Which of the following is an example of a near miss?
The nurse stops the doctor before administering the wrong dosage of a paralytic
✓
A patient's IV line extravasates while receiving contrast dye
A respiratory therapist administers a breathing treatment to the wrong patient
A patient slips and falls in the hallway, spraining their ankle
Correct Answer
The nurse stops the doctor before administering the wrong dosage of a paralytic
A near miss is an event that could have caused harm to a patient, but did not reach the patient (e.g., due to the intervention of another healthcare professional).
Question 2
Which of the following conflict management strategies produces the best outcome?
Compromising
Collaborating
✓
Smoothing
Accommodating
Correct Answer
Collaborating
Collaborating is the conflict management strategy known to produce the best outcome.
Question 3
Which style of leadership is characterized by a hands-off approach where the leader allows the team to make decisions for themselves?
Transactional
Authoritarian
Laissez-faire
✓
Authoritative
Correct Answer
Laissez-faire
A laissez-faire leader is considered a "hands off" leader.
Question 4
A patient with Alzheimer's disease displays increasing confusion and agitation in the evening. The nurse correctly identifies this as which finding?
Urosepsis
Sundowning
✓
Fugue state
Delirium tremens
Correct Answer
Sundowning
Sundowning is a finding of increased confusion or agitation in the evening in patients with Alzheimer's.
Question 5
A 78 year old patient informs the nurse that she is suffering from presbycusis. The nurse correctly identifies this as which type of condition?
Unexpected vision loss for the patient's age
Bilateral hearing loss associated with age
✓
Bilateral vision loss associated with age
Unexpected hearing loss for the patient's age
Correct Answer
Bilateral hearing loss associated with age
Presbycusis is the bilateral hearing loss which occurs with aging.
Question 6
Which disorder of close-vision is common in older adults?
Presbyopia
✓
Hyperopia
Myopia
Amblyopia
Correct Answer
Presbyopia
Presbyopia is the age-related difficulty focusing on close-up objects.
Question 7
Older adults with urinary tract infections often present with which key symptom?
Confusion
✓
Urgency
Frequency
Dysuria
Correct Answer
Confusion
Older patients with UTIs may not experience any urinary symptoms such as dysuria, frequency, or urgency, but may exhibit confusion.
Question 8
The nurse educates a patient's family that dementia is an expected part of aging beginning at what age?
Never
✓
85
65
75
Correct Answer
Never
Dementia is not an expected part of aging.
Question 9
How does a patient's anterior-posterior chest diameter change as they age?
It stays the same
It decreases
It increases
✓
It becomes equal
Correct Answer
It increases
AP chest diameter increases as a patient ages.
Question 10
A nurse is providing teaching to a patient regarding coronary artery disease (CAD). Which of the following terms refers to the build-up of plaque on the arterial walls, which leads to narrowing of the arteries?
Hypertension
Hyperlipidemia
Vasculitis
Atherosclerosis
✓
Correct Answer
Atherosclerosis
Atherosclerosis is the build-up of plaque on the arterial walls, which leads to narrowing of the arteries. When this plaque build-up occurs in the coronary arteries, it is known as coronary artery disease.
Question 11
How full should the reservoir bag on a partial rebreather mask be inflated?
2/3 full
✓
There is no specific requirement
Completely full
1/3 full
Correct Answer
2/3 full
A partial rebreather mask should have the reservoir bag inflated approximately 2/3 of the way.
Question 12
Which of the following is a late sign of hypoxia?
Tachycardia
Use of accessory muscles
Pallor
Hypotension
✓
Correct Answer
Hypotension
Hypotension is a late sign of hypoxia. The other findings are early signs of hypoxia.
Question 13
Which of the following is an early sign of hypoxia?
Bradycardia
Restlessness
✓
Cyanosis
Decreased LOC
Correct Answer
Restlessness
Restlessness is an early sign of hypoxia. The other findings are late signs of hypoxia.
Question 14
When administering an enema, how high should the nurse position the solution?
6″ above the patient's anus
12″ above the patient's anus
At the level of the patient's anus
18″ above the patient's anus
✓
Correct Answer
18″ above the patient's anus
Enema solution should be positioned 18″ above the patient's anus. If the patient reports cramping or discomfort, the solution bag may be lowered for comfort.
Question 15
Which of the following choices is appropriate for a patient who is on a clear liquid diet?
Chicken noodle soup
Orange juice
Milk
Lime jello
✓
Correct Answer
Lime jello
Clear liquid diets allow any liquid that is translucent and liquid at room temperature, such as jello. Orange juice and milk are not clear liquids, and the patient may not have the solids in chicken noodle soup.
Question 16
Which of the following BMIs is categorized as overweight?
17.3
27.2
✓
32.7
22.9
Correct Answer
27.2
A patient considered "overweight" has a BMI ranging from 25 - 29.9.
Question 17
Which macronutrient is most important for building and repair of tissues?
Carbohydrates
Nucleic Acids
Protein
✓
Lipids
Correct Answer
Protein
Protein is important for the building and repair of tissues, immune system support, and energy.
Question 18
Which of the following is a sign of fluid volume excess?
Weight loss
Dry mucous membranes
Flattening of the jugular vein
Hypertension
✓
Correct Answer
Hypertension
Hypertension is a potential sign of fluid volume excess. The other signs are associated with fluid volume deficit.
Question 19
Which of the following is a sign of fluid volume deficit?
Rapid, thready pulse
✓
Edema
Bounding pulses
Coarse crackles
Correct Answer
Rapid, thready pulse
A rapid, thready pulse is associated with fluid volume deficit. The other signs are associated with fluid volume excess.
Question 20
How should the nurse record a patient's intake if they had 240 mL of ice chips?
240 mL
200 mL
120 mL
✓
100 mL
Correct Answer
120 mL
Ice chips should be recorded as half of their volume, so 240 mL of ice chips would be charted as 120 mL of water intake.
Question 21
What is a solution's tonicity if it causes water to move into a cell?
Crystalloid
Isotonic
Hypotonic
✓
Hypertonic
Correct Answer
Hypotonic
A hypotonic solution is one where the tonicity is less than the body's cell, causing fluid to enter the cell.
Question 22
During which stage of sleep does vivid dreaming occur?
Stage III
Rapid eye movement (REM)
✓
Stage I
Stage II
Correct Answer
Rapid eye movement (REM)
Vivid dreaming occurs during the REM stage of sleep.
Question 23
Which type of pain is related to the organs?
Neuropathic pain
Cutaneous pain
Visceral pain
✓
Chronic pain
Correct Answer
Visceral pain
Visceral pain is organ-related. Neuropathic is related to nerves, and cutaneous is related to the skin. Chronic pain may have many different causes.
Question 24
What amount of a sterile field's border is considered non-sterile?
2 inches
None
1 inch
✓
6 inches
Correct Answer
1 inch
1 inch of a sterile field's border is considered non-sterile.
