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NUR-111 final Exam Questions with Complete
Solutions
1.A nurse is caring for a client who states, "My doctor was just here, but
I still do not understand my diagnosis." The nurse contacts the provider to
return to speak with the client. Which of the following principles is the nurse
demonstrating
A. Advocacy
B. Accountability
C. Confidentially
D. Fidelity: Advocacy
Rationale: The nurse is demonstrating advocacy. The nurse is
advocating for the client by notifying the provider that the client has
questions and concerns about their diagnosis. As a client advocate, the
nurse should act on behalf of the client to protect their rights, health,
and safety.
2.A nurse is caring for a client who acquired a Staphylococcus aureus in-
fection from touching a contaminated towel. Through which of the
following modes of transmission did the client acquire the infection?
A. Airborne
B. Vector
C. Indirect contact
D. Droplet: Indirect contact-
Rationale: Indirect contact occurs when an infectious agent is
transmitted to an individual through an inanimate object, such as a
towel.
3.A nurse is teaching a client about maintaining skin integrity to decrease
the risk of infection. Which of the following instructions should the nurse
include?
A. Rub your skin firmly when cleaning
B. Use a moisturizer on your skin after cleaning
C. Wash your skin daily with hot water
D. Allow your sin to dry after bathing: Use a moisturizer on your skin
after cleaning."
Rationale: The client should use gentle moisturizers on the skin to
promote hydration and protect the skin from injury that might lead to an
infection.
4.A nurse is preparing a client for a procedure. Which of the following is
an acceptable identifier to use identify the client
,A. Telephone number
B. Home address
C. Room number
D. Medical condition: Telephone number
5.A nurse is assessing a client who was brought to the emergency
department with an ankle injury. Which of the following manifestations
should the nurse identify as localized inflammation of the tissues.
A. 3+ palpable pedal pulses below the affected injury site.
B. Sanguineous drainage at site of injury
C. Full range of motion at the site of injury
D. Localized warmth at the site of injury: Localized warmth at the site of
injury Rationale: Manifestations of localized inflammation can include
redness, pain, warmth, and decreased function
6.A nurse is providing change-of-shift report to another nurse for a client
us- ing the Introduction, Situation, Background, Assessment and
Recommenda- tion (ISBARR) communication tool. Which of the following
information should the nurse include as part of the situation component of
this communication tool?
A. Medical condition
B. Vital signs
C. List of medications
D. Treatment: Medical condition
Rationale: The nurse should include the client's medical condition or
diagnosis in the situation component of the ISBARR communication tool.
Other findings that can be included in this component are the client's
age, chief complaint, and urgent needs.
7.A nurse is reviewing laboratory values for a client. Which of the
following findings indicates the presence of an infection?
A. Creatinine kinase 75units/L
B. WBC count 22,000/mm3
C. Platelet count 200,000mm3
D. Hgb 15 g/dL: WBC count 22,000/mm3
Rationale: The client's WBC count is greater than the expected
reference range of 5,000 to 10,000/mm3. An elevated WBC count is a
manifestation of an infection
8.A nurse is observing a newly licensed nurse perform hand hygiene. Which
of the following actions by the newly licensed nurse indicates an
understanding of the procedure?
A. Holds their hands below the elbows while rinsing off soap
B. Uses hot water to wash their hands
,C. Turns off faucet with their hands
D. Washes their hands for 10 seconds: Holds their hands below the elbows
while rinsing off soap
Rationale: The nurse should keep their hands below the elbows while
rinsing off soap so water flows from the least contaminated to the most
contaminated area
9.A nurse sees smoke coming from the central supply room. Which of
the following actions should the nurse take first?
A. Close all the doors
B. Wrap clients in blankets
C. Stay close to the ground
D. Walk to a safe area: Close all the doors.
Rationale: The greatest risk to clients is injury from smoke inhalation or
burns; therefore, the first action the nurse should take is to close all the
doors to contain the smoke or fire.
10.A nurse is reviewing a client's medical record. Which of the
following findings should the nurse identify as a fall risk?
A. Multiple sclerosis
B. Hyperthyroidism
C. Hyperlipidemia
D. Inguinal hernia: Multiple sclerosis
Rationale: The nurse should identify that multiple sclerosis is a physical
disorder that can place the client at risk for falls due to problems with
mobility. Other physical disorders that can contribute to falls are visual
impairment, recent surgery, and stroke.
11.A nurse is caring for a client who is experiencing a seizure. Which of
the following actions should the nurse take?
A. Place a towel under the client's head
B. Hold the client's arms and legs still.
C. Leave the client to get help
D. Place the client in the prone position.: Place a towel under the client's
head. Rationale: The nurse should place a folded towel or pillow under
the client's head to help protect the client from injury.
