Detailed Answer Key

NUR450C Exam 1

1. A nurse is caring for a client who has received chemotherapy. The client experiences severe nausea and
vomiting. The nurse should monitor the client for which of the following clinical manifestations?

A. Metabolic acidosis
Rationale: Metabolic acidosis occurs when there is a loss in gastrointestinal fluid.

B. Metabolic alkalosis
Rationale: Metabolic alkalosis occurs when there is excessive vomiting and there is a loss in
hydrochloric acid.

C. Respiratory acidosis
Rationale: Respiratory acidosis occurs when there is an alteration in respiratory function.

D. Respiratory alkalosis
Rationale: Respiratory alkalosis occurs when there is an alteration in respiratory function.

2. A client with sleep apnea receives a new prescription for a continuous positive airway pressure (CPAP)
device. A week later the client returns to the clinic and says that severe daytime fatigue is still a problem.
Which action should the nurse take first?

A. Teach the patient about radiofrequency ablation.

B. Plan to schedule a night-time sleep study.

C. Ask the client if the CPAP device is being used every night.
Rationale: CORRECT ANSWER. CPAP is very effective in reducing sleep apnea, but
compliance is frequently a problem. Surgery and other studies may be indicated, but
the nurse's first action should be to assess whether the CPAP is being used as
prescribed. (ATI Adult Med-Surg Nursing, 9th ed., p. 207; Brunner & Suddarth, p.
511)

D. Discuss the possible surgical approaches used for sleep apnea.

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3. A client has a warm, moist compress to the lower extremity. Which of the following actions should the nurse
recognize as a risk to client safety?

A. Placing plastic wrap around the client’s compress and extremity

Rationale: Plastic wrap can be used to insulate the compress and retain heat. This does not
pose a risk to client safety.

B. Securing the client’s moist compress with a dry towel

Rationale: A dry towel can be used to retain heat. This is not a risk to client safety.

C. Changing the client’s warm, moist compress frequently

Rationale: Heat from the warm compress dissipates quickly. The compress should be changed
often to maintain a constant temperature.

D. Removing the client’s robe and blankets covering compress

Rationale: Moist heat promotes vasodilation and evaporation of heat from the skin’s surface.
The client can become cool and shiver. This could potentially decrease the client’s
body temperature and place the client at risk. The nurse should control drafts within
the room and keep the client covered with a blanket or robe.

4. A nurse is caring for a client who is confused and refuses to let the nurse insert an NG tube. The provider tells
the nurse to restrain the client in order to insert the tube. The nurse recognizes that following the provider’s
order is

A. assault.
Rationale: The nurse commits assault if she threatens to touch the client without consent.

B. invasion of privacy.
Rationale: Invasion of privacy occurs when the nurse violates the client’s confidentiality.

C. defamation of character.
Rationale: Defamation of character occurs if the nurse writes derogatory statements about the
client’s refusal of the treatment.

D. false imprisonment.
Rationale: False imprisonment occurs when the nurse restrains the client in order to perform a
treatment that the client has refused.

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5. 200 mcg = _____ mg

0.2 mg

6. A nurse is providing health promotion teaching to an adolescent. Which of the following is the leading cause of
death among this age group?

A. Suicide
Rationale: Suicide is the third leading cause of death among adolescents.

B. Homicide
Rationale: Homicide is the second leading cause of death among adolescents.

C. Accidents
Rationale: Accidents are the leading cause of death among adolescents.

D. Cancer
Rationale: Cancer is the fourth leading cause of death among adolescents.

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7. A nurse is caring for a client who has diverticular disease. When palpating the client’s abdomen where should
the nurse anticipate abdominal pain?

A. Lower left quadrant

Rationale: The nurse should expect the client to have abdominal pain in the lower left quadrant
of the abdomen. The disease is usually found in the sigmoid colon where high
pressure to move fecal contents from the rectum causes pouch formation.

B. Upper left quadrant

Rationale: The nurse should not expect the client to have abdominal pain in the upper left
quadrant area because the disease is generally located in the sigmoid colon.

C. Lower right quadrant

Rationale: The nurse should not expect the client to have lower right quadrant abdominal pain
because the disease is generally located in the sigmoid colon.

D. Upper right quadrant

Rationale: The nurse should not expect the client to have upper right quadrant because the
disease is generally located in the sigmoid colon.

8. A nurse is caring for a client who has received chemotherapy. The nurse is aware that a client with
myelosuppression is at risk for which of the following?

A. Anorexia and malnutrition

Rationale: Anorexia and malnutrition is not directly related to myelosuppression, but can occur
with chemotherapy.

B. Bleeding from the gums

Rationale: Bleeding from the gums is directly related to myelosuppression due to inhibited
production of blood cells and platelets. This results in bleeding which can show up
in the gums.

C. Diarrhea and dehydration

Rationale: Diarrhea and dehydration is not directly related to myelosuppression, but can occur
with chemotherapy.

D. Full body alopecia

Rationale: Full body alopecia is not directly related to myelosuppression, but can occur with
chemotherapy.

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9. The nurse recognizes that a developmental task of young adults is establishing intimate relationships. What
question should the nurse include in a young adult patient’s assessment interview to gather data related to this
task?

A. “How do you spend your leisure time?”

Rationale: This would be more appropriate for a patient in middle adult stage.

B. “Describe your relationship with the other members of your family.”

Rationale: Other options would not provide appropriate information about sexual practices.

C. “How honest can you be with your friends?”

Rationale: Does not provide appropriate information about sexual practices.

D. “What protection do you use when you have sexual intercourse?”

Rationale: Providing accurate information about certain sexual health risks is an important
nursing intervention for young adults (18 - 25 years old) in Erikson's Intimacy vs.
Isolation stage. Other options would not provide appropriate information about
sexual practices.

10. The value of having a certified practice area for nurses in Health Information Technology is important
especially for implementing the Electronic Health Record (E.H.R.). Nurses recognize that their unique
contribution is based on which of the following?

A. Education in medicine and nursing.

B. Ability to communicate with all health care professionals.

Rationale: The coordination of information and user acceptance is achieved through
communicating with all health care professionals. Nurses do this all the time when
planning patient care with the multi-disciplinary team.

C. Know the documentation requirements of all health care professionals.

D. Regularly interact with lawyers who also will use E.H.R.

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11. A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of
cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

A. Obtain a pair of slipper-socks for the client.

Rationale: Slipper-socks are soft, short socks with a non-skid bottom that are dispensed to
hospital clients to help provide warmth and increase the client's level of comfort.

B. Rub the client's feet briskly for several minutes.

Rationale: Massaging of the legs or feet may cause a clot to break loose in the bloodstream
and is contraindicated in any client with impaired arterial or venous circulation of the
lower extremities.

C. Increase the client's oral fluid intake.

Rationale: Increasing oral intake will not increase circulation to an area impaired by occlusion.

D. Place a moist heating pad under the client's feet.

Rationale: Heating pads are contraindicated for clients with impaired arterial or venous
circulation to a lower extremity. If there is co-existing sensory involvement, the client
may not be able to feel a burn and be prone to severe injury.

12. A nurse is notified that a client has filed a complaint about care received on the nursing unit from one of the
assistive personnel (AP). The nurse should understand that the delivery of quality care to a specific client is
primarily the responsibility of the

A. admitting provider.
Rationale: The admitting provider is responsible for prescribing client care.

B. institution providing the care.

Rationale: The institution is responsible for making resources available for care.

C. staff member providing care.

Rationale: The responsibility for the delivery of quality care rests with the staff member who
directly provides the care. Individuals have the greatest impact on the perceived
quality of care provided to a specific client in any health care organization.

D. the nurse manager for the unit.

Rationale: The nurse manager is responsible for providing staff to carry out client care.

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13. What group constitutes the largest group of healthcare professionals, including experts who serve on national
committees and initiatives focused on policy, standards and terminology development, and standards
coordination, and electronic health record adoption?

A. Nurses
Rationale: There are some 3 million registered nurses in the work force today. They are, by far,
the largest group of practicing healthcare professionals today. (TNA & TONE, 2013,
Powerpoint)

B. Physicians

C. Health Information Professionals

D. Nurse informaticists

14. A client who was in a motor vehicle accident reported chest pain and difficulty breathing. The chest x-ray
reveals a pneumothorax and arterial blood gases are drawn. Which findings should the nurse expect?

A. pH 7.12; PaO2-89, PaCO2-51, HCO3-24.

Rationale: CORRECT ANSWER. With a low pH indicating acidosis, the PaCO2 is elevated
which indicates the problem is respiratory acidosis and is what is expected with this
diagnosis. (Craven, 2013; Brunner & Suddarth, pp. 269-271)

B. pH 7.42; PaO2-100, PaCO2-36, HCO3-23

Rationale: INCORRECT ANSWER. : This is a normal blood gas result.

C. pH 7.06; PaO2-98, PaCO2-35, HCO3-20

Rationale: INCORRECT ANSWER. This is metabolic acidosis

D. pH 7.51; PaO2 96, PaCO2-38, HCO3-29

Rationale: INCORRECT ANSWER. This is metabolic alkalosis.

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15. A client who is admitted with post-traumatic stress disorder is provided with education about methods to
reduce stress. The nurse recognizes further instruction is required when the client identifies which of the
following as a stress reduction technique?

A. The client begins reading a book when he experiences hand tremors in response to loud noise.
Rationale: This is an adaptive use of dissociation by temporarily blocking memories and
perceptions from conscious thought. Dissociation involves a disruption in the usually
integrated functions of consciousness, memory, identity, or perception of the
environment. This client has a physical response of hand trembling when he hears
loud noise, and chooses to dissociate from the loud noise by reading.

