LEADERSHIP
1. A client is brought to the emergency department following a motor-vehicle crash.
Drug use is suspected in the crash, and a voided urine specimen is ordered. The client
repeatedly refuses to provide the specimen. Which of the following is the appropriate
action by the nurse?
a. Tell the client that a catheter will be inserted.
b. Document the client’s refusal in the chart.
c. Assess the client for urinary retention.
d. Obtain a provider’s prescription for a blood alcohol level.
2. A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
a. Pick up the meal trays after lunch.
b. Administer a nasogastric tube feeding.
c. Plan break times for assistive personnel.
d. Determine adequacy of ventilator settings.
3. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with
a sterile procedure.
Which of the following actions indicates the newly licensed nurse is maintaining sterile
technique? (SATA)
a. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile
field
b. Opens the sterile pack by first unfolding the top flap away from her body
c. Prepares a container of sterile solution on the field after putting on sterile gloves
d. Removes the outside packaging of a sterile instrument before dropping it onto
the sterile field
e. Holds the sterile solution bottle with the label facing up
4. A nurse enters a client’s room and identifies that the client is receiving too much IV
fluid because the IV pump is not working properly. Which of the following actions
should the nurse take first?
Auscultate the client’s lungs.
a. Notify the provider.
b. Place a faulty equipment tag on the pump.
c. Complete an incident report.
5. A nurse is planning care for a group of clients and can delegate care to a licensed
practical nurse (LPN) and assistive personnel. Which of the following tasks should the
nurse assign to the LPN?
a. Reinforcing teaching with a client who is learning to self-administer insulin
b. Ambulating a client who is scheduled for discharge later in the day
c. Administering morphine IV bolus to a client who is __ hr postoperative
d. Admitting a new client who has chronic back pain to the unit
6. A nurse is supervising a newly licensed nurse who is performing surgical asepsis.
After donning a sterile gown and gloves, which of the following actions by the newly
licensed nurse demonstrates correct aseptic technique?
a. The nurse applies goggles.
b. The nurse turns her back to the sterile field.
The nurse holds her hands above her waist.
c. The nurse puts on a face mask.
7. A nurse who is caring for a group of client’s delegates collection of vital signs to an
assistive personnel (AP).
Which of the following actions should the nurse take to evaluate the delegated task?
a. Review vital sign trends at the end of the shift.
, b. Recheck vital signs that are outside the expected reference range.
c. Ask the AP to write a summary of the delegated tasks during the shift.
d. Compare the vital signs the AP obtained with those taken by another AP on a
previous shift.
8. A nurse is caring for four clients. Which of the following tasks can be delegated to
assistive personnel?
a. Obtaining a stool sample from a client who has renal failure
b. Monitoring a client who has a fluid restriction
c. Assessing a client who just returned from hemodialysis
d. Reviewing dietary instructions for a client who has kidney stones
9. A nurse is triaging a group of clients following a disaster. Which of the following
clients should the nurse recommend for treatment first?
a. A client who has a neck injury and is unable to breathe spontaneously
b. A client who has two open chest wounds with a left tracheal deviation
c. A client who has major burns over 75% of her body surface area
d. A client who has bipolar disorder and is exhibiting signs of hallucination (Class
3)
10. A nurse manager is reviewing guidelines for informed consent with the nursing staff.
Which of the following statements by a staff nurse indicates that the teaching was
effective?
a. “A family member can interpret to obtain informed consent from a client who
is deaf.”
b. “Consent can be given by a durable power of attorney.”
c. “Guardian consent is required for an emancipated minor.”
d. “The nurse can answer any questions the client has about the procedure.”
11. A nurse is caring for four clients. For which of the following clients should the nurse
collaborate with the facility ethics committee?
a. A middle adult client who leaves the facility against medical advice
b. An older adult client who has advanced directives on file
c. A young adult client who is participating in a medical research study
d. An adolescent client whose parents refuse a blood transfusion for religious
reasons
12. A nurse in an ambulatory care setting is orient a newly licensed nurse who is
preparing to return a call to a client. The nurse should explain that which of the
following is an objective of telehealth?
a. Assessing client needs
b. Developing client treatment protocols
c. Providing medication reconciliation
d. Establishing communication between providers (Community Health pg.