12.A nurse is caring for a client who is placed on droplet precautions.
Which of the following actions should the nurse take?
A. Move the client to a positive airflow room
B. Place a surgical mask on the client when they leave their room
C. Wear a surgical mask when within 0.6 m (2ft) of the client
D. Remove fresh flowers from the client's room.: Place a surgical mask on
the client when they leave their room.
, Rationale: The nurse should place a surgical mask on the client when
they leave their room to reduce the risk of transmission of the infection.
13.A nurse is caring for a client who has a new diagnosis of Clostridium
difficile and is placed on contact precautions. Which of the following
actions should the nurse take?
A. Remove the protective gown before leaving the client's room
B. Shake bed linens before placing them in a linen bag
C. Remove protective gown before removing gloves
D. Use an electronic thermometer to take the client's temperature: Remove
the protective gown before leaving the client's room.
Rationale: The nurse should remove the protective gown and gloves
before leaving the client's room to reduce the risk of transmission of the
infectio
14.A nurse enters a client's room and finds the client on the floor. After
the nurse has ensured the client's safety, which of the following actions
should the nurse take?
A. Notify the client's provider about the occurrence
B. Document the completion of an occurrence report in the client's medical
record
C. Contact risk management about the occurrence
D. Request another nurse to complete the occurrence report: Notify the
client's provider about the occurrence.
Rationale: Once the client has been assessed and is safe, the nurse
should notify the client's provider about the occurrence and determine if
further treatment is needed.
15.A charge nurse is providing an in-service to a group of staff nurses
about unexpected events. Which of the following should the nurse include
in the teaching as an example of a sentinel event?
A. A client had bowel surgery and died from sepsis
B. A client fell out of bed and fractured their hip.
C. A client was almost given another client's medication
D. A client was prescribed a medication they were allergic to, but the
prescrip- tion was canceled before the medication was given.: A client had
bowel surgery and died from sepsis.
Rationale: The nurse should include in the in-service that a client who
had a bowel surgery and then died from sepsis is a sentinel event. A
sentinel event is an unexpected event that caused severe or permanent
harm to the client and even death.
16.A nurse is teaching a newly licensed nurse about reducing the risk of
needlestick injuries. Which of the following instructions should the
NUR-111 final Exam Questions with Complete
Solutions
1.A nurse is caring for a client who states, "My doctor was just here, but
I still do not understand my diagnosis." The nurse contacts the provider to
return to speak with the client. Which of the following principles is the nurse
demonstrating
A. Advocacy
B. Accountability
C. Confidentially
D. Fidelity: Advocacy
Rationale: The nurse is demonstrating advocacy. The nurse is
advocating for the client by notifying the provider that the client has
questions and concerns about their diagnosis. As a client advocate, the
nurse should act on behalf of the client to protect their rights, health,
and safety.
2.A nurse is caring for a client who acquired a Staphylococcus aureus in-
fection from touching a contaminated towel. Through which of the
following modes of transmission did the client acquire the infection?
A. Airborne
B. Vector
C. Indirect contact
D. Droplet: Indirect contact-
Rationale: Indirect contact occurs when an infectious agent is
transmitted to an individual through an inanimate object, such as a
towel.
3.A nurse is teaching a client about maintaining skin integrity to decrease
the risk of infection. Which of the following instructions should the nurse
include?
A. Rub your skin firmly when cleaning
B. Use a moisturizer on your skin after cleaning
C. Wash your skin daily with hot water
D. Allow your sin to dry after bathing: Use a moisturizer on your skin
after cleaning."
Rationale: The client should use gentle moisturizers on the skin to
promote hydration and protect the skin from injury that might lead to an
infection.
4.A nurse is preparing a client for a procedure. Which of the following is
an acceptable identifier to use identify the client
,A. Telephone number
B. Home address
C. Room number
D. Medical condition: Telephone number
5.A nurse is assessing a client who was brought to the emergency
department with an ankle injury. Which of the following manifestations
should the nurse identify as localized inflammation of the tissues.
A. 3+ palpable pedal pulses below the affected injury site.
B. Sanguineous drainage at site of injury
C. Full range of motion at the site of injury
D. Localized warmth at the site of injury: Localized warmth at the site of
injury Rationale: Manifestations of localized inflammation can include
redness, pain, warmth, and decreased function
6.A nurse is providing change-of-shift report to another nurse for a client
us- ing the Introduction, Situation, Background, Assessment and
Recommenda- tion (ISBARR) communication tool. Which of the following
information should the nurse include as part of the situation component of
this communication tool?