B. The client makes a decision to postpone a needed surgery.

Rationale: This is a maladaptive use of suppression, which is voluntarily denying unpleasant
thoughts and feelings. Suppression is the conscious denial of a disturbing situation
or feeling. This client is consciously suppressing the need to get a surgery.

C. The client focuses on discussing a daily routine when asked about a tragedy.
Rationale: This is a maladaptive use of intellectualization. Intellectualization is a process in
which events are analyzed based on remote cold facts and without passion, rather
than incorporating feeling and emotion into the processing. This client chooses to
focus on a remote daily routine rather than processing the recent tragedy.

D. The client develops stomach pains when fire is seen on television.

Rationale: This is a maladaptive use of conversion. Conversion is the unconscious
transformation of anxiety into a physical symptom with no organic cause. This client
feels anxious when seeing fire on television due to his recent tragedy. This feeling
then converts into stomach pains.

16. A client who is pregnant asks the nurse for her due date. The client's last menstrual period began on July 27.
What is the client's due date? (State the date in MMDD. For example, July 27 will be 0727)

A. 0504
Correct Rationale: Using Nägele's rule, the nurse should subtract three months from the date
of the last menstrual period, then add 7 days. July minus 3 months equals
April (07 - 3 = 04). There are 30 days in April, so 27 + 7 = (28, 29, 30, 1, 2,
3) 4. The client's estimated due date is May 4 (05/04).
Incorrect Rationale: Using Nägele's rule, the nurse should subtract three months from the date
of the last menstrual period, then add 7 days. July minus 3 months equals
April (07 - 3 = 04). There are 30 days in April, so 27 + 7 = (28, 29, 30, 1,
2, 3) 4. The client's estimated due date is May 4 (05/04).

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17. Which of the following terms best describes the ideal method of operation for health information technology?

A. Interfaced
Rationale: the parts of the system are connected together but each part only functions with the
given part it is connected to, not with the whole system. (TNA & TONE, 2013,
Powerpoint)

B. Integrated
Rationale: all parts of the process are smoothly matching each other and provide efficient
functioning of the entire system. (TNA & TONE, 2013, Powerpoint)

C. Individualistic
Rationale: not correct

D. Independent
Rationale: not correct

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18. A nurse is preparing to administer morphine 6 mg via IV bolus. Available is morphine 4 mg/mL. How many mL
should the nurse administer? (Round the answer to the nearest tenth place.)

A. 1.5 mL
Correct Rationale: Desired x Quantity
—————————— = Amount to give
Have

6 mg x 1 mL
——————————— = Amount to give
4 mg

6
————— = X mL
4

X = 1.5 mL
Incorrect Rationale: Desired x Quantity
—————————— = Amount to give
Have

6 mg x 1 mL
——————————— = Amount to give
4 mg

6
————— = X mL
4

X = 1.5 mL

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19. A nurse has spilled doxorubicin (Adriamycin) on a client’s hand. Which of the following should be the nurse's
initial action?

A. Notifying the hazardous materials response team

Rationale: It is appropriate to contact the facility’s hazardous materials response team
(Hazmat). The Hazmat team would be trained in appropriate containment and
disposal of the chemical spill. However, this is not the initial action the nurse should
take.

B. Calling the poison control center

Rationale: Material, Safety, and Data Sheets (MSDS) should be located in all areas where
biohazard chemicals are being used. MSDS provide information specific to
chemicals and procedures for their cleanup and treatment. The poison control
center would also be able to provide information, but this should not be the initial
action taken.

C. Taking the client to the emergency department

Rationale: Material, Safety, and Data Sheets (MSDS) should be located in all areas where
biohazard chemicals are being used. MSDS provide information about chemicals
and procedures for cleanup and treatment. Doxorubicin comes in powder form and
could possibly be inhaled and/or spilled after dilution. The client should be
evaluated, but decontamination should be the first action. If inhalation were to
occur, then oxygen should be administered and the provider contacted.

D. Washing the affected area with cool soapy water

Rationale: The nurse should immediately wash the affected area to remove any residual of the
chemical from the area. Contaminated clothing should be removed as well to avoid
further contact with the chemical. The contaminated clothing should be placed into a
large sealed plastic bag. Physical removal of the chemical is the highest priority
because there is a direct relationship between contact time and effect for most
chemical contact. Aside from a few exceptions, water is the universal antidote. The
Material, Safety, and Data Sheet (MSDS) for doxorubicin indicates that first aid
treatment includes washing the affected area with cool, soapy water.

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20. A nurse is caring for a client who has diabetes mellitus and has been prescribed prednisone (Deltasone) for an
allergic response to poison ivy exposure. Which of the following client statements indicates a need for further
education?

A. “I may need to increase my Regular insulin during this time.”

Rationale: Prednisone belongs to a classification of steroidal medications called
glucocorticoids. Use of prednisone has been noted to alter adrenal balance and
may dramatically increase serum glucose levels, especially in clients who have
diabetes mellitus.

B. “When my rash goes away, I can stop the Deltasone.”

Rationale: If prednisone, a glucocorticoid medication, is taken for longer than 7 days, adrenal
suppression will occur. If a client suddenly stops taking prednisone, adrenal
insufficiency or crisis can develop. Insufficient adrenal hormones result in Addison’s
disease and Addisonian crisis or profuse adrenal insufficiency can develop with
sudden cessation. The adrenal glands are primarily responsible for release of
hormones related to stress responses. The adrenal glands synthesize
corticosteroids and impact renal function through the secretion of
aldosterone.Clients should be educated to taper off of the medication to avoid
adrenal crisis. Written directions should be provided to the client on how to taper.
Alternatively, prednisone is available in a pre-tapered package.

C. “It is normal to feel a little emotional when I am on this medicine.”

Rationale: Emotional lability and anxiety are common side effects when beginning prednisone
therapy. Clients should be educated regarding the possibility that they may be more
emotionally sensitive during this time. Care and caution should be taken when
providing deltasone to clients with a known history of anxiety or other mental health
disorders.

D. “I may have a hard time falling asleep or staying asleep while on Deltasone.”
Rationale: Insomnia is a common side effect of prednisone. Encourage clients to exercise
caution when driving or operating machinery because of this. Alcohol should be
avoided when taking prednisone, as this may add to the insomnia. Clients may also
notice overwhelming fatigue when taking prednisone.

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21. A nurse is assessing a client for hospice services. Which of the following disease types makes a client eligible
for this type of service?

A. Chronic
Rationale: Having a chronic disease does not make a client eligible for hospice services.

B. Terminal
Rationale: A client who has been diagnosed with a terminal disease, and who is deemed to
have less than 6 months to live, is eligible for hospice services.

C. Genetic
Rationale: Having a genetic disease does not make a client eligible for hospice services.

D. Contagious
Rationale: Having a contagious disease does not make a client eligible for hospice services.

22. A nurse is admitting a 6-month-old infant who has dehydration. When she tracks the client’s urinary output,
which of the following amounts should indicate to the nurse that the treatment has corrected the fluid
imbalance?

A. 0.5 mL/kg/hr
Rationale: This amount of urine indicates that the infant is still dehydrated.

B. 2 mL/kg/hr
Rationale: The expected urinary output for infants up to the age of 1 year is 2 mL/kg/hr. An
infant who is not dehydrated should produce this amount of urine.

C. 7.5 mL/kg/hr
Rationale: This is outside the expected range of urine output for an infant who is 6 months old.

D. 15 mL/kg/hr
Rationale: The expected urinary output for adults is 15 mL/kg/hr.

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23. What is the advantage to nurses of using a nursing information technology system in the hospital system?

A. Computer screen reminders prompt relevant charting.

Rationale: Only option that involves a nursing activity. (TNA, TONE, 2013, Powerpoint)

B. Hospital costs are increased.

C. Compliance with government regulations is enhanced.

D. The hospital image in the community is improved.

24. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already
receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse’s priority?

A. Increase the oxygen flow

Rationale: The client may need more oxygen, but this requires a provider’s prescription after a
careful assessment of oxygenation status.

B. Assist the client to fowler’s position.

Rationale: B is the correct answer. The priority action the nurse should take when using the
airway, breathing, circulation (ABC) approach to care delivery is to relieve the
client’s dyspnea (difficulty breathing). Fowler’s position facilitates maximal lung
expansion and thus optimizes breathing. With the client in this position, the nurse
can better assess and determine the cause of the client’s dyspnea. (ATI
Fundamentals, 8th edition, 2013, p. 570; p. 556)

C. Promote removal of pulmonary secretions.

Rationale: The client may need suctioning or expectoration, as pulmonary secretions may be
the cause of his difficulty breathing. However, there is a higher priority given the
nature of the client’s distress.

D. Obtain a specimen for arterial blood gases.

Rationale: It is important to check the client’s oxygenation status, and in many nursing
situations, assessment precedes action, but there is a higher priority given the
nature of the client’s distress. (all rationales found on ATI fundamentals, 8th ed., p.
570)

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25. The nurse is planning care for a client who has been identified as "at risk" for falling. Which nursing
intervention is most likely to prevent injury if the client falls?

A. Obtain a bedside commode.

B. Place the bed in the lowest position.

Rationale: CORRECT ANSWER. This will help reduce injury if the client tries to get out of bed.
This is one of the four P's for client care. (Craven, 2013)

C. Have a sitter stay with the client.

Rationale: INCORRECT ANSWER. This may not prevent falling.

D. Move the chair to the window.

Rationale: INCORRECT ANSWER. This will not prevent falling.

26. A nurse is teaching a newly licensed nurse on the proper procedure for inserting an IV catheter for a
preoperative client. Which of the following statements by the nurse indicates understanding of the procedure?

