1. When a nurse is tried under criminal law, the nurse is being brought to trial by:
2. The newly licensed practical/vocational nurse begins work on a hospital unit where LPNs/LVNs are allowed to start intravenous fluids. The physician orders intravenous fluids to be started on one of this nurse's assigned clients. Which of the following actions would be most necessary on the part of this newly hired and newly licensed nurse before starting an intravenous on the client?
3. When working as a licensed vocational nurse, you determine that your client scheduled for surgery does not understand the physician's earlier explanation of the surgery. The client is asking many questions about the risks and seems worried. Which of the following actions would be best on your part?
4. You are the nurse working with an elderly, competent client who refuses a vitamin B injection ordered by the physician. The family insists that this injection be given, and you give it while the client is objecting. Even though the client improves, the client contacts a lawyer. From your knowledge of nursing and the law, you realize that you:
5. When an LVN/LPN is working for a health-care organization that has professional liability insurance, the nurse needs to base a decision on whether to buy individual professional liability insurance on which of the following things?
6. When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?
7. When the licensed practical/vocational nurse is checking the physician's orders against the medication record prior to setting up medications, the nurse discovers a medication error made on the previous shift. The nurse reports this error to the supervising nurse. Which of the following persons will need to fill out an incident report?
8. You are a student nurse working as a part-time or temporary nursing assistant in a nursing home. The nurse on duty asks you to insert a nasogastric tube in a patient. You have recently passed an examination on putting in a nasogastric tube. Which of the following actions is best on your part?
9. According to the nursing code of ethics, when working as a nurse and a conflict comes up between your client's needs and what the family and/or the physician wants, and/or the hospital policies, your first loyalty is to the:
10. Which of the following strategies can most help you as a nurse to enhance your ethical practice and client advocacy?
11. Which of the following actions by a practical/vocational nursing student represents the best example of deductive reasoning?
12. In the daily practice of nursing, nurses use critical thinking in:
13. When the nurse problem solves and has implemented a solution from several solutions identified, the nurse most needs to do which of the following things?
14. Using Strader's seven-step decision-making process, the nurse needs to first identify the purpose. What must the nurse do next?
15. Nurses, as they progress in their education, will most likely do which of the following things?
16. When nurses assist clients in exploring their lifestyle habits and health behaviors to identify health risks, nurses are most likely to use which of the following models?
17. The lowest level of needs in Maslow's Hierarchy of Needs is which of the following?
18. In Hildegard Peplau's Interpersonal Relations Model, the focus is on which of the following?
19. In Virginia Henderson's 1966 definition of nursing, a person/client has which of the following numbers of fundamental needs ?
20. Which of the following therorists stressed energy fields in their nursing theory?
21. Which of the following reasons is the most important, as well as the most widely accepted, reason for nurses using nursing process?
22. The primary source of data for the client's database is which of the following sources?
23. Which of the following statements best describes a wellness nursing diagnosis for an individual, family, or community?
24. When reading the nursing-care plan of a newly assigned client prior to caring for this client, the LPN/LVN will notice that potential problems are stated using how many parts in the statement?
25. The physician writes an order for "progressive ambulation, as tolerated." The RN writes an order for "Dangle for 5 min. 12 h post op and stand at bedside 24 h post op." The LVN assigned to care for this client should do which of the following?
26. When does the nurse chart an intervention that involves administering medication to a client?
27. When writing goals/outcomes for clients, the nurse should do which of the following?
28. The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
29. Which of the following activities on the part of the nurse most demonstrates individualization of the nursing-care plan for a client?
30. You are doing the evaluation step of the nursing process and find that two of the goals for the client have not been met. Which of the following actions would be best on your part?
31. When you discover an electrical fire and decide you need a fire extinguisher, you will need to find a fire extinguisher that is rated for which class of fire?
32. Which of the following statements is an OBRA regulation that the nurse must keep in mind when considering applying a restraint to a client?
33. When restraining a client in bed with a sleeveless jacket (vest) with straps, you will do which of the following things?