Question 25
What kind of room is required for a patient on airborne precautions?
Windowless
Positive airflow
Semi-private
Negative airflow
✓
Correct Answer
Negative airflow
A patient on airborne precautions requires a negative airflow room.
Question 26
Which piece of PPE should be put on last?
Mask
Eyewear
Gown
Gloves
✓
Correct Answer
Gloves
PPE should be put on in the following order: Gown, mask, eyewear, gloves. Therefore, gloves should be put on last.
Question 27
What piece of PPE should be removed second?
Mask
Eyewear
✓
Gown
Gloves
Correct Answer
Eyewear
PPE should be removed in the following order: Gloves, eyewear, gown, mask. Therefore, eyewear should be removed second.
Question 28
A nurse is providing teaching on infection prevention. The nurse should state that which of the following is the most important step in preventing infection?
PPE
Hand hygiene
✓
Prophylactic antibiotics
Clustering care
Correct Answer
Hand hygiene
Washing hands before and after patient care is the best way to prevent the spread of infection.
Question 29
What does the R in SBAR stand for?
Recommendation
✓
Response
Request
Rejection
Correct Answer
Recommendation
SBAR is a type of interdisciplinary communication which stands for Situation, Background, Assessment, Recommendation.
Question 30
What is the first step of the nursing process?
Implementation
Planning
Diagnosis
Assessment
✓
Correct Answer
Assessment
Assessment is the first step of the nursing process. ADPIE = Assessment, Diagnosis, Planning, Implementation, Evaluation
Question 31
Which mnemonic can be used to help remember the proper steps in using a fire extinguisher?
RACE
FIRE
PASS
✓
FAST
Correct Answer
PASS
PASS: pull the pin, aim at the base of the fire, squeeze the handle, sweep side to side.
Question 32
Which of the following are modifiable risk factors?
Stress
✓
Ethnicity
Family history
Age
Correct Answer
Stress
Age, ethnicity, and family history are non-modifiable risk factors (i.e., risk factors the patient cannot change). A patient may modify their risk for disease associated with stress.
Question 33
A nurse is teaching a patient about modifiable risk factors. Which of the following should the nurse include?
Ethnicity
Genetics
Age
Obesity
✓
Correct Answer
Obesity
Modifiable risk factors are able to be decreased or eliminated with lifestyle changes. Examples include obesity, smoking, and stress.
Question 34
What stage of illness is characterized by general signs and symptoms, such as malaise?
Incubation
Illness
Convalescence
Prodromal
✓
Correct Answer
Prodromal
The prodromal period includes non-specific, general signs and symptoms such as malaise and fatigue.
Question 35
In the chain of infection, which term is used to describe how the agent gets from the reservoir to the new host?
Vector
Portal of entry
Portal of exit
Mode of transmission
✓
Correct Answer
Mode of transmission
The mode of transmission is how an agent gets from the reservoir to the new host.
Question 36
Which part of the chain of infection is where the infectious organism lives and grows?
Portal of exit
Agent
Reservoir
✓
Portal of entry
Correct Answer
Reservoir
The reservoir is where the infectious organism lives and grows. Examples include animals, soil, and humans.
Question 37
Malaria is spread by what mode of transmission?
Droplet
Airborne
Contact
Vector
✓
Correct Answer
Vector
Malaria is transmitted via mosquito (a vector).
Question 38
How should a patient be positioned for most gynecologic exams?
High-Fowler's
Trendelenburg
Lithotomy
✓
Semi-Fowler's
Correct Answer
Lithotomy
Lithotomy position involves laying the patient on their back with their legs separated, raised, and supported (typically in stirrups). This is the most common position for gynecologic and urologic procedures.
Question 39
Which of the following foods is most likely to be appropriate for a patient who is Kosher-observant?
Eggs and bacon
Cheeseburger
Grilled chicken sandwich
✓
Lobster bisque
Correct Answer
Grilled chicken sandwich
Patients who are Kosher-observant are likely to avoid consuming pork products, shellfish, and meat with dairy (e.g., cheeseburger). A grilled chicken sandwich is likely the most appropriate choice.
Question 40
A patient reports that they are experiencing nausea. What type of data is this an example of?
Subjective
✓
Measurable
Objective
Autonomous
Correct Answer
Subjective
The patient's report of nausea is an example of subjective data.
Question 41
A nurse has a patient practice administering their own insulin injections in order to have them engage in which domain of learning?
Spiritual
Affective
Psychomotor
✓
Cognitive
Correct Answer
Psychomotor
The psychomotor domain of learning involves action.
Question 42
A patient states, "I am mad at the doctor." Which of the following is an appropriate response by the nurse?
Why are you mad at the doctor?
Let's talk about your health instead.
You should try to put those feelings aside.
I understand you are mad at the doctor.
✓
Correct Answer
I understand you are mad at the doctor.
Restating is a therapeutic communication technique. Using "why" questions, giving advice, and changing the subject are all non therapeutic.
Question 43
According to Piaget's theory of cognitive development, which stage would a patient be in if they are developing object permanence?
Sensorimotor
✓
Formal Operational
Preoperational
Concrete Operational
Correct Answer
Sensorimotor
The preoperational stage is from birth to two years old. This is when learning through the senses and movement occurs and object permanence develops.
Question 44
According to Maslow, which needs must be met following physiological needs?
Love and belonging
Self esteem
Self-actualization
Safety
✓
Correct Answer
Safety
Maslow's hierarchy (from bottom to top): Physiological needs, safety, love and belonging, self esteem, self-actualization.
Question 45
What is at the bottom of Maslow's hierarchy of needs?
Love and belonging
Safety
Physiological needs
✓
Self esteem
Correct Answer
Physiological needs
Maslow's hierarchy (from bottom to top): Physiological needs, safety, love and belonging, self esteem, self-actualization.
Question 46
The nurse is observing a new graduate nurse perform oropharyngeal suctioning on a client. Which of the following techniques requires immediate intervention?
The nurse should apply suction while withdrawing the catheter
The nurse should perform no more than 3 passes per session
Suction passes should be 30-40 seconds in length
✓
Patients may receive oxygen prior to suctioning to decrease hypoxia
Correct Answer
Suction passes should be 30-40 seconds in length
Suction passes should be no longer than 15 seconds to reduce the risk for hypoxia.
Question 47
A nurse is caring for a client diagnosed with a deep vein thrombosis. Which statement made by the client's family requires immediate intervention?
He should use an incentive spirometer 10 times per hour while awake
We should massage his leg every 4 hours
✓
He will receive an infusion of IV heparin
We should place a pillow underneath his foot to elevate his leg
Correct Answer
We should massage his leg every 4 hours
A patient with a DVT should avoid massaging their limb due to the risk of dislodging the clot, causing a pulmonary embolism. Elevating the leg under the foot (but not the knee) is appropriate, along with use of an incentive spirometer and IV heparin treatment.
