It is almost midnight, the unit is dark, and the nurse pulls the last pill from the patient's medication drawer to administer to the
patient. The patient is drowsy, takes the medication, and soon has a reaction. What is the most likely cause of this
incident?During the progressive stage of shock, you may note an increase in which assessment value?
A. Lactic acid
B. Oxygen saturation
C. Urine output
https://www.registerednursern.com/stages-of-shock-nclex-review/
Lungs: ARDS (acute respiratory distress syndrome) will develop. In a nutshell, this occurs due to increased capillary
permeability in the alveoli sacs (this is where gas exchange occurs). The alveoli sacs will collapse due to the fluid surrounding
them and the lung will lose its elasticity. The patient will need intubation and mechanical ventilation to breathe. The patient will
have fluid in the lungs (crackles), increase respiratory rate, decrease oxygen level, and respiratory failure.
The constriction in the venous system will lead to more blood return to the heart, and the constriction in the arterial system
will increase blood pressure. All this together will lead to an increase in tissue perfusion and the cells will receive more oxygen.
The increase in lactate production is usually caused by impaired tissue oxygenation, either from decreased oxygen delivery or a
defect in mitochondrial oxygen utilization.
when cells become hypoxic, lactate levels increase.
Which method should you use when selecting interventions to support optimum patient outcomes for treatment of a stage 1
pressure injury?
A. Ask the most experienced nurses for their advice, and then adopt the information that sounds most logical.
B. Find which supplies are readily available, and develop a treatment plan using these.
C. Ask the clinical specialist which guidelines your organization uses to support wound management policies.
A patient with sudden onset of aphasia and right hemiparesis 2 hours ago has been diagnosed with an ischemic stroke. Vital signs
include a heart rate of 87 bpm, respiratory rate of 20, and blood pressure of 165/92 mmHg. You can expect which of the
following orders?
A. Administer antihypertensives to keep the systolic blood pressure below 140 mmHg
B. Administer enoxaparin in conjunction with the thrombolytic medication
C. Administer intravenous tPA as per the hospital protocol
What medications are used for ischemic stroke?
The main very early treatments for ischemic stroke are: Thrombolytic therapy – This involves giving a medication
called alteplase (also known as tPA, for "tissue plasminogen activator"), or a similar medication called tenecteplase, by IV
(through a vein)
Question 4 of 100
You are educating a patient about his newly prescribed antibiotic. Which statement best helps to reinforce this education?
A. “Now it’s your turn. Please share with me how you will take this medication.”
B. “Here is the written information about the medication, so you can read it when you have time.”
C. “The pharmacist can tell you more when you go to pick up your medication.”
Question 5 of 100
A patient with atrial fibrillation has been started on intravenous heparin. Which of the following complaints by the patient would
be most concerning related to the new medication?
A. “I feel really sleepy today. I think I will take a nap.”
B. “That dinner did not taste good. I just don’t seem to have an appetite today.”
C. “My lower back has started to hurt. I can’t get comfortable.”
Question 6 of 100
A severe weather event has knocked out the main hospital power source. The emergency generator supplies power to the red
emergency outlets. Only one outlet is available near two patients, one with orders for a nebulizer and the other with orders for IV
normal saline fluid to run at 100 ml/hr for hydration.
A. Provide the nebulizer treatment using the outlet and initiate the IV fluid using a flow control device.
B. Hold the IV fluid and give the nebulizer treatment.
C. Run the IV fluid for one hour, then pause it to provide the nebulizer treatment.
The new nurse is caring for a patient with an indwelling catheter. Which action demonstrates the need for further education?
A. Emptying the catheter collection bag before it gets full
B. Leaving the catheter in because the patient is incontinent
C. Cleaning the catheter port before collecting specimens
Question 8 of 100
A newly licensed nurse was elated in the early phase of a first nursing job, sometimes known as the honeymoon phase. Later in
orientation, the nurse makes comments showing a distorted view of the role. Which situation best shows signs of the nurse's
negative role distortion?
A. She perceives the patients for whom she is caring as being the same patients that she cared for in nursing school.
B. She perceives herself as super-nurse and feels invincible in her role.
C. She perceives nurses from another unit as being more competent than those on her unit.
Question 9 of 100
The nurse educator is providing education to a new nurse about community-associated pneumonia. Which statement by the new
nurse demonstrates the need for additional teaching?
A. One risk factor for community-associated pneumonia is home infusion therapy
B. The most common cause is pneumococcal pneumonia
C. Poor dentition can put people at greater risk
Question 10 of 100
You are beginning your shift and assess your first patient who was reported to have uncontrolled pain, despite the administration
of analgesics. How should you approach this patient?
A. “Hello Mrs. Smith. My name is Sally and I will be caring for you today. Please tell me about the pain you have been
having.”
B. “Hi Mrs. Smith. I hear you’re having terrible pain. You don’t look as though the pain is that bad.”
C. “Hello Mrs. Smith. My name is Sally. I know you’re having pain, but I can’t give you any more medicine for about two more
hours.”
Question 11 of 100
It is almost midnight, the unit is dark, and the nurse pulls the last pill from the patient's medication drawer to administer to the
patient. The patient is drowsy, takes the medication, and soon has a reaction. What is the most likely cause of this incident?
A. The hospital system for stocking and administering medications.
B. The nurse’s carelessness in not checking the medication more closely.
C. The pharmacy tech who stocked the incorrect medication in the drawer.
Question 12 of 100
A patient admitted with generalized weakness has a Glasgow Coma Scale score of 15, heart rate of 123 bpm, a respiratory rate of
24, a blood pressure of 98/51 mmHg, a serum white blood cell count of 17,000 x 10 9/L, and a blood lactate level of 0.5 mmol/L
after receiving 3 liters of normal saline solution intravenously. Which of the following syndromes does the nurse suspect?
A. Septic shock
B. Sepsis with altered mental status
C. Sepsis
Question 13 of 100
You have been caring for a patient in the end stages of a terminal illness. Which of the following signs or symptoms should you
recognize as being a typical part of the dying process?
A. The patient’s breathing is slow and there are audible rattles.
B. The patient gradually becomes more and more alert.
C. The patient consistently asks for more food at mealtimes.
Question 14 of 100
A patient awaiting surgery states they want to avoid the use of opioids during the surgery and recovery because they've been
prescribed too many opioids in the past. Which is your best response?
A. "Let me contact your surgeon and the anesthesia team to discuss this with you."
B. "For most surgery it is not possible to manage pain without opioids."
C. "The surgeon will prescribe your medication based on your records and the state medication prescription monitoring
program."
Question 15 of 100
You are caring for a patient with heart failure who has pulmonary crackles and an S3 heart sound. The patient complains of
having difficulty breathing, even at rest. Which of the following should you incorporate into this patient's plan of care?
A. Teach the patient how to perform pursed-lip breathing.
B. Encourage extra fluid intake to thin any secretions.
C. Keep the bed in a supine position so the patient can rest.
Question 16 of 100
For which patient should you be most concerned about the possibility of a surgical site infection?
A. Patient who has insulin-dependent diabetes mellitus
B. Patient who was recently placed on 5 days of topical prednisone for a skin rash
C. Patient who had a small cancerous skin lesion removed 2 years ago
Question 17 of 100
Which situation represents an ethical dilemma?
A. The nurse sustains a needle stick to the finger while drawing up a medication for intravenous administration.
B. The provider orders a high dose of medication for patient comfort, but administration of this high dose is outside the
scope of safe nursing practice.
C. The patient complains to the nurse that this hospital food is not as tasty as the food at other hospitals.
Question 18 of 100
You are caring for a patient with chronic obstructive pulmonary disease (COPD). The patient complains of a cough and dyspnea
on exertion. Further assessment reveals distended jugular veins and dependent pitting edema. What order should you anticipate?
A. Diuretics
B. High-flow oxygen
C. Vasoconstrictors
Question 19 of 100
You are providing teaching for a patient who received an intracoronary stent after experiencing an acute myocardial infarction
(AMI). Which statement by the patient indicates understanding of the instructions?
A. "I should participate in a physical rehabilitation program."
B. "I will not smoke inside the house anymore. I will go out on the porch to smoke."
C. "When my blood pressure comes down, I can stop taking the aspirin my doctor prescribed."
Question 20 of 100
You are completing an admission assessment on a 70-year-old patient with chronic kidney disease (CKD) who has been admitted
for cardiac surgery. Which of the following assessment findings would be most concerning for developing acute kidney injury?
A. ECG show sinus dysrhythmia
B. Fingerstick blood sugar is 97 mg/dl
C. Blood pressure measures 88/50 mmHg
Question 21 of 100
You assess the patients in your assignment, and two patients have worsening conditions. You believe you cannot safely manage
all of the patients in your assignment. Which is the most appropriate action to help ensure patient safety?
A. Prioritize and complete as many tasks as possible
B. Collaborate with the charge nurse to delegate tasks that can safely be performed by unlicensed personnel
C. Leave the lesser important tasks for the nurse on the next shift
Question 22 of 100
In which of the following scenarios does the nurse professionally address a potential conflict?
A. The nurse tells a provider about a contraindication the patient has to a medication that is ordered.
B. The nurse tells other staff that the charge nurse has made an unfair assignment.
C. A nurse passes out invitations to a party to only selected staff during the shift huddle.
Question 23 of 100
A patient who often jokes cheerily with the staff is unusually quiet. He tells you he is having difficulty dealing with his cancer
diagnosis. Which statement will best help promote therapeutic communication?
A. “I noticed you are quiet today. How are you feeling?”
B. “I know just how you feel. My brother had the same type of cancer.”
C. “Hang in there. You can beat this!”
Question 24 of 100
After the handoff report on your assignment for the shift, you demonstrate critical thinking and professional judgment by
delegating which activity to an unlicensed assistive personnel (UAP) team member?