34. When you encounter the victim of an electrical-current injury who is still holding an electrical appliance, you would do which of the following things first?
35. When instructing the family of a client who has diabetes with neuropathy causing impaired skin sensitivity, you would stress the importance of which one of the following things in regard to showering or bathing?
36. The nurse finds that an assigned client is restless, agitated, and confused and is thinking of restraining the client. Which of the following questions is most important for the nurse to ask?
37. The nurse giving discharge instructions advises the client to get out of bed slowly and to get up in stages from lying to sitting to standing. The client understands that the reason for doing this is:
38. Which of the following interventions on the part of the nurse would most help a confused ambulatory client find their room?
39. When assessing the noise level that clients are exposed to, the nurse is aware that levels below which of the following number of decibels is usually safe in terms of hearing?
40. One of your assigned clients who is scheduled for radiation therapy asks you to stay with her during radiation because she is scared. Your best response to this request would be which of the following responses?
41. A true pathogen will cause disease or infection:
42. A client asks you to explain viruses. Which of the following statements would be true and therefore best to include in your answer?
43. The nursing supervisor has asked the staff to reduce the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing iatrogenic infections?
44. Your assigned client has encephalitis, and there are other cases in the community. In a team meeting regarding your client and prevention of other cases of encephalitis, the nurse supervisor talks about breaking the chain of infection at the second link: the reservoir. You realize the nurse supervisor is talking about which of the following things?
45. On a home visit, you notice some dust on a vent in your client's room and on the windowsill. Which of the following methods would you teach the family to use for removing dust?
46. A client asks you how to best prevent vaginal infections. Your best answer would include which of the following statements?
47. You would refer to the early phase of scar tissue formation as which of the following kinds of tissue?
48. Which of the following situations represents the best example of passive immunity?
49. You are working with a client who has cancer and is undergoing treatment. The client complains of a loss of appetite. You will most need to make certain that your client eats which one of the following foods?
50. Your assigned client has a leg ulcer that has a dressing on it. During your assessment, you find that the dressing is wet. The client admits to spilling water on the dressing. What action would be best on your part?
51. A fellow nurse who is working on another unit asks to read the chart of your assigned client. Which one of the following criteria would enable the nurse to have access to the chart?
52. When charting in the client's record or chart, the nurse most needs to do which one of the following things?
53. While giving a shift report on your assigned client, you realize that you forgot to record a nursing procedure done on your client. Which of the following methods of documentation would be best on your part?
54. One of your assigned clients gets up to go to the bathroom without calling you. The client falls to the floor and calls for help. You answer the call and alert your supervisor. After assuring that the vital signs are normal and there does not appear to be any injuries, you are told to fill out an incident report. In addition to noting that the client was found on the floor, which of the following statements would you most need to record in the nursing notes for the client?
55. When the physician telephones to order a therapy such as a medication for the client of a student nurse, who is the best person to take this telephone order?
56. The nurse is sending some lab results to the primary physician's office. The nurse most needs to do which of the following things?
57. In the Problem Oriented Medical Record documentation system (POMR), which of the following answers best represents the person or persons who may contribute to the problem list representing the client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs?
59. When working in a facility that uses focus charting, the nurse will use which of the following as a focus of care?
60. When the nurse's assigned client is being discharged to another institution or a home setting where a visit by the community health nurse is required, which of the following information is most likely to be included in the discharge and referral summaries?
61. Which of the following words represents the basic unit of all life and is the simplest structure that possesses all the characteristics of life: organization, metabolism, responsiveness, homeostasis, growth, and reproduction?
62. Which of the following cells of the body are in almost constant mitosis?
63. Where is ribosomal RNA used in protein synthesis produced?
64. Tissue in the urinary bladder called transitional epithelium is best described in which of the following ways?
65. When teaching someone about endocrine glands, which of the following statements could you use?
66. The vocal cords have and function with which of the following kinds of tissue?
67. The thoracic and abdominopelvic cavities are divided by which of the following body structures?
68. The body's biggest organ is which of the following components of the body?
69. The skeletal system acts as a storehouse for calcium, which is a very important component in muscle contractions, as well as which of the following activities in the body?