Question 48
The nurse is educating a client on urinary tract prevention. Which of the following statements made by the client would require follow up?
Wear cotton underwear
Drink 1 L of water per day
✓
Avoid bubble baths
Urinate after sexual intercourse
Correct Answer
Drink 1 L of water per day
The patient should be instructed to drink approximately 3 L of fluid per day to decrease the risk for UTI.
Question 49
The nurse is discussing client risk factors with a student. When listing previous history that would be a risk factor for stress incontinence which of the following would require follow up?
Stroke
✓
Menopause
Prior pregnancy
Obesity
Correct Answer
Stroke
Menopause, prior pregnancy, and obesity are risk factors associated with stress incontinence. Stroke is not a risk factor for stress incontinence.
Question 50
The nurse is reviewing delegation of client care to an LPN/LVN with a new graduate nurse. Which of the following tasks stated by the nursing student as appropriate to delegate would require the nurse to follow up?
Tracheostomy care
NG tube insertion
Wound dressing change
Blood transfusion
✓
Correct Answer
Blood transfusion
The LPN may perform tracheostomy care, wound dressing changes, and may insert NG tubes. Blood transfusions are outside of the LPN's scope of practice, and should not be delegated.
Question 51
The nurse is providing care for a client with continuous tube feeding. Which of the following options indicates an appropriate frequency and amount of water to flush the feeding tube?
Every 2 hours with 30 mL water
Every 4 hours with 30 mL water
✓
Every 4 hours with 60 mL water
Every 2 hours with 60 mL water
Correct Answer
Every 4 hours with 30 mL water
During continuous feeds, a patient's feeding tube should be flushed with 30 mL water every 4 hours.
Question 52
The nurse is reviewing common assessment findings in older adults with a new graduate nurse. Which assessment finding made by the student nurse would require follow up?
Increased oil production
✓
Decreased sweat production
Presence of senile lentigines
Paler skin
Correct Answer
Increased oil production
Decreased oil production, not increased, is expected in the older adult.
Question 53
A patient has told the nurse they are going to leave the hospital against medical advice. Which of the following actions by the nurse would require immediate follow up by the charge nurse?
Obtaining an AMA form
Calling security
✓
Removing the patient's IV
Notifying the provider
Correct Answer
Calling security
Security should not be called, the patient has a right to leave AMA.
Question 54
After receiving education on diabetic foot care, which statement made by the client demonstrates the need for follow up?
I should look at my feet daily in a mirror
I should cut my nails in a round shape
✓
I should wear cotton socks and professionally fitted shoes
I should avoid soaking my feet in the bath
Correct Answer
I should cut my nails in a round shape
The patient should cut their nails straight across, not in a rounded shape.
Question 55
The nurse is working in a pediatric outpatient clinic. Which of the following clients requires parent or guardian consent for treatment?
Minor seeking STI treatment
Minor seeking routine vaccinations
✓
Emancipated minor seeking primary care
Minor seeking substance abuse treatment
Correct Answer
Minor seeking routine vaccinations
Minors may provide consent in limited circumstances: when they are emancipated or married, if they are in the military, or if they are seeking mental health, substance abuse, or STI treatment.
Question 56
A nurse is helping a client who follows a kosher diet set up their lunch tray. Which of the following options would require the nurse to intervene?
Cheeseburger
✓
Grilled cheese
Hamburger
Salad
Correct Answer
Cheeseburger
The kosher diet avoids meat and cheese together in a meal.
Question 57
When delegating a task to a UAP, the nurse understands the UAP is responsible for which of the following "rights"?
Right task
Right circumstance
Right documentation
✓
Right person
Correct Answer
Right documentation
The five rights of delegation are: right task, circumstance, person, direction, and supervision.
Question 58
The new graduate nurse is delegating tasks to a UAP. Which of the following tasks would require immediate follow up by the precepting nurse?
Charting I&O
CPR
Bathing
Wound care
✓
Correct Answer
Wound care
Bathing, CPR, and documenting intake and output are all within the scope of practice for a UAP. Wound care is not within the UAP's scope of practice, and should not be delegated.
Question 59
The nurse is working with a client when the UAP enters to obtain a fingerstick blood glucose. Which of the following actions made by the UAP would require immediate follow up?
Wipe away the first drop of blood before obtaining the sample
Ensure the glucometer has been recently calibrated
Wipe the finger with alcohol and allow it to dry
Use a lancet to puncture the middle of the finger pad
✓
Correct Answer
Use a lancet to puncture the middle of the finger pad
A lancet should be used to puncture the lateral, distal end of the fingertip, not the middle of the finger pad. All other steps are indicated.
Question 60
The nurse is assisting a colleague in securing a restraint for a client. Which action made by the nurse would require immediate follow up?
Reposition the patient every two hours
Ensure one finger can fit between the restraint and the patient
✓
Use a slip knot to secure the restraint
Affix the restraints to an immovable part of the bed frame
Correct Answer
Ensure one finger can fit between the restraint and the patient
Restraints should be affixed to the patient so that two fingers may fit between the restraint and the patient. If only one finger can fit, the restraint is too tight.
Question 61
The nurse is reviewing actions to take after a medication error event with a new graduate nurse. Which statement made by the new graduate nurse would require follow up?
Notify the provider of the medication error
Document the objective facts of the error in the patient's chart
Assess the patient thoroughly for changes to their status
Document completion of an incident report in the patient's chart
✓
Correct Answer
Document completion of an incident report in the patient's chart
While an incident report should be completed, it should not be included or referenced in the patient's chart as it is an internal document and not part of their permanent health record.
Question 62
The nurse is observing a new graduate nurse obtain informed consent prior to a procedure. Which action made by the new graduate nurse would require follow up?
Answer patient questions about the procedure
✓
Ensure the patient is competent to provide consent
Ensure appropriate translation services are used
Sign the consent form as a witness
Correct Answer
Answer patient questions about the procedure
The nurse may act as a witness to informed consent, and should ensure the patient is competent to consent and has the use of an approved medical translator if needed. It is the provider (e.g., MD, DO, NP, PA) who must answer any patient questions about the procedure.
Question 63
The nurse is caring for a client with influenza who has a fever of 102.3, chills, a cough, and muscle pain. The nurse correctly identifies this client to be in which stage of infection?
Illness stage
✓
Incubation stage
Convalescence stage
Prodromal stage
Correct Answer
Illness stage
The illness stage of infection is characterized by the appearance of infection-specific signs and symptoms.
Question 64
A client is experiencing fluid volume deficit. Which of the following laboratory findings does the nurse anticipate?
Elevated D-dimer
Decreased hemoglobin
Decreased BUN
Increased hematocrit
✓
Correct Answer
Increased hematocrit
A patient with fluid volume deficit is likely to experience increased hematocrit/hemoglobin, BUN, blood osmolality, and urine specific gravity and osmolality. Fluid volume deficit is unlikely to cause an elevated D-dimer.
