Nursing Comprehensive Exam! Trivia Questions Quiz
Are you on your way to become a nurse? The process of getting there is all about having enough time to study. The nursing comprehensive exam questions below are designed to help out just how attentive you have been when it comes to your classes and your chances of acing the upcoming exams. Be sure to take up more quizzes just like it!
- 1.
A client’s vital signs have noticeably deteriorated over the past four hours following surgery. A nurse does not recognize the significance of these changes in vital signs and keep no action. The client later requires emergency surgery. The nurse could be prosecuted for inaction according to the definition of which of these?
- A.
Tort
- B.
Misdemeanor
- C.
Common law
- D.
Statutory law
Correct Answer
A. TortExplanation
A tort is a wrongful act intentionally or unintentionally committed against a person or his or her property. The nurses’ inaction in the situation described is consistent with the definition of a tort offense. Option B is an offense under criminal law. Option C describes case law that has evolved over time via precedents. Option D describe laws that are enacted by state, federal, or local governments.Rate this question:
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- 2.
A nurse calls the physician of a client scheduled for a cardiac catherization because the client has numerous questions regarding the procedures and has requested to speak to the physician. The physician is very much upset and arrives at the unit to visit the client after prompting by the nurse. The nurse is outside of the client’s room and hears the physician tell the client in derogatory manner that the nurse “doesn’t know everything”. Which legal tort has the physician violated?
- A.
Libel
- B.
Slander
- C.
Assault
- D.
Negligence
Correct Answer
B. SlanderExplanation
Defamation takes place when something untrue is said (slander) or written (libel) about a person. Resulting injury to that person’s good name and reputation. An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for specific professional group.Rate this question:
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- 3.
A nurse enters a client’s room and finds the client sitting on the floor. The nurse performs a thorough assessment and assists the client back to bed. The nurse completes an incident report and notifies the physician of the incident. Which of the following is the next appropriate nursing action regarding the incident?
- A.
Make a copy of the incident report for the physician
- B.
Place the incident report on the client’s chart
- C.
Document a complete entry in the client’s record concerning the incident
- D.
Document in the client’s record that an incident report has been completed
Correct Answer
C. Document a complete entry in the client’s record concerning the incidentExplanation
The incident report is confidential and privileged information and should not be copied, placed in the chart or have any reference made to it in the client’s record. The incident report is not a substitute for complete entry in the client’s record concerning the incidentRate this question:
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- 4.
A client had a colon resection. A Levin tube is placed when a regular diet was brought to the client’s room. The client didn’t want to eat the solid food and ask the physician to be called. The nurse insisted that the solid food was the correct diet. The client ate and subsequently had additional surgery because of complications. The determination of negligence is based on:
- A.
A duty existed and it was breached
- B.
Not calling the physician
- C.
The dietary department sending the wrong food
- D.
The nurse’s persistence
Correct Answer
A. A duty existed and it was breachedExplanation
For negligence to be proven, there must be a duty, then a breach of duty; the breach of duty must cause the injury, and damages or injury must be experienced. Options B, C and D do not fall under the criteria for negligence. Option A is the only option that fits the criteria of negligence.Rate this question:
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- 5.
A new nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the facility. The nurse is told that the nursing model is the primary nursing approach. The nurse understands which of the following is a characteristic of this type of nursing model of practice?
- A.
The nurse manager assigns tasks to the staff members
- B.
Critical paths are used in providing client care
- C.
A single registered nurse (RN) is responsible for planning and providing individualized nursing care
- D.
Nursing staff are led by an RN leader in providing care to a group clients.
Correct Answer
C. A single registered nurse (RN) is responsible for planning and providing individualized nursing careExplanation
Primary nursing is concerned with keeping the nurse at the bedside actively involved in direct care while planning goal directed, individualized client care. Option A identifies functional nursing. Option B identifies a component of case management. Option D identifies team nursing.Rate this question:
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- 6.
A client asks the nurse how to become an organ donor. Which of the following would not be a component of the nurse’s response?
- A.
The donor must be 18 years of age or older
- B.
The donation is done by written consent
- C.
The family is responsible for making that decision at the time of death.
- D.
Clients have the right to donate their own organs for transplantation
Correct Answer
C. The family is responsible for making that decision at the time of death.Explanation
The client has the right to donate her or his own organs for transplantation. Any person 18 years of age or older may become an organ donor by written consent. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent’s organs.Rate this question:
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- 7.
A registered nurse (RN) is providing instructions to a licensed practical nurse (LPN) who is preparing to care for a deceased client. The RN notes on the client’s record that his/her eye will be donated. The nurse avoids telling the LPN to do which of the following?
- A.
Elevate the head of the bed
- B.
Close the client’s eye
- C.
Place wet saline gauze pads and an ice pack on the eyes
- D.
Close the client’s eyes and place a dry sterile dressing over the eyes
Correct Answer
D. Close the client’s eyes and place a dry sterile dressing over the eyesExplanation
When a corneal donor dies, the eyes are closed and gauze pads wet with saline solution are placed over them with a small ice pack. Within 2 to 4 hours, the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. The head of the bed should also be elevated.Rate this question:
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- 8.