A. Assisting a stable patient with a steady gait and an IV pole who is 2 days post-op from an open appendectomy to
ambulate.
B. Titrating the flow of oxygen for a patient with COPD while the patient is ambulating.
C. Checking on a patient and taking vital signs 15 minutes after initiating a blood transfusion.
Question 25 of 100
During an assessment for a patient, which of the following statements demonstrates a culturally congruent approach?
A. “Please tell me about healing practices in your culture.”
B. “You will need to speak English while you are here in the hospital.”
C. “Please look at me when I ask you a question so I get this information correct in your chart.”
Question 26 of 100
A patient with a history of atrial fibrillation and hypertension is being admitted for weakness and fatigue. In report from the ED
you learn his medications include warfarin and metoprolol, his laboratory results show an international normalized ratio (INR) of
5.3 and a hemoglobin of 7.5 g/dL, and the prehospital emergency team inserted an 18-gauge intravenous catheter in the left
antecubital vein. When the patient arrives to the unit, there is an area of blood on the stretcher, and the IV catheter is lying beside
the patient. What should be your first action?
A. Apply direct pressure to the IV site.
B. Check to ensure the patient's level of weakness has not worsened during transport.
C. Call the provider and request a stat order for a coumadin reversal agent.
Question 27 of 100
You are providing education to a patient with diabetes mellitus and multiple microvascular complications who just arrived on the
unit. What would be an important piece of information to include in this initial education?
A. Verbal description of the layout of the room, including location and use of the call bell.
B. Written description of the daily routine, including times for insulin administration.
C. Descriptions of newly ordered medications, including potential interactions and complications.
Question 28 of 100
You are caring for a postsurgical patient who does not have a diagnosis of diabetes. The patient's fasting glucose level this
morning was 159 mg/dL. Which intervention is most appropriate?
A. Ask the provider for orders to increase the frequency of blood glucose monitoring.
B. Call the provider for insulin orders.
C. Continue to check the patient's blood glucose as ordered.
Question 29 of 100
You receive report on your three patients at 700 hrs. Mrs. Smith was admitted post laparoscopic cholecystectomy from yesterday,
and slept through the night. She requested of the night nurse that someone come in first thing this morning to answer her
questions about discharge. Mr. Jones was transferred from the critical care unit yesterday after treatment for diabetic
ketoacidosis, and receives regular insulin 4 times per day on a sliding scale. Miss Eakin was admitted last night for nausea and
vomiting, and is currently not eating. The nurse's aide is recording vital signs, and the morning breakfast trays have arrived on the
unit. Using the critical thinking process, what should be the nurse's first priority?
A. Assess Miss Eakin for nausea and vomiting, and administer prn medications as ordered.
B. Check a fingerstick glucose on Mr Jones and administer the appropriate amount of insulin per the sliding scale.
C. Gather teaching materials for Mrs. Smith to answer her questions and ease her mind about discharge.
Question 30 of 100
Which action displays culturally congruent care?
A. Telling the patient that the doctor knows best how to treat the disease.
B. Telling the patient that meals must be ordered from the hospital menu.
C. Asking the patient directly about cultural preferences.
Question 31 of 100
You plan to delegate the task of obtaining vital signs to the UAP. Which statement by the nurse demonstrates safe delegation
skills?
A. “After you get the vital signs, please document them. I will check them later.”
B. “Can you please obtain vital signs for both patients in room 1 now and inform me of any abnormal values?”
C. “Please check vital signs for me. Let me know if the patient has any other signs of fever.”
Question 32 of 100
Which statement demonstrates that the patient understands your teaching about medications for her mental health disorder?
A. “If the depression medicine isn’t helping by next week, I will call the doctor for a different med.”
B. “It’s okay to eat potato chips when I take the lithium.”
C. “If I take this dementia medication, I will start remembering and thinking clearly again.”
Question 33 of 100
Two nurses working the same shift are each assigned six patients of high acuity, and one nurse is assigned 5 patients of low
acuity. Which stage of conflict can occur when all three nurses become aware of each other's assignments?
A. Manifest Conflict
B. Perceived Conflict
C. Conflict Aftermath
Question 34 of 100
Which member of the interprofessional team is enacting a potential barrier to effective communication?
A. The new therapist who is having trouble remembering the standard report format the team uses.
B. The provider who addresses team members using job titles and surnames.
C. The nurse who is certified in the unit's specialty practice.
Question 35 of 100
A patient with diabetes mellitus has been admitted for abdominal pain and vomiting. Although a blood glucose by fingerstick
shows an elevated glucose outside of the meter's range, serum lab results are not yet available. The provider has ordered a stat
computed tomography (CT) scan. What is your best action?
A. Keep the patient NPO and start IV fluids at a keep vein open (KVO) rate
B. Call the lab to request results as soon as possible before sending the patient for the CT scan
C. Call to see if they can get the patient in for a CT scan immediately
Question 36 of 100
Which of the following interventions should you perform for a patient complaining of "an elephant sitting on the chest"?
A. Obtain an EKG one hour after the patient begins to complain of pain.
B. Apply oxygen to achieve a saturation level of at least 95%.
C. Draw a blood sample to send to the lab to obtain liver function tests.
Question 37 of 100
When caring for a patient with chronic obstructive pulmonary disease (COPD), which intervention should you include in the
daily plan?
A. Maintain an oxygen saturation level of at least 98%
B. Schedule physical therapy just before lunch time
C. Administer bronchodilators, as ordered
Question 38 of 100
Which of the following demonstrates the ANA's Code of Ethics principle to act with "compassion and respect for the inherent
dignity, worth, and uniqueness of every individual?"
A. Addressing an older adult patient as “Honey.”
B. Waking an exhausted patient from a nap to make the bed.
C. Sitting at eye level to communicate with a teenager.
Question 39 of 100
Which of the following signs or symptoms would most likely alert you to a possible surgical site infection?
A. Increased urine output
B. Clear wound drainage
C. Low blood pressure
Question 40 of 100
You are caring for a patient newly diagnosed with left ventricular systolic dysfunction (LVSD) heart failure. Which medication
might be included in the treatment plan?
A. Nifedipine
B. Lisinopril ACE
C. Naproxen
Question 41 of 100
You have medicated a postoperative patient for pain as ordered. When you assess the patient one hour later, the patient is sitting
calmly in bed but complains of pain at the surgical site, which she rates a 10 (the highest). The surgical site is clean, dry, and
intact, without redness. Which is the most appropriate response for the nurse to give the patient?
A. “You are not scheduled for more pain medication yet, so just try to get some rest.”
B. “Your body is not acting like “10 out of 10” pain. I will check back in another hour.”
C. “Will you tell me some more about your pain so I can better understand how to help you?"
Question 42 of 100
An novice nurse approaches another nurse and asks to switch patients, stating, "My patient is actively dying, and I just can't stop
crying." How should the nurse best respond?
A. "Did you take the learning module on caring for patients who are actively dying? It really helped me care for dying
patients."
B. "At first taking care of a dying patient was tough for me. It will get easier each time."
C. "Dying can trigger your emotions. I'll help you today, but consider asking the manager about contacting the bereavement
team."
Question 43 of 100
A nursing unit has been experiencing a high number of patient falls. Which of the following represents a systems thinking
approach to this issue?
A. Provide education for the nurse’s aides about ambulating patients
B. Ask “why?” for all interactions related to the patient falls
C. Request that the physicians write stricter orders about patient ambulation
Question 44 of 100
A patient admitted yesterday with chest pain and an abnormal EKG is preparing for discharge. As you begin discharge teaching,
the patient states that he won't be taking the new medications because he can't afford them. Which of the following statements
promotes quality care?
A. “I see you have a pack of cigarettes with you. You should be giving up smoking, and the money you save can be used to buy
the medication.”
B. “This medication is very important to decrease the work of your heart. I will call the case manager to come and meet
with us about medication assistance programs.”
C. “Perhaps you can think of friends or family members who could help you out with a little money so you can buy the
medication that you need for your heart.”
Question 45 of 100
A patient has a fever of 102.2 degrees F (39.0 C), a heart rate of 102 bpm, respiratory rate of 28, an oxygen saturation of 90%,
and moist clammy skin. The nurse suspects this patient is suffering from which disorder?
A. COPD exacerbation
B. Bacterial pneumonia
C. Cor pulmonale
Question 46 of 100
Which nurse is most likely to be experiencing burnout?
A. A nurse complains of headaches every shift and has developed a flat affect.
B. A nurse strictly eats healthy food and repeatedly encourages other nurses to follow the same diet.
C. A nurse is very active on the unit and exercises during breaks, often offering to help other nurses with assignments.
Question 47 of 100
A patient with a respiratory infection requires airborne precautions. Which of the following should the nurse institute in this
patient's care?
A. Keep the room door open to allow flow of fresh air.
B. The nurse should put on a facemask that extends under the chin.
C. Limit movement of the patient outside of the room to medically necessary purposes.
Question 48 of 100
While rounding you find that the alarms on a patient's cardiac monitor have been silenced. The patient states, "That noise just
kept going and going, and my daughter works in health care, so she turned it off so I could sleep." What is your best response?
A. “The alarms are there for your safety. I would be happy to talk to your daughter about the importance of these
alarms.”
B. “I am so glad your daughter cares about your sleep, but she does not have the knowledge or permission to turn off the alarms.”
C. “It sounds like your daughter knows what she is doing. Those alarms can get very annoying sometimes.”
Question 49 of 100
When assessing a patient who received narcotic analgesia in the post-anesthesia recovery unit (PACU) and has just been
transferred to your unit, you note a heart rate of 52 bpm, respiratory rate of 10, and SpO2 of 89%. The patient briefly opens his
eyes and mumbles in response to verbal stimuli. When notifying the provider, which order should you anticipate?