75)
13. A nurse is providing discharge teaching to a client who has a new diagnosis of
diabetes. The client expresses concern about the cost of blood-glucose monitoring
supplies. Which of the following actions should the nurse take?
a. Refer the client to the social services department.
b. Provide the client with a week’s worth of supplies from the hospital (still needs
help paying after)
c. Ask the provider about the possibility of less frequent monitoring (pt needs to
monitor often)
d. Recommend the client reuse the testing lancets (breaks the safety & infection
protocol)
14. A charge nurse is receiving change-of-shift report. Which of the following situations
should the charge nurse address first?
a. A nurse on the previous shift wrote an incident report about a medication error.
, b. Two staff members have called to say they will be absent.
c. Transport assistance is unavailable to take a client to occupational therapy.
d. The emergency department nurse is waiting to give report on a new
admission.
15. A nurse who is precepting a newly licensed nurse is discussing the client assignment
for the shift. Which of the following actions should the nurse preceptor take first to
demonstrate appropriate time management? a. Complete required tasks.
b. Review the client’s new laboratory values.
c. Determine client care goals (set/plan goals)
d. Document assessment data.
16. A charge nurse is reviewing information about HIPAA with a group of staff nurses.
Which of the following statements by a staff nurse indicates understanding?
a. “Clients who participate in research studies forfeit their HIPAA right to
privacy.”
b. “HIPAA allows facility-specific coding of client health care information to
ensure privacy.”
c. “HIPAA prohibits the uploading of photographs of client’s providers to social
media sites.”
d. “HIPAA allows clients to request a review of their own medical records.”
17. A nurse is caring for a client who has a tumor. The provider recommends surgery.
The client refuses, but the client’s partner wants the surgery performed. Which of the
following is the deciding factor in determining if the surgery will be done?
a. Whether the client understands the risk of refusing the procedure
b. Whether the facility ethics committee reached a consensus on the case
c. Whether the partner is the client’s durable power of attorney for health care
d. Whether the client’s refusal is based on religious belief
18. A charge nurse is planning the care of four newborns. An assistive personnel and
licensed practical nurse are available for staffing. Which of the following tasks
should the nurse assign to a licensed practical nurse?
a. Conduct the newborn hearing screening. (RN assessment)
a. Conduct the newborn hearing screening. (RN assessment)
b. Administer a hepatitis B vaccine.
c. Perform a New Ballard screening. (RN assessment)
d. Obtain vital signs. (CNA)
19. During a staff meeting a unit manager reviews the results for documenting client
education and finds that they are below the benchmark. Which of the following
strategies should the nurse manager implement first?
a. Train LPNs to reinforce teaching with clients using a standardized teaching
plan.
b. Determine factors that interfere with the documentation of client
education.
c. Include documentation of client education as part of unit nurses’ annual
performance evaluation.
d. Offer incentives for the staff once the unit’s results are back in adherence with
the benchmark.
20. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should
explain that preventing client injury by removing a fall hazard demonstrates which of
the following ethical principles?
a. Utility
b. Autonomy
c. Nonmaleficence
d. Veracity
21. A nurse is caring for a group of clients. Which of the following clients should the
nurse plan to assess first?
, a. A client who has congestive heart failure and has lost 0.9 kg (2 lb) in the past
24 hr (improvement)
b. A client who has diabetes mellitus and reports paresthesia in his fingers and
toes (ABC--circulation)
c. A client who has a nasogastric tube and has crackles in the lungs (ABC--
airway)
d. A client who has a new diagnosis of Graves’ disease and a TSH level of 0.2
microunits/mL
22. A charge nurse is planning to evacuate clients on the unit because there is a fire on
another floor. Which of the following clients should the nurse evacuate first?
a. A client who is in Buck’s traction for a left hip fracture (can’t necessarily move
too much)
b. A client who is 1 day postoperative following thoracic surgery and has a chest
tube (possible physical instability)
c. A client who is confused and restrained for safety (still needs continual nursing
care/assessment)
d. A client who is receiving IV chemotherapy and is ambulatory
23. A nurse enters the room of a client who is unconscious and finds that the client’s son
is reading her electronic medical records from a monitor located at the bedside.