A clinical nurse manager is planning an in-service educational session for the staff nurses. The topic of the discussion is case management. Which of the following is not a characteristic of case management and would not be included in the discussion?
- A.
Represents a primary health prevention managed by a single case manager
- B.
Manages the client care by managing the client care environment
- C.
Designed to promote appropriate use of hospital personnel and material resources
- D.
Maximizes hospital revenues while providing for optimal outcome of client care
Correct Answer
A. Represents a primary health prevention managed by a single case managerExplanation
Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing optimal outcome care. It manages the client care by managing the client care environment.Rate this question:
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- 9.
A registered nurse is delegating activities to the nursing staff. Which activity is least appropriate for the nursing assistant?
- A.
Assist a 12-year old boy who is profoundly developmentally disabled to eat lunch
- B.
Obtain frequent oral temperatures on a client
- C.
Accompany a 51-year-old man, being discharged to home following a bowel resection 8 days ago, to his transportation
- D.
Collect a urine specimen from a 70-year old woman admitted 3 days go
Correct Answer
A. Assist a 12-year old boy who is profoundly developmentally disabled to eat lunchExplanation
Work that is delegated to others must be done consistent with the individual’s level of expertise and licensure or lack of licensure. In this case, the least appropriate activity for a nursing assistant would be assisting with feeding profoundly developmentally disabled child. The child is likely to have difficulty in eating, and therefore has a high potential for complications such as choking and aspiration. The remaining three options do not include situations to indicate that these activities carry any risk.Rate this question:
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- 10.
A clinical nurse manager is reviewing the critical paths of the clients on the nursing unit. The nurse manager collaborates with each nurse assigned to the clients and performs variance analysis. Which of the following would indicate the need for further action and analysis
- A.
A client is performing own colostomy care
- B.
A 1-day postoperative client has a temperature of 98 degrees F
- C.
Purulent drainage is noted from a postoperative wound incision
- D.
A new diabetic client is preparing own insulin for injection
Correct Answer
C. Purulent drainage is noted from a postoperative wound incisionExplanation
Variances are actual deviation or detours from the critical path. Variances can be either positive or negative, avoidable, or unavoidable and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early so that appropriate action can be taken. Option C is the only option that identifies the need for further action.Rate this question:
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- 11.
A nurse manager is conducting a conference with the nursing staff regarding concerns and proposals for actions related to the nursing unit. The nurse manager presents his or her own analysis of the problem and proposals for actions to members of the team, and invites the team members to comment and provide input. Which style of leadership is the nurse manager specifically employing?
- A.
Laissez-faire
- B.
Authoritarian
- C.
Situational
- D.
Participative
Correct Answer
D. ParticipativeExplanation
Participative leadership suggests a compromise between authoritarian and democratic style. In participative leadership, the leader represents his and her own analysis of the problems and proposal for action to members of the team, inviting critics and comments. The participative leader then analyzes the comments and makes final decision. A laissez-faire leader abdicates leadership and responsibilities, allowing staff to work without assistance, direction, and supervision. The autocratic style of leadership is task oriented and directive. In the situational leadership style, the style employed depends on the situation and events.Rate this question:
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- 12.
A client with a right pleural effusion noted on a chest x-ray film is being prepared for thoracentesis. The client experiences severe dizziness when sitting upright. The nurse assists the client to which of the following positions for the procedure?
- A.
Prone, with the head turned to the side supported by a pillow
- B.
Sims’ position, with the head of the bed flat
- C.
Right side-lying, with the head of bed elevated 45 degrees
- D.
Left side-lying with the head of the bed elevated 45 degrees
Correct Answer
D. Left side-lying with the head of the bed elevated 45 degreesExplanation
To facilitate removal of fluid from the chest wall, the client is positioned sitting at the edge of bed leaning over the bedside table with the feet supported on a stool. If the client is unable to sit up, the client is positioned lying in bed on the unaffected side with the head of the bed elevated 30 to 45 degrees. The prone and Sims’ positions are inappropriate positions for this procedure.Rate this question:
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- 13.
A physician’s order reads: theophylline timed-release capsule (Slo-bid), 100mg PO every 6 hours. The medication label reads: 50 mg /capsules. The nurse prepares how many capsule(s) to administer one dose?
- A.
1
- B.
2
- C.
3
- D.
4
Correct Answer
B. 2Explanation
Use the following formula for calculating medication dosages: Desired divided by Available multiplied by 1 Capsule = Capsule(s) per dose; 100 mg divided by 50 mg multiplied by 1 Capsule = 2 CapsulesRate this question:
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- 14.
A physician has written an order for a vest restraint to be applied on a client from 10:00 PM to 7:00 AM because the client becomes disoriented during the night and is at risk for fall. At 6:30 AM, the nurse manager takes rounds on all the clients in the unit. When assessing the client with vest restraint, which observation would indicate that the nurse who cared for this client performed unsafe care in the use of the restrain?
- A.
A hitch knot was used to secure the restrain
- B.
The client’s record indicates that the restraint was released every 2 hours
- C.
The restraint was applied tightly to prevent a fall
- D.
