PN1 FINAL EXAM (REALLL)
1. Which dietary adjustments does the nurse recommend to an older adult client asking what changes she
should institute to prevent or manage constipation?
A. Increase your calcium intake
B. Limit your fluid intake
C. Include plenty of fiber
D. Take a laxative with every meal
ANS: C. Rationale: Older adults are prone to constipation. To manage or prevent constipation, teach the older
client to drink eight glasses of water daily and to take in plenty of fiber. These guidelines are good for other
clients as well. The other suggestions will not prevent or help manage constipation
2. The strategy to avoid medication errors endorsed by the Institute for Safe Medication Practices (ISMP)
to differentiate products with look- alike names is referred to as
A. computer order
B. Tallman Lettering
C. Bar coding
D. Automatic alerts
ANS: B. Rationale: Tallman lettering is a term coined by ISMP to describe the practice of using unique letter
characteristics of similar drug names known to have been confused with one another. Tallman lettering is used
to differentiate products with look-alike names such as BenaDRYL (antihistamine) and BenaZEPRIL (ace
inhibitor). The other options are examples of safety-enhancing technologies strategies designed to minimize
drug errors, but they are not directed at look-alike medications. Automatic alerts are computer-generated alarms
that can be programmed to occur with such things as allergies and incompatible medications. Bar coding is used
with medication administration systems that can be programmed to match patient identification bracelets with
documentation. Computer order entry systems are designed to include components of a standard medication
order.
3. A home care nurse receives a physician order for a medication that the patient does not want to take
because the patient has a history of side effects from this medication. The nurse carefully listens to the
patient, considers it in light of the patient's condition, questions its appropriateness, and examines
alternative treatments. This nurse would most likely
Call the physician, explain the rationale, and suggest a different medication.
Rationale: Determining how best to proceed on behalf of a patient's best health care outcomes may require
clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities
have been examined. A home care nurse who is using good clinical judgment techniques should have
confidence in their decision and may not have another nurse available as this is an autonomous setting. Holding
the drug might jeopardize the patient's health, so this is not the best solution. The nurse working at this level of
critical thinking makes choices based on careful examination of situations and alternatives; whether or not the
physician is open to nursing input is not relevant.
4. A nurse is caring for a client with stress incontinence. The nurse knows that which effect could have led
to such a condition?
A. Loss of muscle tone
B. Reduce bladder capacity
C. Decreased urine formation
D. Reduction renal blood flow
ANS: A. Rationale: The nurse should know that the loss of muscle tone leads to stress incontinence in the
elderly. The bladder muscles become weak, which also leads to urinary retention and dribbling as stress
incontinence. Reduced bladder capacity, decreased urine formation, and reduced renal blood flow are common
problems associated with the urinary system as a result of advanced age, but they do not specifically lead to
stress incontinence.
,5. A client will be undergoing palliative surgery. The client’s daughter asks what this means. What is the
nurse’s best response?
“The surgery will relieve the symptoms but will not cure your father.”
Rationale: The purpose of palliative surgery is to improve the client’s quality of life by reducing or eliminating
distressing symptoms. It does not cure a health problem and often does not prolong life.
6. The nursery nurse identifies a newborn at significant risk for hypothermic alteration in
thermoregulation because the patient is;
A. large for gestational age. C. born at term.
B. low birth weight. D. well nourished.
ANS: B. Rationale: Low birth weight and poorly nourished infants (particularly premature infants) and children
are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant
born at term is not considered at significant risk. A well-nourished infant is not at significant risk.
7. The priority nursing intervention for a patient suspected to be hypothermic would be to:
A. Remove wet clothes
B. assess vital signs.
C. hydrate with intravenous (IV) fluids.
D. provide a warm blanket.
ANS: A. Rationale: The first thing to do with a patient suspected to be hypothermic is to remove wet clothes,
because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet
clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of
dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an
effective warming strategy.
8. The pediatric clinic nurse has just administered a dose of Hemophilus influenzae type B (Hib) vaccine
to a child. The nurse explains to the parents that they can expect which type of local reaction following
the injection?
