NURS EXAM QUESTIONS WITH CORRECT
ANSWERS
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 semiprivate room with the privacy curtain in place
between beds
4. Interprets the results of a client's diagnostic testing to the unit clerk
5. Writes a client's last name and room number on a whiteboard hanging in
the nurse's station on which scheduled procedures are logged - answer-1,2,4
The registered nurse is working with a licensed vocational nurse and unlicensed
assistive personnel. A client has just returned to the cardiac unit after having a
percutaneous coronary intervention. Which actions are most appropriate for the
registered nurse to assign to the licensed vocational nurse? Select all that apply.
1. Administer oral pain medication if client reports low back pain
2. Assist the client with the use of a urinal post-procedure
3. Check for bleeding at the catheter insertion site every 15 minutes
4. Perform post-procedure vital sign measurements
Page 1 of 94
,5. Review ECG for dysrhythmias - answer-1,3
After receiving the shift report, the nurse should assess which infant first?
1. An infant born 6 hours ago after 38 weeks gestation who has a respiratory
rate of 52/min
2. An infant born 12 hours ago who is jittery and has a blood glucose level
of 40 mg/dL (2.2 mmol/L)
3. An infant with bilateral crackles who was delivered vaginally 30 minutes
ago
4. An infant wrapped in a warm blanket 15 minutes ago due to a
temperature of 97.7 F (36.5 C) -
answer-2
A nurse notices that a client who is 1-day postoperative knee replacement
surgery has a cool numb foot with a weak peripheral pulse. The nurse pages and
asks the health care provider (HCP) to come see the client. The HCP states that
the client's foot has been like that since surgery and that there is no need to
come. Under the Team Strategies and Tools to Enhance Performance and
Patient Safety (TeamSTEPPS) process, what step should the nurse take next?
1. Continue to assess the foot hourly
2. Document the HCP's statement
3. Elevate the affected leg on a pillow
4. Repeat request for HCP to come - answer-4
Page 2 of 94
,Four clients come to the emergency department (ED). Which client should the
triage registered nurse (RN) assign as highest priority for definitive diagnosis
and treatment?
1. Client with chronic obstructive pulmonary disease (COPD) with yellow
expectoration and an oxygen saturation of 91%
2. Healthy child with new-onset fiery-red rash on cheeks and the "flu"
3. Middle-aged client with vaginal itching and white, curdlike discharge
4. Unconscious elderly client who smells of alcohol and has fresh vomit on
the face - answer-4
The nurse is working in a busy emergency department and is assigned 4 clients.
Which client should the nurse see first?
1. Client receiving cyclophosphamide reporting bloody urine
2. Client who reports severe nausea and vomiting after chemotherapy
3. Client with an elbow abrasion and a lip laceration possibly requiring
sutures
4. Homeless client who appears drowsy with a temperature of 95 F (35 C) -
answer-4
Which of these tasks are appropriate for the registered nurse (RN) to delegate to
unlicensed assistive personnel (UAP)? Select all that apply.
1. Assign lunch times to the other UAP on the unit
2. Assist a client with a new ostomy with bathing and changing pouches
3. Collect vital signs on a client 4 hours after laparoscopic appendectomy
Page 3 of 94
, 4. Pick up an intravenous antibiotic from the pharmacy
5. Record intake and output for a client with metabolic alkalosis - answer-
3,4,5
The nurse on a medical unit is preparing to assess assigned clients after
receiving change of shift report. Which client should the nurse assess first?
1. Client with Grave's disease and heart rate of 110/min
2. Client with pneumonia on day 3 of antibiotics needs a new IV line
3. Client with sickle cell disease who rates pain as 9 on a scale of 0-10
4. Client with type 2 diabetes and fingerstick glucose level of 220 mg/dL
(12.2 mmol/L) - answer-3
A client with terminal cancer has named the sister as the durable power of
attorney for health care (health care proxy). The client arrives unconscious at
the emergency department with a heart rate of 20/min. The client's spouse and
sister are present. How should the caregiving be handled?