Question 65
Which of the following steps should the nurse take when caring for a client with an indwelling urinary catheter?
Ensure there are no dependent loops
✓
Empty the drainage bag every two hours
Place the drainage bag on the patient during transportation
Apply antibacterial ointment to the urethral meatus
Correct Answer
Ensure there are no dependent loops
The nurse should make sure the bag is hanging below the level of the bladder at all times, check tubing for kinks, ensure there are no dependent loops, and empty the drainage bag every 8 hours. There is no need to apply antibacterial ointment to the urethral meatus.
Question 66
The nurse is administering an enema to a client who reports abdominal cramping. What is the nurse's priority action?
Contact the provider
Administer pain medication
Stop the enema
Lower the solution container
✓
Correct Answer
Lower the solution container
The priority action for a patient experiencing abdominal cramping during an enema is to lower the solution container.
Question 67
The nurse is reviewing the urine specific gravity levels for a client. Which of the following findings indicates concentrated urine?
1.008
1.041
✓
1.002
1.022
Correct Answer
1.041
The normal urine specific gravity range is 1.005-1.030. An elevated level such as 1.041 indicates concentrated urine, while a decreased level such as 1.002 indicates dilute urine.
Question 68
The nurse is caring for a client on contact precautions. Which of the following personal protective equipment (PPE) should the nurse prepare to use?
Gown, gloves, and eyewear
Gown, gloves, eyewear, N95 respirator
Gown, gloves, eyewear, surgical mask
Gown and gloves
✓
Correct Answer
Gown and gloves
A gown and gloves are required when caring for a patient on contact precautions.
Question 69
The nurse is educating a client and their family about using a PCA pump. Who should the nurse inform them is going to activate the PCA pump to administer pain medication prior to a potentially painful treatment?
The patient's family or visitors
The provider
The patient
✓
The nurse
Correct Answer
The patient
Only the patient should use a PCA pump to administer pain medication. Educate patients and their visitors that it is only the patient who may push the button.
Question 70
The nurse is assessing a client's chest tube. Where should the nurse expect to see continuous bubbling in the chest tube drainage system?
Suction control chamber
✓
Drainage tube
At the site of insertion
Water seal chamber
Correct Answer
Suction control chamber
Continuous bubbling is expected at the suction control chamber. Continuous bubbling in the water seal chamber, within the drainage tube, or at the site of insertion could indicate a leak.
Question 71
A nurse is performing a fecal occult blood test on a client's sample. What color indicates the presence of blood in the client's stool?
Yellow
Blue
✓
Green
Red
Correct Answer
Blue
Blue coloration appearing on the fecal occult blood test card indicates the presence of blood in the patient's stool.
Question 72
A client has an order for chest physiotherapy. When would be most appropriate for the nurse to schedule this treatment?
After the first meal of the day
Every 12 hours
Every 4 hours
Before meals or 1-2 hours after meals
✓
Correct Answer
Before meals or 1-2 hours after meals
Chest physiotherapy should be administered to a patient before meals or 1-2 hours following meals to decrease the risk for nausea and vomiting.
Question 73
A client being discharged home is being prescribed home oxygen therapy. The nurse educates the client that which type of clothing material is most appropriate for the client to wear?
Wool socks
Acrylic sweater
Nylon shorts
Cotton shirt
✓
Correct Answer
Cotton shirt
Patients who are receiving oxygen therapy should wear cotton clothes, as these are less likely to spark as a result of static electricity (and are therefore more fire-safe). Wool and synthetic fibers such as nylon and acrylic should be avoided.
Question 74
A client has a sigmoid colostomy. At what point should the nurse be prepared to empty the bag?
When it is 1/3 full
✓
After each bowel movement
Once the bag begins to separate from the wafer
Every two hours
Correct Answer
When it is 1/3 full
A colostomy bag should be emptied when it is approximately 1/3 full to avoid putting undue pressure on the wafer and stoma. There is no need to empty it on a specific schedule or after each bowel movement. The bag is overfull if it is separating from the wafer.
Question 75
The nurse has an order to insert a nasogastric tube. How should the nurse estimate the appropriate insertion amount for this client prior to insertion?
Measure from the corner of the mouth to the thyroid cartilage
Measure from the tip of the nose to the earlobe to the manubrium
Measure from the corner of the mouth to the angle of the jaw
Measure from the tip of the nose to the earlobe to the xiphoid process
✓
Correct Answer
Measure from the tip of the nose to the earlobe to the xiphoid process
NG tube length estimation is done by measuring from the tip of the nose to the earlobe and then to the xiphoid process.
Question 76
A client describes their pain as "burning," "shooting," or "pins and needles". The nurse understands this is most likely which type of pain?
Cutaneous pain
Neuropathic pain
✓
Visceral pain
Somatic pain
Correct Answer
Neuropathic pain
Injury to the nerves causing burning/shooting or pins and needles pain is known as neuropathic.
Question 77
The nurse is caring for a client who has an order for violent restraints. How often should the nurse assess the client's status and behavior?
Every four hours
Every hour
Every 15 minutes
✓
Every half hour
Correct Answer
Every 15 minutes
A patient in violent restraints should have their status and behavior assessed every 15 minutes.
Question 78
A nurse is speaking with a client and their family after the client was diagnosed with terminal cancer. Which type of grief might the family experience?
Normal grief
Complicated grief
Anticipatory grief
✓
Disenfranchised grief
Correct Answer
Anticipatory grief
Anticipatory grief is an individual's response to an impending loss.
Question 79
A client is admitted with a diagnosis of varicella. Which type of transmission precaution would be appropriate for this patient?
Airborne
✓
Droplet
Contact
Standard
Correct Answer
Airborne
Varicella (chickenpox) requires airborne precautions. This includes a private room with negative-pressure airflow.
Question 80
The nurse is on a committee discussing client safety. Which is the first step in the quality improvement process?
Evaluate effectiveness of implementations
Perform root cause analysis
Identify the standard of care
✓
Collect data using a chart audit
Correct Answer
Identify the standard of care
Identifying the benchmark or standard of care is the first step in the quality improvement process.
Question 81
The nurse is discussing client safety with a student. Which of the following is an example of a sentinel event?
A patient chooses to leave against medical advice
The surgeon amputates the wrong leg
✓
A nurse recognizes a potential medication error before it happens
A patient elopes from their room with an IV in place
Correct Answer
The surgeon amputates the wrong leg
A sentinel event is a medical error which reaches the patient and results in temporary severe harm, permanent harm, or the death of a patient.
Question 82
The nurse is assessing a client who is an older adult. Which of the following findings would the nurse anticipate?
Intolerance to sour foods
Stronger gag reflex
Decreased taste
✓
Increased thirst
Correct Answer
Decreased taste
As an adult ages, they may experience decreased taste, appetite, salivation, and thirst. They may also have a weaker gag reflex and decreased bowel motility. Intolerance to sour foods is not associated with aging.
