1. Which are appropriate examples of cost-effective care? Select all that apply.

1.) Which are appropriate examples of cost-effective care? Select all that apply.

• Considering the inside of the sterile glove wrapper as a small sterile field
• Donning clean, rather than sterile, gloves to remove a client’s dressing
• Returning opened, unused supplies from a client’s room to the central supply room
• Reusing a tourniquet for multiple clients unless it is visibly soiled
• Using remaining sterile saline in a bottle opened 48 hours ago before discarding

2.) Which issue would a unit quality improvement committee address?

• A 10% decrease in client satisfaction in the registration process
• A nurse who made 3 medication errors in the past quarter
• An increase in catheter-associated urinary tract infections
• Staff perception of hospital laboratory personnel incivility

3.) The risk management nurse is reviewing client records. Which nursing intervention could have contributed to a sentinel event?

• Administered flumazenil to a client who overdosed on lorazepam
• Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmo/L)
• Administered warfarin to a client with International Normalized Ratio of 6
• Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg

4.) The nurse removes personal protective equipment (PPE) after completing a wound dressing change for a client in airborne transmission-based precautions. Which PPE should the nurse remove first?

• Face shield/goggles
• Gloves
• Gown
• Mask/respirator

5.) The emergency department nurse receives report on 4 clients. Which client will the nurse prioritize for placement in an isolation room?

• 4-year-old diagnosed with scabies who has red burrows and bumps along the neckline and

inner elbows

• 7-year-old diagnosed with measles who has a fever, conjunctivitis, cough, and maculopapular

rash

• 12-year-old with a positive rapid influenza test who has a fever, cough, and runny nose
• 14-year-old with 4-inch wound on inner aspect of thigh with a positive culture for methicillin-

resistant staphylococcus aureus

6.) The nurse is caring for a client with Clostridium difficile colitis. Which of the following infection control measures by the nurse are appropriate? Select all that apply.

• Applies sterile gloves before performing client care
• Ensures surgical masks are worn by staff in the client’s room
• Requests that the client be assigned to a single-client room
• Uses alcohol-based sanitizers for hand hygiene
• Wears a single-use disposable gown during client care

7.) A client arrives in the emergency department on a cold winter day. The client is calm, alert, and oriented with a respiratory rate of 20/min and a pulse oximeter reading of 78%. The nurse suspects that

the client’s pulse oximeter reading is inaccurate. Which factors could be contributing to this reading?Select all that apply.

• Black fingernail polish
• Cold extremities
• Elevated WBC count
• Hypotension
• Peripheral arterial disease

8.) The nurse is working in a busy emergency department and is assigned 4 clients. Which client should the nurse see first?

• Client receiving cyclophosphamide reporting bloody urine
• Client who reports severe nausea and vomiting after chemotherapy
• Client with an elbow abrasion and a lip laceration possibly requiring sutures
• Homeless client who appears drowsy with a temperature of 95 F (35 C)

9.) A client with a history of diverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? Select all that apply.

• Drink plenty of fluids
• Exercise regularly
• Follow a low-residue diet
• Include whole grains, fruits, and vegetables in the diet
• Increase intake in red meat

10.) The nurse is triaging clients in the emergency department. Which client needs to be seen first?

• 18-year-old female with fever, suprapubic pain, and dysuria
• 21-year-old male with diffuse abdominal pain and a rigid abdomen
• 64-year-old male with a pulsatile mass in the periumbilical area and back pain
• 75-year-old with nausea, fever, and left lower quadrant pain

11.) Multiple clients present to be emergency department. Which client should the triage nurse prioritize for diagnostic testing and definitive care?

• 26-year-old IV drug user reporting fever and right arm redness and swelling
• 32-year-old kidney transplant client reporting low-grade fever and generalized body pains
• 69-year-old with diverticulosis reporting left lower quadrant pain and fever
• 74-year-old with right knee replacement reporting fever and right knee swelling

12.) A nurse in the emergency department assesses 4 clients. Based on the laboratory results, which client is the highest priority for treatment?