A. Mild to moderate fever
B. Pain or redness at site
C. Irritability
D. Decreased appetite
ANS: B. Rationale: The parents should be taught to expect pain and redness at the site as possible local
reactions to the Hib vaccine. Fever, irritability, and decreased appetite are common side effects of the
heptavalent pneumococcal conjugate vaccine (PCV).
9. A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the
safest method of transfer, which of the following is most important for the nurse to determine?
A. The type of equipment used in the past
B. The client's current weight-bearing status
C. The client's ability to communicate
D. The clients height
ANS: B. Rationale: This is the most important information the nurse needs to know to identify the safest
method of transfer.
10. A client with tuberculosis asks the nurse if visitors will need to wear masks. What response by the
nurse is most accurate?
A. "Masks would not be necessary for visitors who have had tuberculosis before."
B. "It is less important for your family to wear masks, since they live in close contact with you."
C. "Everyone who enters your room must wear a mask to protect themselves from tuberculosis."
D. "Only visitors who are at risk for tuberculosis need wear a mask."
,ANS: C. Rationale: Tuberculosis is highly contagious and spread by inhalation of airborne droplets. Airborne
precautions would be initiated, requiring everyone to wear a special particulate respirator fit-tested mask.
Individuals who have had tuberculosis in the past can be re-exposed and develop the active form of the disease
again.
11. The nurse is removing personal protective equipment (PPE). Which item should be removed first?
A. Gown
B. Gloves
C. Mask
D. Face shield
ANS: B. Rationale: The gloves are removed first because they are usually the most contaminated PPE and must
be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed
second, then the mask or face shield, and finally, the hair covering.
12. For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the
following signs and symptoms?
A. Flushed skin.
B. Hypertension.
C. Weak, thready pulse.
D. Dry mucous membranes
ANS: B. Rationale: Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with
fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and
flushed skin are both symptomatic of fluid volume deficit, not excess.
13. The nurse is caring for a client in the post-anesthesia care unit (PACU) 2 hours after abdominal
surgery. The nurse auscultates the client’s abdomen and notes that there are no bowel sounds. What
action does the nurse take?
A. Position the client on the left side with the bed flat.
B. Insert a nasogastric tube to low intermittent suction.
C. Palpate the bladder and measure abdominal girth
D. Document the finding and continue to monitor.
ANS: D. Rationale: Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that
should be documented. No intervention specific to this finding is needed at this time.
14. Which of the following is false regarding state licensure laws?
A. These laws establish the requirements for licensure to practice.
B. Licensure is not necessary if the individual has completed training.
C. The state regulatory agencies such as the state board of nursing are responsible
for creating and enforcing these rules.
D. The scope of practice defines what the professional can and cannot do within the
scope of their licensure.
ANS: B. Rationale: Licensure is required to practice after the completion of all required training for the
profession. The state laws establish the requirements to practice and the state regulatory agencies are
responsible for creating and enforcing the rules. The scope of practice defines what activities the professional is
legally authorized to perform.
15. A client enters the emergency department (ED) with an injury to the wrist. In assessment, the nurse
notes that the area is red, warm, and edematous. What is the nurse’s best action?
a. Apply a heating pad to the area.
b. Inject pain medication directly at the site.
c. Start an IV infusion of a vasoconstrictive drug.
d. Assess circulation and elevate the extremity.
, ANS: D. Rationale: Blood flow to the area of injury is increased, causing edema. Edema at the site of injury
protects the area from further injury by creating a cushion. A heating pad would enhance circulation to the area.
Injecting pain medication and starting an IV infusion of a vasoconstricting drug would not be warranted. The
best action is to elevate the extremity after ensuring adequate circulation.
16. The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the
following instructions would be most important for the nurse to include?
A. Be sure to put mittens on the baby.
B. Layer the infants clothing.
C. Place a cap on the infants head.
D. Put warm booties on the baby.
ANS: C. Rationale: All interventions are correct, but because of the many blood vessels close to the skin surface
in the head, infants lose approximately one third of their body heat through the head. Therefore, to prevent heat
loss, it is most important to cover the head.
17. Before the nurse brings the client to the operating room for knee surgery, the client reports to the
nurse that he did not mark the operative knee with the surgeon. What is the priority action of the nurse?
