NURS COURSES STUDY GUIDES, EXAM
QUESTIONS AND ANSWERS, TEST BANKS,
AND NURSING SCHOOL RESOURCES
CLIENT CALL LIGHTS
A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and
flooding in collapsed buildings. Multiple victims come to the triage area. Which client would the nurse
care for first?
1. Charred leathery skin over entire back, chest, and legs
2. Client shivering from sitting in water until rescued
3. Diabetic client who was unable to take insulin today
4. High-pitched, crowing inspiratory respirations - answer-4
The charge nurse on a medical-surgical step-down unit is responsible for making assignments. Which
client is most appropriate to assign to a new graduate nurse who is still in orientation?
1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a
diminished pedal pulse
2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102
mm Hg; reports headache and blurred vision
3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago;
unresponsive with right-sided paralysis
,4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes
due to excessive drainage - answer-4
An unaccompanied 16-year-old female comes to the emergency department with severe abdominal pain
and vomiting. The minor has a temperature of 102.2 F (39 C) and a pulse of 120 /min and is lethargic.
The parents are out of town, and no guardians could be reached. How should the care be handled?
1. Administer care until parents or guardians can be reached
2. Keep the minor but without giving care until parents or guardians can be reached
3. Perform a pregnancy test to see if the minor qualifies as an emancipated minor
4. Provide health care and follow-up advice but do not give any direct care - answer-1
A staff nurse automatically takes a lunch break first every day instead of asking other staff nurses about
their preferences. Another nurse would like to take the first lunch break time sometimes. Which is the
best way for the staff nurse to handle the situation initially?
1. Ask the nurse manager to talk to the nurse who takes the first break time
2. Poll the other staff nurses to see what they think about the situation
3. Realize that some matters are not worth bringing up and say nothing
4. Tell the nurse directly of wanting to take the first lunch break sometimes - answer-4
The risk management nurse is reviewing client records. Which nursing intervention could have
contributed to a sentinel event?
1. Administered flumazenil to a client who overdosed on lorazepam
2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
3. Administered warfarin to a client with International Normalized Ratio of 6
4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg - answer-3
pg. 2
,The registered nurse is caring for multiple clients on a busy surgical unit and should delegate which
action to the unlicensed assistive personnel?
1. Assist client, post hip fracture repair, to the bathroom
2. Check the appearance of client's wound
3. If client tolerates oral liquids, discontinue nasogastric tube
4. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L) - answer-1
Which statements related to ethical nursing practices are correct? Select all that apply.
1. Accountability is documenting that the nurse administered the wrong medication
2. Autonomy is informing the client of the decision the family made for the client
3. Confidentiality is respecting a client's request to keep suicidal ideation a secret
4. Justice is providing the same cardiac care to a homeless person as a businessperson 5.Nonmaleficence
is reporting abuse for a client with Alzheimer disease - answer-1,4,5
The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the
nurse to report to the primary health care provider?
1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized
Ratio (INR) of 1.3
2. Client with chronic bronchitis who has a hematocrit of 56% [0.56] and hemoglobin of 19 g/dL
(190 g/L)
3. Client with Clostridium difficile infection who has a white blood cell count of 15,000/mm3 (15 ×
109/L)
4. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL (53 µmol/L) - answer-
1
, It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these
illustrate appropriate delegation instructions for the registered nurse (RN) to give the UAP? Select all
that apply.
1. "Elevate the right leg on two pillows."
2. "Measure client for compression stockings."
3. "Please let me know what the urine looks like."
4. "Tell me what the client eats at lunch."
5. "Verify wrist restraints are on correctly." - answer-1,4
The nurse is leaving at the end of the shift on an elevator crowded with visitors. A health care provider
(HCP) gets on the elevator and asks, "How is my client Mrs. Jones in Room 312 doing?" Which of the
following is the best response to the HCP's question?
1. "I don't know because I am off duty."
2. "Mrs. Jones was fine when I last saw her."
3. "Why don't we step off the elevator and discuss it."
4. "You will have to talk to Nurse Smith, who is her nurse now." - answer-3
The charge nurse supervising a graduate nurse would need to intervene when that nurse violates the
Health Insurance Portability and Accountability Act with which action? Select all that apply.
1. Accesses the medical record of a client not currently assigned, but previously cared for, to assess
client improvement
2. Advises the client transport technician, "This client has fragile bones due to cancer, so move the
client very carefully."