• Client with abdominal pain, respirations 28/min, and blood alcohol level 80 mg/dL (0.08 mg%

[17.4 mmol/L])

• Client with chronic obstructive pulmonary disease, pH 7.34, pO2 86 mm Hg (11.5 kPa), Pco2 48

mm Hg (6.4 kPa), and HCO3 30 mEq/L (30 mmol/L)

• Client with dull headache, pulse oximeter reading 95%, and serum carboxyhemoglobin level

20%

• Client with emesis of 100 mL coffee-ground gastric contents and serum haemoglobin 15 g/dL

(150 g/L)

13.) The nurse caring for a client with tuberculosis (TB) transports the client to the radiology department for a chest x-ray. The nurse ensures that the client uses which personal protective equipment when out of the negative-pressure room?

• Isolation gown, surgical mask, goggles, and gloves
• Isolation gown and surgical mask
• N95 respirator mask
• Surgical mask

14.) The nurse is caring for a client with bacterial meningitis, identified as Neisseria meningitidis who has a stage 4 pressure injury. What personal protective equipment is most appropriate for the nurse to wear when performing a dressing change? Select all that apply.

• Disposable gown
• Face shield
• Gloves
• N95 respirator
• Surgical mask

15.) The nurse is teaching general skin care guidelines to a client receiving teletherapy (external beam radiation therapy). Which statements does the client make that indicate proper understanding of the teaching? Select all that apply.

1.”I may apply an ice pack to the treatment site if it begins to burn.” 2.”I will rub baby oil after each treatment to prevent dry skin.” 3.”I will use extra measures to protect my skin from sun exposure.” 4.”I will wash the treatment site with lukewarm water and mild soap.” 5.”I will swear soft, loose-fitting clothing.”

16.) The nurse is reviewing phone messages from client in surgery clinic. Which client would be the priority to call back first?

• Client 1 week postoperative appendectomy who has not had a bowel movement in 4 days
• Client 8 days postoperative ileostomy placement who reports nausea, vomiting, and

abdominal bloating

• Client postoperative right below-the-knee amputation who is concerned about a new tingling

sensation in the right foot

• Client with a temperature of 101.2 F (38.4 C) who is scheduled for a shoulder arthroplasty the

next morning

17.) During the emergent phase of burn management, you would expect the following lab values:*

• Low sodium, low potassium, high glucose, low hematocrit
• High sodium, low potassium, low glucose, high hematocrit
• High sodium, high potassium, high glucose, low hematocrit
• Low sodium, high potassium, high glucose, high hematocrit

18.) A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury?

• Carbonaceous sputum
• Hair singeing on the head and nose
• Lhermitte’s Sign
• Bright red lips

• Hoarse voice
• Tachycardia

19.) A 25 year old female patient has sustained burns to the back of the right arm, posterior trunk, front of the left leg, anterior head and neck, and perineum. Using the rule of Nines, calculate the total body surface area percentage that is burned?

1. 46%

2. 37%

3. 36%

4. 28%

20.) A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin (NTG) to treat angina. Which statement by the client indicates that further teaching is required?

1.”I may experience flushing but will continue to take the medication as prescribed.” 2.”I should lie down before taking the medication.” 3.”I should not swallow the tablet.” 4.”I will wait to call 911 if I don’t experience relief after the third tablet.”

21.) The orthopaedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the office nurse teach the client?

• 2-point gait
• 3-point gait
• 4-point gait
• 5-point gait

22.) Figure 1 represents what type of one fracture: This is a fracture that is slanted across the bone shaft.*

• Transverse Fracture
• Spiral Fracture
• Oblique Fracture
• Compound Fracture

23.) Which statement related to ethical nursing practices are correct? Select all that apply.

• Accountability is documenting that the nurse administered the wrong medication
• Autonomy is informing the client of the decision the family made for the client
• Confidentiality is respecting a client request to keep suicidal ideation a secret
• Justice is providing the same cardiac care to a homeless person as a businessperson
• Nonmaleficence is reporting abuse for a client with Alzheimer disease

24.) A male client has terminal metastatic disease. He arrives at the emergency department of respirations of 6/min and an advance directive indicating to withhold resuscitative efforts. What should the nurse’s response be?

• Apply oxygen at 2 L by nasal cannula
• Ask the client if he wants to change his mind
• Ask the spouse what she wants done