The call light was placed within reach of the client
Correct Answer
C. The restraint was applied tightly to prevent a fallExplanation
Restraints should never be applied tightly, because it could impair the circulation. The restraint should be applied securely to prevent the client from slipping through the restraint and endangering himself/herself. A hitch knot may be used on the client because it can easily be released in an emergency over 2 hours (or per agency policy) to inspect the skin for abnormalities. The call light must always be within the client’s reach in case the client needs assistanceRate this question:
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- 15.
The nurse is providing an educational session to a group of students who are enrolled in a certified nursing assistant program. The nurse prepares an instructional list for the students regarding the correct procedure for hand washing. Which instructions does the nurse include on the list?
- A.
Turn on the water. Allow warm water to wet the hands. Apply soap to the hands and rub them vigorously. Keeps hands pointed downward. Rinse the hands. Dry the hands using a paper towel.
- B.
Turn the water faucet off with the paper towel. Turn on the water. Allow the warm water to wet the hands. Apply soap to the hands and rub them vigorously. Keep hands pointed upward. Rinse the hands. Dry the hands using a paper towel. Turn the water faucet off with the paper towel.
- C.
Turn on the water. Allow the warm water to wet the hands. Apply soap to the hands and rub them vigorously. Keep the hands pointed down ward. Rinse the hands using a paper towel. Turn the water off with the clean hands.
- D.
Turn on the water; allow the cold water to wet the hands. Apply soap to the hands and rub it vigorously. Keep hands pointed upward. Rinse the hands using a paper towel and warm water. Turn the water off with clean hands.
Correct Answer
A. Turn on the water. Allow warm water to wet the hands. Apply soap to the hands and rub them vigorously. Keeps hands pointed downward. Rinse the hands. Dry the hands using a paper towel.Explanation
Warm water should be used for hand washing, because it increases the sudsing action of the soap. Hands should be kept downward to enable the unsanitary material to fall off the skin. The faucet should be turns off by using towels to prevent the hands from getting recontaminated.Rate this question:
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- 16.
A nurse is preparing to suction a client through a tracheostomy tube. Which of the following protective items would the nurse wear to perform this procedure?
- A.
Gown, mask and sterile gloves
- B.
Goggles, mask and sterile gloves
- C.
Mask, gown and a cap
- D.
Mask, sterile, gloves and a cap
Correct Answer
B. Goggles, mask and sterile glovesExplanation
Standard precautions involves body substance and universal precautions. The nurse would wear a mask and goggles when suctioning the client. Sterile gloves are worn. A mask would offer full protection of the nose and the mouth. Goggles would protect the eyes from getting injured. A gown would protect the nurse’s uniform and a cap would protect the nurse hair, but these items are not required for suctioning a client.Rate this question:
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- 17.
A nurse is instructing a client on how to safely use crutches for ambulating at home. Which measure would the nurse recommend to minimize the risk of falls while ambulating with crutches?
- A.
Use grab bars in the bath tub or shower
- B.
Remove scatter rugs in the home
- C.
Keep all pets out of the house
- D.
Use soft-soled slippers when walking with the crutches.
Correct Answer
B. Remove scatter rugs in the homeExplanation
To reduce the risk of falls, all obstacles must be removed from the home. Not all pets are trip hazards (fish, birds, guinea pigs). Grab bars in the bath tub or shower will not necessarily assist the client while walking with crutches. Shoes with nonslip soles should be worn.Rate this question:
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- 18.
An 85-year-old client is on postoperative day 2 following repair of a fractured hip. The nurse has observed that the client has episodes of extreme agitation. Which of the following nursing interventions would be most appropriate for the nurse to implement to avoid these episodes of agitation?
- A.
Walk up behind the client and gently put a hand on the client’s shoulder while speaking
- B.
Speak to the client at the entrance of the room to avoid any episodes of violence
- C.
Speak and move slowly to the client while assessing the client’s needs
- D.
Wait until the client’s agitation has subsided before approaching the client.
Correct Answer
C. Speak and move slowly to the client while assessing the client’s needsExplanation
Speaking and moving slowly toward the client will prevent the client from becoming further agitated. Any sudden moves or speaking too quickly may cause the client to have a violent episode. Walking up behind the client may cause the client to become startled and react violently. Remaining at the entrance of the room may make the client feel alienated. If the client’s agitation is not addressed, it will only increase. Therefore waiting for the agitation to subside is not an appropriate option.Rate this question:
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- 19.
A nurse has administered an injection to a client. After the injection, the nurse accidentally drops the syringe on the floor. Which nursing action is the most appropriate in this situation?
- A.
Carefully pick-up the syringe from the floor and gently recap the needle
- B.
Carefully pick up the syringe in the floor and dispose it in sharps container
- C.
Obtain a dust pan and mop to sweep up the syringe
- D.
Call the housekeeping department to pick up the syringe
Correct Answer
B. Carefully pick up the syringe in the floor and dispose it in sharps containerExplanation
Syringes should never be recapped in any circumstances because of the risk of getting pricked with a contaminated needle. Used syringe should always be placed in a sharps container immediately after use to avoid individuals getting injured. A syringe should not be swept up, because this action poses an additional risk for getting pricked. It is not the responsibility of the housekeeping department to pick up the syringeRate this question:
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- 20.
A nurse is observing a client using a walker. The nurse determines that the client is using the walker correctly if the client is:
- A.