Call the surgeon to mark the site with the client before transfer to the OR.
Rationale: According to The Joint Commission, the surgical site should be marked by both the client and the
surgeon before anesthesia is administered and surgery begins when the surgery involves a specific side.
18. The nurse is working on a plan of care with her patient which includes turning and positioning and
adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize
that this breaks the chain of infection by eliminating a:
A. Host
B. Portal of entry
C. Intact tissue
D. Intact skin
ANS: B. Rationale: Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact
tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is
incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of
transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does
not eliminate the location for pathogens to live and grow.
19. The nurse is identifying diagnoses appropriate for a client scheduled for a surgical procedure. Which
of the following is a diagnosis commonly used for preoperative client?
Anxiety
Rationale: The preoperative experience may be one of the most tension- producing periods of hospitalization.
The nursing diagnosis “anxiety” is commonly used for preoperative clients. The other diagnoses are not
commonly used as preoperative diagnoses.
20. A patient is talking with the nurse about hip fractures. The patient would like to know the best
approach to strengthen the bones. The nurse's best response is which of the following?
A. "Walk at least 5 miles every day for exercise."
B. "Wear proper fitting shoes to prevent tripping."
C. "Talk with your physician about a calcium supplement."
D. "Stand up slowly so you don't feel faint."
ANS: C. Rationale: Calcium strengthens the bones. A calcium supplement will help strengthen bones as they
may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones but a calcium
supplement is a good addition. Wearing proper shoes and standing slowly to prevent dizziness is important but
they will not prevent fractures
1. Which dietary adjustments does the nurse recommend to an older adult client asking what changes she
should institute to prevent or manage constipation?
A. Increase your calcium intake
B. Limit your fluid intake
C. Include plenty of fiber
D. Take a laxative with every meal
ANS: C. Rationale: Older adults are prone to constipation. To manage or prevent constipation, teach the older
client to drink eight glasses of water daily and to take in plenty of fiber. These guidelines are good for other
clients as well. The other suggestions will not prevent or help manage constipation
2. The strategy to avoid medication errors endorsed by the Institute for Safe Medication Practices (ISMP)
to differentiate products with look- alike names is referred to as
A. computer order
B. Tallman Lettering
C. Bar coding
D. Automatic alerts
ANS: B. Rationale: Tallman lettering is a term coined by ISMP to describe the practice of using unique letter
characteristics of similar drug names known to have been confused with one another. Tallman lettering is used
to differentiate products with look-alike names such as BenaDRYL (antihistamine) and BenaZEPRIL (ace
inhibitor). The other options are examples of safety-enhancing technologies strategies designed to minimize
drug errors, but they are not directed at look-alike medications. Automatic alerts are computer-generated alarms
that can be programmed to occur with such things as allergies and incompatible medications. Bar coding is used
with medication administration systems that can be programmed to match patient identification bracelets with
documentation. Computer order entry systems are designed to include components of a standard medication
order.
3. A home care nurse receives a physician order for a medication that the patient does not want to take
because the patient has a history of side effects from this medication. The nurse carefully listens to the
patient, considers it in light of the patient's condition, questions its appropriateness, and examines
alternative treatments. This nurse would most likely
Call the physician, explain the rationale, and suggest a different medication.
Rationale: Determining how best to proceed on behalf of a patient's best health care outcomes may require
clinical judgment. At the committed level of critical thinking, the nurse chooses an action after all possibilities
have been examined. A home care nurse who is using good clinical judgment techniques should have
confidence in their decision and may not have another nurse available as this is an autonomous setting. Holding
the drug might jeopardize the patient's health, so this is not the best solution. The nurse working at this level of
critical thinking makes choices based on careful examination of situations and alternatives; whether or not the
physician is open to nursing input is not relevant.
4. A nurse is caring for a client with stress incontinence. The nurse knows that which effect could have led
to such a condition?