70. When reading an autopsy report, the nurse encounters the term "mid-sagittal plane." This nurse understands that this means the body was viewed using a plane that matched which of the following descriptions?
71. The nurse receives a report at the beginning of the shift and learns that the client scores 7 on the Glasgow Coma Scale. The nurse realizes that this client is at which of the following levels of consciousness?
72. You partially darken a room and ask the client to look straight ahead. You use a penlight and, approaching from the side you shine the light, it constricts. You remove the light and then shine it on the same pupil again. You also observe the response of the other pupil. You would normally find the other pupil doing which of the following things?
73. The nurse is preparing to do a focused assessment of the abdomen on an assigned client. Which of the following is most important for the nurse to do prior to the examination?
74. The physician of your assigned client tells you that the client has a heart murmur that can be detected by direct auscultation. You realize that the physician is telling you which of the following things?
75. When weighing a client daily, you will most need to weigh the client at which of the following times?
76. When counting the apical pulse during the physical assessment, it is the most accepted practice for the nurse to count the apical pulse in which of the following ways?
77. While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings?
78. When examining the client's abdomen, the nurse will most facilitate the examination by positioning the client in which of the following ways?
79. You highly suspect that your assigned client has abdominal distention. You most need to do and chart which of the following things?
80. When a client's skin is dry, which of the following nursing interventions would be most helpful?
81. To protect the client's skin from injury during hygiene care, including bathing or showering, application of lotion, and bed making, you most need to do which of the following things?
82. The skin produces and absorbs which of the following vitamins in conjunction with the ultraviolet rays of the Sun, which activate this particular vitamin's precursor present in the skin?
83. You are working with a client who has dentures but does not wear them. When questioned about the reason for not wearing the dentures, the client says it makes him feel old. Which of the following responses would be best?
84. When assessing the client's hair, you are especially looking for pediculosis capitis. If it is present, which of the following signs will you most likely find?
85. You are preparing to bathe and wash the hair of an African American woman. Which of the following questions would be most important to ask the client?
86. You need to remove the artificial eye of a client, and you need to clean it. Which of the following methods is recommended for removal?
87. It is most likely that an acutely ill client will need the room temperature set at which of the following temperatures?
88. You are cleaning a client's partial dentures, which have a metal clasp. Which of the following actions are best on your part?
89. A nurse getting report at the beginning of shift learns that an assigned client has hyperpyrexia. The nurse realizes that this client is experiencing which of the following signs or symptoms?
100. You are ready to take the client's oral temperature. You ask this client how long it has been since drinking something hot or cold or smoking. The client admits having just drunk a cup of hot coffee. You will wait how long before taking the temperature?
91. In which of the following clients is a rectal temperature most usually contraindicated?
92. When taking a radial pulse for half a minute, the nurse finds it to be irregular. Which of the following would be best for the nurse to do next?
93. The nurse wants to check the popliteal pulse. This pulse can be better palpated if the nurse does which of the following things?
94. The nurse positioning a client after surgery will take into account that the position, which most often predisposes a client to physiologic processes that suppress respiration, is which of the following positions?
95. The nurse is taking the client's blood pressure. The physician asks for the pulse pressure. To obtain the pulse pressure, the nurse will have to do which of the following things?
96. The nurse notices that the client has a hematocrit of 70 percent. This level of hematocrit will most likely affect the vital signs in which of the following ways?
97. The nurse finds that a newborn has a mean systolic pressure of 75 mmHg. How would this blood pressure be best described?
98. When working with clients experiencing pain, you will define their pain in regard to whether they have pain or not and how intense it is based on which of the following things?
99. When pain impulses are transmitted via the A-delta fibers, which of the following types of pain will your client have?
100. Your assigned client, who has been talking with the doctor about pain control, later asks you what the doctor meant by "pain threshold." Which of the following would be the best reply?
