Every 2 hours\ B. Every 3 hours\ C. Every 4 hours\ D. Every 6 hours 94\. The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan? A. Wearing gloves when emptying the client's bedpan\ B. Keeping all linens in the room until the implant is removed\ C. Wearing a lead apron when providing direct care to the client\ D. Placing the client in a semiprivate room at the end of the hallway 95\. Contact precautions are initiated for a client with a healthcare-associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The nurse prepares to provide colostomy care and would obtain which protective items to perform this procedure? A. Gloves and gown\ B. Gloves and goggles\ C. Gloves, gown, and shoe protectors\ D. Gloves, gown, goggles, and a mask or face shield 96\. The nurse enters a client's room and finds that the waste basket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action? A. Call for help.\ B. Extinguish the fire.\ C. Activate the fire alarm.\ D. Confine the fire by closing the room door. 97\. A parent calls a neighbor who is a nurse and tells the nurse that their 3-year-old child has just ingested liquid furniture polish. The nurse would direct the parent to take which immediate action? A. Induce vomiting.\ B. Call an ambulance.\ C. Call the Poison Control Center.\ D. Bring the child to the emergency department. 98\. The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse would take which initial action? A. Prepare the triage rooms.\ B. Activate the emergency response plan specific to the facility.\ C. Obtain additional supplies from the central supply department.\ D. Obtain additional nursing staff to assist in treating the casualties. 99\. The nurse is caring for a client with meningitis and implements which transmission-based precaution for this client? A. Private room or cohort client\ B. Personal respiratory protection device\ C. Private room with negative airflow pressure\ D. Mask worn by staff when the client needs to leave the room 100\. The nurse working in the emergency department (ED) is assessing a client who recently returned from Nigeria and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action would the nurse take next? A. Check the client's temperature.\ B. Isolate the client in a private room.\ C. Check a complete set of vital signs.\ D. Contact the primary health care provider. 101\. The nurse is assigned to care for four clients. In planning client rounds, which client would the nurse assess first? A. A postoperative client preparing for discharge with a new medication\ B. A client requiring daily dressing changes of a recent surgical incision\ C. A client scheduled for a chest x-ray after insertion of a nasogastric tube\ D. A client with asthma who requested a breathing treatment during the previous shift 102\. 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 would assign priority to which client? A. A client complaining of muscle aches, a headache, and a history of seizures\ B. A client who twisted their ankle when rollerblading and is requesting medication for pain\ C. A client with a minor laceration on the index finger sustained while cutting an eggplant\ D. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce 103\. 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? A. Each staff member is assigned a specific task for a group of clients.\ B. A staff member is assigned to determine the client's needs at home and begin discharge planning.\ C. A single registered nurse (RN) is responsible for providing care to a group of six clients with the aid of an assistive personnel (AP).\ D. An RN leads two licensed practical nurses (LPNs) and three APs in providing care to a group of 12 clients. 104\. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client would the nurse plan to care for first? A. A client who is ambulatory, demonstrating steady gait\ B. A postoperative client who has just received an opioid pain medication\ C. A client scheduled for physical therapy for the first crutch-walking session\ D. A client with a white blood cell count of 14,000 mm3 (14 × 109/L) and a temperature of 38.4° C 105\. The nurse is giving a bed bath to an assigned client when 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? A. Finish the bed bath and then administer the pain medication to the other client.\ B. Ask the AP to find out when the last pain medication was given to the client.\ C. Ask the AP to tell the client in pain that medication will be administered as soon as the bed bath is complete.\ D. Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. 106\. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. 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? A. Ignore the resistance.\ B. Exert coercion on the AP.\ C. Provide a positive reward system for the AP.\ D. Confront the AP to encourage verbalization of feelings regarding the change. 107\. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for assistive personnel (AP)? A. A client requiring a colostomy irrigation\ B. A client receiving continuous tube feedings\ C. A client who requires urine specimen collections\ D. A client with difficulty swallowing food and liquids 108\. The nurse manager is discussing with the staff the facility's protocol in the event of a tornado. Which instructions would the nurse manager include in the discussion? Select all that apply. A. Open doors to client rooms.\ B. Move beds away from windows.