Exam Questions

1. The nurse is making assignments for the day. Which client should be assigned to

the pregnant nurse? a. The client receiving radium linear accelerator radiation therapy for cancer b. The client with a radium implant for vaginal cancer c. The client who has just been administered radioactive isotopes for cancer d. The client who returned from placement of iridium seeds for prostate Cancer ANSWER: A is correct. The pregnant nurse should not be assigned to any client with radioactivity present. The client receiving linear accelerator therapy travels to the radium department for therapy, and the radiation stays in the department. Thus, the client is not radioactive. The client in answer B poses a risk to the pregnant client, so answer B is incorrect. Answer C is incorrect because the client is radioactive in very small doses. For approximately 72 hours, the client should dispose of urine and feces in special containers and use plastic spoons and forks. The client in answer D is also radioactive in small amounts, especially upon return from the procedure, so answer D is incorrect.
2. The nurse is planning room assignments for the day. Which client should be

assigned to the only private room? a. The client with Cushing s disease b. The client with diabetes c. The client with acromegaly d. The client with myxedema ANSWER: A is correct. The client with Cushing s disease has adrenocortical hypersecretion. This increase in the level of cortisone causes the client to be immunesuppressed. The client with diabetes poses no risk to other clients and is not immunosuppressed, so answer B is incorrect. The client in answer C has an increase in growth hormone and poses no risk to himself or others, so the answer is incorrect. The client in answer D has hyperthyroidism, or myxedema, and poses no risk to others or himself, so it is incorrect.
3. The charge nurse witnesses the nursing assistant being abusive to a client in the

nursing home facility. The nursing assistant can be charged with which of the following? a. Negligence b. Tort c. Assault d. Malpractice ANSWER: C is correct. Assault is defined as striking or touching the client inappropriately. Negligence is failing to perform care for the client, so answer A is incorrect. A tort is a wrongful act committed on the client or his belongings, so answer B is incorrect. Malpractice is failing to perform an act that the nurse knows should be done or doing something wrong that causes harm to the client, so answer D is incorrect.

4. Which assignment is outside the realm of nursing practice for the licensed practical

nurse? a. Inserting a Foley catheter b. Discontinuing a nasogastric tube c. Obtaining a sputum specimen d. Starting a blood transfusion ANSWER: D is correct. The LPN can be assigned to insert Foley and French urinary catheters, discontinue Levin and gavage gastric tubes, and obtain all types of specimens.
5. The client returns to the unit from surgery with a blood pressure of 100/50, pulse

122, and respirations 30. Which action by the nurse should receive priority? a. Continue to monitor the vital signs b. Contact the physician c. Ask the client how he feels d. Ask the LPN to continue the postop care ANSWER: B is correct. The vital signs are abnormal and should be reported immediately. Continuing to monitor the vital signs can result in deterioration of the client s condition, so answer A is incorrect. Asking the client how he feels would supply only subjective data, so answer C is incorrect. The LPN is not the best nurse to be assigned to this client because he is unstable, so answer D is incorrect.
6. Which nurse should be assigned to care for the client with preeclampsia?

a. The RN with 2 weeks experience on postpartum b. The RN with 3 years experience in labor and delivery c. The RN with 10 years experience in surgery d. The RN with 1 year experience in the neonatal intensive care unit ANSWER: B is correct. The nurse in answer B has the most experience in knowing the possible complications involved with preeclampsia. The nurse in answer A is a new nurse to this unit, so the answer is incorrect. The nurse in answer C has no experience with the postpartal client, so the answer is incorrect. The nurse in answer D also has no experience with postpartal clients, so the answer is incorrect.
7. Which information should be reported to the state board of nursing?

a. The facility fails to provide literature in both Spanish and English. b. The narcotic count has been incorrect on the unit for the past three days. c. The client fails to receive an itemized account of his bills and services received during his hospital stay. d. The nursing assistant assigned to the client with hepatitis fails to feed the client and give him a bath. ANSWER: B is correct. The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C, so they are incorrect. The failure of the nursing assistant to assist the client with hepatitis should be reported to the charge nurse. If the behavior continues, termination can result, but it doesn t need to be reported to the board, so answer D is incorrect.

