NUR 004 FINAL EXAMS 2023/2024 5
DIFFERENT VERSIONS COMBINED ACCURATE
FOR GUARANTEED PASS ALREADY GRADED A
Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads
a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my
clients." What is the best response by the nurse?
1. "Would you mind answering the lights anyway?"
2. "I need you to answer the lights because we want to provide good client care."
3. Say nothing and answer the lights, but write up a disciplinary action
4. Tell the UAP that this is unacceptable and speak to the nurse manager.
2
The risk management nurse is reviewing client records. Which nursing intervention could have
contributed to a sentinel event?
1. Administered flumazenil to a client who overdosed on lorazepam
2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
3. Administered warfarin to a client with International Normalized Ratio of 6
4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
3
The registered nurse is caring for multiple clients on a busy surgical unit and should delegate
which action to the unlicensed assistive personnel?
1. Assist client, post hip fracture repair, to the bathroom
2. Check the appearance of client's wound
3. If client tolerates oral liquids, discontinue nasogastric tube
4. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L)
1
Which statements related to ethical nursing practices are correct? Select all that apply.
1. Accountability is documenting that the nurse administered the wrong medication
2. Autonomy is informing the client of the decision the family made for the client
3. Confidentiality is respecting a client's request to keep suicidal ideation a secret
4. Justice is providing the same cardiac care to a homeless person as a businessperson
5.Nonmaleficence is reporting abuse for a client with Alzheimer disease
1,4,5
A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting
fires and flooding in collapsed buildings. Multiple victims come to the triage area. Which client
,would the nurse care for first?
1. Charred leathery skin over entire back, chest, and legs
2. Client shivering from sitting in water until rescued
3. Diabetic client who was unable to take insulin today
4. High-pitched, crowing inspiratory respirations
4
The charge nurse on a medical-surgical step-down unit is responsible for making assignments.
Which client is most appropriate to assign to a new graduate nurse who is still in orientation?
1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a
diminished pedal pulse
2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently
180/102 mm Hg; reports headache and blurred vision
3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago;
unresponsive with right-sided paralysis
4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing
changes due to excessive drainage
4
An unaccompanied 16-year-old female comes to the emergency department with severe
abdominal pain and vomiting. The minor has a temperature of 102.2 F (39 C) and a pulse of 120
/min and is lethargic. The parents are out of town, and no guardians could be reached. How
should the care be handled?
1. Administer care until parents or guardians can be reached
2. Keep the minor but without giving care until parents or guardians can be reached
3. Perform a pregnancy test to see if the minor qualifies as an emancipated minor
4. Provide health care and follow-up advice but do not give any direct care
1
A staff nurse automatically takes a lunch break first every day instead of asking other staff nurses
about their preferences. Another nurse would like to take the first lunch break time sometimes.
Which is the best way for the staff nurse to handle the situation initially?
1. Ask the nurse manager to talk to the nurse who takes the first break time
2. Poll the other staff nurses to see what they think about the situation
3. Realize that some matters are not worth bringing up and say nothing
4. Tell the nurse directly of wanting to take the first lunch break sometimes
4
The nurse reviews the laboratory results for 4 assigned clients. Which result is most important
for the nurse to report to the primary health care provider?
1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized
Ratio (INR) of 1.3
2. Client with chronic bronchitis who has a hematocrit of 56% [0.56] and hemoglobin of 19 g/dL
,(190 g/L)
3. Client with Clostridium difficile infection who has a white blood cell count of 15,000/mm3
(15 × 109/L)
4. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL (53 µmol/L)
1
It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of
these illustrate appropriate delegation instructions for the registered nurse (RN) to give the UAP?
Select all that apply.
1. "Elevate the right leg on two pillows."
2. "Measure client for compression stockings."
3. "Please let me know what the urine looks like."
4. "Tell me what the client eats at lunch."
5. "Verify wrist restraints are on correctly."
1,4
The nurse is leaving at the end of the shift on an elevator crowded with visitors. A health care
provider (HCP) gets on the elevator and asks, "How is my client Mrs. Jones in Room 312
doing?" Which of the following is the best response to the HCP's question?
1. "I don't know because I am off duty."
2. "Mrs. Jones was fine when I last saw her."
3. "Why don't we step off the elevator and discuss it."
4. "You will have to talk to Nurse Smith, who is her nurse now."
3
The charge nurse supervising a graduate nurse would need to intervene when that nurse violates
the Health Insurance Portability and Accountability Act with which action? Select all that apply.
1. Accesses the medical record of a client not currently assigned, but previously cared for, to
assess client improvement
2. Advises the client transport technician, "This client has fragile bones due to cancer, so move
the client very carefully."