A. Administer intravenous diphenhydramine
B. Administer intravenous epinephrine
C. Administer intravenous naloxone
Question 50 of 100
During recovery from a stroke a patient completes a dysphagia evaluation by the speech therapist, who recommends a modified
consistency for oral nutrition. Which communication do you anticipate with a member of the interprofessional team?
A. The dietary aide—to educate the patient's family about dysphagia
B. The pharmacist—to make sure the patient’s medication are prepared based on recommended consistency
C. The case manager—to request that meals with this level of consistency be delivered to the patient’s home upon discharge from
the rehabilitation unit
Question 51 of 100
Which statement by a new nurse is most appropriate when communicating a practice concern to a more experienced nurse?
A. "I noticed the way you manage IV ports isn't the way I was shown during orientation. Can you help me understand
more about this practice?"
B. "Why didn't you cap the IV port? I thought that was the policy."
C. "In school we learned that there is a better way to manage IV ports than the way you are doing it."
Question 52 of 100
You are providing discharge education to a patient with diabetes mellitus. Which response by the patient demonstrates
understanding of the discharge teaching?
A. Nodding in agreement when the nurse explains how insulin works.
B. Stating, “I will start walking 30 minutes each day.”
C. The patient states they will read insulin dosing instructions once they get home.
Question 53 of 100
A patient who was admitted to the medical-surgical unit one day ago for dehydration and malnutrition reports that he is nauseous,
has a headache, and his hands are starting to shake. You observe diaphoresis and tremors. What condition do you suspect the
patient may be experiencing?
A. Substance withdrawal
B. Depression with suicidal ideation
C. Manic episode related to bipolar disorder
Question 54 of 100
You obtain a fingerstick blood glucose level of 37 mg/dL for a patient with diabetes mellitus. The patient is lethargic,
diaphoretic, and trembling. Your medical-surgical unit has protocol orders to treat hypoglycemia. Which action is your priority?
A. Call the charge nurse to bring IM glucagon to the patient's room
B. Call the provider to report the patient's condition
C. Call the nursing assistant to bring some fruit juice
Question 55 of 100
You are caring for a patient who just became unresponsive with a blood pressure of 60/37 mmHg. You have four other patients in
your assignment. Which of the following is an appropriate plan for safe management of all these patients?
A. Delegate nursing care for the other four patients to an experienced UAP who is familiar with the patients and call the
rapid response team for the critical patient.
B. Call the rapid response team for the critical patient and ask the charge nurse to re-assign the other patients.
C. Quickly check the other patients to make sure they are stable, and then call the rapid response team to help with the critical
patient.
Question 56 of 100
You are assessing a patient who has just been admitted to your unit from the emergency department with a urinary tract infection.
Which of the following should alert you to a potential diagnosis of delirium?
A. The patient remembers all the events from last week.
B. The patient states she feels unsafe going to the bathroom and would like assistance.
C. The patient frequently changes the topic and appears agitated.
Question 57 of 100
The shared governance staffing committee is reviewing the next month's schedule and sees that a holiday does not have any
nurses scheduled who are qualified to perform a procedure that is common on the unit. Recognizing this problem could lead to a
conflict, which suggestion by a committee member would be most appropriate for healthy conflict management?
A. "Let's see if any of the nurses with these competencies are able to switch this holiday for another day."
B. "We should tell the nurses with the correct competencies that one of them has to work."
C. "Since we're responsible for staffing, one of us should take the shift."
Question 58 of 100
A patient is pacing the floor, wringing his hands, and talking loudly to himself. What is your most appropriate intervention after
ensuring personnel are safe?
A. Offer choices and be optimistic
B. Orient the patient by stating his words seem like nonsense
C. Move close to the patient and quietly ask him to sit down
Question 59 of 100
A novice nurse notes that the patient's usual dose of medication may be contraindicated because the patient's serum creatinine
level is elevated. When the nurse provides an SBAR report and recommends a change in dosing, the provider says to give the due
dose and that the team will address a new order during rounds. What is the nurse's best response?
A. Withhold the medication and avoid speaking with the provider during rounds.
B. Give the medication as ordered so as not to cause further conflict with the provider.
C. Talk to the charge nurse about the issue and work together to resolve it and support patient safety.
Question 60 of 100
You are delegating the task of assisting a patient to the bathroom to the UAP. Which of the following is an appropriate
statement?
A. “Please take the man in room 2 to the bathroom. I’m not sure how he walks, but stay with him if you think it is necessary.”
B. “The patient in room 2 needs to go to the bathroom. Please help him for me when you get the chance.”
C. “Please take Mr Jones to the bathroom. His left side is weak, so he will need support. Stay with him, and then help him
back to bed. Let me know how he does.”
Question 61 of 100
When collaborating with a patient, the family, and members of the interprofessional team, which actions best demonstrate
professional nursing standards?
A. Create a plan of care based on the family's preferences
B. Expect the provider's expertise-based orders to be paramount in the plan of care
C. Base the care plan on the patient's goals and evidence-based interventions
Question 62 of 100
A patient admitted with chest pain has an initial troponin I of 0.03 ng/mL and an ECG that shows a pattern of ST depression. The
patient calls you because the pain has suddenly increased. Following ordered chest pain protocols, which of the following should
you do first?
A. Administer sublingual nitroglycerin
B. Increase the oxygen administration to 6L/minute
C. Assess the patient’s vital signs
Question 63 of 100
In the middle of the night a patient with a diagnosis of post-traumatic stress disorder (PTSD) stands in the corner of the room
shouting. Which is the nurse's most appropriate intervention?
A. Turn on all of the lights and speak loudly so the patient can hear you.
B. Tell the patient to calm down and stop disturbing other patients.
C. Orient the patient using a calm and quiet tone of voice.
Question 64 of 100
You are discharging a patient with chronic obstructive pulmonary disease (COPD) to home. Which statement by the patient
demonstrates an understanding of the discharge instructions?
A. “I got a flu shot last year, so I am still protected against the flu.”
B. “I will use the patch the doctor prescribed to try to stop smoking.”
C. “If I have increased shortness of breath, I will lay flat and try to rest.”
Question 65 of 100
A trauma nurse is caring for a teenage victim of a car accident. While at work, her 15-year-old son calls to ask her if he can go
out with his friends. She tells him the roads are not safe tonight, and then tells him about the trauma patient for whom she is
caring. At what point would this nurse potentially violate ethical principles?
A. She warns her son that drinking and driving is very unsafe practice.
B. She asks her son to avoid the specific road where the accident happened.
C. She shares with her son the patient’s first name, age, and school affiliation.
Question 66 of 100
A patient who is one day post-op from hip surgery complains of significantly increased pain at the incision site, stating, "I never
had this kind of pain when I got my other hip done last year." You note redness and swelling around the incision. Which action is
most important for you to perform?
A. Check the condition of the patient's other hip
B. Check neurovascular status in the affected extremity
C. Review the patient's pain management history in the chart
Question 67 of 100
A patient complains of increased shortness of breath with any type of activity. On assessment, you note pitting peripheral edema.
The patient has an oxygen saturation of 92%, an ejection fraction of 23%, and a BNP value of 729 pg/mL. Which of the
following should you implement for this patient?
A. Administer oxygen to achieve an SaO2 of 97%
B. Initiate intravenous fluids at a rate of 100 ml/hr
C. Help the patient sit up and assess vital signs
Question 68 of 100
You are assessing the severity of a patient's chronic back pain. You know that which method is most accurate to assess the
patient's pain?
A. The visual analog scale for pain assessment
B. The patient’s self-report of pain
C. The Brief Chronic Pain Screening Tool
Question 69 of 100
Which question is most likely to be included in a computer-based algorithm to screen patients for risk of self-harm?
A. “What brought you into the hospital?”
B. “Do you have any thoughts of hurting yourself?”
C. “What difficulties are you having at home?”
Question 70 of 100
A patient who is recovering after a percutaneous coronary intervention is being treated for pain with a nonsteroidal antiinflammatory (NSAID) medication. With baseline vital signs of 128/84 mmHg, heart rate of 76 bpm, respiratory rate of 16 bpm,
and a pain level goal of 3 on a 0 to 10 analog scale, which finding is a priority for the nurse to address?
A. Creatinine level 2.4
B. Pain level of 2 at the incision site
C. Blood pressure of 124/83 mmHg
Question 71 of 100
The family member of a dying patient who has elected hospice care expresses gratitude to you for helping the patient retain
dignity near the end of life. Which action is most likely to contribute to the patient's dignity?
A. Supporting a family member's optimism that the patient will return to health
B. Arranging for grooming that the patient requests, including shampooing the hair
C. Limiting visitors to visiting hours so the patient has more time to rest
Question 72 of 100
During the early stages of shock (compensatory stage), the nurse should expect to find which assessment result in the patient?
A. Decreased heart rate
B. Normal blood pressure
C. Warm skin temperature in the fingers
Question 73 of 100
A patient continues to have pain, even though he is receiving intravenous morphine after having leg surgery. After notifying the
provider, you anticipate an order for which adjuvant therapy?
A. An antidepressant
B. A muscle relaxant
C. A nerve block
Question 74 of 100
You are caring for a patient who has diabetes mellitus and is hospitalized to treat an infection of the right toes with intravenous
antibiotics. Which of the following interventions is most appropriate in preventing the patient's condition from worsening?
A. Perform hand hygiene at recommended intervals.
B. Recommend that the medical team place a central venous catheter for antibiotic administration since the patient has poor
vascular access.