8. The nurse is found to have charted blood glucose results without actually

performing the procedure. After talking to the nurse, the charge nurse should do which of the following? a. Call the board of nursing b. File a formal reprimand and monitor the nurse c. Terminate the nurse d. Charge the nurse with a tort ANSWER: B is correct. The next action after discussing the problem with the nurse is to document the incident. If the behavior continues or if harm has resulted to the client, the nurse might be terminated and reported to the board of nursing, so answers A and C are incorrect. A tort is a wrongful act to the client or her belongings, so answer D is incorrect.
9. The home health nurse is planning for the day s visits. Which client should be seen

first? a. The 78-year-old who had a gastrectomy three weeks ago with a PEG tube b. The 5-month-old discharged one week ago with pneumonia who is being treated with amoxicillin liquid suspension c. The 50-year-old with MRSA being treated with vancomycin via a PICC line d. The 30-year-old with an exacerbation of multiple sclerosis being treated with cortisone via a centrally placed venous catheter ANSWER: D is correct. The client who should receive priority is the client with multiple sclerosis being treated with cortisone via the central line because this client is at highest risk for complications. The clients described in answers A and B are stable at the time of the assigned visit. They can be seen later. The client in C has methicillin-resistant staphylococcus aureus (MRSA). Vancomycin is the drug of choice and can be administered later, but it must be scheduled at specific times of the day to maintain a therapeutic level, so answer C is incorrect.
10. The emergency room is flooded with clients injured in a tornado. Which clients

can be assigned to share a room in the emergency department during the disaster? a. A schizophrenic client having visual and auditory hallucinations and the client with ulcerative colitis b. The client who is six months pregnant with abdominal pain and the client with facial lacerations and a broken arm c. A child whose pupils are fixed and dilated and his parents and a client with a frontal head injury d. The client who arrives with a large puncture wound to the abdomen and the client with chest pain ANSWER: B is correct. Out of all these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The other clients need to be placed in separate rooms, so answers A, C, and D are incorrect.

11. The nurse is working in an outpatient same day surgery unit. An 86 years old client signs the surgical consent form and asks the nurse, What did I just sign? My wife always takes care of the paperwork. Which of the following is the priority nursing action? a. Assess what the client understands about the surgery. b. Notify the surgeon that the client does not understand the surgery. c. Ask the client s wife to explain the consent for surgery. d. Ask the client s wife to sign the consent form because the client is not competent. ANSWER: A. Assessment of the client s understanding of the surgery is essential. If the client has signed a surgical consent form then questions what was signed, it is a priority to assess what the client understands. After assessing what the client understands, or if the client is incompetent, then it would be appropriate to notify the physician. 12. Which of the following is the appropriate nursing action when a nursing student assigned to the surgery suite for observation asks the nurse for permission to photocopy the surgical record from a client s chart for an assignment the student must write? a. Photocopy the pages for the student b. Allow the student to photocopy the pages without the client s name c. Allow the student to write down pertinent but no identifying information d. Ask the physician for permission to photocopy the pages ANSWER: C. When a nursing student wants to photocopy a client s medical record, nonidentifying information may be written down. The client has the right to confidentiality and any information that could be linked to the client, such as names or addresses, cannot be shared. 13. The nurse working in a long term care facility is orienting a new nurse to the facility. The nurse should tell the new nurse that which of the following is the priority reason that health care issues of older adults become an ethical dilemma? a. The choices for health care options do not seem to be clearly right or wrong b. Decisions are made based on value systems c. Decisions are made quickly d. The legal rights of the client coexist with the health professional s obligation to provide care for the client ANSWER: D. Although health care options do not seem clearly right or wrong and decisions in a long term care facility are made quickly, the priority reason health care issues in older adults become highly charged ethical dilemmas is that the client s right to care and for dignified death are managed in the context of the health professional s obligations to provide care. 14. A nurse is teaching a class of a new graduate nurses on negligence. Which of the following situations is a priority for the nurse to include in the class as an example of negligence? a. Not giving a prescribed medication to an older adult b. Not turning off the oxygen at the bedside when a client at home wants to smoke in bed