3. Asks a client, "When were you diagnosed with diabetes?" during admission assessment in a
semi-private room with the privacy curtain in place between beds
4. Interprets the results of a client's diagnostic testing to the unit clerk
5. Writes a client's last name and room number on a whiteboard hanging in the nurse's station on
which scheduled procedures are logged
1,2,4
The registered nurse is working with a licensed vocational nurse and unlicensed assistive
personnel. A client has just returned to the cardiac unit after having a percutaneous coronary
intervention. Which actions are most appropriate for the registered nurse to assign to the licensed
vocational nurse? Select all that apply.
1. Administer oral pain medication if client reports low back pain
, 2. Assist the client with the use of a urinal post-procedure
3. Check for bleeding at the catheter insertion site every 15 minutes
4. Perform post-procedure vital sign measurements
5. Review ECG for dysrhythmias
1,3
After receiving the shift report, the nurse should assess which infant first?
1. An infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min
2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL (2.2
mmol/L)
3. An infant with bilateral crackles who was delivered vaginally 30 minutes ago
4. An infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C)
2
A nurse notices that a client who is 1-day postoperative knee replacement surgery has a cool
numb foot with a weak peripheral pulse. The nurse pages and asks the health care provider
(HCP) to come see the client. The HCP states that the client's foot has been like that since
surgery and that there is no need to come. Under the Team Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS) process, what step should the nurse take next?
1. Continue to assess the foot hourly
2. Document the HCP's statement
3. Elevate the affected leg on a pillow
4. Repeat request for HCP to come
4
Four clients come to the emergency department (ED). Which client should the triage registered
nurse (RN) assign as highest priority for definitive diagnosis and treatment?
1. Client with chronic obstructive pulmonary disease (COPD) with yellow expectoration and an
oxygen saturation of 91%
2. Healthy child with new-onset fiery-red rash on cheeks and the "flu"
3. Middle-aged client with vaginal itching and white, curdlike discharge
4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face
4
The nurse is working in a busy emergency department and is assigned 4 clients. Which client
should the nurse see first?
1. Client receiving cyclophosphamide reporting bloody urine
2. Client who reports severe nausea and vomiting after chemotherapy
3. Client with an elbow abrasion and a lip laceration possibly requiring sutures
4. Homeless client who appears drowsy with a temperature of 95 F (35 C)
4
DIFFERENT VERSIONS COMBINED ACCURATE
FOR GUARANTEED PASS ALREADY GRADED A
Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads
a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "Those aren't my
clients." What is the best response by the nurse?
1. "Would you mind answering the lights anyway?"
2. "I need you to answer the lights because we want to provide good client care."
3. Say nothing and answer the lights, but write up a disciplinary action
4. Tell the UAP that this is unacceptable and speak to the nurse manager.
2
The risk management nurse is reviewing client records. Which nursing intervention could have
contributed to a sentinel event?
1. Administered flumazenil to a client who overdosed on lorazepam
2. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
3. Administered warfarin to a client with International Normalized Ratio of 6
4. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
3
The registered nurse is caring for multiple clients on a busy surgical unit and should delegate
which action to the unlicensed assistive personnel?
1. Assist client, post hip fracture repair, to the bathroom
2. Check the appearance of client's wound
3. If client tolerates oral liquids, discontinue nasogastric tube
4. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L)
1
Which statements related to ethical nursing practices are correct? Select all that apply.
1. Accountability is documenting that the nurse administered the wrong medication
2. Autonomy is informing the client of the decision the family made for the client
3. Confidentiality is respecting a client's request to keep suicidal ideation a secret
4. Justice is providing the same cardiac care to a homeless person as a businessperson
5.Nonmaleficence is reporting abuse for a client with Alzheimer disease
1,4,5
A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting
fires and flooding in collapsed buildings. Multiple victims come to the triage area. Which client
,would the nurse care for first?
1. Charred leathery skin over entire back, chest, and legs
2. Client shivering from sitting in water until rescued
3. Diabetic client who was unable to take insulin today
4. High-pitched, crowing inspiratory respirations
4
The charge nurse on a medical-surgical step-down unit is responsible for making assignments.
Which client is most appropriate to assign to a new graduate nurse who is still in orientation?
1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a
diminished pedal pulse
2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently
180/102 mm Hg; reports headache and blurred vision
3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago;
unresponsive with right-sided paralysis
4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing
changes due to excessive drainage
4
An unaccompanied 16-year-old female comes to the emergency department with severe
abdominal pain and vomiting. The minor has a temperature of 102.2 F (39 C) and a pulse of 120
/min and is lethargic. The parents are out of town, and no guardians could be reached. How
should the care be handled?