Which of the following actions should the nurse take first?
a. Recommend the son meet with the provider to get information about his
mother’s condition.
b. Report the possible violation of client confidentiality to the nurse manager.
c. Complete an incident report regarding the breach of the client’s confidentiality.
d. Log out the computer so that the client’s son is unable to view his mother’s
information.
24. A nurse is preparing a client for cardiac catheterization. Just before the procedure, the
client asks the nurse about the risks of the procedure. Which of the following actions
should the nurse take?
a. Explain the risks of the procedure to the client.
b. Convey the client’s request to the nurse who witnessed the consent.
c. Check to see if the medial record indicates the provider explained the procedure
to the client.
d. Notify the provider about the client’s concerns.
25. A nurse is prioritizing care after receiving change-of-shift report on four clients.
Which of the following clients should the nurse assess first?
a. A client who reports a headache with sensitivity to light
b. A client who reports an urge to void but has not urinated during the prior shift
c. A client who reports indigestion and pain in her jaw
d. A client who reports feeling lightheaded when he stands up from a lying
position
26. A charge nurse notices that two staff nurses are not taking meal breaks during their
shifts. Which of the following actions should the nurse take first?
a. Discuss time management strategies with the nurses.
b. Determine the reasons the nurses are not taking scheduled breaks. Assess first
c. Provide coverage for the nurses’ breaks.
d. Review facility policies for taking scheduled breaks.
27. A nurse is preparing to delegate bathing and turning of a newly admitted client who
has end-stage bone cancer to experienced assistive personnel (AP). Which of the
following assessments should the nurse make before delegating care?
a. Has the AP checked the client’s pain level prior to turning her? (RN only - do
not delegate what you can EAT = evaluate, assess, teach)
can EAT = evaluate, assess, teach)
1. A client is brought to the emergency department following a motor-vehicle crash.
Drug use is suspected in the crash, and a voided urine specimen is ordered. The client
repeatedly refuses to provide the specimen. Which of the following is the appropriate
action by the nurse?
a. Tell the client that a catheter will be inserted.
b. Document the client’s refusal in the chart.
c. Assess the client for urinary retention.
d. Obtain a provider’s prescription for a blood alcohol level.
2. A nurse is making shift assignments in a hospital. Which of the following tasks is
appropriate to assign to a licensed practical nurse?
a. Pick up the meal trays after lunch.
b. Administer a nasogastric tube feeding.
c. Plan break times for assistive personnel.
d. Determine adequacy of ventilator settings.
3. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with
a sterile procedure.
Which of the following actions indicates the newly licensed nurse is maintaining sterile
technique? (SATA)
a. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile
field
b. Opens the sterile pack by first unfolding the top flap away from her body
c. Prepares a container of sterile solution on the field after putting on sterile gloves
d. Removes the outside packaging of a sterile instrument before dropping it onto
the sterile field
e. Holds the sterile solution bottle with the label facing up
4. A nurse enters a client’s room and identifies that the client is receiving too much IV
fluid because the IV pump is not working properly. Which of the following actions
should the nurse take first?
Auscultate the client’s lungs.
a. Notify the provider.
b. Place a faulty equipment tag on the pump.
c. Complete an incident report.
5. A nurse is planning care for a group of clients and can delegate care to a licensed
practical nurse (LPN) and assistive personnel. Which of the following tasks should the
nurse assign to the LPN?
a. Reinforcing teaching with a client who is learning to self-administer insulin
b. Ambulating a client who is scheduled for discharge later in the day
c. Administering morphine IV bolus to a client who is __ hr postoperative
d. Admitting a new client who has chronic back pain to the unit
6. A nurse is supervising a newly licensed nurse who is performing surgical asepsis.
After donning a sterile gown and gloves, which of the following actions by the newly
licensed nurse demonstrates correct aseptic technique?
a. The nurse applies goggles.
b. The nurse turns her back to the sterile field.