C. Measure the patient’s blood glucose every 24 hours.
Question 75 of 100
Which patient should you recommend that the medical team urgently investigate for possible sepsis?
A. A patient with late-stage, severe Alzheimer dementia has been crying uncontrollably after falling and sustaining a 1-inch
laceration to the lower leg.
B. A patient with a temperature of 38 degrees C, a heart rate of 117 bpm, a large number of white blood cells in the urine,
and confusion.
C. A patient with diabetes mellitus and an infected left great toe, temperature of 37.4 degrees C, heart rate of 77 bpm, and blood
pressure of 127/81 mmHg.
Question 76 of 100
You have been caring for a terminally ill patient whose condition has been declining for the past 48 hours and who has a do-notresuscitate order. When the patient dies, which of the following is an appropriate initial action?
A. Begin to talk to the family about organ donation.
B. Request a palliative care consult for the family.
C. Be present for the family and offer to call a chaplain.
Question 77 of 100
When assessing the safety needs of the unit, the nurse manager may consider data from which of the following nurse-sensitive
indicators?
A. Patient perspectives on care
B. Physician rounding frequency
C. Nursing hours per patient day
Question 78 of 100
A patient is being discharged home with a prescription for opioids. Which statement by the patient demonstrates the need for
additional education?
A. "I will not drink any alcohol while I am taking these pills."
B. "If I don't need all of the pills in my prescription I'll return them to the pharmacy."
C. "I'll share the extra pills with my dad, who has a prescription for them, but often can't afford them."
Question 79 of 100
You are providing discharge teaching for a patient who was admitted for heart failure. Which statement by the patient
demonstrates understanding of the teaching?
A. “I should weigh myself every day while I am taking the water pill.”
B. "So I don't interrupt my sleep, I should take my water pill before bedtime.”
C. “I can continue smoking, now that I am on medications for my heart failure.”
Question 80 of 100
You are caring for a patient with a surgical site infection. After two days of treatment, which finding indicates the need for
further intervention?
A. Heart rate of 126 beats per minute
B. Decreased drainage on the dressing
C. Pink skin color around the surgical site
Question 81 of 100
One week after delivery a postpartum patient with a newborn was admitted to the medical surgical unit after an emergency open
appendectomy. The patient is medically stable and is receiving IV antibiotics. The patient's primary goal is to bond with and
breastfeed her baby. She is demanding discharge if she cannot see her baby. However, the unit's infection control visitation rules
prohibit children from visiting the unit. Which is your best action to improve the patient's quality of care?
A. Collaborate with the provider to facilitate visitation with the baby outside of the patient unit.
B. Allow the family to bring the baby onto the unit after visiting hours have ended.
C. Request a psychiatric consult to prevent the patient's departure against medical advice.
Question 82 of 100
A patient reports feeling distressed about their prognosis and ability to manage a chronic health disorder. Which of the following
statements demonstrates the best approach to achieving optimum patient outcomes?
A. “The medical team knows best how to manage your chronic illness and will order appropriate care."
B. “You are going to be fine. Just take your medications, do what the home health nurse tells you, and keep all of your scheduled
appointments."
C. “This situation must be very difficult. Tell me about some coping mechanisms that you use in stressful situations like
this.”
Question 83 of 100
Which of the following orders would you anticipate as part of the plan of care for a patient with a surgical site infection when the
wound has purulent and bloody exudate?
A. Apply positive-pressure wound therapy
B. Remove dressing every four hours to inspect the wound
C. Intravenous antibiotics
Question 84 of 100
Two nurses have called out sick for a shift on a medical-surgical unit. After the charge nurse has made assignments to best meet
the patients' acuity and staff mix, the bed-control supervisor calls to admit two patients with exacerbation of heart failure from the
emergency department. During a team huddle to discuss the admissions, which response to the charge nurse best reflects
professional nursing ethics?
A. "Can they assign an additional nurse to our unit or send the admissions to another unit?"
B. "My patients' high acuity probably makes it unsafe, but I'll do the best I can to admit one more patient."
C. "I don't think we should accept any more patients, no matter how sick they are."
Question 85 of 100
A patient with opioid use disorder who was admitted for diarrhea and pain developed an acute kidney injury (AKI). Which
nursing action should be included in this patient's plan of care?
A. Monitor laboratory results and call the provider to report abnormal values.
B. Plan to provide up to the maximum dose of nonsteroidal anti-inflammatory medications (NSAIDS) to treat the patient’s pain.
C. Plan to administer potassium sparing diuretics to treat oliguria.
Question 86 of 100
When planning patient education, which concept underlies the nurse's decision about delegating this activity to an unlicensed
nursing aide?
A. The right circumstance
B. The right supervision
C. The right activity
Question 87 of 100
You are caring for a postoperative patient. Which action helps prevent pneumonia in this patient?
A. Placing the patient in supine position
B. Instructing the patient to suppress any urge to cough
C. Washing your hands before and after caring for the patient
Question 88 of 100
A patient has just been admitted to the unit with chest pain. What should be your priority action?
A. Call the discharge planner to meet with the patient about continuation of care after the hospital stay.
B. Start an IV and hang fluids as ordered by the provider.
C. Ask the patient about the location and quality of the pain.
Question 89 of 100
A nurse who has been off of orientation for 6 months develops apathy, speaks callously to patients and colleagues and
verbalizing the desire to leave the profession. What is the most likely cause of these symptoms of compassion fatigue?
A. The nurse can no longer attend a regular after-work meal with other nurses from the unit.
B. Three patients in the last 2 weeks deteriorated suddenly and died.
C. The nurse manager informs the nurse it is time for the annual performance review.
Question 90 of 100
An unlicensed assistive personnel (UAP) offers to apply oxygen for a patient who is having shortness of breath. The UAP states
that this was common practice at the UAP's former place of employment. Which response is most appropriate?
A. “I need to assess the patient and check the provider orders, so I can't safety delegate that activity to you."
B. “If you applied oxygen at your last hospital, then you should be fine. It’s all about experience! Let me know how the patient
does with it.”
C. “I need to check the hospital policy to see if that’s a procedure that you are allowed to do.”
Question 91 of 100
You are assigned to care for a patient who has no known issues related to immunocompromise and is being admitted for chest
congestion, fever, and a productive cough. The sputum culture was positive for group A streptococci and negative for COVID-19
and influenza. Which type of precautions are not necessary to implement at this time?
A. Transmission-based precautions
B. Standard precautions
C. A protective environment or reverse isolation
Question 92 of 100
A patient must stay in the hospital two extra days because of a medical error. Which of the following is the most ethical practice
for the nurse?
A. Provide limited information to the patient and avoid admission of fault
B. Disclose the medication error to the patient and apologize
C. Do not talk about this error unless the patient specifically asks
Question 93 of 100
You are caring for a patient who suffered an ischemic stroke 24 hours ago. Which of the following assessments will alert you to
possible deterioration of the patient's status?
A. The patient is increasingly more drowsy and unable to maintain a conversation
B. The patient’s mood is light and elated
C. The patient describes increased visual acuity
Question 94 of 100
Which would be the most appropriate first step to improve the outcomes for patients on the unit who have residual volume with
their nasogastric tubes?
A. Review and appraise the current research literature about nasogastric tube residual volume management.
B. Ask a focused clinical practice question about gastric tube residual practice.
C. Recommend a change in practice for nasogastric tube residual volume management.
Question 95 of 100
When caring for a patient whose stool culture was positive for clostridium difficile (c. difficile), you should use which protective
equipment?
A. Non-permeable gown
B. Face mask with shield
C. Alcohol-based hand sanitizer
Question 96 of 100
You are caring for a patient who is reporting a high level of pain, crying out, and moaning. Which response by the nurse impedes
culturally congruent care?
A. “No matter how bad your pain is, patients are not allowed to be so loud because it is disruptive to the unit."
B. “Is there anything you have tried in the past that helps this kind of pain?”
C. “You appear to be in a lot of pain. How can I best help?”
Question 97 of 100
A nurse who has recently come off of orientation feels isolated from the more experienced nurses and goes home exhausted after
every shift. What is the nurse's best response when a coworker asks the nurse to cover a shift?
A. “Thank you for asking. I really want to feel like part of this team, so I will do what it takes to be accepted and will
cover for you.”
B. “Since I got off of orientation I thought you experienced nurses didn't think I was doing that great of a job. I'll do my best
during the extra shift."
C. “I appreciate you asking, but am not able to cover. Right now I really need to balance my work schedule with rest times.”
Question 98 of 100
While caring for patients during your shift, which activity demonstrates attention to preventing infection?
A. Washing your hands before putting on gloves to change a dressing.
B. Leaving in a patient's peripheral intravenous catheter, even though it has not been used in 24 hours.
C. Inserting an indwelling urinary catheter as an intervention for incontinence.
Question 99 of 100
The nurse tells a patient that physical therapy is schedule for 0900. The patient responds that this is the time the patient is
required to perform prayers. Which statement by the nurse demonstrates culturally congruent care?
A. “We will try to make time for your prayers after you return from physical therapy.”
B. “I will call the physical therapy department and have the appointment time switched.”
C. "You really need the physical therapy to be discharged, so if I were you I wouldn't miss the appointment."
Question 100 of 100
You are caring for a patient with suspected sepsis related to a urinary tract infection. Which orders do you expect to be part of the
initial plan of care?
A. Obtain blood cultures
B. Administer intravenous vasopressors
C. Obtain a portable echocardiogram
2. Which method should you use when selecting interventions to support optimum patient outcomes for treatment of a stage 1
pressure injury?
