A nurse is creating a discharge plan. Which of the following nursing statements indicates the nurse understands when
discharge planning should be implemented?
"I will begin upon the client's admission to the facility."
A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the
nurse acting as an advocate?
An older adult client who has no family and is uncertain about moving to assisted living
A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following
clients should the nurse assess first?
A client who was admitted for chest pain and is reporting a new onset of indigestion
A nurse in a clinic is caring for a client who reports pain, crepitus and a popping sound in his temporomandibular joint.
Based on these findings, to which of the following providers should the nurse request a referral for the client?
Oral surgeon
A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a
partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6
on a scale of 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding,
dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?
Obtain vital signs for both clients
A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions
by the nurse is considered an indirect nursing care activity?
Assigning tasks to an assistive personnel (AP)
A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse
delegate to the licensed practical nurse (LPN)?
Scheduling a diagnostic study for a client
A nurse is transcribing a client's medication 0.175
ptions and is having difficulty reading a written prescription by the provider. Which of the following nursing actions
should the nurse take?
Contact the provider to clarify the prescription
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following
actions is an example of a violation of confidentiality?
Reporting laboratory findings to a member of the client's family
A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive
devices. The nurse should initiate a referral with which of the following members of the interprofessional health care
team?
Occupational therapist
A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following
activities first in delivering client care using the nursing process?
Collect and organize client data
A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following
physiological changes?
-Decreased gastric motility
-Decreased skin elasticity
-Increased pain threshold
,A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the
following information should the nurse include?
The nurse may serve as a witness to informed consent for organ donation
A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family
asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?
This service began with client's admission to the hospital
A nurse is orienting a newly licensed nurse about receiving telephone prescriptions. Which of the following statements by
the newly licensed nurse should indicate a need for further teaching?
"Telephone prescriptions are transcribed into the nurse's notes."
A nurse is planning the discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at
night. The nurse should plan to consult with which of the following health care team members to help educate the client?
Respiratory therapist
A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury.
Which of the following information should the nurse include in the background segment of SBAR?
Code status
A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do
not want to have the procedure done." Which of the following actions should the nurse take?
Notify the surgeon that the client wishes to withdraw informed consent for the procedure
A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which
task should the nurse take responsibility for completing?
Removing the abdominal dressing
A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The clients
in the nurses assignment are stable. Which of the following legal torts applies to this situation?
Negligence
A nurse is interviewing a female client who is Hispanic. The client's partner answers the questions and states, "She only
speaks a little English." Which of the following actions should the nurse take?
Arrange to complete the assessment with only the client and a translator present
A nurse is reviewing a provider's prescriptions for four clients. Which of the following prescriptions is outside the legal
scope of practice for the nurse?
Insert a tunneled central venous catheter for a client
A nurse intercepts a messenger at the nurses' station who has a flower deliver for a client on the unit. As the nurse accepts
the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the
following responses should the nurse provide?
"It's my responsibility to remind you that we have to respect our clients' privacy."
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
"Information about a client can be disclosed to family members at any time."
A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take
to conduct the assessment.
-Ask the client about having a history of abdominal pain
-Inspect the abdomen for skin integrity
-Auscultate the abdomen for bowel sounds
-Percuss the abdomen in each of the four quadrants
-Palpate the abdomen lightly for tenderness
,A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care
professionals is responsible for obtaining informed consent from the client for the procedure?
Surgeon
A nurse is admitting a client who is arriving back to the unit from the PACU following hip arthroplasty. Which of the
following tasks should the nurse assign to the assistive personnel (AP)?
Record the amount of urine in the catheter drainage bag
A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability
insurance. Which of the following statements should the preceptor make?
"Personal liability coverage is not mandatory, but you should consider purchasing your own coverage."
An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be
designated as a "do not resuscitate" (DNR) case. Which of the following responses should the nurse provide?
"Your provider needs to talk with you concerning your request."
A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that
the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident
report because no harm came to the client. Which of the following ethical principles did the nurse violate?
Veracity
A nurse is preparing an educational program for a group of newly licensed nurses about client confidentiality. The nurse
should explain that nurses may share a client's protected health information with which of the following groups?
Health care team members caring for the client
A nurse is completing the initial assessment and history of a client. Which of the following is the priority action for the
nurse to take?
Document the client's allergies in the electronic medical record
A nurse is caring for a client who has schizophrenia and is having difficulty with performing ADLs. The nurse should
consult with which of the following members of the interdisciplinary team to assist the client?
Occupational therapist
A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should
the nurse take regarding informed consent?
Witness the client's signature
A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice.
The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the
hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?
False imprisonment
A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should
recognize that the float nurse is most qualified to care for which of the following clients?
A client who is postoperative following a lobectomy and has a chest tube
A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of
the following actions is the nurse's priority?
Schedule a follow-up visit by a home health nurse for dressing changes
A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to
the charge nurse. The nurse is using which level of communication at this time?
