Sierra Colvin 12/8/2020
1. The nurse observes that a client received pain medication 1 hour ago from another nurse, but
the client still has severe pain. The nurse has previously observed this same occurrence several
times. Based on the nurse practice act, the observing nurse should plan to take which action?
1. Report the information to the police.
2. Call the impaired nurse organization.
3. Talk with the nurse who gave the medication.
4. Report the information to a nursing supervisor.
2. A client has died, and the nurse asks a family member about the funeral arrangements. The
family member refuses to discuss the issue. Which is the appropriate nursing action?
1. Show acceptance of feelings.
2. Provide information needed for decision making.
3. Suggest a referral to a mental health professional.
4. Remain with the family member without discussing funeral arrangements.
3. An older woman is brought to the emergency department. When caring for the client, the nurse
notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks
the client how the bruises were sustained. The client, although reluctant, tells the nurse in
confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate
nursing response?
1. "I have a legal obligation to report this type of abuse."
2. "I promise I won't tell anyone, but let's see what we can do about this."
3. "Let's talk about ways that will prevent your daughter from hitting you."
4. “This should not be happening. If it happens again, you must call the emergency
department."
4. The nurse employed in an emergency department is assigned to assist with the triage of clients
arriving to the emergency department. The nurse should assign priority to which client?
1. A client complaining of muscle ache, headache, and malaise
2. A client who twisted their ankle when they fell in-line skating
3. A client with a minor laceration on the index finger sustained while
cutting an eggplant
,Sierra Colvin 12/8/2020
4. A client with chest pain who states that they just ate pizza that was made with a very
spicy sauce
5. The nurse is educating a new nurse about mass casualty events (disasters). Which statement by
the new nurse indicates a need for further teaching? Select all that apply.
1. "An event is termed a mass casualty when it overwhelms local medical
capabilities."
2. "Mass casualty events do not require an increase in the number of staff
that are needed."
3. "A mass casualty event occurs only within the heath care facility and
could endanger staff."
4. "Mass casualty events may require the collaboration of many local
agencies to handle the situation."
5. "A mass casualty event occurs if a fight between visitors occurs in the emergency
department."
6. The nurse is attending an agency orientation meeting about the nursing model of practice
implemented in the facility. The nurse is told that the nursing model is a team nursing approach.
The nurse determines that which describes the team-based model of nursing practice?
1. A task approach method is used to provide care to clients.
2. Managed care concepts and tools are used when providing client care.
3. Nursing staff are led by the nurse when providing care to a group of
clients.
4. A single registered nurse is responsible for providing nursing care to a group of clients.
7. A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and
assigns clearly defined tasks to the work group. In this situation, the nurse is implementing
which leadership style?
1. Autocratic
2. Situational
3. Democratic
4. Laissez-faire
8. The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary
responsibility after the delegation of tasks?
, Sierra Colvin 12/8/2020
1. Document that the task was completed.
2. Assign the tasks that were not completed to the next nursing shift.
3. Allow each staff member to make judgments when performing the tasks.
4. Perform follow-up with each staff member regarding the performance and outcome of the
task.
9. The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding
should the nurse expect to note as a result of this long-term use?
1. Gurgling respirations
2. Increased blood pressure
3. Decreased hematocrit level
4. Increased specific gravity of the urine
10. The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which
sign/symptom would be an indication of this electrolyte imbalance?
1. Twitching
2. Positive Trousseau's sign
3. Hyperactive bowel sounds
4. Generalized muscle weakness
11. The nurse is caring for a client with hyperparathyroidism and notes that the client's serum
calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to
assist in administering to the client?
1. Calcitonin
2. Calcium chloride
3. Calcium gluconate
4. Large doses of vitamin D
12. The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco 2 of 32
mm Hg (32 mm Hg). The nurse determines that these results are indicative of which acid–base
disturbance?
1. Metabolic acidosis
1. The nurse observes that a client received pain medication 1 hour ago from another nurse, but
the client still has severe pain. The nurse has previously observed this same occurrence several
times. Based on the nurse practice act, the observing nurse should plan to take which action?
1. Report the information to the police.
2. Call the impaired nurse organization.
3. Talk with the nurse who gave the medication.
4. Report the information to a nursing supervisor.
2. A client has died, and the nurse asks a family member about the funeral arrangements. The
family member refuses to discuss the issue. Which is the appropriate nursing action?
1. Show acceptance of feelings.
2. Provide information needed for decision making.
3. Suggest a referral to a mental health professional.
4. Remain with the family member without discussing funeral arrangements.
3. An older woman is brought to the emergency department. When caring for the client, the nurse
notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks
the client how the bruises were sustained. The client, although reluctant, tells the nurse in
confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate
nursing response?
1. "I have a legal obligation to report this type of abuse."
2. "I promise I won't tell anyone, but let's see what we can do about this."
3. "Let's talk about ways that will prevent your daughter from hitting you."
4. “This should not be happening. If it happens again, you must call the emergency
department."
4. The nurse employed in an emergency department is assigned to assist with the triage of clients
arriving to the emergency department. The nurse should assign priority to which client?
1. A client complaining of muscle ache, headache, and malaise
2. A client who twisted their ankle when they fell in-line skating
3. A client with a minor laceration on the index finger sustained while
cutting an eggplant
,Sierra Colvin 12/8/2020
4. A client with chest pain who states that they just ate pizza that was made with a very
spicy sauce
5. The nurse is educating a new nurse about mass casualty events (disasters). Which statement by
the new nurse indicates a need for further teaching? Select all that apply.
1. "An event is termed a mass casualty when it overwhelms local medical
capabilities."
2. "Mass casualty events do not require an increase in the number of staff
that are needed."
3. "A mass casualty event occurs only within the heath care facility and
could endanger staff."
4. "Mass casualty events may require the collaboration of many local
agencies to handle the situation."
5. "A mass casualty event occurs if a fight between visitors occurs in the emergency
department."
6. The nurse is attending an agency orientation meeting about the nursing model of practice
implemented in the facility. The nurse is told that the nursing model is a team nursing approach.
The nurse determines that which describes the team-based model of nursing practice?
1. A task approach method is used to provide care to clients.
2. Managed care concepts and tools are used when providing client care.
3. Nursing staff are led by the nurse when providing care to a group of
clients.
4. A single registered nurse is responsible for providing nursing care to a group of clients.
7. A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and
assigns clearly defined tasks to the work group. In this situation, the nurse is implementing
which leadership style?
1. Autocratic
2. Situational
3. Democratic
4. Laissez-faire
8. The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary
responsibility after the delegation of tasks?
, Sierra Colvin 12/8/2020
1. Document that the task was completed.
2. Assign the tasks that were not completed to the next nursing shift.
3. Allow each staff member to make judgments when performing the tasks.
4. Perform follow-up with each staff member regarding the performance and outcome of the
task.
9. The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding
should the nurse expect to note as a result of this long-term use?
1. Gurgling respirations
2. Increased blood pressure
3. Decreased hematocrit level
4. Increased specific gravity of the urine
10. The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which
sign/symptom would be an indication of this electrolyte imbalance?
1. Twitching
2. Positive Trousseau's sign
3. Hyperactive bowel sounds
4. Generalized muscle weakness
11. The nurse is caring for a client with hyperparathyroidism and notes that the client's serum
calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to
assist in administering to the client?
1. Calcitonin
2. Calcium chloride
3. Calcium gluconate
4. Large doses of vitamin D
12. The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco 2 of 32
mm Hg (32 mm Hg). The nurse determines that these results are indicative of which acid–base
disturbance?
1. Metabolic acidosis