Question 83
When performing a comprehensive assessment on a client, which of the following should the nurse consider to be an instrumental activity of daily living (iADL)?
Brushing your teeth
Creating a budget
✓
Walking to the kitchen
Eating breakfast
Correct Answer
Creating a budget
ADLs are basic tasks such as bathing, dressing, eating, toileting, and ambulating. iADLs are more complex tasks such as transportation, handling finances, and going shopping.
Question 84
The nurse receives an order for wrist restraints for a client. Which type of knot should the nurse use to secure the restraint?
Overhand knot
Square knot
Slip knot
✓
Half-hitch knot
Correct Answer
Slip knot
A quick release knot (i.e., a slip knot) should be used to secure a restraint so it may be easily removed in case of emergency.
Question 85
The nurse is discussing dementia and delirium with a student. Which statement made by the student indicates understanding of the disorders?
Dementia is not progressive
Delirium is not usually reversible
Dementia causes a fluctuating level of consciousness
Delirium has a sudden onset
✓
Correct Answer
Delirium has a sudden onset
Dementia has a gradual onset, is progressive and non-reversible, and does not impact a patient's level of consciousness. Delirium has a sudden onset, is typically reversible, and may cause a fluctuating level of consciousness.
Question 86
The nurse has just been alerted to a tornado warning affecting the hospital. What is the nurse's first action?
Move patients into the hallways
✓
Close the doors to each patient room
Teach patients to shelter underneath their beds
Contact command control for further instructions
Correct Answer
Move patients into the hallways
The priority action in case of a tornado is to relocate patients away from windows, ideally towards the middle of the building (e.g., hallways).
Question 87
The nurse is educating patient families on hand hygiene. The nurse includes the need for soap and water (vs. hand sanitizer) for patients with which condition?
Influenza
RSV
C. difficile
✓
Tuberculosis
Correct Answer
C. difficile
C. difficile requires enhanced contact precautions (or "contact plus") which means that along with wearing a gown and gloves, the nurse must use soap and water and not hand sanitizer.
Question 88
A nurse is educating a patient on the use of crutches. The nurse knows the education was successful if the patient states how much space should be between the axilla and the crutch?
None
5 inches
2 inches
✓
1 inch
Correct Answer
2 inches
To avoid causing damage to the nerves of the arm, 2″ of space should be between the patient's axilla and the underarm pad of a crutch.
Question 89
A nurse is caring for a postoperative client after a below-the-knee amputation (BKA). Which position should the nurse assist the patient into to prevent hip contractures?
High-Fowler's
Semi-Fowler's
Prone
✓
Supine
Correct Answer
Prone
The prone position is lying on your stomach. This position prevents hip contractures for patients with a lower extremity amputation.
Question 90
The nurse understands a client needs to have sufficient food, water, shelter, and safety before being able to work on relationships with others. This is explained by which theory?
Kohlberg's theory of moral development
Piaget's theory of cognitive development
Erikson's stages of psychosocial development
Maslow's hierarchy of needs
✓
Correct Answer
Maslow's hierarchy of needs
Maslow's hierarchy of needs is a motivational theory stating that certain human needs have to be met in order to achieve higher levels of needs.
Question 91
According to the transtheoretical model, in which stage is a patient who is doing research into an exercise routine and has established a gym membership but has not yet started working out?
Preparation
✓
Action
Contemplation
Precontemplation
Correct Answer
Preparation
This patient is in the preparation stage, as they have decided to make a change and are preparing to implement it.
Question 92
The nurse knows that which of the following, if present, may enhance a patient's ability to learn?
Language barriers
Mild anxiety
✓
Visual deficits
Presbycusis
Correct Answer
Mild anxiety
Mild anxiety may enhance the patient's ability to learn. Visual deficits, language barriers, and presbycusis are likely to be barriers to learning.
Question 93
A patient who is breathing on their own is requiring oxygen delivery with a precise FiO2. Which delivery device should the nurse anticipate using for this patient?
Venturi device
✓
Simple face mask
Nasal cannula
Mechanical ventilator
Correct Answer
Venturi device
The venturi device allows for the most precise oxygen delivery without intubation. Since this patient is breathing spontaneously and is not currently intubated, it is the best available option.
Question 94
An ER nurse is caring for a patient presenting with signs of hypoxemia. What testing does the nurse anticipate will be needed to diagnose this finding?
D-dimer
Arterial blood gas
✓
Pulmonary function tests
Basic metabolic panel
Correct Answer
Arterial blood gas
An arterial blood gas would be indicated in the diagnosis and treatment of hypoxemia. While a D-dimer, BMP, and PFTs may be indicated, they are not indicated for the diagnosis of acute hypoxemia.
Question 95
The nurse asks a patient, "do I understand you correctly when you say your stomach pain occurs before you get nauseated?" Which therapeutic communication technique is this?
Reflecting
Clarification
✓
Paraphrasing
Summarizing
Correct Answer
Clarification
The nurse is seeking clarification in a therapeutic manner.
Question 96
If there is a fire, which of the following steps should the nurse take first after evacuating patients from the affected area?
Pull the fire alarm
✓
Use a fire blanket
Use a fire extinguisher
Close the doors to each patient room
Correct Answer
Pull the fire alarm
RACE is the mnemonic used to recall the steps to take in the event of a fire. Rescue (e.g., evacuate them from their rooms), Alarm, Contain, Extinguish. After evacuating patients, the nurse should pull the fire alarm.
Question 97
A teenager is working to find their place within a friend group and discover their own interests and hobbies. This child is demonstrating which stage of Erikson's stages of psychosocial development?
Integrity vs. despair
Identity vs. role confusion
✓
Autonomy vs. shame and doubt
Industry vs. inferiority
Correct Answer
Identity vs. role confusion
The adolescent (age 12 - 18 years) will be in the stage of identity vs. role confusion.
Question 98
A preschooler is trying new things at school and begins to take a leader role in a new game. This child is demonstrating which stage of Erikson's stages of psychosocial development?
Autonomy vs. Shame and Doubt
Identity vs. Role Confusion
Trust vs. Mistrust
Initiative vs. Guilt
✓
Correct Answer
Initiative vs. Guilt
The preschooler (age 3 - 6 years) will be in the stage of initiative vs. guilt.
Question 99
The nurse is caring for a patient who is being involuntarily admitted due to suicidal ideations. When it comes time for the morning med pass, the patient states "I don't want any medicine." How should the nurse respond?
Document the patient's refusal
✓
Administer the medications as IM instead of PO
Contact the provider
Inform the patient that they cannot refuse
Correct Answer
Document the patient's refusal
A patient who has been involuntarily admitted still has the right to refuse medications. Their refusal should be documented.
Question 100
A Spanish-speaking patient presents to the emergency room with their spouse, who is fluent in English. How should the nurse proceed?