A. “I will thread the needle all the way into the vein until the hub rests against the insertion site after I
see a flashback of blood.”
Rationale:

B. “I will insert the needle into the client’s skin with the bevel up at an angle of 10 degrees to 30
degrees.”
Rationale: (B is the correct answer. The nurse inserts the catheter into the skin with the bevel
up at an angle of 10-30 degrees using a steady, smooth motion. This is the optimal
angle to prevent puncture of the posterior vein wall. ATI, Fundamentals for Nursing,
8th edition, p. 526)

C. “I will apply pressure approximately 1.25 inches below the insertion site prior to removing the
needle.”

D. “I will choose the antecubital fossa vein for IV insertion due to its size and easily accessible location.”

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27. An older adult client is brought to the hospital by his family after he was found wandering outside. During the
initial assessment, the nurse notes that the client flinches when his abdomen is palpated, and responds to
questions by nodding and smiling only. Which of the following should the nurse recognize as a likely
explanation for the client's behavior?

A. He is hard of hearing.
Rationale: There is no indication that the client is hard of hearing.

B. He is in too much pain to focus on the nurse's questions.

Rationale: A client in pain is usually still able to provide critical assessment information.

C. He is confused.
Rationale: Since the client was manifesting signs of confusion before coming to the emergency
department, and is currently manifesting an inability to understand speech, it is
appropriate to assume the client is confused.

D. He does not speak English.

Rationale: There is no indication that the client does not speak English.

28. A nurse is reinforcing teaching for a client who is neutropenic. Which of the following should the nurse include
in the teaching?

A. Eat plenty of fresh fruits and vegetables.

Rationale: The nurse should inform the client to avoid fresh fruits and vegetables due to the
bacteria they can carry.

B. Avoid crowds.
Rationale: The nurse should inform the client to avoid crowds due to their immune system
being suppressed.

C. Undertake mild exercise like gardening.

Rationale: The nurse should inform the client to avoid gardening due the soil containing
bacteria.

D. Take temperature weekly.

Rationale: The nurse should not inform the client to take their temperature weekly. A client who
is neutropenic may only experience a 1 degree increase from their baseline
temperature.

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29. The nurse understands that in response to an above normal serum Calcium level, the thyroid gland will
increase release of which hormone?

A. Calcitonin

B. Thyroid Stimulating Hormone (TSH)

C. Cholecalciferol

D. Aldosterone

30. A nurse is caring for a client who is prescribed an infusion of 5% dextrose in water. Which of the following is
the amount of dextrose in this solution?

A. 5 g/L
Rationale: This is not the amount of dextrose in a solution of 5% dextrose in water.

B. 500 g/L
Rationale: This is not the amount of dextrose in a solution of 5% dextrose in water.

C. 5 g/100 mL
Rationale: A solution of 5% dextrose in water contains 5 grams of dextrose per 100 mL.

D. 50 g/100 mL
Rationale: This is not the amount of dextrose in a solution of 5% dextrose in water.

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31. A nurse is caring for a 5-year-old client who is postoperative following a tonsillectomy. The surgeon initially
prescribes a clear liquid diet. Which of the following items should the nurse include on the child’s lunch tray?
(Select all that apply.)

A. Broth

B. Grape juice

C. Nonfat milk

D. Custard

E. Lemon gelatin

Rationale: Broth is correct. Broth is an acceptable component of a clear liquid diet.

Grape juice is correct. Grape juice is an acceptable component of a clear liquid diet.

Nonfat milk is incorrect. Nonfat milk is an acceptable component of a full liquid diet,
not a clear liquid diet.

Custard is incorrect. Custard is an acceptable component of a full liquid diet, not a

clear liquid diet.

Lemon gelatin is correct. Lemon gelatin is an acceptable component of a clear

liquid diet.

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32. A nurse is providing teaching to a group of parents of newborns who are planning to formula feed. Which of
the following statements by one of the parents indicates a need for further teaching?

A. “I will give formula to my baby at room temperature.”

Rationale: This is an appropriate statement by a parent. Formula can be served at room
temperature, warmed, or cold.

B. “I will ensure my baby’s feedings last 10 to 15 minutes.”

Rationale: This statement by a parent indicates a need for further teaching. Feedings should
last 20 to 30 minutes.

C. “I will burp my baby half way through each feeding.”

Rationale: This is an appropriate statement by a parent. Burping the infant half way through
each feeding will help to get rid of air swallowed during the feeding.

D. “I will watch for signs my baby is full and stop the feeding.”
Rationale: This is an appropriate statement by a parent. Watching for signs of being full and
stopping the feeding will prevent overfeeding.

33. The nurse understands that in response to an above normal serum Calcium level, the thyroid gland will
increase release of which hormone?

A. Calcitonin

B. Thyroid Stimulating Hormone (TSH)

C. Cholecalciferol

D. Aldosterone

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34. A nurse is preparing an inservice for a group of newly licensed nurses about organ donation. Which of the
following information should the nurse include?

A. The nurse caring for the client at the time of death should request organ donation.
Rationale: Specially trained professionals in the facility request organ donation from the
appropriate parties.

B. Donation costs are the responsibility of the donor’s family and estate.
Rationale: There is no cost to the donor’s family or estate for organ donation.

C. The nurse may serve as a witness to a consent for organ donation.

Rationale: Nurses may witness families signing consents for organ donation after a specially
trained professional requests consent.

D. Clients who meet age requirements may donate whichever organs they choose.
Rationale: Age is not the only criterion for organ donation. The organ procurement organization
has guidelines for screening potential donors according to various criteria.

35. A nurse is conducting a nutritional assessment on a client who weighs 165 lb. Based on this information the
nurse can calculate that the client’s Recommended Dietary Allowance for protein is how much per day?
(Round the answer to the nearest whole number.)
_____________ g

A. 60 g
Correct Rationale: The RDA for protein is 0.8 mg/kg. To calculate the client’s RDA for protein,
the nurse would first determine the client’s weight in kg, and then multiply
by 0.8 mg/kg.

__165 lb__ = 75 kg
2.2 lb/kg
75 kg x __0.8 mg__ = 60 g
1 kg
Incorrect Rationale: The RDA for protein is 0.8 mg/kg. To calculate the client’s RDA for
protein, the nurse would first determine the client’s weight in kg, and then
multiply by 0.8 mg/kg.

__165 lb__ = 75 kg
2.2 lb/kg
75 kg x __0.8 mg__ = 60 g
1 kg

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36. A patient is brought in by ambulance with frostbite to the bilateral lower extremities. The patient states that he
is homeless and lives “in a box in an alley.” What orders for rewarming the patient’s legs would the nurse
expect to receive from the physician?

A. Place in 104 degree Fahrenheit circulating bath until circulation is effectively restored.
Rationale: Option A is the only correct intervention. Options B, C, and D are contraindicated.

B. Place in alternating hot and cold water until circulation is effectively restored.

C. Massage the affected areas once every hour until circulation is effectively restored.

D. Pack armpits and groin with bottles of heated saline until circulation is effectively restored.

37. A nurse is caring for a client who has thickened skin, hyperpigmentation, and parasthesia in the lower
extremities. Which of the following actions should the nurse implement?

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A. Dorsiflex the feet.

Rationale: This finding would be associated with Homans’ sign, which is associated with a
deep-vein thrombosis (DVT). Pain in the calf on dorsiflexion of the foot (positive
Homans’ sign) is no longer used as a valid assessment for DVT and is not advised
for diagnosis because it occurs in only 10% of cases and may represent a false
positive.

B. Apply elastic stockings.

Rationale: This client is exhibiting signs and symptoms of venous insufficiency. Venous
insufficiency occurs as a result of prolonged venous hypertension, which stretches
the veins and damages the valves. Signs and symptoms of venous insufficiency
include itching and tingling, dull aching sensations, cramping and heaviness in legs,
thickened skin, hyperpigmentation, discomfort when standing, painless ulcerations,
and leg edema. Treatment for venous insufficiency focuses on preventing stasis,
decreasing edema, and promoting venous return. Elastic stockings should be worn
during the day and evening, and applied before getting out of bed. Elastic or
compression stockings reduce venous stasis and assist in venous return of blood to
the heart.

C. Immobilize the legs.

Rationale: There is no indication that the legs are injured; it would be appropriate to immobilize
for a strain, sprain, or fracture. It also would be appropriate to immobilize legs (place
client on bed rest) if deep-vein thrombosis (DVT) is suspected. There is no
indication of DVT.

D. Position the legs dependently.

Rationale: Dependent position would be appropriate for arterial insufficiency. This is not an
arterial problem. Signs and symptoms of arterial insufficiency include intermittent
claudication (pain when walking that stops when resting), shiny skin, diminished
pulses, sparse hair, cool extremity, paresthesia, and tingling. This client has venous
insufficiency. Elevation would be appropriate for venous insufficiency. Elevating the
limb (i.e., higher than the heart) would promote return of blood to the heart and
improve circulation. Legs should be elevated for at least 20 min four to five times a
day.

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38. A nurse is planning teaching for the parents of a toddler who follow a vegetarian diet. The nurse should plan to
include which of the following foods as the best source of dietary protein for the child?

A. Soy milk
Rationale: Soy products are a source of complete protein and should be included as the best
source of dietary protein for the child.

B. Peanut butter
Rationale: Peanut butter is a source of incomplete protein and should be included as a source
of dietary protein, but is not the best source.

C. Dried beans
Rationale: Dried beans are a source of incomplete protein and should be included as a source
of dietary protein, but is not the best source.

D. Whole grains
Rationale: Whole grains are a source of incomplete protein and should be included as a source
of dietary protein, but is not the best source.

39. A nurse is preparing to transfuse a client with a unit of RBC. During the first 15 min, which of the following
infusion rates should the nurse start the RBC at?

A. 10 mL min
Rationale: A nurse should set the infusion rate at 5mL/min, not 10mL/min, to observe for a
transfusion reaction and to successfully treat the reaction to the RBC.