\ C. Close window shades and curtains.\ D. Place blankets over clients who are confined to bed.\ E. Relocate ambulatory clients from the hallways back into their rooms. 109\. 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 three assistive personnel (APs) on a nursing team. Which client would the nurse most appropriately assign to the licensed practical nurse? A. A client who requires a bed bath B. An older client requiring frequent ambulation C. A client who requires hourly measurement of vital signs D. A client requiring abdominal wound irrigations and dressing changes every 3 hours 110\. The charge nurse is planning the assignment for the day. Which factors would the nurse remain mindful of when delegating tasks? Select all that apply. A. The acuity level of the clients B. Specific requests from the staff C. The clustering of the rooms on the unit D. The number of anticipated client discharges E. Client needs and workers' needs and abilities 111\. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the primary health care provider, and completes an occurrence report. Which statement would the nurse document on the occurrence report? A. The client fell out of bed. B. The client climbed over the side rails. C. The client was found lying on the floor. D. The client became restless and tried to get out of bed. 112\. A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? A. Obtain a court order for the surgical procedure. B. Ask the EMS team to sign the informed consent. C. Transport the victim to the operating room for surgery. D. Call the police to identify the client and locate the family. 113\. The nurse has just assisted a client back to bed after a fall. The nurse and primary health care provider (PHCP) have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse would implement which action next? A. Conduct a staff meeting to describe the fall. B. Contact the nursing supervisor to update information regarding the fall. C. Document in the nurse's notes that an occurrence report was completed. D. Reassess the client. 114\. The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse would take which best action? A. Clarify the ICU client assignment with the team leader to ensure that it is a safe assignment. B. Ask the nursing supervisor to review the hospital policy on floating. C. Refuse to float to the ICU based on lack of unit orientation. D. Submit a written protest to nursing administration, and then call the hospital lawyer. 115\. The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? A. Call security. B. Call the nursing supervisor. C. Lock the coworker in the medication room until help is obtained. D. Call the police. 116\. A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The nurse plans to make which most appropriate response to the client? A. "I will call the nursing supervisor to seek assistance regarding your request." B. "I will sign as a witness to your signature." C. "Whoever is available at the time will sign as a witness for you." D. "You will need to find a witness on your own." 117\. The nurse has made an error in documentation of the dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another registered nurse (RN) witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the medication administration record (MAR) that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse would take which action(s) to correct the error in the MAR? Select all that apply. A. Complete and file an occurrence report. B. Document the correct information and end with the nurse's signature and title. C. Obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg. D. Right-click on the entry and modify it to reflect the correct information. E. Document in a nurse's note in the client's record detailing the corrected information. 118\. Which notations indicate accurate nursing documentation by the nurse? Select all that apply. A. The client slept through the night. B. Abdominal wound dressing is dry and intact without drainage. C. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. D. The client appears to become anxious when it is time for respiratory treatments. E. The client seemed angry when awakened for measurement of vital signs. 119\. A nursing instructor delivers a lecture to nursing students regarding the issue of clients' rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? A. Observing care provided to the client without the client's permission B. Performing a procedure without consent C. Telling the client that they cannot leave the hospital D. Threatening to give a client a medication 120\. An older client is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that a family member frequently hits the client if supper is not prepared on time when the family member arrives home from work. The nurse plans to make which most appropriate response? A. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." B. "Do you have any friends who can help you out until you resolve these important issues with your family member?" C. "Let's talk about the ways you can manage your time to prevent this from happening." D. "Oh, really? I will discuss this situation with your family member." 121\. The nurse calls the primary health care provider (PHCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the PHCP, and the medication is due to be administered. Which action would the nurse take? A. Administer the dose prescribed. B. Administer the recommended dose until the PHCP can be located. C. Contact the nursing supervisor. D. Hold the medication until the PHCP can be contacted. 