Have the spouse translate for the patient
Use an approved medical interpreting service
✓
Use a medical translation text to triage the patient
Ask the spouse to leave the room
Correct Answer
Use an approved medical interpreting service
Regardless of the presence of a family member who speaks both Spanish and English, the nurse must use an approved medical interpreting service when caring for this patient. There is no need for the spouse to leave the room unless requested by the patient.
Question 101
A nurse believes that the views and practices of their own culture are superior to other cultures. What belief is the nurse exhibiting?
Acculturation
Cultural humility
Ethnocentrism
✓
Cultural competence
Correct Answer
Ethnocentrism
Ethnocentrism is the belief that the views and practices of one's own culture are superior to other cultures. This is a belief that should be avoided in a culturally humble model of care.
Question 102
A patient is informed that he is pre-diabetic, but he feels fine, has no experience with family members or friends who have been diabetic, and doesn't think it's worth changing his behaviors. Based on this information, which theoretical model can be used to predict this patient's health-related behaviors?
Health belief model
✓
Benner's model
Kubler-Ross model
Transtheoretical model
Correct Answer
Health belief model
The health belief model explains and predicts an individual's health-related behaviors based on their perception of the severity of an illness, susceptibility to the illness, and benefits of/barriers to taking action.
Question 103
Despite multiple attempts at reeducation, a patient who is a fall-risk refuses to stay in bed. The nurse states, "If you don't stay in your bed, I'm going to tie you down!" What type of tort has the nurse committed?
Malpractice
False imprisonment
Battery
Assault
✓
Correct Answer
Assault
Assault is any threat made against a patient that makes them fearful.
Question 104
What is the best way for a nurse to be sure that the patient understands teaching about how to self-administer insulin?
The patient provides a return demonstration
✓
When asked, the patient says they have no questions
The patient explains the procedure to the nurse
The patient took lots of notes
Correct Answer
The patient provides a return demonstration
By performing a return demonstration (i.e., the patient self-administers their next dose as the nurse watches), the patient demonstrates their understanding of the education they received.
Question 105
Which type of communication is characterized by an individual's inner thoughts?
Intrapersonal
✓
Nonverbal
Interpersonal
Small group
Correct Answer
Intrapersonal
Intrapersonal communication is used to describe an individual's inner thoughts. Interpersonal is communication between two people.
Question 106
A nurse performs multiple medication checks to avoid causing a medication error. Which nursing ethical principle is this nurse demonstrating?
Nonmaleficence
✓
Justice
Beneficence
Equity
Correct Answer
Nonmaleficence
By performing multiple medication checks, the nurse seeks to avoid causing harm, which is the ethical principle known as nonmaleficence.
Question 107
A nurse shares protected patient information with their spouse. Under which law can this nurse be fined and prosecuted?
Patients Bill of Rights
Patient Rights Legislation of 1992
Confidentiality and Privacy Act
Health Insurance Portability and Accountability Act
✓
Correct Answer
Health Insurance Portability and Accountability Act
The Health Insurance Portability and Accountability Act (HIPAA) is a law which protects patient health information and describes how this information can be shared with others.
Question 108
When lifting an object, how should the nurse position their feet?
Staggered, with one foot in front
With the toes pointing inward
Shoulder-width apart
✓
At a 90 degree angle
Correct Answer
Shoulder-width apart
A wide base of support (e.g., feet shoulder-width apart) is ideal when lifting an object.
Question 109
What term describes an individual who is appointed to be responsible for a patient's medical decision-making should the patient become incapacitated?
Durable power of attorney (DPOA)
✓
Next of kin
Executor of the will
Living will
Correct Answer
Durable power of attorney (DPOA)
Durable power of attorney (DPOA) is a term used to describe an individual who is appointed to make medical decisions for a patient if they become incapacitated.
Question 110
Which organization establishes the ethical standards for the nursing profession?
American Nurses Credentialing Center
American Nurses Association
✓
National League for Nursing
National Council of State Boards of Nursing
Correct Answer
American Nurses Association
The American Nurses Association is responsible for establishing the ethical standards for the nursing profession.
Question 111
Which legal document defines the nursing scope of practice and governs nursing practice in each state?
American Nurses Association
Scope of practice delineating document
Nursing practice act
✓
National Council of State Boards of Nursing
Correct Answer
Nursing practice act
The nursing practice act is the legal document responsible for defining nursing scope of practice and governing nursing practice in each state.
Question 112
What type of immunity is demonstrated when a patient receives a SARS-CoV-2 vaccine?
Passive natural
Active natural
Passive artificial
Active artificial
✓
Correct Answer
Active artificial
Active artificial immunity occurs when the body creates antibodies after artificial exposure to an antigen, such as with vaccination.
Question 113
What type of immunity is demonstrated when antibodies are passed to a baby in the breast milk?
Active artificial
Passive artificial
Passive natural
✓
Active natural
Correct Answer
Passive natural
Passive natural immunity occurs when antibodies are passed through the placenta or breast milk to the baby.
Question 114
Which position is a patient in if the head of the bed is between a 30-45 degree angle?
Reverse Trendelenburg
Semi-Fowler's
✓
High-Fowler's
Lithotomy
Correct Answer
Semi-Fowler's
Semi-Fowler's is a position where the patient is lying on their back with the head of the bed elevated between 30-45 degrees.
Question 115
In the acute care setting, when does discharge planning begin?
When the discharge order is placed
After transfer from ICU
Upon admission
✓
When evaluated by case management
Correct Answer
Upon admission
Discharge planning should begin for all patients upon admission.
Question 116
During admission, the nurse notes that the patient has difficulty swallowing. Which interdisciplinary team member can evaluate the patient for dysphagia?
Speech language pathologist
✓
Respiratory therapist
Physical therapist
Occupational therapist
Correct Answer
Speech language pathologist
The speech language pathologist assists with swallowing issues.
Question 117
A patient asks the nurse a question about risks associated with their upcoming appendectomy. What action should the nurse take?
Assume the provider will tell the patient more information prior to the procedure
Answer the question to the best of their knowledge
Contact the provider to answer the question for the patient
✓
Tell the patient to ask the doctor after the procedure
Correct Answer
Contact the provider to answer the question for the patient
It is the provider's responsibility to answer the patient's questions about a procedure.
Question 118
A patient's urine is positive for leukocyte esterase and nitrates. What may these findings indicate?
Hematuria
Azotemia
Urinary tract infection
✓
Glomerulonephritis
Correct Answer
Urinary tract infection
A patient with leukocyte esterase and nitrates in their urine may be experiencing a urinary tract infection.
Question 119
Which of the following patients would be most likely to have their wound heal via primary intention?
A patient with a stage III pressure injury
A patient with a cat bite
A patient with a traumatic laceration of the left hand
✓
A patient with a diabetic foot ulcer
Correct Answer
A patient with a traumatic laceration of the left hand
A simple laceration of the hand is most likely to be sutured back together and in most cases will heal via primary intention.
Question 120
A 92 year old female presents to the emergency room with confusion, abdominal pain, and fever. Which order should the nurse anticipate?