3. Asks a client, "When were you diagnosed with diabetes?" during admission assessment in a
semi- private room with the privacy curtain in place between beds
pg. 4
QUESTIONS AND ANSWERS, TEST BANKS,
AND NURSING SCHOOL RESOURCES
CLIENT CALL LIGHTS
A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and
flooding in collapsed buildings. Multiple victims come to the triage area. Which client would the nurse
care for first?
1. Charred leathery skin over entire back, chest, and legs
2. Client shivering from sitting in water until rescued
3. Diabetic client who was unable to take insulin today
4. High-pitched, crowing inspiratory respirations - answer-4
The charge nurse on a medical-surgical step-down unit is responsible for making assignments. Which
client is most appropriate to assign to a new graduate nurse who is still in orientation?
1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a
diminished pedal pulse
2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102
mm Hg; reports headache and blurred vision
3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago;
unresponsive with right-sided paralysis
,4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes
due to excessive drainage - answer-4
An unaccompanied 16-year-old female comes to the emergency department with severe abdominal pain
and vomiting. The minor has a temperature of 102.2 F (39 C) and a pulse of 120 /min and is lethargic.
The parents are out of town, and no guardians could be reached. How should the care be handled?
1. Administer care until parents or guardians can be reached
2. Keep the minor but without giving care until parents or guardians can be reached
3. Perform a pregnancy test to see if the minor qualifies as an emancipated minor
4. Provide health care and follow-up advice but do not give any direct care - answer-1
A staff nurse automatically takes a lunch break first every day instead of asking other staff nurses about
their preferences. Another nurse would like to take the first lunch break time sometimes. Which is the
best way for the staff nurse to handle the situation initially?
1. Ask the nurse manager to talk to the nurse who takes the first break time
2. Poll the other staff nurses to see what they think about the situation
3. Realize that some matters are not worth bringing up and say nothing
4. Tell the nurse directly of wanting to take the first lunch break sometimes - answer-4
The risk management nurse is reviewing client records. Which nursing intervention could have
contributed to a sentinel event?
1. Administered flumazenil to a client who overdosed on lorazepam
2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
3. Administered warfarin to a client with International Normalized Ratio of 6
4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg - answer-3
pg. 2
,The registered nurse is caring for multiple clients on a busy surgical unit and should delegate which
action to the unlicensed assistive personnel?
1. Assist client, post hip fracture repair, to the bathroom
2. Check the appearance of client's wound
3. If client tolerates oral liquids, discontinue nasogastric tube
4. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L) - answer-1
Which statements related to ethical nursing practices are correct? Select all that apply.
1. Accountability is documenting that the nurse administered the wrong medication
2. Autonomy is informing the client of the decision the family made for the client
3. Confidentiality is respecting a client's request to keep suicidal ideation a secret
4. Justice is providing the same cardiac care to a homeless person as a businessperson 5.Nonmaleficence
is reporting abuse for a client with Alzheimer disease - answer-1,4,5
The nurse reviews the laboratory results for 4 assigned clients. Which result is most important for the
nurse to report to the primary health care provider?
1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized
Ratio (INR) of 1.3
2. Client with chronic bronchitis who has a hematocrit of 56% [0.56] and hemoglobin of 19 g/dL
(190 g/L)
3. Client with Clostridium difficile infection who has a white blood cell count of 15,000/mm3 (15 ×
109/L)
4. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL (53 µmol/L) - answer-
1
, It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these
illustrate appropriate delegation instructions for the registered nurse (RN) to give the UAP? Select all
that apply.
1. "Elevate the right leg on two pillows."
2. "Measure client for compression stockings."
3. "Please let me know what the urine looks like."
4. "Tell me what the client eats at lunch."
5. "Verify wrist restraints are on correctly." - answer-1,4
The nurse is leaving at the end of the shift on an elevator crowded with visitors. A health care provider
(HCP) gets on the elevator and asks, "How is my client Mrs. Jones in Room 312 doing?" Which of the
following is the best response to the HCP's question?
1. "I don't know because I am off duty."
2. "Mrs. Jones was fine when I last saw her."
3. "Why don't we step off the elevator and discuss it."
4. "You will have to talk to Nurse Smith, who is her nurse now." - answer-3
The charge nurse supervising a graduate nurse would need to intervene when that nurse violates the
Health Insurance Portability and Accountability Act with which action? Select all that apply.
1. Accesses the medical record of a client not currently assigned, but previously cared for, to assess
client improvement
2. Advises the client transport technician, "This client has fragile bones due to cancer, so move the
client very carefully."
3. Asks a client, "When were you diagnosed with diabetes?" during admission assessment in a
semi- private room with the privacy curtain in place between beds
pg. 4