c. Not allowing a family member to awaken an older adult client who is sleeping d. Talking about a client outside of the long term care facility ANSWER: B. Negligence is the result of either omitting to do something that another reasonable person, guided by those ordinary considerations that ordinarily regulate human affairs, would do, or of doing something another reasonable or prudent person would not do. If there is imminent danger to a client, the nurse must take every measure to protect the client. It may be appropriate for the nurse as in the case of a client with a sudden rash and the nurse withholds a prescribed antibiotic, which may contribute to the development of the rash. It is inappropriate to talk about a client outside of a long term care facility because it violates the client s right to privacy, but it is not negligence. 15. One of theunlicensed assistive personnel (UAPs) caring for an older adult with fragile skin report to the nurse a red, painful, and swollen IV site in the hand. Which of the following requests by the nurse does the UAP interpret as inappropriate and illegal? a. Tell the client I ll be there as soon as I can. b. Careful take the IV out. c. Put a cool washcloth on the IV site. d. Elevate the client s hand on a pillow. ANSWER: B. Unlicensed assistive personnel cannot legally perform a nursing function such as removing an IV. This would be interpreted as inappropriate and illegal. 16. After reviewing the records of four older clients in a long term care facility, which of the following situations does the nurse recognize as violating the client s right to privacy? a. Administering a medication to a client in the presence of other clients. b. Placing the client s name on the client s bed c. Placing a photograph of the client in the medication administration record d. Placing a photograph of the client in the medical record ANSWER: A. The medications that a client receives are private. The medications should not be administered where someone else, such as another client, can see what the client is receiving. Placing the client s name on the client s bed, and placing a photograph in the client s medical record or medication administration record are for the client s safety and do not violate the right to privacy. Only authorized personnel have access to that information 17. A 66 years old client is admitted to a long term care facility for rehabilitation following a total hip replacement. The client refuses to stay in the facility and tells the nurse, I am going to walk home. Which of the following is the appropriate action of the nurse? a. Tell the client that rehabilitation is necessary and leaving is not possible b. Restrain the client to prevent the client from leaving c. Call security to restrain the client d. Do not prohibit the client from leaving

ANSWER: D. A client who is in a long term care facility for rehabilitation and who wants to go home is competent and able to make decisions, even if those decisions may endanger the client s health. It would be inappropriate to prevent the client from leaving, because the client can make health care decisions unless incompetence has been declared. Restraining the client would be false imprisonment or battery. 18. The older adult client in a long term care facility is soiled with feces. The client calls out. Stop, don t hurt me. Help! while being bathed by the nurse. Because the nurse did not have the client or the client s guardian s expressed permission to bathe the client, the nurse is at risk for being accused of? a. Assault b. Battery c. Malpractice d. Negligence ANSWER: B. Because the client is protesting the bathing, the nurse could be accused of battery without the permission of the guardian. Battery is the unlawful touching of another person. Assault is an unjustifiable attempt or a treat to touch a person without consent that result in fear of immediate harm. The touching may not actually occur. Malpractice is a type of negligence in which any unreasonable act or professional misconduct results in injury to the client. Negligence is the failure to do something that a reasonable person, led by those ordinary considerations that ordinarily regulate human affairs, would do, or the doing of something another reasonable person would not do. 19. The nurse observes a staff member telling an older adult client that if the client does not take oral prescribed medications, dessert will be withheld. The nurse reports the behavior of the staff nurse as? a. Assault b. Battery c. Malpractice d. Negligence ANSWER: A. Assault is a deliberate threat that the client believes could be carried through, or an unjustifiable attempt or threat to touch a person without consent that results in fear of immediate harm.Battery is the unlawful touching of another person. Malpractice is a type of negligence in which any unreasonable act or professional misconduct results in injury to the client. Negligence is the failure to do something that a reasonable person, led by those ordinary considerations that ordinarily regulate human affairs, would do, or the doing of something another reasonable person would not do. 20. A new employee to a long term care facility asks the nurse if pictures of the residents may be taken. The appropriate response is, Pictures a. Cannot be published without the resident s or guardian s permission. b. May only be taken by the family. c. Can be published if the residents are not identified.

d. Will not violate the right to privacy when taken discreetly. ANSWER: A. The right to privacy includes the publishing of pictures or any other information about a client without the client s or guardian s permission. The nurse has the responsibility to advocate for and protects the client s privacy. Pictures may be taken in a long term care facility for the purpose of placing the photograph in the client s medical record or on the medication administration record.

21. A student nurse asks the nurse, Why did my advisor recommend an ethics class for me? Which of the following is the following is the best response by the nurse? a. b. c. d. It is the responsibility of nurses to recognize ethical dilemmas in clinical situations. Ethics must be learned in order to obey the law. You must have misunderstood because nurses do not have study ethics. You may find studying ethics interesting.

ANSWER: A. Recognizing ethical dilemmas is the responsibility of all nurses, as well as

physicians. Ethical behavior is a component of both law and religion, but knowledge of these areas does not render studying ethics unnecessary. 22. The nurse tells another nurse that which of the following best describes the purpose of the American nurses Association Code of Nurses? a. To communicate the values of the profession. b. To defend the actions of nurses in lawsuits. c. To develop the good character of nurses. d. To help recognize nurses for their ethical behavior. Answer: A. Ethical codes of professions, such as nursing, are developed to communicate the values of the profession and to guide ethical behavior among its member. The code cannot make nurses behave ethically, nor is its purpose to defend nursing to other professionals or in legal matters. 23. Which of the following is the best example of an ethical dilemma faced by the nurse? a. Deciding whether or not to place a client in a private room. b. Deciding whether or not to tell a client about the client s diagnosis c. Deciding the order in which staff members should take their breaks. d. Deciding whether or not to ask another nurse to care for a very complex patient.