A. Ask the most experienced nurses for their advice, and then adopt the information that sounds most logical.
B. Find which supplies are readily available, and develop a treatment plan using these.
C. Ask the clinical specialist which guidelines your organization uses to support wound management policies.
Rationale: You should seek evidence-based interventions that are focused on improving patient outcomes. Using only past
practice methods or basing decisions on available supplies is not an evidence-based approach and may not improve the patient's
outcome.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Application of Evidence-Based Practice
11. It is almost midnight, the unit is dark, and the nurse pulls the last pill from the patient's medication drawer to administer to the
patient. The patient is drowsy, takes the medication, and soon has a reaction. What is the most likely cause of this incident?
A. The hospital system for stocking and administering medications.
B. The nurse’s carelessness in not checking the medication more closely.
C. The pharmacy tech who stocked the incorrect medication in the drawer.
Rationale: According to the Institute of Medicine’s report “To Err is Human; Building a Safer Health System,” the majority of
errors are caused by faulty systems. Both the nurse and the pharmacy tech may have contributed to this incident, but the system
most likely caused the incident.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Medication Management
14. A patient awaiting surgery states they want to avoid the use of opioids during the surgery and recovery because they've been
prescribed too many opioids in the past. Which is your best response?
A. "Let me contact your surgeon and the anesthesia team to discuss this with you."
B. "For most surgery it is not possible to manage pain without opioids."
C. "The surgeon will prescribe your medication based on your records and the state medication prescription monitoring
program."
Rationale: You should contact the patient's surgeon and the anesthesia team to discuss options with the patient, including an
Enhanced Recovery After Surgery (ERAS) protocol, which can reduce or eliminate the use of opioids for many surgeries. The
surgeon and anesthesia team are likely to consider the patient's concerns together with records and information from the state
medication prescription monitoring program.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Pain Management
22. In which of the following scenarios does the nurse professionally address a potential conflict?
A. The nurse tells a provider about a contraindication the patient has to a medication that is ordered.
B. The nurse tells other staff that the charge nurse has made an unfair assignment.
C. A nurse passes out invitations to a party to only selected staff during the shift huddle.
Rationale: The nurse professionally addresses a potential conflict when telling a provider about a contraindication the patient has
to a medication that is ordered. Telling other staff that the charge nurse has made an unfair assignment is not a professional
approach to conflict management. Rather, the nurse should speak directly with the charge nurse. A nurse who passes out
invitations to only selected staff during the shift huddle is potentially causing a conflict between those who have been invited,
those who have be excluded, and the nurse.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Conflict Management
28. You are caring for a postsurgical patient who does not have a diagnosis of diabetes. The patient's fasting glucose level this
morning was 159 mg/dL. Which intervention is most appropriate?
A. Ask the provider for orders to increase the frequency of blood glucose monitoring.
B. Call the provider for insulin orders.
C. Continue to check the patient's blood glucose as ordered.
Rationale: To reduce the risk of developing a surgical site infection, postoperative patients who do not have diabetes usually
require moderate glucose management, which includes keeping the glucose level less than 200 mg/dL. For a postoperative patient
with a fasting glucose level of 159 mg/dL, there is no immediate need to request new orders for insulin or a change in the
monitoring schedule.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Management of Post-Operative Complications
- Surgical Site Infections
33. Two nurses working the same shift are each assigned six patients of high acuity, and one nurse is assigned 5 patients of low
acuity. Which stage of conflict can occur when all three nurses become aware of each other's assignments?
A. Manifest Conflict
B. Perceived Conflict
C. Conflict Aftermath
Rationale: Perceived conflict exists when one or more people become aware of the conflict. Conflict aftermath is the outcome of
conflict management. Manifest conflict is present when individuals try to resolve the conflict. In this scenario, the three
individuals become aware of the conflict, but no attempt has yet been made to resolve it.
35. A patient with diabetes mellitus has been admitted for abdominal pain and vomiting. Although a blood glucose by fingerstick
shows an elevated glucose outside of the meter's range, serum lab results are not yet available. The provider has ordered a stat
computed tomography (CT) scan. What is your best action?
A. Keep the patient NPO and start IV fluids at a keep vein open (KVO) rate
B. Call the lab to request results as soon as possible before sending the patient for the CT scan
C. Call to see if they can get the patient in for a CT scan immediately
Rationale: The best action is to request blood test results before sending the patient off the unit for a CT scan. The patient may
require urgent treatment of the elevated but uncertain blood glucose level while away from the unit. The patient is also at risk for
dehydration, so while remaining NPO, the patient should be receiving adequate hydration and not only KVO level IV fluids.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Diabetes Mellitus
36. Which of the following interventions should you perform for a patient complaining of "an elephant sitting on the chest"?
A. Obtain an EKG one hour after the patient begins to complain of pain.
B. Apply oxygen to achieve a saturation level of at least 95%.
C. Draw a blood sample to send to the lab to obtain liver function tests.
Rationale: This patient is suspected of having an acute myocardial infarction (AMI), so you should first quickly assess ABC’s,
to make sure that the patient’s oxygen saturation is at least 95%. You should also obtain an electrocardiogram (ECG) within the
first few minutes. Information from the ECG will guide further emergency treatment, so perform this test immediately. Blood
should be sent for laboratory tests, but the important tests are the cardiac markers: CK-MB, troponin T, and troponin I.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Acute Myocardial Infarction
42. An novice nurse approaches another nurse and asks to switch patients, stating, "My patient is actively dying, and I just can't
stop crying." How should the nurse best respond?
A. "Did you take the learning module on caring for patients who are actively dying? It really helped me care for dying patients."
B. "At first taking care of a dying patient was tough for me. It will get easier each time."
C. "Dying can trigger your emotions. I'll help you today, but consider asking the manager about contacting the bereavement
team."
Rationale: Past experiences with death may trigger emotions that make it difficult to provide care for a dying patient. A
bereavement team can help the nurse evaluate experiences and identify ways to continue providing compassionate and engaged
care. Education about the dying process is important, but usually involves didactic knowledge, not examining feelings.
Colleagues should help other nurses learn about resources to manage responses to death, not expect that an individual nurse can
overcome this barrier alone.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: End-of-Life and Palliative Care
43. A nursing unit has been experiencing a high number of patient falls. Which of the following represents a systems thinking
approach to this issue?
A. Provide education for the nurse’s aides about ambulating patients
B. Ask “why?” for all interactions related to the patient falls
C. Request that the physicians write stricter orders about patient ambulation
Rationale: Systems thinking encourages the team to explore all related interactions and to better understand the situation by
repeatedly asking the question “why?” Providing education may help at one level, and requesting stricter ambulation orders may
help, but both of these are very focused attempts at solution and do not address the whole scope of the issue.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Ensuring Patient Safety and High Quality
Patient Care
50. During recovery from a stroke a patient completes a dysphagia evaluation by the speech therapist, who recommends a
modified consistency for oral nutrition. Which communication do you anticipate with a member of the interprofessional team?
A. The dietary aide—to educate the patient's family about dysphagia
B. The pharmacist—to make sure the patient’s medication are prepared based on recommended consistency
C. The case manager—to request that meals with this level of consistency be delivered to the patient’s home upon discharge from
the rehabilitation unit
Rationale: In addition to collaborating with a speech therapist, you should also anticipate consulting the pharmacist for
recommendations about medication preparation. The registered nurse, not the dietary aide, is responsible for patient and family
education. Although the case manager may order home meals, the patient’s recommended diet consistency may change during
rehabilitation.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Stroke
55. You are caring for a patient who just became unresponsive with a blood pressure of 60/37 mmHg. You have four other
patients in your assignment. Which of the following is an appropriate plan for safe management of all these patients?
A. Delegate nursing care for the other four patients to an experienced UAP who is familiar with the patients and call the rapid
response team for the critical patient.
B. Call the rapid response team for the critical patient and ask the charge nurse to re-assign the other patients.
C. Quickly check the other patients to make sure they are stable, and then call the rapid response team to help with the critical
patient.
Rationale: You should give full attention to the patient who has become critical to prevent further patient deterioration. Because
you cannot leave this critically ill patient, you should hand off responsibility of the other patients by asking the charge nurse to
re-assign them. You cannot delegate all nursing care to a UAP; you may only delegate activities for which the UAP has the
proper competencies for patients with predictable outcomes.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Critical Thinking: General and Escalation of
Care
58. A patient is pacing the floor, wringing his hands, and talking loudly to himself. What is your most appropriate intervention
after ensuring personnel are safe?
A. Offer choices and be optimistic
B. Orient the patient by stating his words seem like nonsense
C. Move close to the patient and quietly ask him to sit down
Rationale: Appropriate interventions for a patient who is losing control include offering choices and being optimistic, listening
to the patient, and agreeing or agreeing to disagree. Telling him he is speaking nonsense is not helpful. You should respect his
personal space and not move too close to him.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Care of Patients with Mental Health Disorders
76. You have been caring for a terminally ill patient whose condition has been declining for the past 48 hours and who has a donot-resuscitate order. When the patient dies, which of the following is an appropriate initial action?
A. Begin to talk to the family about organ donation.
B. Request a palliative care consult for the family.
C. Be present for the family and offer to call a chaplain.
Rationale: When possible, when a patient dies, nurses should provide care for the family by being present for them, listening,
and offering comfort measures such as offering to call a chaplain or other spiritual support person. Discussions with the organ
donation team and the palliative care team should have occurred when the patient started the process of active dying, not after
death has already occurred.
86. When planning patient education, which concept underlies the nurse's decision about delegating this activity to an unlicensed
nursing aide?