1. Ask the spouse what should be done
2. Get directions about care from the sister
3. Immediately administer epinephrine
4. Provide only comfort measures - answer-2
Client call lights
Page 4 of 94
ANSWERS
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 semiprivate room with the privacy curtain in place
between beds
4. Interprets the results of a client's diagnostic testing to the unit clerk
5. Writes a client's last name and room number on a whiteboard hanging in
the nurse's station on which scheduled procedures are logged - answer-1,2,4
The registered nurse is working with a licensed vocational nurse and unlicensed
assistive personnel. A client has just returned to the cardiac unit after having a
percutaneous coronary intervention. Which actions are most appropriate for the
registered nurse to assign to the licensed vocational nurse? Select all that apply.
1. Administer oral pain medication if client reports low back pain
2. Assist the client with the use of a urinal post-procedure
3. Check for bleeding at the catheter insertion site every 15 minutes
4. Perform post-procedure vital sign measurements
Page 1 of 94
,5. Review ECG for dysrhythmias - answer-1,3
After receiving the shift report, the nurse should assess which infant first?
1. An infant born 6 hours ago after 38 weeks gestation who has a respiratory
rate of 52/min
2. An infant born 12 hours ago who is jittery and has a blood glucose level
of 40 mg/dL (2.2 mmol/L)
3. An infant with bilateral crackles who was delivered vaginally 30 minutes
ago
4. An infant wrapped in a warm blanket 15 minutes ago due to a
temperature of 97.7 F (36.5 C) -
answer-2
A nurse notices that a client who is 1-day postoperative knee replacement
surgery has a cool numb foot with a weak peripheral pulse. The nurse pages and
asks the health care provider (HCP) to come see the client. The HCP states that
the client's foot has been like that since surgery and that there is no need to
come. Under the Team Strategies and Tools to Enhance Performance and
Patient Safety (TeamSTEPPS) process, what step should the nurse take next?
1. Continue to assess the foot hourly
2. Document the HCP's statement
3. Elevate the affected leg on a pillow
4. Repeat request for HCP to come - answer-4
Page 2 of 94
,Four clients come to the emergency department (ED). Which client should the
triage registered nurse (RN) assign as highest priority for definitive diagnosis
and treatment?
1. Client with chronic obstructive pulmonary disease (COPD) with yellow
expectoration and an oxygen saturation of 91%
2. Healthy child with new-onset fiery-red rash on cheeks and the "flu"
3. Middle-aged client with vaginal itching and white, curdlike discharge
4. Unconscious elderly client who smells of alcohol and has fresh vomit on
the face - answer-4
The nurse is working in a busy emergency department and is assigned 4 clients.
Which client should the nurse see first?
1. Client receiving cyclophosphamide reporting bloody urine
2. Client who reports severe nausea and vomiting after chemotherapy
3. Client with an elbow abrasion and a lip laceration possibly requiring
sutures
4. Homeless client who appears drowsy with a temperature of 95 F (35 C) -
answer-4
Which of these tasks are appropriate for the registered nurse (RN) to delegate to
unlicensed assistive personnel (UAP)? Select all that apply.
1. Assign lunch times to the other UAP on the unit
2. Assist a client with a new ostomy with bathing and changing pouches
3. Collect vital signs on a client 4 hours after laparoscopic appendectomy
Page 3 of 94
, 4. Pick up an intravenous antibiotic from the pharmacy
5. Record intake and output for a client with metabolic alkalosis - answer-
3,4,5
The nurse on a medical unit is preparing to assess assigned clients after
receiving change of shift report. Which client should the nurse assess first?
1. Client with Grave's disease and heart rate of 110/min
2. Client with pneumonia on day 3 of antibiotics needs a new IV line
3. Client with sickle cell disease who rates pain as 9 on a scale of 0-10
4. Client with type 2 diabetes and fingerstick glucose level of 220 mg/dL
(12.2 mmol/L) - answer-3
A client with terminal cancer has named the sister as the durable power of
attorney for health care (health care proxy). The client arrives unconscious at
the emergency department with a heart rate of 20/min. The client's spouse and
sister are present. How should the caregiving be handled?
1. Ask the spouse what should be done
2. Get directions about care from the sister
3. Immediately administer epinephrine
4. Provide only comfort measures - answer-2
Client call lights
Page 4 of 94