B. 5 mL/min
Rationale: A nurse should set the infusion rate at 5mL/min to observe for a transfusion reaction
and to successfully treat the reaction to the RBC.

C. 40 mL/ min
Rationale: A nurse should set the infusion rate at 5mL/min, not 40mL/min, to observe for a
transfusion reaction and to successfully treat the reaction to the RBC.

D. 20 mL/min
Rationale: A nurse should set the infusion rate at 5mL/min, not 20mL/min, to observe for a
transfusion reaction and to successfully treat the reaction to the RBC.

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40. A nurse is observing a newly hired nurse on the unit who is preparing to administer a blood transfusion. Which
of the following actions by the newly hired nurse requires intervention by the nurse?

A. Inserts a large-bore IV catheter in the client.

B. Verifies blood compatibility and expiration date of the blood with an assistive personnel.
Rationale: (Correct answer = b. The nurse must verify blood with a RN or physician. ATI, 2013,
8th ed., RN Adult Medical Surgical Nursing, p. 455; Brunner-Suddarth, p. 892. The
other options are all correct interventions that the nurse would do for a blood
transfusion.)

C. Administers 0.9% sodium chloride IV.

D. Assesses for a history of blood-transfusion reactions.

41. A nurse has several tasks to delegate to an assistive personnel (AP). Which of the following tasks should the
nurse ask the AP to perform first?

A. Take an arterial blood gas specimen to the laboratory.

Rationale: Arterial blood gas samples are placed on ice and must be transported to the
laboratory immediately or the specimen will deteriorate, making any results
inaccurate. This is the task that the AP should perform first.

B. Transport a client to the radiology department for an x-ray.

Rationale: Although this task is important and appropriate to the skills of an AP, there is
another task that should be performed first.

C. Pass fresh water to each client who is not NPO.

Rationale: Although this task is important and appropriate to the skills of an AP, there is
another task that must be performed first.

D. Obtain a routine urine sample from a newly admitted client.

Rationale: Although this task is important and appropriate to the skills of an AP, there is
another task that should be performed first.

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42. After radiation treatment, the patient complains of dryness, redness, and scaling within the designated
radiation treatment markings. What should the nurse instruct the client to do?

A. Apply hydrating lotions.

Rationale: The nurse should instruct the client to apply hydrating lotions that do not contain
metal, alcohol, or perfume.

B. Apply moist heat.

Rationale: It is not appropriate for the nurse to instruct the client to apply heat. Extreme
temperature can traumatize new cells.

C. Sit in the sun for 10 minutes a day.

Rationale: It is not appropriate for the nurse to instruct the client to sit in the sun. Extreme
temperature can traumatize new cells.

D. Wash with plain soap and water.

Rationale: It is not appropriate for the nurse to instruct the client to wash with plain soap and
water. Soaps can be irritating as well as traumatize new cells.

43. A nurse is a long-term care facility is planning care for several clients. Which of the following activities should
the nurse plan to delegate to the licensed practical nurse (LPN)?

A. Admission assessment of a new client

Rationale: Delegation of the admission assessment is not appropriate as this requires nursing
judgment.

B. Scheduling a swallowing study for a client

Rationale: The LPN can schedule a swallowing study as this does not involve assessment,
judgment or special skills. (KEY)

C. Evaluating changes to a client's pressure ulcer

Rationale: Delegation of assessing changes to a pressure ulcer requires specialized
knowledge and judgment.

D. Teaching a client insulin injection technique

Rationale: Delegation of teaching is not appropriate as this requires evaluation.

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44. A client on 2 gm/hr of magnesium sulfate has decreased deep tendon reflexes. Identify the priority nursing
assessment to ensure client safety.

A. Assess uterine contractions continuously.

B. Assess respiratory rate.

C. Assess urinary output.

Rationale: Urinary output does not correlate to decreased deep tendon reflexes.

D. Assess fetal heart rate continuously.

Rationale: Magnesium sulfate will decrease fetal variability and not provide an accurate
assessment of magnesium toxicity.

45. A nurse is caring for a client who received an injection of penicillin G procaine (Bicillin). The client experiences
dyspnea and states, “My tongue feels swollen.” Which of the following should be the nurse’s priority action?

A. Obtain intravenous fluids for administration.

Rationale: A goal of treatment in anaphylaxis is to raise the blood pressure. Fluid

administration along with vasopressors can correct hypotension during an
anaphylactic response. Vasopressor medications, such as vasopressin (Pitressin),
act to raise blood pressure quickly in emergencies such as anaphylaxis by
vasoconstriction of the coronary arteries and can be given IM or subcutaneously.
Fluid therapy is one component of treatment, but it is not the priority action for the
nurse. Normal saline is isotonic and would be the expected intravenous fluid for the
RN to give to increase volume. Airway is the priority by Maslow’s hierarchy rather
than circulation, which is provided by blood volume and pressure.

B. Record the observed data in medical record.

Rationale: It is critical to the safety of the client that any anaphylactic event be recorded in the
medical record. The record should clearly indicate which medication was identified
as the cause by the provider. This will be completed when the client has been
treated for immediate life-threatening symptoms. It is not the priority action for the
nurse.

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C. Deliver a dose of albuterol (Proventil) by inhalation.

Rationale: Improvement of breathing is a component of the treatment for anaphylaxis.

Albuterol is a rapid-acting bronchodilator that is available by inhalation. This may be
used, but it is not the first medication given. It will be expected that the RN would
administer theophylline IV as a rescue medication. Theophylline (Aminophylline)
provides a rapid-onset bronchodilation and is administered as a slow push during
emergencies such as anaphylaxis. Although this drug works on airway, epinephrine
is a better choice because it both bronchodilates and interferes with the physiologic
cause of anaphylaxis.

D. Administer epinephrine (Adrenalin) subcutaneously.

Rationale: Epinephrine (Adrenalin) is the drug of choice in response to anaphylaxis that occurs
in a non-acute setting. Because this medication is given subcutaneously, the nurse
can administer this medication. It can be given subcutaneously in the upper arm or
in the thigh. The location should be above the location of the injection that resulted
in the anaphylaxis. Epinephrine can be given through clothing to prevent delay of
administration. The effect of the epinephrine is to act on adrenergic receptors,
causing bronchodilation of the lungs and an elevation of blood pressure. By
stimulating both alpha and beta adrenergic receptors to cause these effects, it
accomplishes more of the goals of treatment of anaphylaxis than any other single
therapy. This action is the priority action of the nurse to save the client.

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46. A nurse is preparing to complete a daily weight on a client in renal failure. Which of the following actions
should the nurse implement?

A. Use any available scale to weigh the client.

Rationale: The nurse should use the same scale, not a different scale, when weighing the
client for a more accurate weight.

B. The scale should be balanced at minus two before weighing the client.
Rationale: The nurse should balance the scale at zero, not minus two, before weighing the
client for a more accurate weight.

C. Weigh the client at the same time each day.

Rationale: The nurse should weigh the client at the same time each day for a more accurate
weight.

D. The client should be weighed before voiding.

Rationale: The nurse should have the client void before, not after, obtaining the client’s daily
weight for a more accurate weight.

47. A nurse is discussing the norming stage of the group development process with a student nurse. Which of the
following statements by the student indicates understanding of the discussion?

A. “This stage involves constructive efforts on the part of the group members.”
Rationale: The development of constructive efforts occurs during the performing stage of the
group development process.

B. “This stage is when testing occurs to identify boundaries of interpersonal behaviors.”

Rationale: Testing to identify interpersonal behaviors of group members occurs during the
forming stage of the group development process.

C. “Consensus evolves in this stage.”

Rationale: Consensus occurs and cooperation develops during the norming stage of the group
development process.

D. “Resistance is evident as subgroups form in this stage.”

Rationale: Resistance to task requirements occurs during the storming stage of the group
development process.

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48. Informatics Nurse Specialists are nurses with specialized, advanced knowledge of information methods for
enhancing the quality and delivery of health care through the use of digital information. Their roles include all
of the following EXCEPT:

A. The collection and analysis of data.

Rationale:

B. Planning the design of information systems.

C. Ensuring that information is protected by securing computers and computer components.

Rationale: The roles and functions of the Nurse Informaticist have been designated by
agencies and groups and accepted by the profession. ANCC in response and
recognition of this new role, now offers a certification for that advanced role. (TNA &
TONE, 2013, Powerpoint)

D. Training nurses and administrators in the use of information systems.

49. A nurse is administering a cold application to a client. Which of the following manifestations indicates the need
to discontinue the application due to a systemic response by the client?

A. Bradycardia
Rationale: A rapid pulse occurs in the client with a systemic response.

B. Numbness
Rationale: Numbness occurs with a localized response.

C. Shivering
Rationale: Shivering is a systemic response to cold in order to promote heat production.

D. Bounding pulses
Rationale: Weak pulses are noted in the client with a systemic response.

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50. When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L; potassium, 4.1 mEq/L;
calcium, 7.9 mg/dL; and magnesium, 1.9 mg/dL; the nurse should notify the physician about which of the
client's lab values?

A. Low potassium
Rationale: Potassium is within normal limits of 3.5-5.3.

B. Low calcium
Rationale: Calcium between 9.o and 11.2 is normal, thus it is low. (Kee, 2011, p.)

C. High sodium
Rationale: Sodium is within the normal range of 135-145.

D. High magnesium
Rationale: Magnesium is within normal range.

51. Following a suicide bombing at a shopping mall, an unidentified, unconscious client is admitted to the
emergency department with an acute intra-abdominal hemorrhage. The nurse should recognize that consent
for the surgery

A. should be obtained from an officer of the court.

Rationale: Awaiting legal intervention could mean an inordinate delay until surgery is
performed.