A. The right circumstance
B. The right supervision
C. The right activity
Rationale: When planning delegation the nurse must consider factors such as the right patient, the right circumstance, the right
supervision, the right evaluation, the right communication, and the right training. The nurse must consider that planning patient
education is not an appropriate activity to delegate to an unlicensed nursing aide. Planning patient education must be performed
by a registered nurse. Unlicensed personnel are not permitted to perform this activity, no matter the circumstance or the
supervision.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Delegation
89. A nurse who has been off of orientation for 6 months develops apathy, speaks callously to patients and colleagues and
verbalizing the desire to leave the profession. What is the most likely cause of these symptoms of compassion fatigue?
A. The nurse can no longer attend a regular after-work meal with other nurses from the unit.
B. Three patients in the last 2 weeks deteriorated suddenly and died.
C. The nurse manager informs the nurse it is time for the annual performance review.
Rationale: Repeated care of high acuity patients or patients who decline suddenly can lead to feelings of frustration and
inadequacy, from which compassion fatigue may follow. Going out after-work with other nurses provides a support network and
socialization, but does not directly address the root issues of compassion fatigue. Reviewing progress with the nurse manager will
provide feedback and provide discussion of areas in which to grow. This type of discussion is not associated with compassion
fatigue.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Stress Management: Minimizing Reality
Shock and Compassion Fatigue
91. You are assigned to care for a patient who has no known issues related to immunocompromise and is being admitted for chest
congestion, fever, and a productive cough. The sputum culture was positive for group A streptococci and negative for COVID-19
and influenza. Which type of precautions are not necessary to implement at this time?
A. Transmission-based precautions
B. Standard precautions
C. A protective environment or reverse isolation
Rationale: A protective environment or reverse isolation is used for patients with certain types of immunocompromise to protect
them from healthcare-acquired infections. These include patients who are undergoing allogeneic hematopoietic stem cell
transplant (HSCT). Transmission-based precautions would be appropriate based on the patient's diagnosis of a transmittable
infection that is spread through the droplet route. Standard precautions should be used for all patients in all healthcare settings.
If this question is missed, review: Mosby's Medical-Surgical Nursing Orientation: Infection Prevention and Control
92. A patient must stay in the hospital two extra days because of a medical error. Which of the following is the most ethical
practice for the nurse?
A. Provide limited information to the patient and avoid admission of fault
B. Disclose the medication error to the patient and apologize
C. Do not talk about this error unless the patient specifically asks
Rationale: Collaboration with the provider to give the patient a full disclosure of an error is an ethical responsibility of the nurse.
Providing limited information and avoiding talking about the error does not promote patient-centered care and is contrary to
nursing ethics.
94. Which would be the most appropriate first step to improve the outcomes for patients on the unit who have residual volume
with their nasogastric tubes?
A. Review and appraise the current research literature about nasogastric tube residual volume management.
B. Ask a focused clinical practice question about gastric tube residual practice.
C. Recommend a change in practice for nasogastric tube residual volume management.
Rationale: When seeking to improve patient outcomes, a usual first step is to formulate and ask a focused researchable clinical
practice question. Then a subsequent step would be to develop a plan. Recommending changes would occur after an analysis of
the evidence and creating a plan.
97. A nurse who has recently come off of orientation feels isolated from the more experienced nurses and goes home exhausted
after every shift. What is the nurse's best response when a coworker asks the nurse to cover a shift?
A. “Thank you for asking. I really want to feel like part of this team, so I will do what it takes to be accepted and will cover for
you.”
B. “Since I got off of orientation I thought you experienced nurses didn't think I was doing that great of a job. I'll do my best
during the extra shift."
C. “I appreciate you asking, but am not able to cover. Right now I really need to balance my work schedule with rest times.”
Rationale: Answering the request by honestly reporting the need to balance work life with rest is a better approach to gain
respect and acceptance with other nurses on the unit than to accept an additional shift when the nurse is already exhausted.
1. During the progressive stage of shock, you may note an increase in which assessment value?
A. Lactic acid
B. Oxygen saturation
C. Urine output
Rationale: During the progressive stage of shock, cells switch from aerobic to anaerobic metabolism to produce energy. A
byproduct of the anaerobic metabolism is lactic acid. There is a lack of oxygen to the cells, so oxygen saturation will fall. As the
kidneys shut down from lack of blood circulation, urine output decreases.
3. A patient with sudden onset of aphasia and right hemiparesis 2 hours ago has been diagnosed with an ischemic stroke. Vital
signs include a heart rate of 87 bpm, respiratory rate of 20, and blood pressure of 165/92 mmHg. You can expect which of the
following orders?
A. Administer antihypertensives to keep the systolic blood pressure below 140 mmHg
B. Administer enoxaparin in conjunction with the thrombolytic medication
C. Administer intravenous tPA as per the hospital protocol
Rationale: This patient is within the 3-hour window of onset of symptoms for an ischemic stroke, so the most appropriate
treatment is thrombolytic therapy, such as tPA. Anticoagulants, such as enoxaparin, should not be administered for at least 24
hours after the thrombolytic, to decrease the risk for bleeding. To maintain adequate cerebral blood flow, antihypertensives would
likely be ordered only if the patient's blood pressure exceeds 180/105 mmHg after tPA administration, or if the systolic blood
pressure exceeds 220 mmHg without tPA administration.
4. You are educating a patient about his newly prescribed antibiotic. Which statement best helps to reinforce this education?
A. “Now it’s your turn. Please share with me how you will take this medication.”
B. “Here is the written information about the medication, so you can read it when you have time.”
C. “The pharmacist can tell you more when you go to pick up your medication.”
Rationale: By using the teach-back method – asking the patient to reiterate what was taught – the nurse can assess the patient’s
knowledge and clarify any information that was not understood. Giving the patient a written description may help, but it does not
allow the patient to ask questions. Referring to the pharmacist may also help, but the patient should leave the hospital with a clear
understanding about any new medication prescribed.
5. A patient with atrial fibrillation has been started on intravenous heparin. Which of the following complaints by the patient
would be most concerning related to the new medication?
A. “I feel really sleepy today. I think I will take a nap.”
B. “That dinner did not taste good. I just don’t seem to have an appetite today.”
C. “My lower back has started to hurt. I can’t get comfortable.”
Rationale: A complaint of lower back pain is of concern for a patient taking an anticoagulant medication because it may indicate
retroperitoneal bleeding. Being extra sleepy or lacking appetite could be concerning as side effects of another medication or
another factor negatively impacting the healing environment, but the primary concern related to the anticoagulant is an increased
risk for bleeding.
6. A severe weather event has knocked out the main hospital power source. The emergency generator supplies power to the red
emergency outlets. Only one outlet is available near two patients, one with orders for a nebulizer and the other with orders for IV
normal saline fluid to run at 100 ml/hr for hydration.
A. Provide the nebulizer treatment using the outlet and initiate the IV fluid using a flow control device.
B. Hold the IV fluid and give the nebulizer treatment.
C. Run the IV fluid for one hour, then pause it to provide the nebulizer treatment.
Rationale: At times, technology fails, and you need to use critical thinking to make care decisions. If a patient needs a nebulizer,
their breathing may be compromised. The nebulizer takes 15 to 20 minutes, and the IV fluids can be started using a flow-control
device and switched to a controller pump immediately following the nebulizer treatment. You should document the reason for the
start of the IV fluids using the flow-control device, such as a low risk infusion and the patient’s clinical status.
7. The new nurse is caring for a patient with an indwelling catheter. Which action demonstrates the need for further education?
A. Emptying the catheter collection bag before it gets full
B. Leaving the catheter in because the patient is incontinent
C. Cleaning the catheter port before collecting specimens
Rationale: Evidence supports restricting the use of indwelling catheters and removing them quickly. Incontinence is not
justification for a catheter, as the risk of infection may cause an infection, which is harmful to the patient and costly to the
hospital. The catheter bag should be emptied before it gets completely full, and the port should always be cleaned before
collecting specimens.
8. A newly licensed nurse was elated in the early phase of a first nursing job, sometimes known as the honeymoon phase. Later in
orientation, the nurse makes comments showing a distorted view of the role. Which situation best shows signs of the nurse's
negative role distortion?
A. She perceives the patients for whom she is caring as being the same patients that she cared for in nursing school.
B. She perceives herself as super-nurse and feels invincible in her role.
C. She perceives nurses from another unit as being more competent than those on her unit.
Rationale: After the honeymoon phase of reality shock, a nurse will often gain a negatively distorted view of her unit, and will
see other units in a more favorable light. If this happens, she should seek a mentor from outside the unit. The other situations do
not describe negative distortion.
9. The nurse educator is providing education to a new nurse about community-associated pneumonia. Which statement by the
new nurse demonstrates the need for additional teaching?
A. One risk factor for community-associated pneumonia is home infusion therapy
B. The most common cause is pneumococcal pneumonia
C. Poor dentition can put people at greater risk
Rationale: Home infusion therapy is a risk factor for healthcare-associate pneumonia, which develops during or after a stay in a
healthcare facility. The most common cause of community-acquired pneumonia is pneumococcal pneumonia. Poor dentition can
put people at greater risk for community-acquired pneumonia.
10. You are beginning your shift and assess your first patient who was reported to have uncontrolled pain, despite the
administration of analgesics. How should you approach this patient?
A. “Hello Mrs. Smith. My name is Sally and I will be caring for you today. Please tell me about the pain you have been having.”
B. “Hi Mrs. Smith. I hear you’re having terrible pain. You don’t look as though the pain is that bad.”
C. “Hello Mrs. Smith. My name is Sally. I know you’re having pain, but I can’t give you any more medicine for about two more
hours.”
Rationale: Effective communication helps to improve the patient’s perception about the quality of care. After introducing
yourself, acknowledge the patient’s pain without being judgmental and use open-ended questions to allow the patient to describe
her pain.