1. Administer care until parents or guardians can be reached
2. Keep the minor but without giving care until parents or guardians can be reached
3. Perform a pregnancy test to see if the minor qualifies as an emancipated minor
4. Provide health care and follow-up advice but do not give any direct care
1
A staff nurse automatically takes a lunch break first every day instead of asking other staff nurses
about their preferences. Another nurse would like to take the first lunch break time sometimes.
Which is the best way for the staff nurse to handle the situation initially?
1. Ask the nurse manager to talk to the nurse who takes the first break time
2. Poll the other staff nurses to see what they think about the situation
3. Realize that some matters are not worth bringing up and say nothing
4. Tell the nurse directly of wanting to take the first lunch break sometimes
4
The nurse reviews the laboratory results for 4 assigned clients. Which result is most important
for the nurse to report to the primary health care provider?
1. Client with atrial fibrillation receiving warfarin for 7 days with an International Normalized
Ratio (INR) of 1.3
2. Client with chronic bronchitis who has a hematocrit of 56% [0.56] and hemoglobin of 19 g/dL
,(190 g/L)
3. Client with Clostridium difficile infection who has a white blood cell count of 15,000/mm3
(15 × 109/L)
4. Client with sepsis receiving gentamycin who has a creatinine of 0.6 mg/dL (53 µmol/L)
1
It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of
these illustrate appropriate delegation instructions for the registered nurse (RN) to give the UAP?
Select all that apply.
1. "Elevate the right leg on two pillows."
2. "Measure client for compression stockings."
3. "Please let me know what the urine looks like."
4. "Tell me what the client eats at lunch."
5. "Verify wrist restraints are on correctly."
1,4
The nurse is leaving at the end of the shift on an elevator crowded with visitors. A health care
provider (HCP) gets on the elevator and asks, "How is my client Mrs. Jones in Room 312
doing?" Which of the following is the best response to the HCP's question?
1. "I don't know because I am off duty."
2. "Mrs. Jones was fine when I last saw her."
3. "Why don't we step off the elevator and discuss it."
4. "You will have to talk to Nurse Smith, who is her nurse now."
3
The charge nurse supervising a graduate nurse would need to intervene when that nurse violates
the Health Insurance Portability and Accountability Act with which action? Select all that apply.
1. Accesses the medical record of a client not currently assigned, but previously cared for, to
assess client improvement
2. Advises the client transport technician, "This client has fragile bones due to cancer, so move
the client very carefully."
3. Asks a client, "When were you diagnosed with diabetes?" during admission assessment in a
semi-private room with the privacy curtain in place between beds
4. Interprets the results of a client's diagnostic testing to the unit clerk
5. Writes a client's last name and room number on a whiteboard hanging in the nurse's station on
which scheduled procedures are logged
1,2,4
The registered nurse is working with a licensed vocational nurse and unlicensed assistive
personnel. A client has just returned to the cardiac unit after having a percutaneous coronary
intervention. Which actions are most appropriate for the registered nurse to assign to the licensed
vocational nurse? Select all that apply.
1. Administer oral pain medication if client reports low back pain
, 2. Assist the client with the use of a urinal post-procedure
3. Check for bleeding at the catheter insertion site every 15 minutes
4. Perform post-procedure vital sign measurements
5. Review ECG for dysrhythmias
1,3
After receiving the shift report, the nurse should assess which infant first?
1. An infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min
2. An infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL (2.2
mmol/L)
3. An infant with bilateral crackles who was delivered vaginally 30 minutes ago
4. An infant wrapped in a warm blanket 15 minutes ago due to a temperature of 97.7 F (36.5 C)
2
A nurse notices that a client who is 1-day postoperative knee replacement surgery has a cool
numb foot with a weak peripheral pulse. The nurse pages and asks the health care provider
(HCP) to come see the client. The HCP states that the client's foot has been like that since
surgery and that there is no need to come. Under the Team Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS) process, what step should the nurse take next?
1. Continue to assess the foot hourly
2. Document the HCP's statement
3. Elevate the affected leg on a pillow
4. Repeat request for HCP to come
4
Four clients come to the emergency department (ED). Which client should the triage registered
nurse (RN) assign as highest priority for definitive diagnosis and treatment?
1. Client with chronic obstructive pulmonary disease (COPD) with yellow expectoration and an
oxygen saturation of 91%
2. Healthy child with new-onset fiery-red rash on cheeks and the "flu"
3. Middle-aged client with vaginal itching and white, curdlike discharge
4. Unconscious elderly client who smells of alcohol and has fresh vomit on the face
4
The nurse is working in a busy emergency department and is assigned 4 clients. Which client
should the nurse see first?
1. Client receiving cyclophosphamide reporting bloody urine
2. Client who reports severe nausea and vomiting after chemotherapy
3. Client with an elbow abrasion and a lip laceration possibly requiring sutures
4. Homeless client who appears drowsy with a temperature of 95 F (35 C)
4