B. must be obtained from a relative of the client.

Rationale: In urgent situations, it is preferable for consent to be obtained from a relative or
health care proxy (HCP). However, in this situation, the next of kin cannot be readily
identified.

C. can be inferred since the client is in critical condition.

Rationale: The client is unconscious and in critical condition, and consequently, is incapable of
providing consent. Preferably, consent should be obtained from a relative or health
care proxy (HCP). However, the client is also unidentified, meaning the client could
die while awaiting identification and next of kin. Therefore, consent should be
implied and the surgery will be performed as an emergency life-saving procedure.

D. will be delayed until the client is identified.

Rationale: This is not an appropriate action. The client could die awaiting identification and
next of kin.

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52. A 6-month-old infant has had surgery to correct intussusception. The surgeon has prescribed clear liquids by
mouth. The nurse correctly administers which of the following?

A. Oral electrolyte solution

Rationale: After gastrointestinal surgery, infants should receive clear liquids that contain
glucose and electrolytes, such as an oral electrolyte or rehydration solution, and
then advance to formula or breast milk as they demonstrate tolerance.

B. Half-strength infant formula

Rationale: Half-strength formula is not a clear liquid.

C. Full-strength orange juice

Rationale: Half-strength orange juice is not a clear liquid.

D. Sterile water
Rationale: Sterile water does not contain nutrients; this it is not appropriate to include in a clear
liquid diet for an infant who is postoperative.

53. An older adult client who lives alone tells the nurse at the clinic that he is unable to drive himself to the store
and is afraid to cook on the stove. The nurse should recommend which of the following community resources
for this client?

A. Hospice care
Rationale: Hospice care is palliative care for clients who are very ill or terminally ill.

B. Meals on Wheels
Rationale: Meals on Wheels is a service that delivers meals daily to older adults who need
them, either at senior centers or directly to their homes. This is an appropriate
referral for this client.

C. Visiting nurse services

Rationale: Visiting nurse services provide skilled nursing care in the client’s home.

D. The American Association of Retired Persons

Rationale: The American Association of Retired Persons (AARP) is a national organization for
people over 50 years old. It does not provide health care.

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54. A nurse is discussing good food choices with a client who is recovering from an exacerbation of inflammatory
bowel disease and is to start a low-lactose diet. Which of the following foods is the best choice for the client?

A. Soy milk
Rationale: Soy milk is the best choice for this client because soy milk is lactose-free.

B. Cheddar cheese
Rationale: Cheddar cheese, a low lactose food, is a good choice for this client; however, it is
not the best choice because it does contain lactose.

C. Low-fat yogurt
Rationale: Low-fat yogurt, a low lactose food, is a good choice for this client; however, it is not
the best choice because it does contain lactose.

D. Cottage cheese
Rationale: Cottage cheese, a low lactose food, is a good choice for this client; however, it is
not the best choice because it does contain lactose.

55. The nurse is caring for a client in active labor. The healthcare provider artificially ruptures her membranes and
port wine colored amniotic fluid is noted from the vagina. The nurse concludes which of the following has
occurred.

A. The client is fully dilated and ready to start pushing.

Rationale: The amniotic fluid should normally be clear throughout labor. p. 174

B. The client has passed the mucous plug.

Rationale: This is a normal sign of impending labor. p. 186

C. The placenta has abrupted.

Rationale: Dark blood from the separated placenta mixes with the amniotic fluid, coloring the
fluid the color of port wine. p. 160

D. The fetus has passed meconium.

Rationale: Meconium stained fluid is yellow to brown in color, depending upon quantity.

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56. A nurse is caring for a client with a wound infection. Which of the following actions should the nurse take when
obtaining a wound drainage specimen for culture?

A. Wipe away pus with a gauze swab prior to culturing the wound.
Rationale: Pus should be wiped away with gauze prior to culturing the wound because the pus
may be contaminated.

B. Irrigate the wound with prescribed antiseptic prior to culturing the wound.
Rationale: Irrigating with an antiseptic prior to obtaining the specimen may destroy the
bacteria.

C. Include intact skin at the wound edges in the culture.

Rationale: Intact skin at the wound edges should not be included in the culture because this
can result in the inclusion of superficial skin organisms in the culture.

D. Swab an area of skin away from the wound to identify normal flora for comparison with culture.
Rationale: Normal flora of intact skin is not identified for comparison with the wound culture.
This is not an appropriate action by the nurse.

57. Which method of oxygen administration will the nurse use for acutely ill clients with chronic obstructive
pulmonary disease (COPD)?

A. A nasal cannula
Rationale:

B. An oropharyngeal catheter

C. A non-rebreathing mask

D. A Venturi mask

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58. A nurse is caring for a client who is receiving TPN (Total Parenteral Nutrition) solution. It has been 24 hours
since the current bag of solution was hung, but 400 ml remains in the bag. Which of the following is the
appropriate action for the nurse to take?

A. Remove the current bag and hang a bag of Lactated Ringer’s solution

B. Infuse the remaining solution at the current rate; then hang a new bag.

C. Increase the infusion rate so that the remaining solution is administered within the hour and hang a
new bag.

D. Remove the current bag and hang a new bag.

Rationale: (Correct Answer = d. TPN is administered over a 24-hr period or less. Brunner-
Suddarth, p. 1228. ATI, 2013, 8th ed., RN Adult Medical-Surgical Nursing, p. 525 &
535.)

59. A nurse in a community clinic is assessing an older adult client who has a body mass index of 17.5. When
evaluating the client for dehydration, the nurse should look for

A. hypothermia.
Rationale: Older adult clients who have dehydration are more likely to have an elevated body
temperature.

B. protruding eyeballs.
Rationale: In older adult clients, sunken eyeballs are an indication of dehydration.

C. elevated blood pressure.

Rationale: In older adult clients, orthostatic hypotension is an indication of dehydration.

D. swollen tongue.
Rationale: In older adult clients, a swollen tongue is an indication of dehydration.

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60. A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following
statements indicates an understanding?

A. “The legal requirement for client confidentiality does not apply if the client is deceased.”
Rationale: The Dead Man’s Statute legally requires the client’s confidentiality to be protected
even after death.

B. “Staff members are required to divulge information to attorney’s if they call for information.”
Rationale: Some states may require that information be provided to law enforcement or
attorneys but only with the proper documentation. Communication should then be
done in person so that identification can be verified.

C. “Health care workers can use client confidentiality for their own legal defense.”
Rationale: Health care professionals cannot use client confidentiality for their own defense.

D. “Providers are required to warn individuals if the client threatens harm.”

Rationale: Health care professionals have a duty to warn and protect third party individuals
who may be in danger due to the client’s threats of harm.

61. A nurse is assessing a client with possible fluid volume deficit. Which signs and symptoms on assessment
would indicate a fluid deficit is present? (Select all that apply

A. Bounding pulse.

B. Sticky mucus membranes

C. Crackles in both lungs.

D. Constipation

E. Decreased urinary output

Rationale: Dry, sticky mucus membranes, constipation, decreased urine production, nonelastic
skin turgor, and lack of tear production are all indications of a fluid deficit. (Craven,
2013).

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62. Information technology makes client care easier as well as more challenging for nurses. Which action by the
nurse demonstrates compliance with HIPAA?

A. Log-in with user name and password and log-out once every shift.
Rationale: Client information will be accessible until the computer times out. This is enough
time for someone to view info for which there is no need for that person to know
about.

B. Invite a nurse from another hospital to use an absent nurse's access information to log-in to a
computer to read lab data.
Rationale: The nurse from another hospital does not have a need to know about lab data of
clients. Using the access information of another nurse hides her identity and
implicates the absent nurse as the viewer of lab data when she is not working.

C. Minimize the client's screen when speaking with someone who is not authorized to view it.
Rationale: Easy and quick to do, protects client information privacy. (TNA & TONE, 2013,
Powerpoint)

D. Allow clergy to visit all patients.

Rationale: Client may not wish to have visitors. Not automatic that client will want clergy to visit
or know she is in hospital.

63. The nurse gave a client twice as much narcotic pain medication as was prescribed. The client stopped
breathing and was resuscitated, but died. What type of error is this classified as?

A. Adverse event
Rationale: Incorrect as an adverse event results in unintended harm to the client

B. Near miss
Rationale: Incorrect. This is an error that occurs but is caught and corrected.

C. Sentinel event
Rationale: CORRECT ANSWER. A sentinel event causes serious physical or psychologic
injury or death. (Craven, 2013)

D. System error
Rationale: Incorrect since a system error results due to a policy or procedure that has errors.

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64. A student nurse is teaching her pregnant patient Mary about the signs of premature labor. Which would the
nurse question as incorrect?

A. You feel "something is not right."

Rationale: Preterm labor symptoms are often vague. p. 134

B. You feel pelvic pressure or low back pain.

Rationale: These are frequently signs of uterine contractions and cervical dilatation. p. 134

C. You have more than 7 contractions in an hour.

Rationale: Regular contractions before 37 weeks is a sign of preterm labor. p. 134

D. You feel increased urinary frequency.

Rationale: Increased frequency occurs in the third trimester as the fetal size presses on the
bladder. p. 56

65. A nurse is completing the preoperative teaching for a client who is to undergo a gastrectomy. Which of the
following information should the nurse include in prevention of postoperative complications?

A. Determine discharge date with the client.

Rationale: The nurse understands determining the discharge date with the client will not
prevent post-operative complications.

B. Apply a sequential compression device.

Rationale: The nurse understands that applying sequential compression device should be
included to prevent post-operative deep venous thrombosis, a post-operative
complication.

C. Discuss the visitation policy.

Rationale: The nurse understands discussing the visitation policy with the client will not prevent
postoperative complications.