12. A patient admitted with generalized weakness has a Glasgow Coma Scale score of 15, heart rate of 123 bpm, a respiratory
rate of 24, a blood pressure of 98/51 mmHg, a serum white blood cell count of 17,000 x 10 9/L, and a blood lactate level of 0.5
mmol/L after receiving 3 liters of normal saline solution intravenously. Which of the following syndromes does the nurse
suspect?
A. Septic shock
B. Sepsis with altered mental status
C. Sepsis
Rationale: This patient likely has sepsis, a life-threatening organ dysfunction from a dysregulated response to infection. In a
medical-surgical setting, the presence of 2 or more qSOFA criteria (systolic blood pressure less than or equal to 100 mmHg, any
Glasgow Coma Scale score less than 15, and tachypnea greater than 22) and a suspected infection is often used to predict the
increased mortality from sepsis. The blood lactate level is less than 2 mmol/L, which would exclude septic shock. Septic shock
has clinical criteria of hypotension that requires vasopressors to maintain a mean BP at 65 mmHg or greater and a serum lactate
level greater than 2 mmol/L after adequate fluid resuscitation. Because the patient has a Glasgow Coma Scale score of 15, no
altered mental status involvement is evident.
13. You have been caring for a patient in the end stages of a terminal illness. Which of the following signs or symptoms should
you recognize as being a typical part of the dying process?
A. The patient’s breathing is slow and there are audible rattles.
B. The patient gradually becomes more and more alert.
C. The patient consistently asks for more food at mealtimes.
Rationale: Typically, as part of the dying process, the breathing slows in rate and the patient's breath sounds include a rattling
noise. Most patients become more lethargic and do not have energy to get out of bed. Some patients may temporarily become
more alert and even agitated, but tend to return to lethargy rather than sustaining a level of alertness near the time of death.
Patients in the dying process will generally decrease their food intake because they do not have the energy to eat.
15. You are caring for a patient with heart failure who has pulmonary crackles and an S3 heart sound. The patient complains of
having difficulty breathing, even at rest. Which of the following should you incorporate into this patient's plan of care?
A. Teach the patient how to perform pursed-lip breathing.
B. Encourage extra fluid intake to thin any secretions.
C. Keep the bed in a supine position so the patient can rest.
Rationale: For patients with heart failure, pursed-lip breathing can help to improve oxygenation through controlled breathing. It
is important to closely monitor fluid intake and output, not to encourage extra fluids, to prevent fluid overload and worsening
pulmonary effort. Elevate the head of the bed at least 30 degrees to promote lung expansion and ease the work of breathing.
16. For which patient should you be most concerned about the possibility of a surgical site infection?
A. Patient who has insulin-dependent diabetes mellitus
B. Patient who was recently placed on 5 days of topical prednisone for a skin rash
C. Patient who had a small cancerous skin lesion removed 2 years ago
Rationale: Diabetes mellitus can lead to poor wound healing, which leaves wounds open and susceptible to infection longer.
Long-term steroid use can decrease the body’s ability to fight infection, but short-term topical use should not affect this ability.
Cancer, if systemic or while receiving treatment, can cause immunosuppression. However, this patient had the small lesion
removed 2 years ago.
17. Which situation represents an ethical dilemma?
A. The nurse sustains a needle stick to the finger while drawing up a medication for intravenous administration.
B. The provider orders a high dose of medication for patient comfort, but administration of this high dose is outside the scope of
safe nursing practice.
C. The patient complains to the nurse that this hospital food is not as tasty as the food at other hospitals.
Rationale: An ethical dilemma arises when decisions need to be made in light of conflicts of morals or principles. When the
provider orders a high dose of pain medication, it is with good intent of patient comfort, but the nurse’s loyalty to practice
guidelines makes her question the safety of this course. A nurse sustaining a needle stick presents a safety issue, but not an ethical
dilemma. A patient’s complaint of hospital food speaks to patient satisfaction, but is not an ethical dilemma.
18. You are caring for a patient with chronic obstructive pulmonary disease (COPD). The patient complains of a cough and
dyspnea on exertion. Further assessment reveals distended jugular veins and dependent pitting edema. What order should you
anticipate?
A. Diuretics
B. High-flow oxygen
C. Vasoconstrictors
Rationale: This patient’s signs and symptoms are consistent with cor pulmonale (right-sided heart failure). The treatment plan
should include continuous low-flow oxygen and vasodilators to reduce vasoconstriction, and diuretics to help reduce preload and
lessen peripheral edema.
19. You are providing teaching for a patient who received an intracoronary stent after experiencing an acute myocardial
infarction (AMI). Which statement by the patient indicates understanding of the instructions?
A. "I should participate in a physical rehabilitation program."
B. "I will not smoke inside the house anymore. I will go out on the porch to smoke."
C. "When my blood pressure comes down, I can stop taking the aspirin my doctor prescribed."
Rationale: Patients who follow an evidence-based exercise prescription after AMI have better long-term outcomes. So
participation in a physical rehabilitation program can encourage safe exercise habits. Tell patients to refrain from smoking to
decrease the risk of progressive coronary disease and other related disorders. To decrease the risk of clot formation, instruct
patients to follow the provider's prescription instructions and to discuss any plans to discontinue a prescription with their
provider.
20. You are completing an admission assessment on a 70-year-old patient with chronic kidney disease (CKD) who has been
admitted for cardiac surgery. Which of the following assessment findings would be most concerning for developing acute kidney
injury?
A. ECG show sinus dysrhythmia
B. Fingerstick blood sugar is 97 mg/dl
C. Blood pressure measures 88/50 mmHg
Rationale: A blood pressure of 88/50 mmHg may signify hypovolemia and poor end-organ perfusion, a possible prerenal cause
of AKI. Sinus dysrhythmia is a non-life-threatening cardiac rhythm that does not compromise tissue perfusion. A fingerstick
glucose of 97 mg/dl is within normal limits.
21. You assess the patients in your assignment, and two patients have worsening conditions. You believe you cannot safely
manage all of the patients in your assignment. Which is the most appropriate action to help ensure patient safety?
A. Prioritize and complete as many tasks as possible
B. Collaborate with the charge nurse to delegate tasks that can safely be performed by unlicensed personnel
C. Leave the lesser important tasks for the nurse on the next shift
Rationale: Delegation is an important communication tool that helps achieve the outcome of patient safety. This means that the
RN can direct others to perform activities and tasks while remaining responsible for their safe completion. If you do not perform
some of the necessary tasks, a patient could be left in an unsafe situation. Leaving tasks for the nurse on the next shift does not
promote an atmosphere of responsibility and integrity, and does not improve communication.
23. A patient who often jokes cheerily with the staff is unusually quiet. He tells you he is having difficulty dealing with his
cancer diagnosis. Which statement will best help promote therapeutic communication?
A. “I noticed you are quiet today. How are you feeling?”
B. “I know just how you feel. My brother had the same type of cancer.”
C. “Hang in there. You can beat this!”
Rationale: You are using the communication technique of observation when you acknowledge that the patient is quiet. This
technique affirms his current behavior, and gives him the chance to talk about any issues. Stating “I know how you feel” is
belittling and takes the focus off the patient because it makes the patient feel unimportant. A cliché, such as, “Hang in there!” is
superficial and empty, and does not provide support.
24. After the handoff report on your assignment for the shift, you demonstrate critical thinking and professional judgment by
delegating which activity to an unlicensed assistive personnel (UAP) team member?
A. Assisting a stable patient with a steady gait and an IV pole who is 2 days post-op from an open appendectomy to ambulate.
B. Titrating the flow of oxygen for a patient with COPD while the patient is ambulating.
C. Checking on a patient and taking vital signs 15 minutes after initiating a blood transfusion.
Rationale: Assisting a stable, steady patient to ambulate with equipment is usually an appropriate task to delegate to an UAP
who has the competencies to do so. Titrating oxygen levels for a patient with COPD during ambulation involves an intervention
based on a nursing assessment, and should therefore not be delegated. Assessing a patient and the patient's vital signs 15 minutes
after a blood transfusion starts requires nursing assessment skills, particularly since adverse reactions often occur during the first
15 minutes of a transfusion.
25. During an assessment for a patient, which of the following statements demonstrates a culturally congruent approach?
A. “Please tell me about healing practices in your culture.”
B. “You will need to speak English while you are here in the hospital.”
C. “Please look at me when I ask you a question so I get this information correct in your chart.”
Rationale: A culturally congruent approach includes finding out more about the patient’s culture, such as accepted healing
practices. Patients are not required to speak English. Instead, staff are required to provide an approved interpreter service for
patients who need and request it. You should also provide a language-assistive device, as the patient is not expected to speak
English. Some cultures regard eye contact as a sign of disrespect, so you should not ask this of the patient.
26. A patient with a history of atrial fibrillation and hypertension is being admitted for weakness and fatigue. In report from the
ED you learn his medications include warfarin and metoprolol, his laboratory results show an international normalized ratio
(INR) of 5.3 and a hemoglobin of 7.5 g/dL, and the prehospital emergency team inserted an 18-gauge intravenous catheter in the
left antecubital vein. When the patient arrives to the unit, there is an area of blood on the stretcher, and the IV catheter is lying
beside the patient. What should be your first action?
A. Apply direct pressure to the IV site.
B. Check to ensure the patient's level of weakness has not worsened during transport.
C. Call the provider and request a stat order for a coumadin reversal agent.
Rationale: As part of a routine assessment you should check for any worsening of the patient's symptoms. However, this patient
is actively bleeding and his clotting is compromised because of anticoagulation. You must act quickly to stop the bleeding by
applying direct pressure to the IV site. Notify the provider and request a reversal agent once the patient is out of immediate
danger.