Interpersonal
, A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task
performance roles that members of the group or the leader must perform?
-Coordinator
-Evaluator
-Energizer
A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside
commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse
committed?
Negligence
A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes
client confidentiality?
Sharing computer passwords with coworkers
A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive
personnel (AP).
-Bathe a client who had an amputation 2 days ago
-Assist a client to ambulate using a gait belt
-Feed a client who had a stroke 3 months ago
A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to
take first?
Suction the tracheostomy of a client who has copious secretions
A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of
protecting the client and supporting the client's decisions?
Advocate
A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker?
-A client who requires placement in an assisted living facility
-A client who requests to secure an emergency notification system in the home
-A client who requests to get school assignments while hospitalized on a pediatric unit
A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs
the client's hospitalization. The client could rightfully sue the nurse for which of the following?
Malpractice
A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record.
Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?
Documentation is a communication tool for the inter professional health care team
A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following
statements by the student indicates understanding of the discussion?
Consensus evolves in this stage
A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following
clients should the nurse assign to the room closest to the nurses' station?
A client who sustained a head injury and is having periods of confusion
A nurse is teaching a newly licensed nurse about transcribing prescriptions. Which of the following examples should the
nurse include in the instructions?
Metformin 500mg, 1 tablet, PO, daily
discharge planning should be implemented?
"I will begin upon the client's admission to the facility."
A nurse on a medical unit is planning care for several clients. Which of the following clients should benefit most from the
nurse acting as an advocate?
An older adult client who has no family and is uncertain about moving to assisted living
A nurse has received change-of-shift report on a group of clients and is preparing her assignment. Which of the following
clients should the nurse assess first?
A client who was admitted for chest pain and is reporting a new onset of indigestion
A nurse in a clinic is caring for a client who reports pain, crepitus and a popping sound in his temporomandibular joint.
Based on these findings, to which of the following providers should the nurse request a referral for the client?
Oral surgeon
A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a
partial bowel resection, requires a dressing change, total parenteral nutrition administration and reports a pain level of 6
on a scale of 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding,
dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?
Obtain vital signs for both clients
A nurse is implementing direct nursing care for a group of clients in an acute care facility. Which of the following actions
by the nurse is considered an indirect nursing care activity?
Assigning tasks to an assistive personnel (AP)
A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse
delegate to the licensed practical nurse (LPN)?
Scheduling a diagnostic study for a client
A nurse is transcribing a client's medication 0.175
ptions and is having difficulty reading a written prescription by the provider. Which of the following nursing actions
should the nurse take?
Contact the provider to clarify the prescription
A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following
actions is an example of a violation of confidentiality?
Reporting laboratory findings to a member of the client's family
A nurse is caring for a client who has rheumatoid arthritis and is experiencing difficulty feeding herself using adaptive
devices. The nurse should initiate a referral with which of the following members of the interprofessional health care
team?
Occupational therapist
A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following
activities first in delivering client care using the nursing process?
Collect and organize client data
A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following
physiological changes?
-Decreased gastric motility
-Decreased skin elasticity
-Increased pain threshold
,A nurse is preparing an educational presentation about organ donation for a group of newly licensed nurses. Which of the
following information should the nurse include?
The nurse may serve as a witness to informed consent for organ donation
A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family
asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?
This service began with client's admission to the hospital
A nurse is orienting a newly licensed nurse about receiving telephone prescriptions. Which of the following statements by
the newly licensed nurse should indicate a need for further teaching?
"Telephone prescriptions are transcribed into the nurse's notes."
A nurse is planning the discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at
night. The nurse should plan to consult with which of the following health care team members to help educate the client?
Respiratory therapist
A nurse is giving change-of-shift report using SBAR to the oncoming nurse on a client who has a traumatic brain injury.
Which of the following information should the nurse include in the background segment of SBAR?
Code status
A nurse has completed an informed consent form with a client. The client then states, "I have changed my mind and do
not want to have the procedure done." Which of the following actions should the nurse take?
Notify the surgeon that the client wishes to withdraw informed consent for the procedure
A nurse is working with an assistive personnel (AP) while caring for a surgical client who is 1 day postoperative. Which
task should the nurse take responsibility for completing?
Removing the abdominal dressing
A nurse plans to leave her scheduled shift an hour early without permission or notification of the charge nurse. The clients
in the nurses assignment are stable. Which of the following legal torts applies to this situation?
Negligence
A nurse is interviewing a female client who is Hispanic. The client's partner answers the questions and states, "She only
speaks a little English." Which of the following actions should the nurse take?
Arrange to complete the assessment with only the client and a translator present
A nurse is reviewing a provider's prescriptions for four clients. Which of the following prescriptions is outside the legal
scope of practice for the nurse?
Insert a tunneled central venous catheter for a client
A nurse intercepts a messenger at the nurses' station who has a flower deliver for a client on the unit. As the nurse accepts
the flowers, the messenger says, "I know Mrs. Welch from the neighborhood. What happened to her?" Which of the
following responses should the nurse provide?