A. Loss of muscle tone
B. Reduce bladder capacity
C. Decreased urine formation
D. Reduction renal blood flow
ANS: A. Rationale: The nurse should know that the loss of muscle tone leads to stress incontinence in the
elderly. The bladder muscles become weak, which also leads to urinary retention and dribbling as stress
incontinence. Reduced bladder capacity, decreased urine formation, and reduced renal blood flow are common
problems associated with the urinary system as a result of advanced age, but they do not specifically lead to
stress incontinence.
,5. A client will be undergoing palliative surgery. The client’s daughter asks what this means. What is the
nurse’s best response?
“The surgery will relieve the symptoms but will not cure your father.”
Rationale: The purpose of palliative surgery is to improve the client’s quality of life by reducing or eliminating
distressing symptoms. It does not cure a health problem and often does not prolong life.
6. The nursery nurse identifies a newborn at significant risk for hypothermic alteration in
thermoregulation because the patient is;
A. large for gestational age. C. born at term.
B. low birth weight. D. well nourished.
ANS: B. Rationale: Low birth weight and poorly nourished infants (particularly premature infants) and children
are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant
born at term is not considered at significant risk. A well-nourished infant is not at significant risk.
7. The priority nursing intervention for a patient suspected to be hypothermic would be to:
A. Remove wet clothes
B. assess vital signs.
C. hydrate with intravenous (IV) fluids.
D. provide a warm blanket.
ANS: A. Rationale: The first thing to do with a patient suspected to be hypothermic is to remove wet clothes,
because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet
clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of
dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an
effective warming strategy.
8. The pediatric clinic nurse has just administered a dose of Hemophilus influenzae type B (Hib) vaccine
to a child. The nurse explains to the parents that they can expect which type of local reaction following
the injection?
A. Mild to moderate fever
B. Pain or redness at site
C. Irritability
D. Decreased appetite
ANS: B. Rationale: The parents should be taught to expect pain and redness at the site as possible local
reactions to the Hib vaccine. Fever, irritability, and decreased appetite are common side effects of the
heptavalent pneumococcal conjugate vaccine (PCV).
9. A nurse is preparing to transfer a client from lying in bed to sitting in a chair. When identifying the
safest method of transfer, which of the following is most important for the nurse to determine?
A. The type of equipment used in the past
B. The client's current weight-bearing status
C. The client's ability to communicate
D. The clients height
ANS: B. Rationale: This is the most important information the nurse needs to know to identify the safest
method of transfer.
10. A client with tuberculosis asks the nurse if visitors will need to wear masks. What response by the
nurse is most accurate?
A. "Masks would not be necessary for visitors who have had tuberculosis before."
B. "It is less important for your family to wear masks, since they live in close contact with you."
C. "Everyone who enters your room must wear a mask to protect themselves from tuberculosis."
D. "Only visitors who are at risk for tuberculosis need wear a mask."
,ANS: C. Rationale: Tuberculosis is highly contagious and spread by inhalation of airborne droplets. Airborne
precautions would be initiated, requiring everyone to wear a special particulate respirator fit-tested mask.
Individuals who have had tuberculosis in the past can be re-exposed and develop the active form of the disease
again.
11. The nurse is removing personal protective equipment (PPE). Which item should be removed first?
A. Gown
B. Gloves
C. Mask
D. Face shield
ANS: B. Rationale: The gloves are removed first because they are usually the most contaminated PPE and must
be removed to avoid contamination of clean areas of the other PPE during their removal. The gown is removed
second, then the mask or face shield, and finally, the hair covering.
12. For a client with a nursing diagnosis of excess fluid volume, the nurse is alert to which one of the
following signs and symptoms?
A. Flushed skin.
B. Hypertension.
C. Weak, thready pulse.
D. Dry mucous membranes
ANS: B. Rationale: Hypertension is a symptom of fluid volume excess. A weak, thready pulse is associated with
fluid volume deficit. A bounding pulse is a symptom of fluid volume excess. Dry mucous membranes and
flushed skin are both symptomatic of fluid volume deficit, not excess.
13. The nurse is caring for a client in the post-anesthesia care unit (PACU) 2 hours after abdominal
surgery. The nurse auscultates the client’s abdomen and notes that there are no bowel sounds. What
action does the nurse take?