Puts all four points of the walker flat on the floor, puts weight on the hand pieces and then walks into it.
- B.
Put weight on the hand pieces, moves the walker forward and then walks to it
- C.
Puts weight on the hand pieces, slides the walker forward and then walks unto it
- D.
Walks into the walker, puts weight into the hand pieces, and then puts all four points of the walker on the flat floor
Correct Answer
A. Puts all four points of the walker flat on the floor, puts weight on the hand pieces and then walks into it.Explanation
When the client uses a walker, the nurse stands adjacent to the affected side. The client is instructed to put all four point of the walker two feet forward flat on the floor before putting weight on the hand pieces. This will ensure client safety and prevent stress cracks in the walker. The client is then instructed to move the walker forward and walk into it.Rate this question:
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- 21.
A client is fitted for crutches and the nurse observes the client to evaluate for the correct height of the crutches. The nurse expects to note which of the following?
- A.
The client is able to rest axillae on the axillary bars
- B.
The nurse is able to place two fingers comfortably between the axillae and the axillary bars
- C.
The client is able to maintain the arms in a straight position when standing with the crutches
- D.
The nurse is able to place four fingers comfortable between the axillae and axillary bars
Correct Answer
B. The nurse is able to place two fingers comfortably between the axillae and the axillary barsExplanation
With the client’s elbows flexed 20 to 30 degrees, the shoulders in a relaxed position, and crutches placed approximately 15 cm (6 inches) anterolateral from the toes, the nurse should be able to place two fingers comfortably between the axillae and axillary bars. Crutches are adjusted if there is too much or too little space for the axillary area. The client is advised never to rest the axillae and the axillary bars because this could injure the brachial plexus (the nerve in axillae that supply the arm and shoulder area). The nurse should terminate ambulation and recheck the crutch height if the client complains of numbness or tingling in the hands or arms.Rate this question:
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- 22.
A client has a risk for infection following radical vulvectomy. The nurse avoids which of the following when giving perineal care to this client?
- A.
Cleanses using warm tap water and a bulb syringe
- B.
Intermittently exposes the wound to air.
- C.
Provides perineal care after each voiding and bowel movement (BM)
- D.
Provides prescribed sitz baths after the sutures are removed
Correct Answer
A. Cleanses using warm tap water and a bulb syringeExplanation
A sterile solution such as normal saline should be used for perineal care using an aseptic syringe or a water pick. This should be done regularly at least twice a day and after each voiding and BM. The wound is intermittently exposed to air to permit drying and prevent maceration. Once sutures are removed, sitz baths may be prescribed to stimulate healing and for the soothing effect.Rate this question:
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- 23.
A nurse prepares to assist a postoperative client to progress from a lying to a sitting position to prepare for ambulation. Which nursing action is most appropriate to maintain safety of the client?
- A.
Assist the client to move quickly from the lying position to the sitting position
- B.
Assess the client for signs of dizziness and hypotension
- C.
Elevate the head of the bed quickly to assist the client to a sitting position.
- D.
Allow the client to rise from the bed to standing position unassisted
Correct Answer
B. Assess the client for signs of dizziness and hypotensionExplanation
Early ambulation should not exceed the client’s tolerance. The client should be assisted before sitting. The client is assessed to rise from the lying position to the sitting position gradually until any evidence of dizziness, if present, has subsided. This position can be achieved by raising the head of the bed slowly. After sitting, the client may be assisted to a standing position. The nurse should be at the client’s side to provide physical support and encouragement.Rate this question:
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- 24.
A nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted to the urethra, urine begins to flow into the tubing. At this point, the nurse:
- A.
Immediately inflates the balloon
- B.
Withdraws the catheter approximately 1 inch and inflates the balloon
- C.
Inserts the catheter until resistance is met and inflates the balloon
- D.
Inserts the catheter 2.5 to 5 cm and inflates the balloon
Correct Answer
D. Inserts the catheter 2.5 to 5 cm and inflates the balloonExplanation
The catheter’s balloon is behind the opening at the insertion tip. The catheter is inserted to 2.5 to 5 cm after urine begins to flow in order to provide sufficient space to inflate the balloon. Inserting the catheter the extra distance will ensure that the balloon is inflated inside the bladder and not in the urethra. Inflating the balloon in the urethra could produce trauma.Rate this question:
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- 25.
A nurse has just collected a sputum specimen by expectoration for a culture on a client who has a productive cough. The nurse plans to implement all of the following interventions. Which of the following nursing action does the nurse identify as the priority?
- A.
Giving the client mouthwash
- B.
Checking to see that the sputum basin is clean
- C.
Sending the sputum specimen to the laboratory immediately
- D.
Providing tissues for the expectoration
Correct Answer
C. Sending the sputum specimen to the laboratory immediatelyExplanation
Sputum specimens for culture should be labeled and transported at the laboratory immediately. Identification of the organism is critical in determining the appropriate treatment for the client. If the sputum sample is not transported immediately for culture, organisms will collect and the potential for contamination of the sample exists, which will then alter results. Options A, B, and D are important but option C identifies the priority action.Rate this question:
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- 26.
A male client who is admitted to the hospital for an unrelated medical problem is diagnosed with urethritis resulting from chlamydial infection. The nursing assistant assigned to the client asks the nurse what measures are necessary to prevent contraction of the infection during care. The nurse tells the assistant that:
- A.
Enteric precautions should be instituted for the client.
- B.
Contact isolation should be initiated, since the disease is highly contagious
- C.
Universal precautions are quite sufficient, since the disease is transmitted sexually
- D.
Gloves and mask should be used when in the clients room.
Correct Answer
C. Universal precautions are quite sufficient, since the disease is transmitted sexuallyExplanation
Chlamydia is a sexually transmitted disease, and is frequently called non-gonococcal urethritis in the male client. It requires no special precautions other than universal precautions. Caregivers cannot acquire the disease during administration of care, and using universal precautions is the only measure that needs to be used.Rate this question:
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- 27.
A client is scheduled for gallbladder surgery is mentally impaired and is unable to communicate. In regard to obtaining permission for the surgical procedure, which nursing intervention would be most appropriate?
- A.
Ensure that the family has signed the informed consent
- B.
Ensure that the client has signed the informed consent
- C.
Inform the family about the advance directive process
- D.
Inform the family about the process of a living will
Correct Answer
A. Ensure that the family has signed the informed consentExplanation
A client must be alert, able to communicate and competent to sign an informed consent. If the client is unable to, the family can sign the consent. A living will lists the medical treatment a person chooses to omit or refuse if the person becomes unable to make decisions and is terminally ill. Advance directives are forms of communication in which persons can give direction on how they would like to be treated when they cannot speak for themselves.Rate this question:
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- 28.
A client diagnosed with tuberculosis (TB) is scheduled to go to the radiology department for a chest x-ray evaluation. Which nursing intervention would be appropriate when preparing to transport the client?
- A.
Apply a mask to the client
- B.
Apply a mask and gown to the client
- C.
Apply a mask, gown, and gloves to the client
- D.
Notify the x-ray department so that the personnel can be sure to wear mask when the client arrives.
Correct Answer
A. Apply a mask to the clientExplanation
Clients known or suspected of having TB should wear a mask when out of the room to prevent the spread of the infection to others. A gown or gloves are not necessary.Rate this question:
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- 29.
A nurse is taking care of a client on contact isolation. After the nursing care has been performed, before leaving the room, which protective item worn during client care would the nurse remove first?
- A.
Gloves
- B.
Mask
- C.
Eye wear (goggles)
- D.
Gown
Correct Answer
C. Eye wear (goggles)Explanation
The nurse removes the goggles first. The nurse unties the gown at the waist and then removes the goggles and discards them. The nurse then removes and discards the mask, unties the neck strings of the gown and allows the gown to fall from the shoulders. The gown is removed without touching the outside of the gown and discarded. The hands are then washed.Rate this question:
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- 30.
A client requests pain medication and the nurse administers an intramuscular (IM) injection. After administration of the injection, the nurse does which of the following first?
- A.
Recaps the needle
- B.
Removes the gloves
- C.
Washes the hands
- D.
Places the syringe in the puncture resistant needle box container
Correct Answer
D. Places the syringe in the puncture resistant needle box containerExplanation
Following administration of an IM injection, the nurse would massage the site to assist in medication absorption. Then the nurse assists the client to a comfortable position. The uncapped needle is discarded in a puncture-resistant container, gloves are removed and hands are washed. A needle is never recapped. Of the options provided, the nurse would perform the option D first.Rate this question:
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- 31.
A nurse is in the process of giving a client a bed bath. In the middle of the procedure, the unit secretary calls the nurse on the intercom to tell the nurse that there is an emergency phone call. The most appropriate nursing action is to:
- A.
Leave the client’s door open so that client can be monitored and answer the phone call
- B.
Finish the bath before answering the phone
- C.
Immediately walk out of the client’s room and answer the phone call
- D.
Cover the client, place the call light within reach, and the answer the phone call
Correct Answer
D. Cover the client, place the call light within reach, and the answer the phone callExplanation
Since the telephone call is an emergency, the nurse may need to answer it. The other appropriate action is to ask another nurse to accept the call. This, however, is not one of the options. To maintain privacy and safety, the nurse covers the client and places the call light within the client’s reach. Additionally, the client’s door should be closed or the room curtains pulled around the bathing area.Rate this question:
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- 32.
A nursing manager is reviewing the purpose for applying restraints with the nursing staff. The nurse manager tells the staff that which of the following is not an indication for the use of restraint?
- A.
To prevent falls
- B.
To restrict movement of a limb
- C.
To prevent the client from pulling out IV lines and catheters
- D.
To prevent the violent client from injuring self and others
Correct Answer
A. To prevent fallsExplanation
Restraints do not necessarily prevent falls. Restraints are devices used to restrict client’s movement in situations when it is necessary to immobilize a limb or other body part. They are applied to prevent self-inflicted injury or from injuring others; from pulling out intravenous lines, catheters, or tubes; or from removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures. Restraints should not be used as a form of punishment.Rate this question:
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- 33.
A nurse has an order to obtain a urinalysis from a client with an indwelling urinary catheter. The nurse avoids which of the following that may contaminate the specimen?
- A.
Obtaining the specimen from the urinary drainage bag
- B.
Clamping the tubing on the drainage bag.
- C.
Aspirating a sample from the port on the drainage bag.
- D.
Wiping the port with an alcohol swab before inserting the syringe
Correct Answer
A. Obtaining the specimen from the urinary drainage bagExplanation
A urine specimen in not taken from the urinary drainage bag. Urine undergoes chemical changes while sitting in the bag and does not necessarily reflect the current client status. In addition, it may become contaminated with bacteria from opening system.Rate this question:
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- 34.
A nursing assistant is caring for an elderly client with cystitis who has an indwelling urinary catheter. The registered nurse provides directions regarding care and ensures that the nursing assistant:
- A.
Uses soap and water to cleanse the perineal area
- B.
Keep the drainage bag above the level of the bladder
- C.
Loops the tubing under the client’s leg
- D.
Lets the drainage tubing rest under the leg.
Correct Answer
A. Uses soap and water to cleanse the perineal areaExplanation
Proper care of an indwelling urinary catheter is especially important to prevent prolonged infection or reinfection in the client with cystitis. The perineal area is cleansed thoroughly using mild soap and water at least twice a day and following a bowel movement. The drainage bag is kept below the level of the bladder to prevent urine from being trapped in the bladder, and for the same reason, the drainage tubing is not placed or looped under the client’s leg. The tubing must drain freely at all times.Rate this question:
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- 35.
A nurse is caring for an elderly client who had a hip pinned for a fractured hip. In planning nursing care, the nurse avoids which of the following to minimize the chance for further injury?
- A.
Side rails in the up position
- B.
Use of the night-light in hospital and bathroom.
- C.
Call bell placed within the client’s reach
- D.
Delays in responding to the call via the intercom that someone will attend to his or her needs.
Correct Answer
D. Delays in responding to the call via the intercom that someone will attend to his or her needs.Explanation
Safe nursing actions intended to prevent injury to the client include keeping the side rails up, the bed in low position, use of a night-light, and providing a call bell that is within the client's reach. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. Communicating with the client via an intercom does not meet the client's need to prevent potential injury.Rate this question:
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- 36.
Following initial assessment, the nurse determines the need to place a vest restraint on a client. The client tells the nurse that he does not want the vest restraint applied. The best nursing action is to:
- A.
Apply the restraint anyway
- B.
Contact the physician
- C.
Medicate the client with a sedative then apply the restraint
- D.
Compromise with the client and use wrist restraints
Correct Answer
B. Contact the physicianExplanation
The use of restraints needs to be avoided if possible. If the nurse determines that a restraint is necessary, this should be discussed with the family and an order needs to be obtained from the physician. The physician’s order protects the nurse from liability. The nurse should explain carefully to the client and family about the reasons that the restraint is necessary, the type of restraint selected, and the anticipated duration of restraint. If the nurse applied a restraint on a client who was refusing it, the nurse could be charged with battery. Compromising with the client is unethical.Rate this question:
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- 37.
A client is being discharged will receive oxygen therapy at home. The nurse is teaching the client and family about oxygen safety measures. Which of the following statements by the client indicates the need for further teaching?
- A.
I realize that I should check the oxygen level of portable tank on a consistent basis.
- B.
I will keep my scented candles within 5 feet of my oxygen tank.
- C.
I will not sit in front of my wood burning fireplace with my oxygen on.
- D.
I will call the physician if I experienced any shortness of breath.
Correct Answer
B. I will keep my scented candles within 5 feet of my oxygen tank.Explanation
Oxygen is a highly combustible gas, although it will not spontaneously burn or cause explosion. It can easily cause a fire to ignite in a client’s room if it contacts a spark from a cigarette, burning candle, or electrical equipment. Options A, C and D are appropriate oxygen safety measures.Rate this question:
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- 38.
A home health nurse visits a client who is to receive intravenous (IV) therapy via an IV pump. The nurse notes that the electrical plug on the wall to be used for the IV pump has only two prongs. Which of the following is the most appropriate action?
- A.
Use the plug anyway
- B.
Tape the electrical cord from the IV pump to the floor before plugging it in
- C.
Run the electrical cord from the IV pump under the carpet before plugging it in
- D.
Obtain a three-prong grounded plug adapter
Correct Answer
D. Obtain a three-prong grounded plug adapterExplanation
Electrical equipment should be grounded. The third longer prong in an electrical plug is the ground. Theoretically, the ground prong carries any stray electrical current back to the ground, hence its name. The other two prongs carry power to the piece of electrical equipment. In this situation the nurse obtains three-prong grounded plug adapter, attaches it to the cord, and plugs it into the wall. Option A, B, and C are unsafe actions.Rate this question:
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- 39.
On an initial home health care visits, the health home care nurse’s assesses the client’s environment for potential hazards. Which observation is an indication that the client needs instruction about safety?
- A.
Skid-resistant small area rugs in the living room
- B.
Clothes hamper at the end of the hallway
- C.
Area rugs on the stairs
- D.