D. Review dressing change procedure.

Rationale: The nurse understands the importance of reviewing the pain scale with the client but
understands this will not prevent post-operative complication.

66. A client is involuntarily admitted to a mental health facility. Which of the following client statements should the
nurse recognize as accurate? (Select all that apply.)

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A. “I do not have to take any medications.”

B. “I have the right to ask the court to decide if I can be held here involuntarily.”

C. “Before I agree to any treatment, you must tell me about my alternatives.”

D. “My wife put me here, and now you can tell her anything I say.”

E. “I am going to kill myself, and there is nothing you can do about it.”

Rationale: “I do not have to take any medications.” is correct. The client was
involuntarily admitted, and therefore has the right to refuse treatment,
including medications. The nurse may be confronted with an ethical dilemma,
such as autonomy vs. duty to protect. If the nurse questions the ability of the
client to make sound judgments, the nurse should follow the agency protocol
for investigating mental competence.“I have the right to ask the court to
decide if I can be held here involuntarily.” is correct. State laws vary. Many
states require medical certification, judicial review, or administration prior to
the admission. Some states do not require a judicial hearing, but these states
often provide the client with an opportunity for a judicial review after the
admission. The agency must then immediately submit the client’s petition to
the court. Involuntary hospitalization generally lasts 60 to 180 days, but this
can also vary.“Before I agree to any treatment, you must tell me about my
alternatives.” is correct. All clients have the right to informed consent. The
client should be informed of the nature of the problem or condition, the
nature and purpose of a proposed treatment, the risks and benefits of the
treatment, the alternative treatment options, the probability that the proposed
treatment will be successful, and the risks of not consenting to treatment.
The nurse should understand that the presence of psychotic thinking does
not mean the client cannot understand. Clients must be considered legally
competent until they are proven legally incompetent through a legal hearing.
If a client is deemed legally incompetent, a legal guardian is appointed to give
or refuse consent.“My wife put me here, and now you can tell her anything I
say.” is incorrect. Any client who is admitted involuntarily retains the right to
confidentiality. Unless the client agrees, information cannot be shared with
his wife unless there is a real threat to the wife's well-being. State laws vary,
but health care providers generally have the duty to warn and protect third
parties of potential harm. If a nurse believes there is the potential of harm to a
third party, the nurse should follow agency protocol for reporting the
danger.“I am going to kill myself, and there is nothing you can do about it.” is
incorrect. The nurse can and should do something about the client who
wants to do harm to himself or others. The nurse should immediately report
this statement and be careful not to leave the client alone. Immediate safety
precautions should be instituted. The agency protocol for suicide prevention
should be implemented. The client should be placed in the least restrictive
environment that will ensure safety.

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67. A nurse is talking with a client about how to use montelukast (Singulair) to treat asthma. Which of the following
client statements should indicate that the client understood the nurse’s instructions?

A. “I’ll rinse my mouth after taking this medication.”

Rationale: Oral candidiasis may develop with inhaled glucocorticoids. It is not likely with
montelukast.

B. “I’ll take this medication when I get an asthma attack."

Rationale: Montelukast is not a rescue medication for an acute asthma attack.

C. “I’ll take this medication once a day in the evening.”

Rationale: The purpose of montelukast, a leukotriene modifier, is to prevent asthma
exacerbations. The client should take it on a daily basis once a day in the evening,
whether or not he has symptoms.

D. “I’ll take this medication with meals."

Rationale: It is inappropriate for the client to take this medication with meals.

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68. A nurse is preparing to administer levothyroxine (Synthroid) 0.275 mg PO to a client. Available are
levothyroxine 137 mcg tablets. How many tablets should the nurse administer? (Round to the nearest whole
number.)

A. 2 tablet(s)
Correct Rationale: 1 mg = 1,000 mcg

0.275 mg = 275 mcg

Desired x Quantity
———————— = Amount to give
Have

275 mcg x 1 tablet

——————–––— = X tablets
137 mcg

275
—— = 2.007 tablets = 2 tablets
137

X = 2 tablets

Incorrect Rationale: 1 mg = 1,000 mcg

0.275 mg = 275 mcg

Desired x Quantity
———————— = Amount to give
Have

275 mcg x 1 tablet

——————–––— = X tablets
137 mcg

275
—— = 2.007 tablets = 2 tablets
137

X = 2 tablets

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69. The value of having a certified practice area for nurses in Health Information Technology is important
especially for implementing the Electronic Health Record (E.H.R.). Nurses recognize that their unique
contribution is based on which of the following?

A. Education in medicine and nursing.

B. Ability to communicate with all health care professionals.

Rationale: The coordination of information and user acceptance is achieved through
communicating with all health care professionals. Nurses do this all the time when
planning patient care with the multi-disciplinary team. (TNA/TONE, 2013,
Powerpoint)

C. Know the documentation requirements of all health care professionals.

D. Regularly interact with lawyers who also will use E.H.R.

70. The nurse is explaining induction of labor to a client. The client asks what the indications for labor induction
are. Which should the nurse include when answering the client?

A. Suspected placenta previa

Rationale: This is a contraindication for induction. p. 275

B. Breech presentation
Rationale: This is a contraindication for induction. p. 275

C. Prolapsed umbilical cord

Rationale: This is a contraindication for induction. p. 275

D. Hypertension
Rationale: This is an indication for induction. p. 264

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71. Q!

A. A1

B. A2

C. A3

D. A4

72. The nurse admits a 2 month old infant to the hospital with a respiratory condition. The baby is coughing up
clear mucous and has a pale skin color. The physician has ordered a cool mist tent and oxygen to run at 2 L.
Which anatomical characteristic of a 2 month old baby does the nurse recognize as contributing to the infant's
illness?

A. Small heart

B. Weak muscles

C. Narrow bronchi
Rationale: Mucous in narrow bronchi product an obstruction to air flow. Small heart, weak
muscles, immature nervous system may play a part, but the narrow bronchi are the
primary issue for infants with gas exchange problems due to secretions in the
bronchial tree.

D. Immature nervous system

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73. A nurse is caring for a client admitted to a mental health facility who asks, “Can I refuse the scheduled
electroconvulsive therapy (ECT)?” Which of the following should be the nurse’s response?

A. “You will be discharged sooner if you have the prescribed ECT treatments.”
Rationale: The tone of this statement may be threatening, and the client may perceive she is
being coerced and has no choice. The role of the nurse is client advocacy. This
statement does not foster communication and establish trust.

B. “You are admitted to a mental health facility and must follow the provider’s orders.”
Rationale: Clients who have been diagnosed or hospitalized with a mental health disorder are
guaranteed the same rights as any other client. This includes the right to informed
consent regarding treatments and procedures, and the right to refuse treatment.

C. “You can refuse them, but the provider believes they are necessary.”
Rationale: The client does have the right to refuse the treatment. The nurse is sending a
subliminal message attempting to persuade the client to follow the prescribed
therapy. The nurse’s response does not promote a trusting nurse-client relationship.

D. “You have the right to refuse even though the consent has been signed.”
Rationale: Informed consent is a communication between provider and client regarding the
risks and benefits of treatment. The client authorizes the treatment with a witnessed
signature to undergo the medical intervention. The client has the right to refuse or
delay treatment, even though the informed consent has been signed. The nurse’s
role is to demonstrate client advocacy and provide support.

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74. A clinic nurse is giving instructions to a mother on the proper technique of applying ophthalmic ointment to her
preschool-age child who has conjunctivitis. Which of the following should the nurse include in the instructions?

A. “Warm the ointment by placing the tube in glass of hot tap water.”
Rationale: The parent should warm the ointment by placing it in glass of warm water, not hot
water.

B. “Cleanse the eye with a wet cotton ball in a direction towards the inner canthus before applying the
ointment.”
Rationale: The parent should clean the eye in a direction from the inside canthus outward in
order to prevent contamination of the lacrimal duct or the other eye.

C. “Discard the first bead of ointment before each application.”

Rationale: The parent should discard the first bead of ointment from the tube because it is
considered contaminated.

D. “Instruct your child to squeeze his eyes shut following application.”

Rationale: Closing the eyes spreads the medication over the eyeball, but squeezing the eyelid
shut can force out some of the medication.

75. What is the primary goal of nurses in the role of Nursing Informatics according to the American Nurse
Credentialing Center (ANCC)?

A. The daily maintenance of multiple clinical information systems at distant locations.

B. The creation of an efficient information handling system that can store and retrieve clinical data.
Rationale: ANCC (TNA & TONE, 2013, Powerpoint)

C. To make client data easier to read.

D. To make the latest technologies available to hospitals and other patient care environments.

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76. A nurse is speaking to the nurse manager about a schedule request, and the nurse manager puts an arm
around the nurse and says, "I bet you are a great lover." Which of the following is the appropriate response by
the nurse?

A. "Let's talk about something else."

Rationale: While this appears to be a response meant to change the subject, this response
does not make it clear that this type of sexually oriented conversation and physical
contact is undesired by the nurse.

B. "Whether or not I am a good lover is irrelevant."

Rationale: While this appears to be a response meant to change the subject, this response
does not make it clear that this type of sexually oriented conversation and physical
contact is undesired by the nurse.

C. "Speaking to me like that makes me uncomfortable."

Rationale: This assertive response makes it clear that this type of sexually oriented
conversation and physical contact is undesired by the nurse.

D. "That is not what I am here to discuss."

Rationale: While this appears to be a response meant to change the subject, this response
does not make it clear that this type of sexually oriented conversation and physical
contact is undesired by the nurse.

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77. A newly licensed nurse is planning to delegate tasks to an assistive personnel (AP). Which of the following
tasks should the nurse plan to perform?

A. Administration of an enema
Rationale: Administration of an enema is a task that an AP has been taught and should be
able to complete.