122\. The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action? A. Call the nursing supervisor and report the occurrence. B. Call the police. C. Call the laboratory and ask for the name of the individual who sent the photograph. D. Cut up the photograph and throw it away. 123\. The nurse is talking with a client who was diagnosed with liver cancer nine months ago and the client\'s family. The family is requesting assistance to deal with the diagnosis. The nurse provides the family with information about palliative care. Which of the following is not a goal of palliative care? a\. To secure financial assistance b\. To provide education to the family c\. To support the family d\. To prevent and treat symptoms and side effects of treatment 124\. A nurse is caring for a patient recently diagnosed with lung cancer. Based on testing, there is no indication that the cancer has spread to other organs. The client is scheduled for surgery to have a lobectomy performed. This is classified as which type of surgical treatment? a\. Prophylactic b\. Diagnostic c\. Curative d\. Palliative 125\. The patient who has undergone which surgical procedure is most at risk for hypocalcemia? a\. Thyroidectomy b\. Adrenalectomy c\. Pancreatectomy d\. Gastrectomy 126\. A nurse is providing education to a client and family that is undergoing radiation as a part of his cancer treatment plan for a brain tumor. Which of the following is not a side effect of radiation? a\. Constipation b\. Skin irritation c\. Cerebral edema d\. Alopecia 127\. What are the normal values for serum sodium? 135-145 mEq/L 128\. Which of the following does not influence cancer growth? a\. Exposure to carcinogens b\. Immunity c\. Gender d\. Genetics 129\. What is the step in which normal cells become damaged? This step is irreversible and leads to cancer development. a\. Metastasis b\. Initiation c\. Promotion d\. Cellular regulation 130\. Calculate a client\'s intake for the 7:00 AM to 2:00 PM shift. At breakfast, the client drank 2 cups of coffee and a 4 oz. glass of orange juice. At lunch, the client drank 8 oz. of chicken broth and 8 oz. of diet soda. The client has an IV of normal saline solution infusing at 100 ml/hr. What is the client's combined oral and IV intake for the 8-hour shift in mL? 131\. A nurse is caring for a 90-year-old female admitted for nausea, vomiting, and diarrhea for the past five days. Heart rate is 130 bpm, blood pressure is 96/50 mmHg, mucous membranes are dry, and the client has poor skin turgor. Which of the following is an appropriate fluid replacement for this client? a\. Colloids b\. Hypotonic c\. Isotonic d\. Hypertonic 132\. Treatment plans for cancer patients can include a single type of treatment or a combination of treatments based on the cancer type. Which of the following is not a cancer treatment option? a\. Radiation treatment b\. Chemotherapy c\. Surgical treatment d\. Vegan diet 133\. The provider wants to administer an isotonic solution to the client. Which of the following concentrations is considered an isotonic solution? a\. 0.9% NaCl b\. 0.225% NaCl c\. 3% NaCl 134\. A client would like to know what it means that her breast cancer has metastasized. What does this mean? a\. Repeated exposure leads to mutation b\. A tumor has sent chemical signals to develop its own vasculature c\. Cancer cells have moved from their primary sites d\. Irreversible damage has caused tumor growth 135\. A client presented to the emergency department with increased shortness of breath and pitting edema of his lower extremities. The client recently saw his primary doctor, who increased his furosemide. The client has a history of heart failure and diabetes. The client\'s laboratory findings are as follows: Na 150 mEq/L, potassium 2.5 mEq/L. Which of the following electrolyte imbalances is the client exhibiting? a\. Hypernatremia and hypokalemia b\. Hypernatremia and hyperkalemia c\. Hypovolemia and hyperkalemia d\. Hyponatremia and hypokalemia 136\. A nurse is caring for a client who presents with a new onset of seizures, confusion, and muscle tremors. Her laboratory results reveal hypomagnesemia. Which of the following would be a cause of hypomagnesemia? a\. Alcoholism b\. Bleeding c\. Addison\'s disease d\. Decreased water intake 137\. Tumor lysis syndrome is an example of what type of oncological emergency? a\. Structural b\. Pathological c\. Metabolic d\. Hematologic 138\. What serum laboratory value does the nurse expect to see in a client with hypokalemia? a\. Calcium less than 11.0 mg/dL b\. Calcium less than 8.0 mg/dL c\. Potassium less than 5.0 mEq/L d\. Potassium less than 3.5 mEq/L 139\. A nurse should instruct the client to follow which strategies to prevent cancer? (Select all that apply) a\. Smoking cessation b\. Avoid alcohol c\. Vaccination d\. Diet low in saturated fats e\. Suntanning with baby oil 140\. A nurse is providing client and family education. Which of the following examples would indicate the client's and family's understanding of secondary cancer prevention? a\. Mammogram b\. Eliminating tobacco use c\. Eating a healthy diet d\. Use of sunscreen 141\. A nurse is calculating the client\'s output at the end of the 0700-1500 shift. The nurse notes the following: the client voids 500 mL at 0730, 520 mL at 1230, and 200 mL at 1430. How many mL will the nurse record for the client\'s total shift output? 