PROPHECY CORE MANDATORY PART 1,2 AND 3 NURSING
RELIAS LATEST 2024 ACTUAL EXAM
When assessing a patient for the first time, which type of assessment will the nurse
complete?
a. Initial assessment
b. Problem-focused assessment
c. Emergency assessment
d. Ongoing assessment - ANSWER: a. Initial Assessment
Rationale: the first assessment is also known as the initial assessment. May also be
referred to as an admission assessment
The nurse has observed a client who reports pain of "6" on a 0-10 pain rating scale.
Which of the following is most accurate?
a. subjective data
b. objective data
c. judgmental data - ANSWER: a. subjective data
Rationale: subjective. Can only be verified by the patient. Cannot be verified by
observation or measurement alone.
The Electronic Health Record (EHR) is an example of which of the following?
a. A database of patient information
b. A public record
c. A record that can be deleted
d. A record never to be seen by the patient - ANSWER: a. A database of patient
information
Rationale: the patient record is a database of patient information, is not public
record, cannot be deleted and can be seen by the patient
An elderly patient who is unable to communicate is being admitted. Which of the
following is/are appropriate sources of Protected Health Information? SELECT ALL
THAT APPLY
a. Family members
b. Healthcare professionals
c. A non-family neighbor
d. Old client records
e. Literature - ANSWER: a. Family members
b. Healthcare professionals
d. Old client records
,e. Literature
Rationale: family members, healthcare professionals, old records and literature can
be used to gather information considered protected health information. Neighbors
who simply want to gain access to private health information are not appropriate
sources of information unless provided in a power of attorney.
When the nurse is assessing a patient for skin temperature, which of the following is
the best technique?
a. Inspection
b. Palpation
c. Auscultation
d. Percussion - ANSWER: b. Palpation
Rationale: using touch to determine texture, temperature, vibration, position,
distension, pulsation and presence of pain on palpation is done using palpation
When assessing a patient, the nurse states, "Tell me more about your home life."
Which type of therapeutic communication does this exemplify?
a. Closed question
b. Neutral question
c. Leading question
d. Open-ended question - ANSWER: d. Open-ended question
Rationale: an open ended question allows the client to elaborate further, without
constraint. Encourages more information to be shared
What is the most appropriate position for the nurse during a patient interview?
a. Standing at the foot of the bed
b. Sitting in a chair near the door
c. Standing at the side of the bed
d. Sitting in a chair near the patient - ANSWER: d. Sitting in a chair near the patient
Rationale: should sit near the patient and keep at/near eye level to establish rapport
A 24-year old patient is admitted to the trauma unit with a diagnosis of a fractured
femur after a motor vehicle accident. He states that he has pain in the injured leg.
What should be the first action taken by the nurse?
a. Administer the lowest dose of pain medication
b. Assess the characteristics of the pain
c. Call the orthopedic surgeon
d. Complete the admission assessment - ANSWER: b. Assess the characteristics of the
pain
, A 7-year old pediatric patient tells you that he is in pain. The patient rates the pain as
4 on the Faces Pain Scale of 0-10. His mother, who is in the room, states that her son
is having pain at a level of 8 on the 0-10 scale. Which is the most accurate
assessment of the patient's pain?
a. The patient is the best resource for assessing the pain and should receive the
appropriate pain medication
b. The patient is the best resource for assessing the pain, but should not receive any
pain medication because his level is only 4 out of 10.
c. The nurse is the best resource for assessing the pediatric patient's pain level and
gives the dose of pain medication that matches the nurses' judgment
d. The mother is the best resource for assessing the pain in this case, and the patient
should receive the maximum dose of pain medication ordered. - ANSWER: a. The
patient is the best resource for assessing the pain and should receive the appropriate
pain medication
Your patient developed respiratory depression after her first dose of intravenous (IV)
morphine. After giving 0.2mg of naloxone (Narcan) IV push, the patient's respiratory
rate and depth are within normal limits. Which action do you take now?
a. Leave the patient alone to sleep now.
b. Discontinue all pain medications ordered
c. Administer another dose of naloxone in 1 hours
d. Assess the patient's vital signs every 15 minutes for 2 hours - ANSWER: d. Assess
the patient's vital signs every 15 minutes for 2 hours
One hour after administering the first dose of an intravenous opioid to your
postoperative patient, about which of the following assessments should you be most
concerned?
a. Respiratory rate of 6 breaths per minute
b. Oxygen saturation of 95% on room air
c. Heart rate of 70 regular
d. Blood pressure of 140/72 - ANSWER: a. Respiratory rate of 6 breaths per minute
A patient with a history of stroke 4 years ago resulting in aphasia (inability to verbally
express thoughts) returns to the surgical unit after a cholecystectomy. The surgeon
ordered an intravenous pain medication every 4 hours as needed (PRN) for
postoperative pain. The best nursing intervention related to pain control after
surgery would be to:
RELIAS LATEST 2024 ACTUAL EXAM
When assessing a patient for the first time, which type of assessment will the nurse
complete?
a. Initial assessment
b. Problem-focused assessment
c. Emergency assessment
d. Ongoing assessment - ANSWER: a. Initial Assessment
Rationale: the first assessment is also known as the initial assessment. May also be
referred to as an admission assessment
The nurse has observed a client who reports pain of "6" on a 0-10 pain rating scale.