B. Application of antiembolic stockings

Rationale: Application of antiembolic stockings is a task that an AP has been taught and
should be able to complete.

C. Assessing a client’s sacrum for edema

Rationale: Assessment requires specialized knowledge of the nurse and cannot be delegated
to an AP.

D. Assisting a client to cough and deep breath

Rationale: Assisting a client to cough and deep breath is a task that an AP has been taught
and should be able to complete.

78. The nurse believes that client information obtained using a 'point of care' device saves the nurse time. What is
the advantage of 'point of care' documentation for the client?

A. Increased accuracy of data

Rationale: Correct. Documented in literature and concept diagram. (TNA & TONE, 2013,
Powerpoint)

B. Less interruption by staff

Rationale: Does not depend on computer documentation

C. Possible sentinel event

Rationale: Negative event when HIT is not used

D. Increased practice errors

Rationale: Reduction in practice errors is a positive outcome of HIT

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79. A pregnant woman is married to an intravenous drug user. She had a negative HIV screening test just after
missing her first menstrual period. What would indicate that the client needs to be retested for HIV?

A. Elevated blood pressure and ankle edema

Rationale: Elevated BP is a symptom of preeclampsia and ankle edema is a normal finding of
pregnancy. p. 61/152

B. Hemoglobin of 11 g/dL and a rapid weight gain

Rationale: This is a normal hemoglobin and a rapid weight gain may indication of increased
edema. p. 59/152

C. Unusual fatigue and recurring Candida vaginitis

Rationale: These are common findings in HIV infections. p. 165

D. Shortness of breath and frequent urination

Rationale: These are normal changes of pregnancy. p. 61-62

80. A nurses is assessing for the development of disseminated intravascular coagulation (DIC) in a client who has
septic shock. Which of the following nursing statements indicates an understanding of the condition?

A. “DIC is controllable with lifelong heparin usage.”

Rationale: The nurse should understand DIC is not controlled with lifelong heparin usage, but
Heparin is administered to minimize the formation of microthrombi to improve tissue
profusion.

B. “DIC is characterized by an elevated platelet count.”

Rationale: The nurse should understand DIC causes bleeding due to a decreased platelet
count, not elevated platelet count.

C. “DIC is caused by abnormal coagulation involving fibrinogen.”

Rationale: The nurse should understand DIC is caused by an abnormal coagulation involving
fibrinogen formation and platelet counts.

D. “DIC is a genetic disorder involving vitamin K deficiency.”

Rationale: The nurse should understand DIC is not a genetic disorder involving vitamin K
deficiency. Vitamin K prolongs bleeding time.

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81. A woman in labor and delivery is being given subcutaneous terbutaline for preterm labor. Which of the
following common medication effects would the nurse expect to see in the mother?

A. Shortness of breath
Rationale: The beta agonists are not associated with shortness of breath.

B. Urticaria
Rationale: The beta agonists are not associated with urticaria.

C. Complaints of nervousness
Rationale: Complaints of nervousness are commonly made by women receiving subcutaneous
beta agonists.

D. Diarrhea
Rationale: The beta agonists are not associated with diarrhea.

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82. Which of the following tasks could a nurse assign to assistive personnel (AP)?

A. Administering an enteral feeding

Rationale: Administration of enteral feedings requires data collection or an assessment. Some
facilities also consider enteral feedings to be medications. For these reasons, the
AP should not perform this task. This task is best suited to a licensed practical nurse
or RN.

B. Inserting indwelling urinary catheter

Rationale: Insertion of an indwelling urinary catheter is a sterile procedure. Assistive personnel
are not allowed to perform sterile procedures. This task should be performed by a
licensed practical nurse or RN.

C. Obtaining vital signs on clients who are stable

Rationale: Obtaining vital signs on stable clients is appropriate for the AP to perform. When
delegating a task to an AP, the nurse should consider the acuity of the client, as
well as the education level and knowledge of the person receiving the assignment.
Vital signs are commonly taught and are an expected skill set of an AP. It remains
the nurse’s responsibility to follow up and check the client based on vital sign
findings.

D. Assisting the client to select a low-residue diet

Rationale: This would provide an opportunity to teach or reinforce teaching. When assisting the
client to select breakfast or other meal choices, the provider must be familiar with
the disease process and the dietary requirements. This task should be performed by
a licensed practical nurse or the RN, not the AP.

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83. A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch.
Which of the following is an appropriate action for the nurse to take?

A. Ask the provider if alcohol was taken with lunch.

Rationale: Signs and symptoms of a potentially impaired provider include the smell of alcohol,
bloodshot eyes, disheveled appearances, and abrupt changes in personality. This
provider is exhibiting signs of being impaired and should not be allowed to continue
providing client care. However, it is not the RN's responsibility to confront the
provider. Instead, the nurse should notify appropriate management for investigation
and follow-up. In the interim, all orders received and care delivered should be
closely monitored to ensure that no harm will come to the provider's clients.

B. Encourage any client who is on his service to immediately change providers.

Rationale: It is not for the RN to judge or assume without an appropriate investigation.
Encouraging clients to change services could be considered libel, and the nurse
could be sued for inappropriate behavior.

C. Inform the state medical board for an immediate investigation.

Rationale: It is the responsibility of hospital management and administration to follow up with
any state licensure boards in cases of impairment or client negligence/harm. It is not
the responsibility of the nurse to do so.

D. Notify the nurse manager or charge nurse of the concerns.

Rationale: This is an appropriate action for the nurse to take. The nurse should immediately
notify hospital or nursing management of the concerns, and then ensure client
safety. It is the responsibility of management to conduct an appropriate
investigation, and client safety is the responsibility of the nurse.

84. What is the maximum amount of time of each aspiration with a sterile catheter when the nurse is performing
nasopharyngeal suctioning?

A. 15 seconds
Rationale:

B. 30 seconds

C. 45 seconds

D. 60 seconds

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85. A nurse is providing staff education about smallpox as a bioterrorism threat. Which of the following statements
indicates an understanding of this agent? (Select all that apply.)

A. "Smallpox is transmitted person to person."

B. "Infection is characterized by severe respiratory distress."

C. "Smallpox vaccination ensures lifelong immunity."

D. "Naturally occurring smallpox has been eradicated from the world."

E. "Smallpox is often confused with varicella."

Rationale: "Smallpox is transmitted person to person" is correct. Smallpox is highly

communicable through droplet or airborne inhalation or contact with
lesions."Infection is characterized by severe respiratory distress" is
incorrect. Severe respiratory distress is a manifestation of inhalation anthrax
rather than smallpox. "Smallpox vaccination ensures lifelong immunity" is
incorrect. The smallpox vaccine does not provide effective lifelong
immunity."Naturally occurring smallpox has been eradicated from the world"
is correct. Naturally occurring cases of smallpox have been considered to be
eradicated since 1979."Smallpox is often confused with varicella" is
correct. Smallpox and varicella both present with rashes that are similar in
appearance and can lead to possible misdiagnosis.

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86. A nurse is caring for a patient who needs a stool specimen collected for ova and parasites. Which of the
following procedures is appropriate for the nurse to use in the collection of this specimen?

A. Refrigerate the specimen until it can be delivered to the lab.

Rationale: Refrigeration will kill the parasites and alter the test results.

B. Place the specimen in a sterile container.

Rationale: A sterile container is not necessary. The feces should be collected in a dry container
free of urine.

C. Take feces from several areas of the stool.

Rationale: Taking samples from various areas of the stool is done when a stool sample for
occult blood is ordered.

D. Send entire stool immediately to the lab.

Rationale: A stool specimen for ova and parasites should be collected in its entirety, placed in
a dry container free of urine, labeled correctly, and sent immediately to the
laboratory.

87. The nurse is caring for Connie, who is 28 weeks pregnant and has been diagnosed with premature labor. The
primary care provider has ordered Terbutaline 0.2mg subcutaneous injection now and may repeat in 30
minutes. Terbutaline is available in a 1 mg/ml vial. How much will you administer now?

A. 0.1 ml

B. 0.2 ml
Rationale: Correct

C. 0.5 ml

D. 2 ml

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88. Health Information Technology (HIT) includes a variety of information sources. Which answer best identifies
sources of information used in HIT?

A. Electronic Medical Records, Electronic Health Records, Personal Health Records, Decision Support
Systems, ePrescribing, and Computerized Physician Order Entry.
Rationale: TNA and TONE have identified these sources as HIT sources (TNA & TONE, 2013,
Powerpoint)

B. Paper health record

C. Lab reports

D. Radiology reports

89. A nurse is teaching a client who has nephrotic syndrome. Which of the following client statements indicates a
need for further teaching?

A. “I can expect to have swelling in my face.”

Rationale: Facial and periorbital swelling are key findings of nephrotic syndrome.

B. “I will lose protein in my urine.”

Rationale: Protein loss in the urine is part of the underlying pathophysiology of nephrotic
syndrome.

C. “I should expect my doctor to prescribe a kidney biopsy.”

Rationale: A kidney biopsy is used to identify the cause of nephrotic syndrome.

D. “I should increase my sodium intake.”

Rationale: A low-sodium diet is appropriate for a client who has nephrotic syndrome due to the
edema associated with this disorder.

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90. A nurse is caring for a client undergoing hemodialysis who will be discharged in the morning. Which of the
following client statements most influences the current plan of care?

A. “My son thinks that it will be best for me to move to an apartment.”

Rationale: The home living environment is important when planning for discharge. This
statement says that a change could take place and may need to be discussed with
the client. Family can be a major influence on health decisions. This information
does not change the discharge plan for tomorrow, but it may affect more
considerations for care on a long-term basis.

B. “My neighbor who takes me everywhere wrecked the car this morning.”
Rationale: Clients receiving hemodialysis will require access to transportation to go to the
dialysis center several times each week. It is essential for the nurse to communicate
this information to the interdisciplinary team. The licensed practical nurse has
collected data that identifies a potential problem after discharge and requires
communication to the RN as part of the plan of care for discharge. It may be
necessary for the social worker to arrange for transportation within the next few
days for the client to receive hemodialysis. The nursing staff also would need to
adjust teaching to ensure the client knows how to contact resources by phone for
follow-up care that would require transportation.

C. “Every time I leave home, I worry about who will take care of my little dog.”
Rationale: It is important to listen to clients who are sharing home concerns that affect the
response to health care. This nurse has provided an environment in which personal
concerns are shared. Although this client concern can be important in adherence to
the treatment plan, it is not the most important information at this time.

D. “It is nice when I am in the hospital because I don’t have to take care of myself.”
Rationale: Self-care at home is an important factor in adherence to medical recommendations
after discharge. The nurse can ask follow-up questions to determine the ability of
the client to provide self-care at home and work to identify the factors that are
challenging for the client. Acute care can give some clients a respite, while others
are distressed by the dependence that occurs during hospitalization. The treatment
plan should reflect the dependency level, but this is not the most important
consideration at this time.

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91. A nurse is supervising a licensed practical nurse (LPN) who is providing care to a postoperative client. Which
of the following statements by the client requires the nurse to follow up with the LPN?

A. “I do not know how to make the remote control work.”

Rationale: It is not the responsibility of the LPN to instruct the client on how to use the remote
control. It is not related to client care that the nurse should be concerned about
while supervising the LPN. When a RN is supervising a LPN or assistive personnel,
they should use appropriate supervisory strategies, including providing direct or
indirect supervision, providing clear directions and understandable expectations,
monitoring performance, providing appropriate feedback and constructive criticism,
intervening when necessary, and evaluating whether client needs were met.

B. “Do you know when I will be going home?”

Rationale: The nurse may or may not know the answer to this question, and it is not an
expectation of the LPN to know the answer to this question. Discharge prescriptions
are written by the admitting provider. Discharge instructions are to be given by the
nurse and reinforced by the LPN.

C. “My dressing was changed earlier this morning.”

Rationale: This would be an appropriate action for the LPN to take, and the RN should follow
up to ensure that this was done as prescribed and in a timely manner. Verbal
confirmation by the client should be followed by an inspection of the dressing area
by the RN and review of the medical record to evaluate the condition of the wound
bed area.

D. “I have not received any of my medications today.”

Rationale: Failure to receive prescribed medications in a timely manner can have a negative
effect on client outcomes. The nurse should immediately follow up with the LPN to
determine if medications have been administered, and if not, to learn why. It is
possible that the client simply does not remember receiving medications or that no
medications had been prescribed as of this time. Effective supervision requires that
any issue that can negatively impact client care be followed up on immediately.

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92. A nurse is working with a team of nursing personnel within the facility. Which of the following are necessary
task performance roles that members of the group or the leader must perform? (Select all that apply.)

A. Self-confessor

B. Coordinator

C. Evaluator

D. Energizer

E. Dominator

Rationale: Self-confessor is incorrect. Self-confessor is a role that some group members use
for personal expression. It is not a role that must be performed.

Coordinator is correct. Coordinator is task performance role that focuses on

clarification and coordination of ideas.

Evaluator is correct. Evaluator is a task performance role that focuses on

comparing group accomplishments with expected standards.

Energizer is correct. Energizer is a task performance role that focuses on

stimulating the group to higher levels of action.

Dominator is incorrect. Dominator is a role that some group members use in

attempting to gain control and manipulate a group. It is not a role that must be
performed.

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93. A nurse is caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into
practice by

A. discussing advance directives with the client and family.

Rationale: Discussing advance directives with the client and family is an example of promoting
client autonomy by respecting the client's right to self-determination.

B. providing comfort care measures to the client.

Rationale: Providing comfort measures to a client who is dying is an example of the principle of
beneficence, which is a moral obligation to act to benefit others.

C. refusing to give a potentially lethal dose of narcotic pain medication.

Rationale: The principle of nonmaleficence is an obligation not to inflict harm intentionally. It is
customary to ease a client's pain via the administration of narcotics. However, if the
nurse believes that the dose is potentially lethal or may hasten the client's death,
the nurse should refuse to administer the medication on the grounds of
nonmaleficence.

D. allowing the client's family unlimited visitation at the time of death.

Rationale: Allowing the client's family unlimited visitation at the time of death is an example of
the principle of beneficence, which is the moral obligation to act in the interest of
others.

94. The nurse assesses the IV site on a client on the unit and thinks that the IV has infiltrated. All of the following
are clinical manifestations of intravenous infiltration except which one?

A. Redness around the site

Rationale: (A is the correct answer. Redness is an indication of infection or inflammation of the
iv site, possible phlebitis. B, C, & D are the signs of infiltration. Brunner & Suddarth,
13th edition, pp. 282-283)

B. Dampness of IV dressing

C. Swelling around IV site

D. Coolness around IV site

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95. Information technology makes client care easier as well as more challenging for nurses. Which action by the
nurse demonstrates compliance with HIPAA?

A. Log-in with user name and password and log-out once every shift.
Rationale: INCORRECT ANSWER. : Client information will be accessible until the computer
times out. This is enough time for someone to view info for which there is no need
for that person to know about.

B. Invite a nurse from another hospital to use an absent nurse's access information to log-in to a
computer to read lab data.
Rationale: The nurse from another hospital does not have a need to know about lab data of
clients. Using the access information of another nurse hides her identity and
implicates the absent nurse as the viewer of lab data when she is not working.

C. Minimize the client's screen when speaking with someone who is not authorized to view it.
Rationale: Easy and quick to do, protects client information privacy. (TNA & TONE, 2013,
Powerpoint)

D. Allow clergy to visit all clients.

Rationale: Client may not wish to have visitors. Not automatic that client will want clergy to visit
or know she is in hospital.

96. A client’s provider prescribes 3,000 mL of dextrose 5% in 0.45% sodium chloride to infuse IV over 24 hr. The
nurse initiates an IV infusion of 1,000 mL of this fluid at 0800. At what time should the nurse prepare to initiate
the second 1,000 mL bag? (Document the response in 24-hr [military] time.)

A. 1600 hr
Correct Rationale: 1,000-mL bag should infuse for 8 hr, for a total of 3,000 mL in 24 hr. The
nurse should initiate the second 1,000 mL-bag at 1600 and the third at
0000 (midnight).
Incorrect Rationale: 1,000-mL bag should infuse for 8 hr, for a total of 3,000 mL in 24 hr. The
nurse should initiate the second 1,000 mL-bag at 1600 and the third at
0000 (midnight).

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97. The following statements are true about the incentive spirometer EXCEPT which one?

A. It has a mouth piece, a goal piston, and a main piston.

B. The incentive spirometer is frequently used with postoperative clients.

C. Taking slow inspiration is better than breathing a big volume.

D. It helps clients learn how to cough.

Rationale: The incentive spirometer was designed to help clients deep breathe after surgery.
A, B, & C are all true about the proper parts of the spirometer and proper operation
of the incentive spirometer. (Brunner & Suddarth, 2014, pp. 498-499; Respiratory
Lecture, MCC, 4-14-14,)

98. A nurse is preparing to document a client’s information on the electronic chart. Which of the following nursing
statements identifies and understands of the purpose of charting?

A. “Charting is a communication tool for the healthcare team.”

Rationale: The nurse charts to communicate client data to the healthcare team.

B. “Charting is to provide reimbursement from the local government.”

Rationale: The nurse charts to receive reimbursement from the federal government not local
government.

C. “Charting is to provide information for a client audit.”

Rationale: The nurse charts to provide information for a nursing audit not client audit to
determine is nursing standards are met.

D. “Charting is to enable physicians to monitor the nurse.”

Rationale: The nurse charts to enable the physicians to monitor the clients care and progress
not to monitor the nurse.

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NUR450C Exam 1

99. A nurse is caring for a client who is at 6 weeks of gestation and has pneumonia. While the nurse is obtaining
the client’s history, she tells the nurse that she takes the herb feverfew for migraine headaches. Which of the
following actions should the nurse take?

A. Tell her that she should take an over-the-counter analgesic instead.

Rationale: The nurse should not recommend any medications to a client who is pregnant.

B. Explain that she should not take this herb while she is pregnant.
Rationale: The nurse should explain that feverfew interferes with platelet action and can
therefore cause bleeding. It is unsafe for the client to take during pregnancy.

C. Ask her why she would take an herb during pregnancy.

Rationale: Asking “why” questions is nontherapeutic because it challenges the client’s
judgment and can make her respond defensively.

D. Suggest that she ask her herbalist about taking it while pregnant.
Rationale: Imposing a delay in advising the client about this herb could result in her taking it
again, which the nurse should not suggest.

100. The nurse is working with a 36-year-old, married client, G6 P6, who smokes. The woman states, “I don’t
expect to have any more kids, but I hate the thought of being sterile.” Which of the following contraceptive
methods would be best for the nurse to recommend to this client?

A. Intrauterine device
Rationale: An intrauterine device (IUD) is an excellent contraceptive method for women who
have had at least one delivery, are in a monogamous relationship, and wish to have
long-term contraception.

B. Contraceptive patch
Rationale: The contraceptive patch contains estrogen is not recommended for women over 35
or for women who smoke.

C. Bilateral tubal ligation

Rationale: A bilateral tubal ligation is a sterilization procedure.

D. Birth control pills

Rationale: Birth control pills are not recommended for women over 35 or for women who
smoke.

End of Test

CAA_DetailedAnswerKey created 11/10/2015 page 60 of 60