"It's my responsibility to remind you that we have to respect our clients' privacy."
A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly
licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?
"Information about a client can be disclosed to family members at any time."
A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take
to conduct the assessment.
-Ask the client about having a history of abdominal pain
-Inspect the abdomen for skin integrity
-Auscultate the abdomen for bowel sounds
-Percuss the abdomen in each of the four quadrants
-Palpate the abdomen lightly for tenderness
,A nurse is caring for a client who has a hip fracture that requires surgical repair. Which of the following health care
professionals is responsible for obtaining informed consent from the client for the procedure?
Surgeon
A nurse is admitting a client who is arriving back to the unit from the PACU following hip arthroplasty. Which of the
following tasks should the nurse assign to the assistive personnel (AP)?
Record the amount of urine in the catheter drainage bag
A newly licensed nurse is seeking advice from her preceptor about the need to purchase personal professional liability
insurance. Which of the following statements should the preceptor make?
"Personal liability coverage is not mandatory, but you should consider purchasing your own coverage."
An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be
designated as a "do not resuscitate" (DNR) case. Which of the following responses should the nurse provide?
"Your provider needs to talk with you concerning your request."
A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that
the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident
report because no harm came to the client. Which of the following ethical principles did the nurse violate?
Veracity
A nurse is preparing an educational program for a group of newly licensed nurses about client confidentiality. The nurse
should explain that nurses may share a client's protected health information with which of the following groups?
Health care team members caring for the client
A nurse is completing the initial assessment and history of a client. Which of the following is the priority action for the
nurse to take?
Document the client's allergies in the electronic medical record
A nurse is caring for a client who has schizophrenia and is having difficulty with performing ADLs. The nurse should
consult with which of the following members of the interdisciplinary team to assist the client?
Occupational therapist
A nurse is caring for a client who is scheduled for an elective surgical procedure. Which of the following actions should
the nurse take regarding informed consent?
Witness the client's signature
A nurse is caring for a client who refuses treatment and asks to be discharged from the hospital against medical advice.
The nurse notifies the client's provider, who tells the nurse to restrain the client, if necessary, to keep her from leaving the
hospital. The nurse understands that restraining this client would be considered which type of civil action by the nurse?
False imprisonment
A nurse in the medical-surgical unit is assigning client care to a nurse who is floating from the PACU. The nurse should
recognize that the float nurse is most qualified to care for which of the following clients?
A client who is postoperative following a lobectomy and has a chest tube
A nurse is preparing to discharge a client who has an abdominal wound that is healing by secondary intention. Which of
the following actions is the nurse's priority?
Schedule a follow-up visit by a home health nurse for dressing changes
A nurse receives a client care assignment from the charge nurse that he believes is unfair. The nurse voices his concern to
the charge nurse. The nurse is using which level of communication at this time?
Interpersonal
, A nurse is working with a team of nursing personnel within a facility. Which of the following are necessary task
performance roles that members of the group or the leader must perform?
-Coordinator
-Evaluator
-Energizer
A nurse is providing care to a client who is on strict bed rest following surgery. The nurse assists the patient to the bedside
commode and the client sustains an injury to the operative area. Which of the following types of torts has the nurse
committed?
Negligence
A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes
client confidentiality?
Sharing computer passwords with coworkers
A charge nurse is making client care assignments. Which of the following tasks should the nurse delegate to assistive
personnel (AP).
-Bathe a client who had an amputation 2 days ago
-Assist a client to ambulate using a gait belt
-Feed a client who had a stroke 3 months ago
A nurse is receiving shift report about a group of assigned clients. Which of the following actions should the nurse plan to
take first?
Suction the tracheostomy of a client who has copious secretions
A nurse assumes a variety of roles while working with clients. Which of the following describes the nursing role of
protecting the client and supporting the client's decisions?
Advocate
A nurse is caring for a group of clients. Which of the following clients should the nurse refer to a social worker?
-A client who requires placement in an assisted living facility
-A client who requests to secure an emergency notification system in the home
-A client who requests to get school assignments while hospitalized on a pediatric unit
A nurse accidentally administers the wrong medication to a client, which results in a severe allergic reaction and prolongs
the client's hospitalization. The client could rightfully sue the nurse for which of the following?
Malpractice
A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record.
Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?
Documentation is a communication tool for the inter professional health care team
A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following
statements by the student indicates understanding of the discussion?
Consensus evolves in this stage
A charge nurse is anticipating the admission of four clients and planning their room assignments. Which of the following
clients should the nurse assign to the room closest to the nurses' station?
A client who sustained a head injury and is having periods of confusion
A nurse is teaching a newly licensed nurse about transcribing prescriptions. Which of the following examples should the
nurse include in the instructions?
Metformin 500mg, 1 tablet, PO, daily