Which of the following is most accurate?
a. subjective data
b. objective data
c. judgmental data - ANSWER: a. subjective data
Rationale: subjective. Can only be verified by the patient. Cannot be verified by
observation or measurement alone.
The Electronic Health Record (EHR) is an example of which of the following?
a. A database of patient information
b. A public record
c. A record that can be deleted
d. A record never to be seen by the patient - ANSWER: a. A database of patient
information
Rationale: the patient record is a database of patient information, is not public
record, cannot be deleted and can be seen by the patient
An elderly patient who is unable to communicate is being admitted. Which of the
following is/are appropriate sources of Protected Health Information? SELECT ALL
THAT APPLY
a. Family members
b. Healthcare professionals
c. A non-family neighbor
d. Old client records
e. Literature - ANSWER: a. Family members
b. Healthcare professionals
d. Old client records
,e. Literature
Rationale: family members, healthcare professionals, old records and literature can
be used to gather information considered protected health information. Neighbors
who simply want to gain access to private health information are not appropriate
sources of information unless provided in a power of attorney.
When the nurse is assessing a patient for skin temperature, which of the following is
the best technique?
a. Inspection
b. Palpation
c. Auscultation
d. Percussion - ANSWER: b. Palpation
Rationale: using touch to determine texture, temperature, vibration, position,
distension, pulsation and presence of pain on palpation is done using palpation
When assessing a patient, the nurse states, "Tell me more about your home life."
Which type of therapeutic communication does this exemplify?
a. Closed question
b. Neutral question
c. Leading question
d. Open-ended question - ANSWER: d. Open-ended question
Rationale: an open ended question allows the client to elaborate further, without
constraint. Encourages more information to be shared
What is the most appropriate position for the nurse during a patient interview?
a. Standing at the foot of the bed
b. Sitting in a chair near the door
c. Standing at the side of the bed
d. Sitting in a chair near the patient - ANSWER: d. Sitting in a chair near the patient
Rationale: should sit near the patient and keep at/near eye level to establish rapport
A 24-year old patient is admitted to the trauma unit with a diagnosis of a fractured
femur after a motor vehicle accident. He states that he has pain in the injured leg.
What should be the first action taken by the nurse?
a. Administer the lowest dose of pain medication
b. Assess the characteristics of the pain
c. Call the orthopedic surgeon
d. Complete the admission assessment - ANSWER: b. Assess the characteristics of the
pain
, A 7-year old pediatric patient tells you that he is in pain. The patient rates the pain as
4 on the Faces Pain Scale of 0-10. His mother, who is in the room, states that her son
is having pain at a level of 8 on the 0-10 scale. Which is the most accurate
assessment of the patient's pain?
a. The patient is the best resource for assessing the pain and should receive the
appropriate pain medication
b. The patient is the best resource for assessing the pain, but should not receive any
pain medication because his level is only 4 out of 10.
c. The nurse is the best resource for assessing the pediatric patient's pain level and
gives the dose of pain medication that matches the nurses' judgment
d. The mother is the best resource for assessing the pain in this case, and the patient
should receive the maximum dose of pain medication ordered. - ANSWER: a. The
patient is the best resource for assessing the pain and should receive the appropriate
pain medication
Your patient developed respiratory depression after her first dose of intravenous (IV)
morphine. After giving 0.2mg of naloxone (Narcan) IV push, the patient's respiratory
rate and depth are within normal limits. Which action do you take now?
a. Leave the patient alone to sleep now.
b. Discontinue all pain medications ordered
c. Administer another dose of naloxone in 1 hours
d. Assess the patient's vital signs every 15 minutes for 2 hours - ANSWER: d. Assess
the patient's vital signs every 15 minutes for 2 hours
One hour after administering the first dose of an intravenous opioid to your
postoperative patient, about which of the following assessments should you be most
concerned?
a. Respiratory rate of 6 breaths per minute
b. Oxygen saturation of 95% on room air
c. Heart rate of 70 regular
d. Blood pressure of 140/72 - ANSWER: a. Respiratory rate of 6 breaths per minute
A patient with a history of stroke 4 years ago resulting in aphasia (inability to verbally
express thoughts) returns to the surgical unit after a cholecystectomy. The surgeon
ordered an intravenous pain medication every 4 hours as needed (PRN) for
postoperative pain. The best nursing intervention related to pain control after
surgery would be to:
