A nurse is caring for a client when they erroneously administer a medication dosage that is greater than the amount

present following ethical principles. Is the nurse demonstrating when they notify the provider of the medication erron?
a. Autonomy
b. Confidentiality
c. Veracity
Can't remember the answer

A nurse is performing morning rounds for a client and finds the client's bedtime medications sitting at the
bedside in a medication cup. Which of the following actions should the nurse take ?
a. Contact the charge nurse to complete an incident report.
b. Document the missed medication administration in the client's medical record.
c. Request that the nurse who prepared the bedtime medications complete a report.
d. Place a copy of an incident report in the client's medical record.
Ans: B

A nurse is providing discharge teaching to a client's adult child regarding the client's discharge to home
with hospice care. Which of the following statements by the client's adult child indicates an understanding
of the teaching?
A. "Once my father is home with hospice, he can no longer be admitted to the hospital."
B. * understand that hospice services are out-of-pocket expenses for the family.
C. "Participating in a hospice program should enable my father to live longer."
D. "The hospice team will provide services for the entire family, not just my father."

Ans: D

A nurse manager is scheduling a meeting to address a conflict between staff members and a client's
family. In the meeting, staff and family members will identify common goals and express their concerns.
Which of the following conflict resolution strategies is the nurse manage implementing?
a. Competition
b. Collaboration
c. Accommodation
d. Smoothing
Ans: B

A nurse in an acute care facility is caring for a client who is leaving against medical advice (AMA).
Which of the following actions should the nurse take? (Select all that apply.)
Attempt to detain the client.
a. Request the client sign an AMA form.
b. Notify the provider of client's intent.
c. Sedate the client while waiting for the provider to arrive.
d. Advise the client about the dangers of leaving.
Ans: a,b,d
A nurse suspects a client is developing opioid use disorder and reduces the client's dosage of pain
medication by 50% without a prescription from the provider. The nurse checks on the client 1 hr later and
sees the client sitting up in a chair. The client tells the nurse, "I am in too much pain to reach the nurse
call button." The nurse is liable for which of the following legal violations?
a. Gross negligence
b. Libel
c. Battery
d. False imprisonment
Ans: A

A nurse is providing teaching for a client about advance directives. Which of the following client
statements indicates an understanding of the teaching?
a. "I need to choose a family member to be my health care proxy."
b. "My family member or a friend will use my living will for health care decisions when I am ill."
c. "I am unable to change my living will after I have signed it."
d. "My health care proxy wifmake my health care decisions when I am no longer able."
Ans: D

A nurse manager is providing disciplinary action for a staff nurse who is claiming 1 hr of overtime every
day for the past month to complete computer documentation. Which of the following actions should the
nurse manager take first?
a. Suspend the nurse.
b. Prepare a written reprimand of the nurse.
c. Terminate the nurse's employment.
d. Speak with the nurse regarding the incident.
Ans: D

A nurse is admitting a client who has heart failure and speaks a different language than the nurse. Which
of the following actions should the nurse take when communicating with the client using an interpreter?
a. Enhance understanding by using metaphors.
b. Observe the client's nonverbal expressions.
c. Address the interpreter when asking questions.
d. Speak words clearly by increasing vocal volume.
Ans: B

A nurse manager is considering changing the policy for administering medications to clients on a unit.
Which of the following actions should the nurse manager take first?
a. Recognize individual efforts during the change process.
b. Develop strategies to enhance acceptance of changes.
c. Create a task force to implement needed changes.
d. Determine the unit staff's perception of the need for change.
Ans: D
A nurse is developing a plan of care for a client who has chronic kidney disease. The client gives the
nurse copies of his advance directives which state that he does not want to begin dialysis. Which of the
following actions should the nurse include in the plan?
a. Document within the medical record that the client has advance directives in place.
b. Place a do-not-resuscitate (DR) bracelet on the client.
c. Ask the client to sign an Against Medical Advice form.
d. Ensure the client's family is aware of the treatment decisions within the advance directives.
Ans: A

A nurse from an acute pediatric unit who has not cared for adult clients in more than 5 years is assigned to
float to a medical surgical of the following actions should the nurse take?
a. Attend a formal orientation training program before reassignment.
b. Negotiate specific tasks to perform with the nursing supervisor.
c. Ask a coworker to take their place.
d. Refuse to accept the assignment to float.
Ans: B

A nurse is caring for a client who was involved in a motor vehicle crash with his partner. The client asks
the nurse about Which of the following actions should the nurse take?
a. Access the electronic health record (HR) of his partner to get a status update for the client.
b. Ask the nurse caring for the partner to come and speak with the client.
c. Tell the client a staff member will check on the partner.
d. Let the dient know that he will be updated as soon as possible.
Ans: D

A nurse manager is meeting with a staff nurse who is consistently late for work. Which of the following
statements by the nurse manager demonstrates an assertive communication style?
a. When you come to work late, I am concerned that client care will be jeopardized."
b. "If you're late one more time I'm going to fire you."
c. No one here likes it when you are late for work and it makes the other staff unhappy. Try to get
here on time."
d. "You disappoint me when you come in late."
Ans: A

A nurse manager on a maternal newborn unit is completing a chart audit on discharged clients to evaluate
the success of breastfeeding education by a lactation consultant. Which of the following types of audits is
the nurse manager utilizing?
a. Structure audit
b. Outcome audit
c. Concurrent audit
d. Prospective audit
Ans: B
A nurse is receiving a change-of-shift report for a group of clients. Which of the following clients should
the nurse
a. A client who requests sumatriptan for a migraine
b. A client who is postoperative and has respiratory rate of 10/min
c. A client who is immobile and has a reddened coccyx
d. A client who is scheduled for a sterile dressing change
Ans: B

A nurse manager is evaluating staffing needs for a unit, including the need for overtime hours. Which of
the following actions should the nurse manager implement first?
a. Develop a written defense of the need for overtime hours to present to the administration.
b. Remind staff members of the importance of avoiding overtime hours.
c. Access computerized data correlating client acuity, staffing, and scheduling.
d. Graph the number of overtime hours in relation to staff to support the need for more staff.
Ans:C

A charge nurse is assigning tasks for a group of clients. Which of the following tasks should the nurse
assign to an assistive personnel (AP)?
a. Collect a urine sample fgg urinalysis.
b. Provide dietary teaching for a client who has a new diagnosis of Crohn's disease.
c. Obtain vital signs for a client who has an unstable blood pressure.
d. Administer medications for a client who has a gastrostomy tube.
Ans: A

A charge nurse is walking outside on the facility's grounds during break time and overhears two nurses
discussing the biopsy results of a client who is on the unit. Which of the following actions should the
nurse take? (Select all that apply.)
a. Tell the nurses to lower their voices when discussing a client.
b. Plan an in-service program for the nurses about HIPAA privacy rules.
c. Ask the nurses to stop discussing the client's protected health information.
d. Inform the nurse manager about the confidentiality breach.
e. Complete an incident report about the nurses' breach of confidentiality.
Ans:B,C,D

A nurse is caring for a client who received pain medication 1 hr ago. The client tells the nurse the
medication is not working because they are still experiencing pain. Which of the following actions by the
nurse demonstrates client advocacy?
a. Provide the client with a back massage to help ease their pain.
b. Recommend the client watch television as a distraction from the pain.
c. Attempt to obtain a prescription for a different analgesic medication.
d. Inform the client that they can receive their next dose in 3 hr.
Ans:C
A nurse is planning care after receiving report for four clients. Which of the following clients should the
nurse plan to assess first?
a. A client who has a BP of 118/74 mm Hg and is receiving treatment for hypertension
b. A cient who has diabetes mellitus and a fasting blood glucose of 96 mg/dL
c. A client who is 2 days postoperative and has a urinary output of 500 mL/24 hr
d. A client who has a heart rate of 68/min and is receiving IV fluids
Ans:C

A nurse in an acute care facility is preparing to discharge an older adult client to home. Which of the
following actions by the nurse demonstrates client advocacy?
a. Providing discharge instructions to the client about medications
b. Documenting the client's emotional concerns regarding discharge
c. Delegating assistive personnel (AP) to discharge the client in a wheelchair
d. Contacting a social worker to assist the client with daily meal delivery services
Ans:D

A nurse is using the situation, background, assessment, recommendation (BAR) format to provide
hand-off report for a client. in which of the following components of the BAR report should the nurse
include information about the client's current vital signs?
a. Situation
b. Background
c. Assessment
d. Recommendation
Ans:C

A nurse is providing care to a group of clients. Which of the following steps should the nurse plan to take
to manage time effectively? (Select all that apply.)
a. Document completed nursing interventions at the end of the day.
b. Complete small tasks first that require the least amount of time and energy.
c. Organize tasks around the priority needs of the clients.
d. Create a list of all planned activities.
e. Delegate tasks to assistive personnel.
C,D,E

A nurse is prioritizing care for four clients. Which of the following clients is the nurse's priority?
a. A client who is postoperative following a thyroidectomy and reports tingling around their mouth.
b. A client who is postoperative following a total hip arthroplasty and reports a pain level of 6 on a
pain scale of 0 to 10.
c. A client who is postoperative following a stapedectomy and reports vertigo.
d. A client who is postoperative following esophageal dilation and has green drainage from a
nasogastric tube.
Ans:A
A charge nurse in an acute care facility is teaching a newly licensed nurse about caring for an
adult client who is cognitively impaired. Which of the following statements by the newly
licensed nurse indicates an understanding of the teaching?
a. "I will let the client sit at the nurses' station during the day."
b. "I will assign the client to a room close to the nurses' station."
c. "I will elevate full-length bed rails while the client is in bed."
d. *I will place a red wrist band on the client to indicate fall risk."
Ans:B

A nurse in an emergency department is assessing an adult client from a long-term care facility who has a
developmental disabili observes bruises in various stages of healing. The client denies any abuse and tells
the nurse not to report the findings actions should the nurse take?
a. Respect the client's wishes.
b. Document the findings for the provider.
c. Share the findings with a close family member of the client.
d. Report the suspected abuse to the client's long-term care facility.
Ans:B

A nurse manager is implementing a plan to motivate unit personnel to provide quality care to clients on
the unit. Which of the following leadership strategies should the nurse manager implement to improve
client care?
a. Democratic leadership
b. Transactional leadership
c. Laissez-faire leadership
d. Authoritarian leadership
Ans:A

A nurse is using the BAR communication tool for reporting a client's condition to the provider. Which of
the following information should the nurse include in the "S" portion of the tool?
a. The client was medicated with morphine 2 mg IV 1 hr ago.
b. The client needs a change in pain medication prescription.
c. The client is reporting a pain level of 8 on a scale from 0 to 10.
d. The client has a heart rate of 110/min and a BP of 148/88 mm Hg.
Ans:C

A nurse is assisting a client who is scheduled to undergo a hysterectomy after signing an informed
consent form. The client states, "Signing this form makes me nervous." Which of the following responses
should the nurse make?
a. "Would you like to speak with the provider again?"
b. "Have you explored alternatives to surgery?"
c. "Would you like one of your family members to sign the form?"
d. "Would you like me to tell you how the provider will perform the procedure?'
Ans: A
A nurse manager is performing a record audit as part of the unit's quality improvement program. The
nurse should identify that which of the following examples demonstrates the correct use of approved
abbreviations in a medical record?
a. Zolpidem 5U PO at bedtime
b. Zolpidem 5 mg PO at bedtime
c. Zolpidem 5 mg PO QD at hs
d. Zolpidem 5.0 mg PO at hs
Ans:B

A nurse manager is preparing a nurse's performance appraisal. Which of the following actions should the
nurse mana
a. Avoid using specific examples of client care to maintain confidentiality.
b. Focus on the nurse's most recent performance just before the evaluation.
c. Present goals to the nurse at the initial meeting.
d. Use a formalized system to discuss important issues.
Ans: D

A charge nurse is following up on a task delegated to another nurse and discovers an error that could harm
the client. Which of the following actions should the charge nurse take?
a. Take accountability for the nurse's mistake.
b. Create an incident report and document it in the client's medical record.
c. Delegate the task to another nurse.
d. Implement interventions to ensure the client's safety.
Ans: D

A nurse in a long-term care facility is caring for a group of clients. The nurse should prioritize which of
the following clients for an interdisciplinary care conference?
a. A client admitted 48 hr ago who has anorexia and a BMI of 23
b. A client who has COPD and an oxygen saturation of 92%
c. A cient who is 1 week postoperative following a hip fracture
d. A client who has decreased mobility and reports constipation
Ans:C

A nurse encounters a client sitting on the floor in the hallway. The client says they slipped on some water
on the floor and now their arm hurts.
Which of the following actions should the nurse take first?
a. Check the client for injuries.
b. Notify the risk management department of the incident.
c. Call for assistance in helping the client back to bed.
d. Call janitorial services to try to dry the floor and post warning signs.
Ans:A
A nurse manager suspects that a staff nurse on the night shift has a substance use disorder. Which of the
following actions should the nurse manager take?
a. Discuss the situation with the facility administrator.
b. Document thoroughly any unusual behavior by the nurse.
c. Impose a 2-week suspension with a strong recommendation for rehabilitation.
d. Counsel the nurse before referring the nurse for help.
B

A nurse manager is anticipating a period when staffing will be especially short. The nurse manager
decides to reorganize the delivery of care on the unit until staffing improves by appointing a charge nurse,
a medication nurse, and a treatment nurse. Which of the following delivery systems is the nurse manager
using?
a. Primary nursing
b. Team nursing
c. Functional nursing
d. Modular nursing
C

A nurse in an emergency department is admitting a 15-year-old client who is accompanied by her

A nurse manager is conducting a disaster-preparedness drill and observes nurses applying triage tags to
clerical staff who are posing as injured clients. The manager should expect the nurses to apply which of
the following tags to a client who has an ankle sprain?
a. Red
b. Yellow
c. Green
d. Black

Ans:C
A nurse is planning care for a client who has hemiparesis and dysphagia following a stroke. The nurse
should collaborate with which of the following members of the interprofessional team to assist the client
with managing ADLs? (Select all that apply.)
a. Occupational therapist
b. Physical therapist
c. Audiologist
d. Respiratory therapist
e. Speech-language pathologist

Ans: A,B,E

A nurse is planning for the discharge of a client who has advanced lung cancer. The client's partner tells
the nurse that she plans to manage the client's care at home but she is concerned about leaving the client
alone to attend to personal errands. Which of the following services should the nurse suggest?
a. Assisted living facility
b. Social services
c. Spiritual support person
d. Respite care
Ans: D

A nurse is assessing a client who is 4 hr postoperative following an open appendectomy. Which the nurse
that the client requires a nasogastric tube with low intermittent suction?
a. creased oxygen saturation
b. bdominal distention
c. Decreased bowel sounds
d. Inosional pain
Ans:B

A nurse manager witnesses an assistive personnel (AP) using incorrect procedure when transferring a
client using a mechanical lift. After reinforcing proper procedure, which of the following methods should
the nurse manager use to evaluate the AP's understanding of the teaching
a. Require the AP's attendance at an in-service about the lift.
b. Assign the AP to work with a senior staff member when using the lift.
c. Observe the AP's technique with the lift at random times throughout the day.
d. Enforce the staff's completion of skills modules about medical equipment.
Ans: C

A nurse manager calls a staff nurse to come in and work due to staffing shortages on several units. The
staff nurse is at home and has influenza Which of the following actions by the staff nurse demonstrates
the ethical principle of nonmaleficence?
a. Report to work as requested.
b. Agree to work only until the supervisor can find a replacement.
c. State that staff nurses do not have an obligation to work on days off.
d. Decline because nurses should not work when ill. Ans:D
A charge nurse is teaching a newly licensed nurse about providing written discharge instructions for a
client who is postoperative following an arthroplasty. The charge nurse should identify that which of the
following discharge instructions written by the newly licensed nurse indicates understanding of the
teaching?
A. Take oxycodone 10 mg, q6h, PRN, for pain.
B. Report pus-like drainage from the wound.
C. Resume Na-restricted diet.
D. Perform quadriceps setting exercises when supine.
Ans: B

A nurse is delegating client care on a labor and delivery unit. Which of the following tasks should the
nurse delegate to assistive personnel?
a. instruct a client about breathing techniques.
b. Complete In an out on clients who are in active labor.
c. Obtain a fetal heart rate from a client who is a primipara and is in early labor.
d. Obtain consent from a client for cesarean birth.
Ans: B

A nursing supervisor in an acute care facility has to recommend a client for discharge to make room for a
client who was injured during an explosion. Which of the following clients should the nurse recommend
for discharge?
a. A young adult client who has a new diagnosis of diabetes insipidus
b. An adult client who is on telemetry for dysrhythmias
c. An older adult client who had a total knee arthroplasty 1 week ago
d. An adult client who had a bowel resection 1 day ago
Ans: C

A nurse is preparing a client for a surgical procedure to continue the revision of a large burn scar on the
left arm. The client tells the nurse that they want to cancel the procedure. Which of the following
responses should the nurse make?
a. *This procedure will improve the appearance of your arm
b. Why have you changed your mind about this procedure?"
c. "I will inform the provider of your decision."
d. "Don't worry, this is a routine procedure."
Ans: C
A charge nurse is observing a newly licensed nurse administer a unit of packed RBCs to a client. The
charge nurse should identify the nurse has completed the procedure correctly when he completes the steps
in which order? (Move the steps into the box on the right, placing them in the selected order of
performance. Use all the steps.)

INITIATE
INFUSE
OBTAIN
VERIFY
INSERT

A nurse manager is planning the staff's annual performance appraisals. Which of the following locations
should the conduct the appraisals?
a. A Dr vate office with the door closed
b. the nurses station to be accessible to staff
c. A quiet location with a witness present
d. in a conference room sitting behind a large desk
Ans:A

A nurse manager is changing the ratio of registered nurses (RNs) to licensed practical nurses (LPs) on a
unit to decrease costs. Which of the following strategies should the nurse manager implement to reduce
resistance from the staff?

a. Send a memo to each staff member announcing the new RN/LP ratio.
b. Assign the staff to read research articles about the process of change.
c. Formulate a sample staffing schedule covering 1 month.
d. Discuss the planned change with other nurse managers.

Ans:C