111. Which one of the following four clients is most likely to tolerate pain best?
2. The newly licensed practical/vocational nurse begins work on a hospital unit where LPNs/LVNs are allowed to start intravenous fluids. The physician orders intravenous fluids to be started on one of this nurse's assigned clients. Which of the following actions would be most necessary on the part of this newly hired and newly licensed nurse before starting an intravenous on the client?
3. When working as a licensed vocational nurse, you determine that your client scheduled for surgery does not understand the physician's earlier explanation of the surgery. The client is asking many questions about the risks and seems worried. Which of the following actions would be best on your part?
4. You are the nurse working with an elderly, competent client who refuses a vitamin B injection ordered by the physician. The family insists that this injection be given, and you give it while the client is objecting. Even though the client improves, the client contacts a lawyer. From your knowledge of nursing and the law, you realize that you:
5. When an LVN/LPN is working for a health-care organization that has professional liability insurance, the nurse needs to base a decision on whether to buy individual professional liability insurance on which of the following things?
6. When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?
7. When the licensed practical/vocational nurse is checking the physician's orders against the medication record prior to setting up medications, the nurse discovers a medication error made on the previous shift. The nurse reports this error to the supervising nurse. Which of the following persons will need to fill out an incident report?
8. You are a student nurse working as a part-time or temporary nursing assistant in a nursing home. The nurse on duty asks you to insert a nasogastric tube in a patient. You have recently passed an examination on putting in a nasogastric tube. Which of the following actions is best on your part?
9. According to the nursing code of ethics, when working as a nurse and a conflict comes up between your client's needs and what the family and/or the physician wants, and/or the hospital policies, your first loyalty is to the:
10. Which of the following strategies can most help you as a nurse to enhance your ethical practice and client advocacy?
11. Which of the following actions by a practical/vocational nursing student represents the best example of deductive reasoning?
12. In the daily practice of nursing, nurses use critical thinking in:
13. When the nurse problem solves and has implemented a solution from several solutions identified, the nurse most needs to do which of the following things?
14. Using Strader's seven-step decision-making process, the nurse needs to first identify the purpose. What must the nurse do next?
15. Nurses, as they progress in their education, will most likely do which of the following things?
16. When nurses assist clients in exploring their lifestyle habits and health behaviors to identify health risks, nurses are most likely to use which of the following models?
17. The lowest level of needs in Maslow's Hierarchy of Needs is which of the following?
18. In Hildegard Peplau's Interpersonal Relations Model, the focus is on which of the following?
19. In Virginia Henderson's 1966 definition of nursing, a person/client has which of the following numbers of fundamental needs ?
20. Which of the following therorists stressed energy fields in their nursing theory?
21. Which of the following reasons is the most important, as well as the most widely accepted, reason for nurses using nursing process?
22. The primary source of data for the client's database is which of the following sources?
23. Which of the following statements best describes a wellness nursing diagnosis for an individual, family, or community?
24. When reading the nursing-care plan of a newly assigned client prior to caring for this client, the LPN/LVN will notice that potential problems are stated using how many parts in the statement?
25. The physician writes an order for "progressive ambulation, as tolerated." The RN writes an order for "Dangle for 5 min. 12 h post op and stand at bedside 24 h post op." The LVN assigned to care for this client should do which of the following?
26. When does the nurse chart an intervention that involves administering medication to a client?
27. When writing goals/outcomes for clients, the nurse should do which of the following?
28. The client you are assigned to has four nursing diagnoses. Which of the following would you assign the highest priority?
29. Which of the following activities on the part of the nurse most demonstrates individualization of the nursing-care plan for a client?
30. You are doing the evaluation step of the nursing process and find that two of the goals for the client have not been met. Which of the following actions would be best on your part?
31. When you discover an electrical fire and decide you need a fire extinguisher, you will need to find a fire extinguisher that is rated for which class of fire?
32. Which of the following statements is an OBRA regulation that the nurse must keep in mind when considering applying a restraint to a client?
33. When restraining a client in bed with a sleeveless jacket (vest) with straps, you will do which of the following things?
34. When you encounter the victim of an electrical-current injury who is still holding an electrical appliance, you would do which of the following things first?
35. When instructing the family of a client who has diabetes with neuropathy causing impaired skin sensitivity, you would stress the importance of which one of the following things in regard to showering or bathing?
36. The nurse finds that an assigned client is restless, agitated, and confused and is thinking of restraining the client. Which of the following questions is most important for the nurse to ask?
37. The nurse giving discharge instructions advises the client to get out of bed slowly and to get up in stages from lying to sitting to standing. The client understands that the reason for doing this is:
38. Which of the following interventions on the part of the nurse would most help a confused ambulatory client find their room?
39. When assessing the noise level that clients are exposed to, the nurse is aware that levels below which of the following number of decibels is usually safe in terms of hearing?
40. One of your assigned clients who is scheduled for radiation therapy asks you to stay with her during radiation because she is scared. Your best response to this request would be which of the following responses?
41. A true pathogen will cause disease or infection:
42. A client asks you to explain viruses. Which of the following statements would be true and therefore best to include in your answer?
43. The nursing supervisor has asked the staff to reduce the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing iatrogenic infections?
44. Your assigned client has encephalitis, and there are other cases in the community. In a team meeting regarding your client and prevention of other cases of encephalitis, the nurse supervisor talks about breaking the chain of infection at the second link: the reservoir. You realize the nurse supervisor is talking about which of the following things?
45. On a home visit, you notice some dust on a vent in your client's room and on the windowsill. Which of the following methods would you teach the family to use for removing dust?
46. A client asks you how to best prevent vaginal infections. Your best answer would include which of the following statements?
47. You would refer to the early phase of scar tissue formation as which of the following kinds of tissue?
48. Which of the following situations represents the best example of passive immunity?
49. You are working with a client who has cancer and is undergoing treatment. The client complains of a loss of appetite. You will most need to make certain that your client eats which one of the following foods?
50. Your assigned client has a leg ulcer that has a dressing on it. During your assessment, you find that the dressing is wet. The client admits to spilling water on the dressing. What action would be best on your part?
51. A fellow nurse who is working on another unit asks to read the chart of your assigned client. Which one of the following criteria would enable the nurse to have access to the chart?
52. When charting in the client's record or chart, the nurse most needs to do which one of the following things?
53. While giving a shift report on your assigned client, you realize that you forgot to record a nursing procedure done on your client. Which of the following methods of documentation would be best on your part?
54. One of your assigned clients gets up to go to the bathroom without calling you. The client falls to the floor and calls for help. You answer the call and alert your supervisor. After assuring that the vital signs are normal and there does not appear to be any injuries, you are told to fill out an incident report. In addition to noting that the client was found on the floor, which of the following statements would you most need to record in the nursing notes for the client?
55. When the physician telephones to order a therapy such as a medication for the client of a student nurse, who is the best person to take this telephone order?
56. The nurse is sending some lab results to the primary physician's office. The nurse most needs to do which of the following things?
57. In the Problem Oriented Medical Record documentation system (POMR), which of the following answers best represents the person or persons who may contribute to the problem list representing the client's physiologic, psychologic, social, cultural, spiritual, developmental, and environmental needs?
59. When working in a facility that uses focus charting, the nurse will use which of the following as a focus of care?
60. When the nurse's assigned client is being discharged to another institution or a home setting where a visit by the community health nurse is required, which of the following information is most likely to be included in the discharge and referral summaries?
61. Which of the following words represents the basic unit of all life and is the simplest structure that possesses all the characteristics of life: organization, metabolism, responsiveness, homeostasis, growth, and reproduction?
62. Which of the following cells of the body are in almost constant mitosis?
63. Where is ribosomal RNA used in protein synthesis produced?
64. Tissue in the urinary bladder called transitional epithelium is best described in which of the following ways?
65. When teaching someone about endocrine glands, which of the following statements could you use?
66. The vocal cords have and function with which of the following kinds of tissue?
67. The thoracic and abdominopelvic cavities are divided by which of the following body structures?
68. The body's biggest organ is which of the following components of the body?
69. The skeletal system acts as a storehouse for calcium, which is a very important component in muscle contractions, as well as which of the following activities in the body?