The nurse holds her hands above her waist.
c. The nurse puts on a face mask.
7. A nurse who is caring for a group of client’s delegates collection of vital signs to an
assistive personnel (AP).
Which of the following actions should the nurse take to evaluate the delegated task?
a. Review vital sign trends at the end of the shift.
, b. Recheck vital signs that are outside the expected reference range.
c. Ask the AP to write a summary of the delegated tasks during the shift.
d. Compare the vital signs the AP obtained with those taken by another AP on a
previous shift.
8. A nurse is caring for four clients. Which of the following tasks can be delegated to
assistive personnel?
a. Obtaining a stool sample from a client who has renal failure
b. Monitoring a client who has a fluid restriction
c. Assessing a client who just returned from hemodialysis
d. Reviewing dietary instructions for a client who has kidney stones
9. A nurse is triaging a group of clients following a disaster. Which of the following
clients should the nurse recommend for treatment first?
a. A client who has a neck injury and is unable to breathe spontaneously
b. A client who has two open chest wounds with a left tracheal deviation
c. A client who has major burns over 75% of her body surface area
d. A client who has bipolar disorder and is exhibiting signs of hallucination (Class
3)
10. A nurse manager is reviewing guidelines for informed consent with the nursing staff.
Which of the following statements by a staff nurse indicates that the teaching was
effective?
a. “A family member can interpret to obtain informed consent from a client who
is deaf.”
b. “Consent can be given by a durable power of attorney.”
c. “Guardian consent is required for an emancipated minor.”
d. “The nurse can answer any questions the client has about the procedure.”
11. A nurse is caring for four clients. For which of the following clients should the nurse
collaborate with the facility ethics committee?
a. A middle adult client who leaves the facility against medical advice
b. An older adult client who has advanced directives on file
c. A young adult client who is participating in a medical research study
d. An adolescent client whose parents refuse a blood transfusion for religious
reasons
12. A nurse in an ambulatory care setting is orient a newly licensed nurse who is
preparing to return a call to a client. The nurse should explain that which of the
following is an objective of telehealth?
a. Assessing client needs
b. Developing client treatment protocols
c. Providing medication reconciliation
d. Establishing communication between providers (Community Health pg.
75)
13. A nurse is providing discharge teaching to a client who has a new diagnosis of
diabetes. The client expresses concern about the cost of blood-glucose monitoring
supplies. Which of the following actions should the nurse take?
a. Refer the client to the social services department.
b. Provide the client with a week’s worth of supplies from the hospital (still needs
help paying after)
c. Ask the provider about the possibility of less frequent monitoring (pt needs to
monitor often)
d. Recommend the client reuse the testing lancets (breaks the safety & infection
protocol)
14. A charge nurse is receiving change-of-shift report. Which of the following situations
should the charge nurse address first?
a. A nurse on the previous shift wrote an incident report about a medication error.
, b. Two staff members have called to say they will be absent.
c. Transport assistance is unavailable to take a client to occupational therapy.
d. The emergency department nurse is waiting to give report on a new
admission.
15. A nurse who is precepting a newly licensed nurse is discussing the client assignment
for the shift. Which of the following actions should the nurse preceptor take first to
demonstrate appropriate time management? a. Complete required tasks.
b. Review the client’s new laboratory values.
c. Determine client care goals (set/plan goals)
d. Document assessment data.
16. A charge nurse is reviewing information about HIPAA with a group of staff nurses.
Which of the following statements by a staff nurse indicates understanding?
a. “Clients who participate in research studies forfeit their HIPAA right to
privacy.”
b. “HIPAA allows facility-specific coding of client health care information to
ensure privacy.”
c. “HIPAA prohibits the uploading of photographs of client’s providers to social
media sites.”
d. “HIPAA allows clients to request a review of their own medical records.”