142\. An outdoor construction worker with profuse diaphoresis is at risk for which of the following conditions? a\. Hypervolemia b\. Hypernatremia c\. Hyponatremia d\. Hypoxia 143\. A nurse is caring for a 72-year-old female with a diagnosis of dehydration. All of the following nursing diagnoses should be included in the plan of care for the patient except: a\. Safety fall risk b\. Fluid volume overload c\. Fluid volume deficit d\. Knowledge deficit 144\. A nurse is providing client and family education regarding common problems associated with a cancer diagnosis. Which of the following statements would indicate an understanding? a\. \"I am at an increased risk of developing an infection.\" b\. \"I will likely experience weight gain.\" c\. \"I will not experience any pain.\" d\. \"There are few problems associated with a cancer diagnosis.\" 145\. A nurse is caring for a client recently diagnosed with cancer who is exhibiting signs and symptoms of superior vena cava syndrome. Which of the following is a priority medical treatment for the relief of airway obstruction? a\. High-dose radiation b\. Fluid restriction c\. Immunotherapy d\. Chemotherapy 146\. A nurse is caring for a client who presented to the emergency department with a nagging cough, unusual bleeding, and changes in bowel and bladder habits. Based on these findings, the nurse would anticipate which of the following diagnoses? a\. Cancer b\. Cirrhosis of the liver c\. Influenza d\. Gastritis 147\. Which of the following are causes of hypovolemia? (Select all that apply) a\. Renal failure b\. Blood loss c\. Fever d\. Vomiting e\. Heart failure 148\. A client undergoing chemotherapy is receiving education about reducing the risk of infection. Which action reduces the risk of infection? a\. Weight-bearing exercises b\. Liver vaccines c\. Monitoring for bruising d\. Hand hygiene 149\. A client asks the nurse to explain the differences between benign and malignant tumor cells. What is an appropriate response by the nurse? a\. \"A benign tumor is normal cells growing in the wrong place, or at the wrong time, but they are not cancerous.\" b\. \"A benign tumor will kill you, whereas a malignant tumor cannot.\" c\. \"Don\'t worry about that. The point is that you are okay.\" d\. \"A benign tumor has not undergone apoptosis, whereas a malignant tumor has.\" 150\. What does the nurse expect when left palmar flexion in response to a blood pressure cuff\'s inflation is assessed in a client? a\. Hypoglycemia, and it\'s called a positive Trousseau's sign b\. Hypocalcemia, and it\'s called a positive Chvostek's sign c\. Hypoglycemia, and it\'s called a positive Chvostek's sign d\. Hypocalcemia, and it\'s called a positive Trousseau's sign 151\. A nurse is caring for a client with a diagnosis of hypernatremia. Which of the following assessment findings would the nurse expect to see? a\. Headache b\. Hypothermia c\. Increased thirst d\. Muscle cramps 152\. A nurse is caring for a 72-year-old client with a diagnosis of dehydration. Which of the following nursing diagnoses should not be included in the plan of care for the client? a\. Knowledge deficit b\. Safety: fall risk c\. Fluid volume deficit d\. Fluid volume overload 153\. Ellen is a 56-year-old female who was brought to the emergency room by her family with complaints of fever over the last three days. She recently completed a cycle of chemotherapy. Upon assessment, the nurse notes the client's temperature is 103.6°F, heart rate is 128 beats/min, respiratory rate is 28 breaths/min, and blood pressure is 88/60 mmHg. The doctor orders a complete blood count, complete metabolic panel, and arterial blood gas. What do you anticipate the lab work to reveal? a\. Decreased potassium level b\. Decreased sodium level c\. Normal white blood count d\. Decreased absolute neutrophil count 154\. A nurse is caring for a client who is being treated for hypokalemia. Which of the following is correct regarding potassium administration? a\. Administer IM or IV b\. Infuse at a rate no greater than 40 mEq/mL per hour c\. Administer via an infusion pump d\. Administer IV push 155\. A nurse should instruct a client with a positive family history of colon cancer to adhere to which of the following recommendations? a\. Encourage baseline colonoscopy screening b\. Encourage the client to reduce the intake of dietary fiber c\. Restrict physical activity d\. Encourage the client to increase the dietary intake of red meats 156\. A nurse is caring for a client who is undergoing external radiation treatment for liver cancer. What information needs to be provided to the client and the family? a\. Family should avoid contact with the client b\. Treatment can last 4-6 hours c\. Radiation treatment has few side effects d\. Importance of maintaining external markings for future treatment 157\. A client weighs 194 lb. What is the client's weight in kg? 88.2 kg 158\. A tumor was staged T4, N3, M0. What does this mean? a\. The tumor is large, has not metastasized, and has much node involvement b\. The tumor has four points of origin, three nodes involved, and may metastasize within the next week c\. The tumor is small and nodal involvement is minimal d\. A small tumor is showing signs of increased mass from