70. When reading an autopsy report, the nurse encounters the term "mid-sagittal plane." This nurse understands that this means the body was viewed using a plane that matched which of the following descriptions?
71. The nurse receives a report at the beginning of the shift and learns that the client scores 7 on the Glasgow Coma Scale. The nurse realizes that this client is at which of the following levels of consciousness?
72. You partially darken a room and ask the client to look straight ahead. You use a penlight and, approaching from the side you shine the light, it constricts. You remove the light and then shine it on the same pupil again. You also observe the response of the other pupil. You would normally find the other pupil doing which of the following things?
73. The nurse is preparing to do a focused assessment of the abdomen on an assigned client. Which of the following is most important for the nurse to do prior to the examination?
74. The physician of your assigned client tells you that the client has a heart murmur that can be detected by direct auscultation. You realize that the physician is telling you which of the following things?
75. When weighing a client daily, you will most need to weigh the client at which of the following times?
76. When counting the apical pulse during the physical assessment, it is the most accepted practice for the nurse to count the apical pulse in which of the following ways?
77. While listening to a client's lung sounds, you hear something that you believe is not normal, and you note that it is a continuous sound. You will chart this as which of the following findings?
78. When examining the client's abdomen, the nurse will most facilitate the examination by positioning the client in which of the following ways?
79. You highly suspect that your assigned client has abdominal distention. You most need to do and chart which of the following things?
80. When a client's skin is dry, which of the following nursing interventions would be most helpful?
81. To protect the client's skin from injury during hygiene care, including bathing or showering, application of lotion, and bed making, you most need to do which of the following things?
82. The skin produces and absorbs which of the following vitamins in conjunction with the ultraviolet rays of the Sun, which activate this particular vitamin's precursor present in the skin?
83. You are working with a client who has dentures but does not wear them. When questioned about the reason for not wearing the dentures, the client says it makes him feel old. Which of the following responses would be best?
84. When assessing the client's hair, you are especially looking for pediculosis capitis. If it is present, which of the following signs will you most likely find?
85. You are preparing to bathe and wash the hair of an African American woman. Which of the following questions would be most important to ask the client?
86. You need to remove the artificial eye of a client, and you need to clean it. Which of the following methods is recommended for removal?
87. It is most likely that an acutely ill client will need the room temperature set at which of the following temperatures?
88. You are cleaning a client's partial dentures, which have a metal clasp. Which of the following actions are best on your part?
89. A nurse getting report at the beginning of shift learns that an assigned client has hyperpyrexia. The nurse realizes that this client is experiencing which of the following signs or symptoms?
100. You are ready to take the client's oral temperature. You ask this client how long it has been since drinking something hot or cold or smoking. The client admits having just drunk a cup of hot coffee. You will wait how long before taking the temperature?
91. In which of the following clients is a rectal temperature most usually contraindicated?
92. When taking a radial pulse for half a minute, the nurse finds it to be irregular. Which of the following would be best for the nurse to do next?
93. The nurse wants to check the popliteal pulse. This pulse can be better palpated if the nurse does which of the following things?
94. The nurse positioning a client after surgery will take into account that the position, which most often predisposes a client to physiologic processes that suppress respiration, is which of the following positions?
95. The nurse is taking the client's blood pressure. The physician asks for the pulse pressure. To obtain the pulse pressure, the nurse will have to do which of the following things?
96. The nurse notices that the client has a hematocrit of 70 percent. This level of hematocrit will most likely affect the vital signs in which of the following ways?
97. The nurse finds that a newborn has a mean systolic pressure of 75 mmHg. How would this blood pressure be best described?
98. When working with clients experiencing pain, you will define their pain in regard to whether they have pain or not and how intense it is based on which of the following things?
99. When pain impulses are transmitted via the A-delta fibers, which of the following types of pain will your client have?
100. Your assigned client, who has been talking with the doctor about pain control, later asks you what the doctor meant by "pain threshold." Which of the following would be the best reply?
111. Which one of the following four clients is most likely to tolerate pain best?