A. Position the client on the left side with the bed flat.
B. Insert a nasogastric tube to low intermittent suction.
C. Palpate the bladder and measure abdominal girth
D. Document the finding and continue to monitor.
ANS: D. Rationale: Absence of bowel sounds 2 hours after abdominal surgery is an expected finding that
should be documented. No intervention specific to this finding is needed at this time.
14. Which of the following is false regarding state licensure laws?
A. These laws establish the requirements for licensure to practice.
B. Licensure is not necessary if the individual has completed training.
C. The state regulatory agencies such as the state board of nursing are responsible
for creating and enforcing these rules.
D. The scope of practice defines what the professional can and cannot do within the
scope of their licensure.
ANS: B. Rationale: Licensure is required to practice after the completion of all required training for the
profession. The state laws establish the requirements to practice and the state regulatory agencies are
responsible for creating and enforcing the rules. The scope of practice defines what activities the professional is
legally authorized to perform.
15. A client enters the emergency department (ED) with an injury to the wrist. In assessment, the nurse
notes that the area is red, warm, and edematous. What is the nurse’s best action?
a. Apply a heating pad to the area.
b. Inject pain medication directly at the site.
c. Start an IV infusion of a vasoconstrictive drug.
d. Assess circulation and elevate the extremity.
, ANS: D. Rationale: Blood flow to the area of injury is increased, causing edema. Edema at the site of injury
protects the area from further injury by creating a cushion. A heating pad would enhance circulation to the area.
Injecting pain medication and starting an IV infusion of a vasoconstricting drug would not be warranted. The
best action is to elevate the extremity after ensuring adequate circulation.
16. The nurse is instructing a client how to appropriately dress an infant in cold weather. Which of the
following instructions would be most important for the nurse to include?
A. Be sure to put mittens on the baby.
B. Layer the infants clothing.
C. Place a cap on the infants head.
D. Put warm booties on the baby.
ANS: C. Rationale: All interventions are correct, but because of the many blood vessels close to the skin surface
in the head, infants lose approximately one third of their body heat through the head. Therefore, to prevent heat
loss, it is most important to cover the head.
17. Before the nurse brings the client to the operating room for knee surgery, the client reports to the
nurse that he did not mark the operative knee with the surgeon. What is the priority action of the nurse?
Call the surgeon to mark the site with the client before transfer to the OR.
Rationale: According to The Joint Commission, the surgical site should be marked by both the client and the
surgeon before anesthesia is administered and surgery begins when the surgery involves a specific side.
18. The nurse is working on a plan of care with her patient which includes turning and positioning and
adequate nutrition to help the patient maintain intact skin integrity. The nurse helps the patient to realize
that this breaks the chain of infection by eliminating a:
A. Host
B. Portal of entry
C. Intact tissue
D. Intact skin
ANS: B. Rationale: Broken or impaired skin creates a portal of entry for pathogens. By maintaining intact
tissue, the patient and the nurse have broken the chain of infection by eliminating a portal of entry. Host is
incorrect because you are not eliminating the person or organism. Intact tissue does not eliminate the mode of
transmission. Skin can still be used to transfer pathogens regardless of it being intact or broken. Intact skin does
not eliminate the location for pathogens to live and grow.
19. The nurse is identifying diagnoses appropriate for a client scheduled for a surgical procedure. Which
of the following is a diagnosis commonly used for preoperative client?
Anxiety
Rationale: The preoperative experience may be one of the most tension- producing periods of hospitalization.
The nursing diagnosis “anxiety” is commonly used for preoperative clients. The other diagnoses are not
commonly used as preoperative diagnoses.
20. A patient is talking with the nurse about hip fractures. The patient would like to know the best
approach to strengthen the bones. The nurse's best response is which of the following?
A. "Walk at least 5 miles every day for exercise."
B. "Wear proper fitting shoes to prevent tripping."
C. "Talk with your physician about a calcium supplement."
D. "Stand up slowly so you don't feel faint."
ANS: C. Rationale: Calcium strengthens the bones. A calcium supplement will help strengthen bones as they
may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones but a calcium
supplement is a good addition. Wearing proper shoes and standing slowly to prevent dizziness is important but
they will not prevent fractures