a previous scan 159\. Which of these factors in a client\'s history is most likely related to the development of lung cancer? a\. Poor diet b\. Lack of screening c\. History of smoking for 20 years d\. Lack of exercise 160\. A client asks the nurse to explain what radiation exposure refers to. Which of these is a correct response? a\. \"That refers to the amount of local treatment only\" b\. \"That refers to the amount of radiation absorbed\" c\. \"That refers to the amount of radiation delivered\" d\. \"That refers to ionizing liquefaction\" 161\. The nurse knows that which side effect of chemotherapy is the most serious? a\. Nausea and vomiting b\. Peripheral neuropathy c\. Bone marrow suppression d\. Dry desquamation of the skin 162\. Cancer management requires a collaborative approach, including establishing a multidisciplinary team. After diagnosis, which is the next priority step? a\. Provide discharge instructions b\. Provide education c\. Develop a treatment plan d\. Establish the nursing plan of care 163\. The nurse uses which phrase to describe palliative care correctly? a\. Client education about relevant treatment alternatives b\. Palliative care is introduced at the end of life c\. Client care with a focus on treatment of symptoms d\. Care for clients with a prognosis of six months or less 164\. A nurse is caring for a client presently diagnosed with cancer and undergoing chemotherapy. A review of the morning labs reveals hyperphosphatemia, hyperkalemia, and hyperuricemia. Based on the laboratory findings, which of the following conditions is the patient exhibiting? a\. Tumor lysis syndrome b\. Hypercalcemia of malignancy c\. Syndrome of inappropriate antidiuretic hormone (SIADH) d\. Febrile neutropenia 165\. Which of the following cancers arise from blood cell-forming tissue? a\. Neuroblastomas b\. Leukemias c\. Melanomas d\. Carcinomas 166\. A nurse is caring for a 46-year-old female who presented to the emergency department with fever, nausea, vomiting, and fatigue over the past few days. The client has recently been diagnosed with breast cancer and has been undergoing chemotherapy. The client's labs reveal the following: Na 150 mEq/mL, potassium 3.2 mEq/mL, calcium 15 mEq/mL. Which of the following fluid and electrolyte imbalances is the client exhibiting? a\. Hypervolemia and hypercalcemia b\. Hypervolemia, hypercalcemia, hyperkalemia c\. Hypovolemia, hypernatremia, hypokalemia, hypercalcemia d\. Hyponatremia and hypercalcemia 167\. A client has congestive heart failure (HF) and renal failure. Which of these statements by the client requires further education to help the client avoid hypovolemic episodes? a\. \"I will monitor my weight daily.\" b\. \"I will go to the emergency room if I have difficulty breathing.\" c\. \"I will eat ham instead of chicken.\" d\. \"I will eat foods low in salt.\" 168\. Patients diagnosed with cancer who have exhausted all treatment options are good candidates for: a\. Palliative care b\. Home health c\. Hospice care d\. Outpatient care 169\. The nurse is caring for a client who is on a fluid restriction and is preparing for discharge. Which of the following should be included in the education? (Select all that apply) a\. Determine the client's dietary preferences when planning a diet after discharge b\. Explain the purpose of the fluid restriction c\. Teach the client and family about performing daily weights d\. Add additional salt to food to increase flavor e\. Advise the client it\'s not necessary to follow fluid restrictions at home 170\. A client asks the nurse how radiation works to destroy cancer cells. How does the nurse respond? a\. \"The goal of localized radiation therapy is to kill all of the rapidly dividing cells throughout the body.\" b\. \"The goal of radiation therapy is to destroy the cancer cells while minimizing further damage to the body.\" c\. \"The goal of radiation therapy is to localize the tumor and reverse it back to normal tissue.\" d\. \"The goal of radiation therapy is to promote cell proliferation.\" 171\. A nurse is caring for a newly diagnosed leukemia patient who recently completed the initial round of chemotherapy. Which of the following should be included in the patient and family education? a\. The client may resume normal activity following discharge b\. The client has no increased risk for bleeding c\. The client will not experience any pain as a result of the leukemia d\. The client is at increased risk of developing mucositis 172\. A nurse is caring for an 84-year-old with nausea who has been vomiting for the past three days and as recently as this morning. Upon assessment, the nurse notes an elevated heart rate, dry oral mucous membranes, and poor skin turgor. What priority intervention would be based on the assessment findings? a\. Administer antiemetics b\. Obtain IV access and administer fluids c\. Monitor output by counting the number of wet diapers d\. Schedule small feedings 173\. The nurse is caring for a 26-year-old with a family history of breast cancer. The client lost her mother and sister to breast cancer and is concerned about her risk. The client underwent genetic testing, which indicates that she also has a genetic predisposition for breast cancer. The client has opted to have a bilateral mastectomy. What surgical treatment option would this fall under? a\. Diagnostic b\. Prophylactic c\. Palliative d\. Curative