Carpeted stairs secured with carpet tacks
Correct Answer
C. Area rugs on the stairsExplanation
Area rugs and runners should not be based on stairs. Any carpeting on the stairs should be secured with carpet tacks. Injuries from the home frequently result from objects, including small rugs on the stairs and on the floor, wet spots on the floor, clutter on the bedside tables, on closet shelves, on the top of refrigerator, and on bookshelves. Care should always be taken to ensure that the tables are secure and have stable straight legs. Nonessential items should be placed in drawers to eliminate clutter.Rate this question:
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- 40.
A hospitalized client with a history of alcohol abuse tells the nurse, "I am leaving now, I have to go. I don’t want any more treatment. I have things that I have to do right away." The client has not been discharged. In fact, the client is scheduled for an important diagnostic test to be performed in 1 hour. After discussing the client’s concerns, the client dresses and begins to walk out of the hospital room. The most appropriate nursing action is to:
- A.
Restrain the client until the physician can be reached
- B.
Call security to block all exit areas
- C.
Tell the client that he can not return to this hospital again if he leaves now
- D.
Call the nursing supervisor.
Correct Answer
D. Call the nursing supervisor.Explanation
A nurse can be charged with false imprisonment if a client is made to wrongfully believe that he or she cannot leave the hospital. Most health care facilities have documents for the client to sign that relate the client’s responsibilities when he or she leaves against medical advice (AMA). The client should be asked to sign this document before leaving. The nurse should request the client to wait and speak to the physician before leaving, but if the client refuses to do so, the nurse cannot hold the client against his will. Restraining the client and calling security to block exits constitutes false imprisonment. Any client has a right to health care and cannot be told otherwise.Rate this question:
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- 41.
Two nurses are in the cafeteria having lunch in a quiet secluded area. A physical therapist from P.T. department joins the nurses. During lunch, the nurses discuss a client who was physically abused. After lunch, the physical therapist provides therapy as prescribed to this physically abused client and asks the client questions about the physical abuse. The client discovers that the nurses told the therapist about the abuse situation and is emotionally harmed. The ramifications associated with the nurses' discussion about the client are most appropriately associated with which of the following?
- A.
None, because the discussion took place in a quiet secluded area
- B.
They can be charged with slander
- C.
They can be charged with libel
- D.
None, because the physical therapist is involved in the client’s care
Correct Answer
B. They can be charged with slanderExplanation
Defamation occurs when information is communicated to a third party that causes damage to someone else's reputation either in writing (libel) or verbal (slander). Common examples are discussing information about a client in public areas, or speaking negatively about co-workers. The situation identified in the question can cause emotional harm to the client and the nurses could be charged with slander. This situation also violates the client’s right to confidentiality.Rate this question:
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- 42.
A nurse arrives at work and is told that the intensive care unit (ICU) is in need of assistance. The nurse is told by the supervisor that the assignment today is to work in the ICU. The nurse has never worked in the ICU and shares concerns with the supervisor regarding unfamiliarity with technological equipment used in the unit. The nurse is again told to report to the ICU. The most appropriate action by the nurse is to:
- A.
Refuse to go to the ICU
- B.
Go to the ICU, and tell the charge nurse he or she is ill and needs to go home
- C.
Call the hospital lawyer
- D.
Go to the ICU and inform the charge nurse of those tasks that cannot be performed
Correct Answer
D. Go to the ICU and inform the charge nurse of those tasks that cannot be performedExplanation
Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can only work in specified areas, or the nurse can prove the lack of knowledge for the performance of an assigned task. When encountered with this situation, the nurse should set priorities and identify potential areas of harm to the client. All pertinent facts related to client care problems and safety issues should be documented. The nurse should perform only those tasks in which training has been received. It is the nurse’s responsibility to clearly describe these tasks.Rate this question:
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- 43.
A registered nurse (RN) asks a licensed practical nurse (LPN) to change the colostomy bag on a client. The LPN tells the RN that although attendance at the hospital in-service was complete regarding this procedure, the procedure has never been performed on a client. The most appropriate action by the RN is:
- A.
Request that the LPN review the materials from the inservice before performing the procedure.
- B.
Request that the LPN review the procedure in the hospital manual and to bring the written procedure into the client’s room for guidance during the procedure
- C.
Request that another LPN observe the procedure when it is performed
- D.
Perform the procedure with the LPN
Correct Answer
D. Perform the procedure with the LPNExplanation
The RN must remember that even though a task may be delegated to someone, the nurse who delegates maintains accountability for the overall nursing care of the client. Only the task, not the ultimate accountability may be delegated to another. The RN is responsible for ensuring that competent and accurate care is delivered to the client. Requesting that another LPN observe the procedure does not ensure that the procedure will be done correctly. Since this is a new procedure for this LPN, the RN should accompany the LPN, provide guidance and answer questions following the procedure.Rate this question:
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- 44.
A nurse administers the morning dose of digoxin (Lanoxin) to the client. When the nurse charts the medication, the nurse discovers that a dose of 0.25 mg is administered rather than prescribed dose of 0.125 mg. Which nursing action is most appropriate?
- A.
Administer the additional 0.100 mg
- B.
Tell the client that the dose administered was not the total amount and administer the additional dose.
- C.
Tell the client that too much medication was administered and an error was made.
- D.