ANSWER: B. An ethical dilemma exists when the nurse must make decision about what is right

or wrong, but there are conflicting moral principles or rules with any action taken. While deciding on room assignments and breaks are decisions nurses make daily, these are not ethical dilemmas. Nurses should use the good judgment and refuse being assigned to clients whose care is too complex for their training. Withholding information about the diagnosis potentially brings up conflicting issues of veracity, fidelity, and beneficence and is, therefore, an ethical dilemma. 24. After the physician explains the surgery of the client, the nurse provides the client with information about surgery, and allows the client to agree or refuse to have surgery. Which of the following ethical principles is best described by the nurse s actions? a. Nonmaleficence b. Beneficence c. Truth telling d. Autonomy ANSWER: D. The principle of autonomy is upheld when sufficient information and guidance are provided by the nurse so that the client may freely give informed consent. Beneficence is doing good, while nonmaleficence is not doing harm. Truth telling is an ethical rule rather than a principle, and relates to the nurse s obligation to be truthful put of respect for the client. 25. The nurse informs a young, healthy client that the scarce amount of flu vaccine will be given to older clients and those with immunosuppressed responses first. Which of the following ethical principles is best described by the nurse s statement? a. Beneficence b. Autonomy c. Justice d. Nonmaleficence
ANSWER: C. Equitable distribution of resources is described by the principle of justice.

Beneficence is doing good, nonmalifecence is not doing harm. Autonomy is providing the freedom to act.

26. The nurse chooses to delay taking a break so that the pain medication could be administered on time rather than making the client wait until the nurse s break is complete. Which of the following ethical principles is bet described by the nurse s action? a. Beneficence b. Justice c. Nonmaleficence d. Autonomy
ANSWER: A. Beneficence is described as doing what ought to do to promote good. Nonmaleficence is not causing intentional harm. Justice is the equitable distribution of resources. Autonomy is upholding a client s right to make informed choices. 27. A mentally ill client with an order for a general diet requests a vegetarian meal. Which of the following actions by the nurse s understanding of the principle of autonomy? a. Tell the client that a vegetarian meal cannot be substituted for a general diet. b. If necessary, obtain an order from the physician for a vegetarian meal; otherwise, provide a vegetarian meal per the client s request.

c. Contact the client s family and obtain their consent to provide a vegetarian meal to the client. d. Contact the client s medical power of attorney for permission to make a diet change.
ANSWER: B. Limited autonomy, such as what type of meal to eat, may be granted to those clients who are not deemed competent for other medical decisions. Neither the client s family nor the power of attorney needs to be contacted to make a diet change, even if they make other types of medical decisions for the client. 28. The nurse returns to the client s room in exactly four hours to administer the next dose of pain medication as promised. Which of the following ethical rules is best demonstrated by the nurse? a. justice b. Nonmaleficence c. Fidelity d. Confidentiality ANSWER: C. Justice and nonmaleficence are ethical principles dealing with the fair distribution of services and doing no harm. These are principles, not rules. Confidentiality is an ethical rule emphasizing

the importance of respecting the client s right to privacy of information. Fidelity is the rule demonstrated by this nurse by keeping the promise made and returning with the pain medication. 29. The registered nurse is preparing the client assignments for the day in a long-term care facility. Which of the following client assignments would be appropriate for the registered nurse to delegate to unlicensed personnel? a. Application of a prescribed restraints b. Administration of medications through a nasogatric tube c. Assessment of a postoperative stoma d. Irrigation of a foley catheter. ANSWER: A. Although unlicensed assistive personnel should not perform any assessments on a client with a restraint, they have been trained to apply the restraint. Administration of medications through a nasogastric tube, assessment of a postoperative stoma, and irrigation of a Foley catheter should be performed by a nurse. 30. The nurse appropriately applies a mummy restraint to which of the following clents? a. An older adult client who is confused b. A screaming child prior to an eye irrigation c. An adolescent who is having a drug reaction d. An older adult client who is combative and scratching the staff ANSWER: B. A mummy restrain is most generally use with a small child during some kind of short-term examination or treatment. Older adult clients should never be restrained because they are confused or combative. An adolescent would never be restrained just because of a drug reaction.