ASSESSMENT LEVEL 1 PROCTORED
EXAM QUESTIONS WITH ACTUAL
ANSWERS
A nurse is caring for a client who is 2 days postoperative following an above-the-knee
amputation. The client states he is experiencing a dull, burning pain in the leg that was
amputated. Which of the following actions should the nurse take to treat the client's
neuropathic pain? - correct answer-Administer a beta-blocking medication to the client.
(The nurse should administer a beta-blocking medication to the client. This classification of
medication has been shown to relieve the phantom limb pain manifestations of constant dull
and burning type pain.)
A newly licensed nurse asks a charge nurse where to find information about scope of practice
for registered nurses. Which of the following responses should the charge nurse make? - correct
answer-"The state board of nursing can provide this information"
(each state develops a nurse practice act, which defines scope of practice for nurses in that
state. This practice act is available on the board of nursing website for each state.)
A nurse is planning care to prevent a catheter-related bloodstream infection for a client who is
receiving IV fluid therapy. Which of the following interventions should the nurse include in the
plan? - correct answer-Perform hand hygiene before touching the IV tubing.
(The nurse should perform thorough hand hygiene before touching any part of the infusion
system or the client to reduce the risk of catheter-related blood stream infections.)
A nurse is creating a plan of care for a client who is non-ambulatory and has bladder and bowel
incontinence. Which of the following interventions should the nurse include to prevent skin
breakdown? - correct answer-Offer the client a glass of water every two hour when
repositioning.
(The nurse should offer the client a glass of water every two hours on the clients repositioning
schedule. This helps prevent dehydration, which increases the risk of skin breakdown.)
,A nurse is teaching a young adult female client about health screening for breast cancer. Which
of the following statements by the client indicates an understanding of breast self-examination
(BSE)? - correct answer-"I should expect to feel a firm ridge along the bottom curve of each
breast."
(The nurse should instruct the client at a firm ridge is expected along the bottom curve of each
breast. The client should be able to feel this area during the BSE. Performing a BSE promotes
breast self awareness so that the client knows how her breast normally feel. The awareness
increases the clients ability to identify changes that require further evaluation.)
A nurse is caring for an adolescent who is in critical condition following a motor vehicle crash
which he was the passenger. The clients parent shout at the nurse, asking why her son is dying
instead of the driver. Which of the following actions should the nurse take to provide emotional
support to the parent? - correct answer-Inform the parent that anger is a natural response
when dealing with loss.
(The nurse should identify that the parent is in the anger stage of grief. The nurse should assist
the parent to understand that anger is a natural response to loss and encourage her to talk
about her feelings.)
Axnursexisxteachingxanxolderxadultxclientxaboutxaccessingxelectronicxresourcesxforxhealthcare
informationxonxthexinternet.xWhichxofxthexfollowingxstatementsxshouldxthexnursexincludexinxthe
teaching?x-xcorrectxanswer-"Websitesxendingxinx'.gov'xarexreliablexsitesxforxobtainingxhealth
informationxfromxgovernmentxagencies."
(Thexnursexshouldxteachxthexclientxhowxtoxselectxreliablexinternetxwebsitesxwhenxresearching
healthxcarexinformation.xThexnursexshouldxidentifyxthatxwebsitesxendingxinx'.gov'xandx'.edu'xare
consideredxreliablexandxcrediblexsourcesxforxhealthxinformation.xWebsitesxendingxinx'.com'
shouldxnotxbexusedxforxresearchingxcrediblexhealthcarexinformation.)
Axnursexentersxaxclientsxroomxandxfindsxthexclientxlyingxonxthexfloor.xThexclientxstatesxthatxonxth
e
wayxtoxthexbathroomxherx"kneexlocked,"xcausingxherxtoxfall.xWhichxofxthexfollowingxactions
shouldxthexnursextakexfirst?x-xcorrectxanswer-Checkxthexclientxforxinjuries.
(Thexfirstxactionxthexnursexshouldxtakexwhenxusingxthexnursingxprocessxisxtoxassessxthexclient.
Thexnursexshouldxfirstxcheckxthexclientxforxinjuriesxandxmeasurexvitalxsignsxtoxhelpxdetermine
physiologicxstability.xThexnursexshouldxalsoxinformxthexproviderxofxthexclientsxfallxandxofxthe
assessmentxfindings.)
,x
Axnursexisxteachingxaxclientxwhoxhasxrheumatoidxarthritisxaboutxchronicxpainxmanagement.
Whichxofxthexfollowingxstatementsxbyxthexclientxindicatesxanxunderstandingxofxthexteaching?x -
correctxanswer-"Ixshouldxusexaxwarmxparaffinxdipxforxmyxhandsxandxfeet."
(Thexnursexshouldxinstructxthexclientxtoxdipxherxhandsxandxfeetxinxwarmxparaffinxtoxalleviatexpai
n
andxstiffness.xThexclientxcanxmorexeasilyxperformxhandxandxfingerxexercisesxfollowingxthe
treatment.)
Axcommunityxhealthxnursexisxplanningxpreventionxstrategiesxforxhypertensionxamongxmembers
ofxherxcommunity.xThexnursexshouldxidentifyxthatxwhichxofxthexfollowingxethnicxgroupsxinxthe
communityxisxatxgreatestxriskxofxdevelopingxhypertension?x-xcorrectxanswer-AfricanxAmerican
(Evidence-basedxpracticexindicatesxthatxindividualsxofxAAxethnicityxhavexthexhighestxprevalence
ofxhypertension.xTherefore,xthexnursexshouldxidentifyxcommunityxmembersxofxthisxethnicityxare
atxgreatestxriskxofxdevelopingxhypertension.)
Axnursexisxpreparingxtoxextinguishxaxsmallxfirexinxaxclientsxroom.xWhichxofxthexfollowingxactions
shouldxthexnursextakexwhenxusingxthexfirexextinguisher?x-xcorrectxanswer-Slidexthexpinxonxtopxof
thexfirexextinguisherxstraightxout.
(Thexnursexshouldxpullxthexpinxonxtopxofxthexfirexextinguisherxtoxallowxforxusextoxextinguishxth
e
fire.)
AxnursexisxpreparingxtoxadministerxintermittentxexternalxnutritionxviaxaxclientsxNGxtube.xInxwhich
orderxshouldxthexnursextakexthexfollowingxactions?x-xcorrectxanswer-1.xAssistxthexclientxtoxan
uprightxposition.
2.xAspiratex5xmLxofxgastricxcontents.
3.xTestxthexpHxofxgastricxaspirate.
4.xMeasurexgastricxresidualxvolume.
5.xFlushxthexNGxtubexwithx30xmLxofxwater.
(First,xthexnursexshouldxassistxthexclientxintoxhighxFowler'sxpositionxorxraisexthexHOBxatxleastx30
degreesxtoxhelpxpreventxaspiration.xThen,xthexnursexshouldxverifyxthextubesxplacementxby
aspiratingx5xmLxofxgastricxcontentsxandxthenxtestingxthexpH.xThen,xthexnursexshouldxcheckxfor
gastricxresidualxvolume.xExcessivexGRVxisxanxindicationxofxdelayedxgastricxemptying,xwhichxplaces
thexclientxatxriskxofxaspirationxifxadditionalxformulaxisxgiven.xFinally,xthexnursexshouldxflushxthe
tubingxwithx30xmLxofxwaterxtoxensurexthextubexisxclearxandxpatent.)