Complete an incident report
Correct Answer
D. Complete an incident reportExplanation
In accordance with the agency's policies, nurses are required to file incident reports when a situation arises that could or did cause client harm. The nurse also contacts the physician. If a dose of 0.125 mg was prescribed, and a dose of 0.25 was administered, then the client received too much medication. Additional medication is not required and in fact could be detrimental. The client should be informed when an error has occurred, but in a professional manner so as not to cause great fear and concern. In many situations, the physician will discuss this with the client.Rate this question:
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- 45.
A nurse is preparing to transfer an average sized client with right-sided hemiplegia from the bed to the wheelchair. The client is able to support weight on the unaffected side. The nurse plans to use the hemiplegic transfer technique. The client is dangling on the side of the bed. For the safest transfer, the wheelchair should be positioned:
- A.
Near the client's right leg
- B.
Next to either leg
- C.
As space in the room permits
- D.
Near the client's left leg
Correct Answer
D. Near the client's left legExplanation
Although space in the room is an important consideration for placement of the wheelchair for a transfer, when the client has an affected lower extremity, movement should always occur toward the client's unaffected (strong) side. For example, if the client's right leg is involved, and the client is sitting on the edge of the bed, position the wheelchair next to the client's left side. This wheelchair position allows the client to use the unaffected leg effectively and safely.Rate this question:
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- 46.
A nurse is caring for a client with a grave clinical condition who is a potential organ donor. Before approaching the family to discuss organ donation, the nurse reviews the client's medical record for contraindications to organ donation, which would include:
- A.
Allergy to penicillin - type antibiotics
- B.
Age of 38 years
- C.
Hepatitis B infection
- D.
Negative rapid plasma reading ( RPR ) laboratory result
Correct Answer
C. Hepatitis B infectionExplanation
A potential organ donor must meet age eligibilty requirements, which vary by organ. For example, age must not exceed 65 years for kidney donation, 55 years for pancreas or liver donation, and 40 years for heart donation. The client should be free of communicable disease, such as human immunodeficiency virus, hepatitis, or syphilis and the involved organ must not be diseased. Another contraindication is malignancy, with the exception of noninvolved skin and cornea.Rate this question:
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- 47.
A nurse is monitoring the ongoing care given to the potential organ donor who has been diagnosed with brain death. The nurse evaluates that the standard of care had been maintained if which of the following data is observed?
- A.
Urine output 45 mL / hr
- B.
Capillary refill 5 seconds
- C.
Serum pH 7.32
- D.
Blood pressure 90 / 48 mm Hg
Correct Answer
A. Urine output 45 mL / hrExplanation
Adequate perfusion must be maintained to all vital organs in order for the client to remain viable as an organ donor. A urine output of 45 mL / hr indicates adequate renal perfusion. Low blood pressure and delayed capillary refill time are circulatory system indicators of inadequate perfusion. A serum pH of 7.32 is acidotic, which adversely affects all body tissues.Rate this question:
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- 48.
A client who suffered a severe head injury had a vigorous treatment to control cerebral edema. Brain death has now been determined. The nurse prepares to carry out which of the following that will maintain viability of the kidneys before organ donation?
- A.
Monitoring temperature
- B.
Administering IV fluids
- C.
Assessing lung sounds
- D.
Performing range of motion exercises to extremities
Correct Answer
B. Administering IV fluidsExplanation
Perfusion to the kidney is affected by blood pressure, which is in turn affected by blood vessel tone and fluid volume. Therefore, the client who was previously dehydrated to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. Thus, the nurse prepares to infuse IV fluids as prescribed, and continues to monitor urine output. Options A, C and D will not maintain viability of the kidneys.Rate this question:
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- 49.
A nurse is working in the emergency room of a small local hospital when a client with multiple gunshot wounds arrives by ambulance. Which of the following actions by the nurse is contraindicated in the proper care of handling legal evidence?
- A.
Cut clothing along seams, avoiding bullet holes.
- B.
Initiate a chain of custody log
- C.
Place personal belongings in a labeled, sealed paper bag
- D.
Give clothing and wallet to the family.
Correct Answer
D. Give clothing and wallet to the family.Explanation
Basic rules for handling evidence include limiting the number of people with access to the evidence; initiating a chain of custody log to track handling and movement of evidence; and careful removal of clothing to avoid destroying evidence. This usually includes cutting clothes along seams, while avoiding areas where there are obvious holes or tears. Potential evidence is never released to the family to take home.Rate this question:
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- 50.
A nurse working on a medical nursing unit during an external disaster is called to assist with care for clients coming into the emergency room. Using principles of triage, the nurse initiates immediate care for a client with which of the following injuries?
- A.
Bright red bleeding from a neck wound
- B.
Penetrating abdominal injury
- C.
Fractured tibia
- D.
Open massive head injury in deep coma
Correct Answer
A. Bright red bleeding from a neck woundExplanation
The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as delayed, requiring intervention within 30 to 60 minutes. A green or minimal designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant would be applied to the client with massive injuries and minimal chance of survival. This client would be color coded black in the triage process. The client who is color-coded black is given supportive care and pain management, but is given definitive treatment last.Rate this question:
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Current Version
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Mar 21, 2023Quiz Edited by
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Jul 10, 2012Quiz Created by
Mark Fredderick
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