17. A nurse is caring for a client who has a tumor. The provider recommends surgery.
The client refuses, but the client’s partner wants the surgery performed. Which of the
following is the deciding factor in determining if the surgery will be done?
a. Whether the client understands the risk of refusing the procedure
b. Whether the facility ethics committee reached a consensus on the case
c. Whether the partner is the client’s durable power of attorney for health care
d. Whether the client’s refusal is based on religious belief
18. A charge nurse is planning the care of four newborns. An assistive personnel and
licensed practical nurse are available for staffing. Which of the following tasks
should the nurse assign to a licensed practical nurse?
a. Conduct the newborn hearing screening. (RN assessment)
a. Conduct the newborn hearing screening. (RN assessment)
b. Administer a hepatitis B vaccine.
c. Perform a New Ballard screening. (RN assessment)
d. Obtain vital signs. (CNA)
19. During a staff meeting a unit manager reviews the results for documenting client
education and finds that they are below the benchmark. Which of the following
strategies should the nurse manager implement first?
a. Train LPNs to reinforce teaching with clients using a standardized teaching
plan.
b. Determine factors that interfere with the documentation of client
education.
c. Include documentation of client education as part of unit nurses’ annual
performance evaluation.
d. Offer incentives for the staff once the unit’s results are back in adherence with
the benchmark.
20. A nurse is explaining ethics and values to a newly licensed nurse. The nurse should
explain that preventing client injury by removing a fall hazard demonstrates which of
the following ethical principles?
a. Utility
b. Autonomy
c. Nonmaleficence
d. Veracity
21. A nurse is caring for a group of clients. Which of the following clients should the
nurse plan to assess first?
, a. A client who has congestive heart failure and has lost 0.9 kg (2 lb) in the past
24 hr (improvement)
b. A client who has diabetes mellitus and reports paresthesia in his fingers and
toes (ABC--circulation)
c. A client who has a nasogastric tube and has crackles in the lungs (ABC--
airway)
d. A client who has a new diagnosis of Graves’ disease and a TSH level of 0.2
microunits/mL
22. A charge nurse is planning to evacuate clients on the unit because there is a fire on
another floor. Which of the following clients should the nurse evacuate first?
a. A client who is in Buck’s traction for a left hip fracture (can’t necessarily move
too much)
b. A client who is 1 day postoperative following thoracic surgery and has a chest
tube (possible physical instability)
c. A client who is confused and restrained for safety (still needs continual nursing
care/assessment)
d. A client who is receiving IV chemotherapy and is ambulatory
23. A nurse enters the room of a client who is unconscious and finds that the client’s son
is reading her electronic medical records from a monitor located at the bedside.
Which of the following actions should the nurse take first?
a. Recommend the son meet with the provider to get information about his
mother’s condition.
b. Report the possible violation of client confidentiality to the nurse manager.
c. Complete an incident report regarding the breach of the client’s confidentiality.
d. Log out the computer so that the client’s son is unable to view his mother’s
information.
24. A nurse is preparing a client for cardiac catheterization. Just before the procedure, the
client asks the nurse about the risks of the procedure. Which of the following actions
should the nurse take?
a. Explain the risks of the procedure to the client.
b. Convey the client’s request to the nurse who witnessed the consent.
c. Check to see if the medial record indicates the provider explained the procedure
to the client.
d. Notify the provider about the client’s concerns.
25. A nurse is prioritizing care after receiving change-of-shift report on four clients.
Which of the following clients should the nurse assess first?
a. A client who reports a headache with sensitivity to light
b. A client who reports an urge to void but has not urinated during the prior shift
c. A client who reports indigestion and pain in her jaw
d. A client who reports feeling lightheaded when he stands up from a lying
position
26. A charge nurse notices that two staff nurses are not taking meal breaks during their
shifts. Which of the following actions should the nurse take first?
a. Discuss time management strategies with the nurses.
b. Determine the reasons the nurses are not taking scheduled breaks. Assess first
c. Provide coverage for the nurses’ breaks.
d. Review facility policies for taking scheduled breaks.
27. A nurse is preparing to delegate bathing and turning of a newly admitted client who
has end-stage bone cancer to experienced assistive personnel (AP). Which of the
following assessments should the nurse make before delegating care?
a. Has the AP checked the client’s pain level prior to turning her? (RN only - do
not delegate what you can EAT = evaluate, assess, teach)
can EAT = evaluate, assess, teach)