A. Medical condition
B. Vital signs
C. List of medications
D. Treatment: Medical condition
Rationale: The nurse should include the client's medical condition or
diagnosis in the situation component of the ISBARR communication tool.
Other findings that can be included in this component are the client's
age, chief complaint, and urgent needs.
7.A nurse is reviewing laboratory values for a client. Which of the
following findings indicates the presence of an infection?
A. Creatinine kinase 75units/L
B. WBC count 22,000/mm3
C. Platelet count 200,000mm3
D. Hgb 15 g/dL: WBC count 22,000/mm3
Rationale: The client's WBC count is greater than the expected
reference range of 5,000 to 10,000/mm3. An elevated WBC count is a
manifestation of an infection
8.A nurse is observing a newly licensed nurse perform hand hygiene. Which
of the following actions by the newly licensed nurse indicates an
understanding of the procedure?
A. Holds their hands below the elbows while rinsing off soap
B. Uses hot water to wash their hands
,C. Turns off faucet with their hands
D. Washes their hands for 10 seconds: Holds their hands below the elbows
while rinsing off soap
Rationale: The nurse should keep their hands below the elbows while
rinsing off soap so water flows from the least contaminated to the most
contaminated area
9.A nurse sees smoke coming from the central supply room. Which of
the following actions should the nurse take first?
A. Close all the doors
B. Wrap clients in blankets
C. Stay close to the ground
D. Walk to a safe area: Close all the doors.
Rationale: The greatest risk to clients is injury from smoke inhalation or
burns; therefore, the first action the nurse should take is to close all the
doors to contain the smoke or fire.
10.A nurse is reviewing a client's medical record. Which of the
following findings should the nurse identify as a fall risk?
A. Multiple sclerosis
B. Hyperthyroidism
C. Hyperlipidemia
D. Inguinal hernia: Multiple sclerosis
Rationale: The nurse should identify that multiple sclerosis is a physical
disorder that can place the client at risk for falls due to problems with
mobility. Other physical disorders that can contribute to falls are visual
impairment, recent surgery, and stroke.
11.A nurse is caring for a client who is experiencing a seizure. Which of
the following actions should the nurse take?
A. Place a towel under the client's head
B. Hold the client's arms and legs still.
C. Leave the client to get help
D. Place the client in the prone position.: Place a towel under the client's
head. Rationale: The nurse should place a folded towel or pillow under
the client's head to help protect the client from injury.
12.A nurse is caring for a client who is placed on droplet precautions.
Which of the following actions should the nurse take?
A. Move the client to a positive airflow room
B. Place a surgical mask on the client when they leave their room
C. Wear a surgical mask when within 0.6 m (2ft) of the client
D. Remove fresh flowers from the client's room.: Place a surgical mask on
the client when they leave their room.
, Rationale: The nurse should place a surgical mask on the client when
they leave their room to reduce the risk of transmission of the infection.
13.A nurse is caring for a client who has a new diagnosis of Clostridium
difficile and is placed on contact precautions. Which of the following
actions should the nurse take?
A. Remove the protective gown before leaving the client's room
B. Shake bed linens before placing them in a linen bag
C. Remove protective gown before removing gloves
D. Use an electronic thermometer to take the client's temperature: Remove
the protective gown before leaving the client's room.
Rationale: The nurse should remove the protective gown and gloves
before leaving the client's room to reduce the risk of transmission of the
infectio
14.A nurse enters a client's room and finds the client on the floor. After
the nurse has ensured the client's safety, which of the following actions
should the nurse take?
A. Notify the client's provider about the occurrence
B. Document the completion of an occurrence report in the client's medical
record
C. Contact risk management about the occurrence
D. Request another nurse to complete the occurrence report: Notify the
client's provider about the occurrence.
Rationale: Once the client has been assessed and is safe, the nurse
should notify the client's provider about the occurrence and determine if
further treatment is needed.
15.A charge nurse is providing an in-service to a group of staff nurses
about unexpected events. Which of the following should the nurse include
in the teaching as an example of a sentinel event?
A. A client had bowel surgery and died from sepsis
B. A client fell out of bed and fractured their hip.
C. A client was almost given another client's medication
D. A client was prescribed a medication they were allergic to, but the
prescrip- tion was canceled before the medication was given.: A client had
bowel surgery and died from sepsis.
Rationale: The nurse should include in the in-service that a client who
had a bowel surgery and then died from sepsis is a sentinel event. A
sentinel event is an unexpected event that caused severe or permanent
harm to the client and even death.
16.A nurse is teaching a newly licensed nurse about reducing the risk of
needlestick injuries. Which of the following instructions should the