Liver function tests
Urinalysis and culture
✓
C-reactive protein
Enema administration
Correct Answer
Urinalysis and culture
An elderly patient with confusion, abdominal pain, and fever may be experiencing a urinary tract infection. Urinalysis and culture are indicated for this patient. Without further assessment findings, LFTs, CRP, and enema administration are unlikely to be ordered.
Question 121
The nurse is caring for a patient with a urine output of 18 mL/hr. What is the nurse's priority action?
Have the patient drink more water
Have the patient ambulate in the halls
Notify the provider
✓
Insert an indwelling urinary catheter
Correct Answer
Notify the provider
The provider should be immediately notified if a patient's urinary output is less than 30 mL/hr.
Question 122
Following a surgical procedure with general anesthesia, when should the patient be allowed to drink water?
Upon arrival to the PACU
2 hours after extubation
After the gag reflex returns
✓
As soon as the patient expresses thirst
Correct Answer
After the gag reflex returns
The nurse should not allow a patient to drink water until their gag reflex has returned.
Question 123
A nurse is caring for a patient receiving total parenteral nutrition. The patient's TPN bag is almost empty and the next one has not been delivered yet. What should the nurse prepare to administer?
Normal saline
Nothing, wait for TPN
10% dextrose in water
✓
3% NaCl
Correct Answer
10% dextrose in water
If TPN is unavailable, 10-20% dextrose in water should be given until it arrives to decrease the risk of hypoglycemia.
Question 124
Prior to transporting the patient from their the room for a procedure, what should the nurse do for a patient on airborne precautions?
Call ahead to have security clear the halls prior to transport
Place an N95 respirator on the patient
Place a surgical mask on the patient
✓
Ensure the patient is wearing a gown, gloves, eyewear, and surgical mask
Correct Answer
Place a surgical mask on the patient
A patient with airborne precautions should wear a surgical mask when leaving the room. An N95 respirator is indicated for those providing care to this patient. There is no need for the patient to wear a gown, gloves, and eyewear, or for security to clear the halls.
Question 125
Which electrolyte imbalance should the nurse expect when caring for a patient with tachycardia, hypertension, and increased deep tendon reflexes?
Hypomagnesemia
✓
Hypermagnesemia
Hyperkalemia
Hypocalcemia
Correct Answer
Hypomagnesemia
Hypomagnesemia is likely to cause a patient to have tachycardia, hypertension, and increased deep tendon reflexes.
Question 126
A patient presents to the emergency room following an overdose on heroin. The patient is receiving mechanical ventilation because they are not breathing spontaneously. Which acid/base imbalance does the nurse anticipate this patient will have?
Metabolic alkalosis
Respiratory acidosis
✓
Respiratory alkalosis
Metabolic acidosis
Correct Answer
Respiratory acidosis
A patient who is not breathing spontaneously will be trapping carbon dioxide, leading to respiratory acidosis.
Question 127
The nurse is caring for a patient who is anxious about an upcoming procedure and is breathing 28 times per minute. The patient reports her lips and fingers are beginning to tingle. Which acid/base imbalance does the nurse suspect?
Respiratory alkalosis
✓
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Correct Answer
Respiratory alkalosis
Hyperventilation due to anxiety can cause the patient to lose too much carbon dioxide, creating a state of respiratory alkalosis.
Question 128
The nurse is caring for a patient who recently lost her husband to cancer. She states that it has been difficult for her to get out of bed recently, and she has had a hard time taking care of her personal hygiene. The nurse expects the patient to be in which stage of grief?
Depression
✓
Anger
Denial
Bargaining
Correct Answer
Depression
The patient is exhibiting signs of the depression stage of grief, including a lack of energy and difficulty performing self-care tasks.
Question 129
In which of the following situations is hand sanitizer permissible for hand hygiene?
Prior to eating lunch
Hands are visibly dirty
After caring for a patient with infectious diarrhea
Leaving a patient's room who is on contact precautions
✓
Correct Answer
Leaving a patient's room who is on contact precautions
The nurse should use soap and water instead of hand sanitizer when hands are visibly dirty, prior to eating, after using the bathroom, and after caring for a patient with infectious diarrhea (e.g., C. diff). Hand sanitizer is permissible for hand hygiene following providing care for a patient on regular contact precautions.
Question 130
The nurse is performing an admission assessment of a patient and discovers what appears to be a pressure injury covered by a large amount of slough. How should this be staged?
Stage II
Stage III
Stage IV
Unstageable
✓
Correct Answer
Unstageable
When the wound bed of the pressure injury is not visible due to slough or eschar, it is considered unstageable. It can be properly staged once it has been appropriately debrided.
Question 131
The nurse is caring for a patient with an area of non-blanchable erythema over their coccyx which is still intact. How should this pressure injury be described?
Unstageable
Stage II
Stage I
✓
Stage III
Correct Answer
Stage I
A stage I pressure injury is an area of intact skin with unblanchable erythema.
Question 132
The nurse is assessing a patient's pressure injury and notes that it is deep, with visible tendon. How should this be staged?
Stage I
Stage III
Stage II
Stage IV
✓
Correct Answer
Stage IV
A pressure injury is considered to be stage IV if muscle, tendon, or bone is visible.
Question 133
What is the nurse's priority action should a chest tube become disconnected from the drainage system?
Remove the chest tube from the patient
Assess the patient's respiratory status
Call the provider
Place the end of the tube in sterile water
✓
Correct Answer
Place the end of the tube in sterile water
Although the nurse should alert the provider and assess the patient's respiratory status, the priority action is to place the end of the tube into sterile water to maintain the water seal and prevent additional complications.
Question 134
The nurse is caring for a patient in a positive air pressure room. What type of isolation precautions does the nurse anticipate this patient is receiving?
Droplet
Reverse isolation
✓
Contact
Airborne
Correct Answer
Reverse isolation
Positive air pressure rooms are indicated for patients who are on reverse (or "protective") isolation. Negative pressure is indicated for airborne precautions.
Question 135
The nurse is showing a student how to use the bladder scanner. Which of the following actions demonstrates that the student has understood the teaching?
Thoroughly dries the skin prior to placing the probe on the patient
Places the probe 1″ above the symphysis pubis, pointing towards the bladder
✓
Asks the patient to bear down prior to measuring the bladder volume
Places the probe below the pubic bone, pointing upward
Correct Answer
Places the probe 1″ above the symphysis pubis, pointing towards the bladder
The bladder scanner probe should be positioned approximately 1″ above the symphysis pubis, pointed towards the bladder. Conductive jelly is needed for the scan, so the skin should not be dried prior to scanning. There is no need to bear down.
Question 136
Which of the following instructions should the nurse provide to a patient who is using a cane for the first time?
Hold the cane on the strong side of your body
✓
Use the cane as a base of support when rising from a seated position
The cane should be at least waist-level height
Move the cane first, then bring your feet up to meet it
Correct Answer
Hold the cane on the strong side of your body
The nurse should educate the patient to hold the cane on the strong side of their body. The other statements are incorrect, and could cause injury to the patient.
Question 137
A patient reports to the nurse that they've been working with "someone who's helping me learn how to write my name again after my stroke." Which interdisciplinary team member does the nurse anticipate has been working with this patient?
Physical therapist
Occupational therapist
✓
Speech language pathologist
Play therapist
Correct Answer
Occupational therapist
An occupational therapist is responsible for helping the patient maintain and improve their ability to perform activities of daily living, such as writing with a pen.
Question 138
Following insertion of an NG tube, what action should the nurse take first?
Request an order for an x-ray to confirm placement
✓
Connect the tube to low-intermittent wall suction
Begin tube feeds per order
Flush the tube with 30 mL sterile water
Correct Answer
Request an order for an x-ray to confirm placement
Prior to using the NG tube in any way, the nurse should request an order for an abdominal x-ray to confirm placement.
Question 139
A nurse is providing teaching to a patient who will be receiving brachytherapy. The patient asks if they can have visitors. What is the best response from the nurse?
No, due to the type of therapy nobody can visit
Yes, but they are limited to 30 minute visits
✓
Yes, there are no restrictions on visitors
Yes, but they are only allowed to visit for an hour at a time
Correct Answer
Yes, but they are limited to 30 minute visits
A patient receiving brachytherapy can have visitors for ≤ 30 minutes and the visitors must remain > 6 feet away from the patient.
Question 140
A nurse is preparing to reposition a patient in bed. At what height should the nurse position the bed?
Chest level
Waist level
Hip level
✓
Knee level
Correct Answer
Hip level
Hip level is appropriate for repositioning or transferring patients to help prevent back injury.
Question 141
Which of the following patients would receive a black tag during mass casualty triage?
Patient with difficulty breathing
Patient with a GCS of 3
✓
Patient with a sucking chest wound
Patient with a broken arm
Correct Answer
Patient with a GCS of 3
Because a patient with a GCS of 3 is already dead, or unlikely to survive even with significant medical intervention, they should receive a black (expectant) tag during mass casualty triage.
Question 142
A nurse is doing their annual review of inpatient safety including how to respond to bomb threats. What action is appropriate if the nurse receives a call with a bomb threat?
Ask for their phone number and hang up
Leave the caller on the phone, place the phone down, and wait for authorities
Hang up as quickly as possible
Keep the caller talking
✓
Correct Answer
Keep the caller talking
Do not hang up, keep the caller talking, and write down as much about the call as you can.
Question 143
A nurse is preparing to administer an intravenous medication. The IV pump continues to shut off while the nurse is programming the pump. What is the best action for the nurse to take?
Get a new pump and notify the next nurse which pump works and which is broken
Tag the IV pump and notify the appropriate department
✓
Leave the pump and see if the medication runs
Figure out what is wrong with the electronics and fix the pump
Correct Answer
Tag the IV pump and notify the appropriate department
The best action is to tag the pump as broken and to notify the appropriate department. Do not leave the broken pump in the room as another nurse may try to use it.
Question 144
The nurse is aware that which type of exaggerated spinal curvature is often present in older adults?
Thoracic kyphosis
✓
Sacral kyphosis
Cervical lordosis
Lumbar lordosis
Correct Answer
Thoracic kyphosis
Thoracic kyphosis, an exaggerated "humpback," is often present in older adults.
Question 145
An older adult appears fearful of the visitor present at the bedside and flinches whenever the visitor moves. What is the nurse's priority action?
Report the concern for abuse
✓
Document the interaction in the patient's chart
Interview the visitor and the patient separately
Notify the provider
Correct Answer
Report the concern for abuse
The nurse should immediately report any concern for abuse of a vulnerable adult.
Question 146
In the chain of infection, which term is used to describe where the infectious agent lives and multiplies?
Agent
Reservoir
✓
Portal of entry
Susceptible host
Correct Answer
Reservoir
In the chain of infection, the reservoir is the term used to describe where the infectious agent lives and multiplies.
Question 147
Which type of elder abuse is characterized by a failure of a caretaker to provide for basic needs (e.g., medical care, nutrition, hygiene)?
Neglect
✓
Financial abuse
Sexual abuse
Physical abuse
Correct Answer
Neglect
Neglect is the failure to provide for basic needs.
Question 148
Despite a patient stating that they don't want an IV, the nurse holds them down and attempts to start an IV, causing a large hematoma. Which type of tort has the nurse committed?
False imprisonment
Battery
✓
Negligence
Assault
Correct Answer
Battery
Battery is any touching of a patient without their consent which causes harm.
Question 149
A patient states they wish to leave against medical advice and the nurse locks them in their room. Which type of tort has the nurse committed?
Battery
Negligence
False imprisonment
✓
Assault
Correct Answer
False imprisonment
Preventing a patient from leaving is an intentional tort known as "false imprisonment."
Question 150
When caring for a geriatric patient, which vital sign alteration does the nurse anticipate?
Narrow pulse pressure
Tachycardia
Hyperventilation
Systolic hypertension
✓
Correct Answer
Systolic hypertension
It is normal for an older adult to have an elevated systolic blood pressure. The other alterations in vital signs are unexpected.
Question 151
A 4-year-old patient makes a decision in order to get a reward. The nurse understands this is which stage of Kohlberg's theory of moral development?
Conventional
Postconventional
Periconvential
Preconventional
✓
Correct Answer
Preconventional
Preconventional is typical of age 5 years and younger. In this stage, decisions are made to avoid consequences or to get rewarded.
Question 152
Which of the following findings should the nurse report to the provider when assessing a patient's stoma?
Stoma is red
Stoma is pale
✓
Ileostomy bag contains liquid output
Stoma is moist
Correct Answer
Stoma is pale
A pink/red moist stoma is expected, along with liquid output from an ileostomy. The nurse should report any signs of ischemia, including pallor or cyanosis.
Question 153
A patient asks their nurse if the shot they are going to receive will hurt. The nurse tells the truth by stating, "'You may feel a quick pinch." Which ethical principle is this nurse following?
Justice
Veracity
✓
Autonomy
Nonmaleficence
Correct Answer
Veracity
Veracity means to tell the truth, which the nurse does by stating the shot may hurt.
Question 154
A patient states they are planning to quit smoking within the next three months. Which stage are they in according to the transtheoretical model?
Preparation
Precontemplation
Termination
Contemplation
✓
Correct Answer
Contemplation
The contemplation stage occurs when a person is thinking of making a change within six months.
Question 155
Which of the following patients should the nurse assess first?
Patient with inspiratory stridor
✓
Patient with new onset chest pain
A patient with a GCS of 13 following a car accident
Patient with severe abdominal pain
Correct Answer
Patient with inspiratory stridor
The patient with inspiratory stridor is experiencing a threat to their airway and breathing and should be assessed first.