27. You are providing education to a patient with diabetes mellitus and multiple microvascular complications who just arrived on
the unit. What would be an important piece of information to include in this initial education?
A. Verbal description of the layout of the room, including location and use of the call bell.
B. Written description of the daily routine, including times for insulin administration.
C. Descriptions of newly ordered medications, including potential interactions and complications.
Rationale: A patient with the microvascular complications of diabetes mellitus may suffer from retinopathy and have impaired
vision. To ensure patient safety, first orient patients with poor vision to their room. Demonstrate how to use the call bell system
so that the patient can communicate needs to the staff. Before providing written materials or detailed medication information,
first assess the patient's health literacy and learning preferences.
29. You receive report on your three patients at 700 hrs. Mrs. Smith was admitted post laparoscopic cholecystectomy from
yesterday, and slept through the night. She requested of the night nurse that someone come in first thing this morning to answer
her questions about discharge. Mr. Jones was transferred from the critical care unit yesterday after treatment for diabetic
ketoacidosis, and receives regular insulin 4 times per day on a sliding scale. Miss Eakin was admitted last night for nausea and
vomiting, and is currently not eating. The nurse's aide is recording vital signs, and the morning breakfast trays have arrived on the
unit. Using the critical thinking process, what should be the nurse's first priority?
A. Assess Miss Eakin for nausea and vomiting, and administer prn medications as ordered.
B. Check a fingerstick glucose on Mr Jones and administer the appropriate amount of insulin per the sliding scale.
C. Gather teaching materials for Mrs. Smith to answer her questions and ease her mind about discharge.
Rationale: You must constantly prioritize and re-prioritize patient care throughout your shift. In this case, Mr. Jones should be
seen first. He was admitted with a life-threatening condition, and now needs to receive the required amount of insulin before he
eats breakfast to help control his blood glucose level. Miss Eakin should be seen next, but can wait until Mr Jones receives his
insulin. Discharge teaching is very important, but does not need to be done first thing in the morning.
30. Which action displays culturally congruent care?
A. Telling the patient that the doctor knows best how to treat the disease.
B. Telling the patient that meals must be ordered from the hospital menu.
C. Asking the patient directly about cultural preferences.
Rationale: Asking the patient about cultural preferences will allow you to view care from the patient perspective and alter care
accordingly. Telling the patient that the doctor knows best belittles the patient’s own beliefs and practices. Insisting that the
patient eat hospital food may violate cultural dietary restrictions.
31. You plan to delegate the task of obtaining vital signs to the UAP. Which statement by the nurse demonstrates safe delegation
skills?
A. “After you get the vital signs, please document them. I will check them later.”
B. “Can you please obtain vital signs for both patients in room 1 now and inform me of any abnormal values?”
C. “Please check vital signs for me. Let me know if the patient has any other signs of fever.”
Rationale: You are demonstrating safe delegation skills by giving clear direction and asking for verification from the UAP on
their ability to complete the task in the timeline needed. Asking the UAP to document vital signs without asking for report of any
abnormal values could impair patient safety. Assessing the patient for signs of fever is outside the scope of practice of the UAP.
32. Which statement demonstrates that the patient understands your teaching about medications for her mental health disorder?
A. “If the depression medicine isn’t helping by next week, I will call the doctor for a different med.”
B. “It’s okay to eat potato chips when I take the lithium.”
C. “If I take this dementia medication, I will start remembering and thinking clearly again.”
Rationale: If dietary sodium is not adequate, the kidneys retain lithium. The higher lithium levels could lead to toxicity.
Therefore, it is necessary for patients taking lithium to maintain an adequate level of sodium. As a result, eating a salty snack,
such as potato chips, is permitted. Medications for depression can take several weeks to work before symptoms are improved.
Dementia medications may slow the progression of the disease, but they do not reverse or stop the progression.
34. Which member of the interprofessional team is enacting a potential barrier to effective communication?
A. The new therapist who is having trouble remembering the standard report format the team uses.
B. The provider who addresses team members using job titles and surnames.
C. The nurse who is certified in the unit's specialty practice.
Rationale: Lack of proficiency in standard reporting formats can become a communication barrier between team members. It is
less likely that using a formal, professional manner to address team members will cause a communication barrier. Clinical
experience and advanced learning are more likely to enhance effective communication rather than creating a barrier.
37. When caring for a patient with chronic obstructive pulmonary disease (COPD), which intervention should you include in the
daily plan?
A. Maintain an oxygen saturation level of at least 98%
B. Schedule physical therapy just before lunch time
C. Administer bronchodilators, as ordered
Rationale: Bronchodilators relax bronchial muscles, allowing air to move more freely within the airways, so they are an
important part of the plan of care for COPD patients. For patients with COPD, the goal is usually to keep oxygen saturation levels
at or above 88% or within ordered parameters. Patients should be well-rested at mealtime to minimize meal-related dyspnea.
Proper nutrition is important for patients with COPD because the increased work of breathing increases caloric consumption.
38. Which of the following demonstrates the ANA's Code of Ethics principle to act with "compassion and respect for the inherent
dignity, worth, and uniqueness of every individual?"
A. Addressing an older adult patient as “Honey.”
B. Waking an exhausted patient from a nap to make the bed.
C. Sitting at eye level to communicate with a teenager.
Rationale: Sitting at eye level promotes dignity by communicating that the nurse is on the same level and not superior to the
patient. Addressing a patient as “Honey” instead of using the patient’s name can be degrading. Waking a patient to change the
bed because it fits the staff's schedule does not respect that patient’s individual needs and worth.
39. Which of the following signs or symptoms would most likely alert you to a possible surgical site infection?
A. Increased urine output
B. Clear wound drainage
C. Low blood pressure
Rationale: Low blood pressure can be a sign of a surgical site infection and possibly sepsis. Other signs of surgical site infection
include decreased (not increased) urine output and purulent or bloody drainage.
40. You are caring for a patient newly diagnosed with left ventricular systolic dysfunction (LVSD) heart failure. Which
medication might be included in the treatment plan?
A. Nifedipine
B. Lisinopril
C. Naproxen
Rationale: Lisinopril is an angiotensin converting enzyme inhibitor (ACEI). As a quality measure for patients without
contraindications, an ACEI or an angiotensin receptor blocker (ARB) should be prescribed at hospital discharge. ACEIs help to
decrease afterload and blood pressure, and can slow the progression of heart failure. Nifedipine is a calcium channel blocker.
This class of medication should be avoided in patients with heart failure because it increases contractility and fluid retention.
Naproxen is a nonsteroidal anti-inflammatory drug (NSAID), a class of medication that should also be avoided because it
increases fluid retention.
41. You have medicated a postoperative patient for pain as ordered. When you assess the patient one hour later, the patient is
sitting calmly in bed but complains of pain at the surgical site, which she rates a 10 (the highest). The surgical site is clean, dry,
and intact, without redness. Which is the most appropriate response for the nurse to give the patient?
A. “You are not scheduled for more pain medication yet, so just try to get some rest.”
B. “Your body is not acting like “10 out of 10” pain. I will check back in another hour.”
C. “Will you tell me some more about your pain so I can better understand how to help you?"
Rationale: One barrier to effective pain management is an inadequate pain assessment. Factors such as the patient's pain goal,
the source and sensation associated with the pain, what has helped the patient in the past, and what methods the patient hasn't yet
tried are part of a pain assessment. Consider that some patients have culturally related behaviors for the use of body language to
express pain, so nurses should not make assumptions based only on their interpretation of a patient's facial expression or body
language. Not all patients respond the same way to pain medication. In the postoperative period, a patient may receive new
medication that does not improve their pain, thus requiring the provider to change the pain medication orders and the nurse to
explore nonpharmacologic methods of pain management with the patient.
44. A patient admitted yesterday with chest pain and an abnormal EKG is preparing for discharge. As you begin discharge
teaching, the patient states that he won't be taking the new medications because he can't afford them. Which of the following
statements promotes quality care?
A. “I see you have a pack of cigarettes with you. You should be giving up smoking, and the money you save can be used to buy
the medication.”
B. “This medication is very important to decrease the work of your heart. I will call the case manager to come and meet with us
about medication assistance programs.”
C. “Perhaps you can think of friends or family members who could help you out with a little money so you can buy the
medication that you need for your heart.”
Rationale: Quality of patient care extends beyond the hospital stay. It is important to facilitate transition from hospital to home.
By offering to include the case manager in the discharge process, you are providing patient-centered and collaborative care, using
the most appropriate resource to help the patient obtain the needed medication.
45. A patient has a fever of 102.2 degrees F (39.0 C), a heart rate of 102 bpm, respiratory rate of 28, an oxygen saturation of
90%, and moist clammy skin. The nurse suspects this patient is suffering from which disorder?
A. COPD exacerbation
B. Bacterial pneumonia
C. Cor pulmonale
Rationale: Bacterial pneumonia is often the most serious type of pneumonia, and can present with all of the signs and symptoms
listed. A COPD exacerbation may present with an increased respiratory rate and signs of hypoxia, but is not usually associated
with a fever. Cor pulmonale will usually present with signs of right-sided heart failure.
46. Which nurse is most likely to be experiencing burnout?
A. A nurse complains of headaches every shift and has developed a flat affect.
B. A nurse strictly eats healthy food and repeatedly encourages other nurses to follow the same diet.
C. A nurse is very active on the unit and exercises during breaks, often offering to help other nurses with assignments.
Rationale: A flat affect, loss of motivation, physical complaints, and emotional displays are often signs of burnout. Nurses who
eat and advocate for healthy nutrition or those who exercise frequently may be attempting to forestall their own burnout. Nurses
who frequently offer to help others may be seeking to preempt burnout amongst team members.
47. A patient with a respiratory infection requires airborne precautions. Which of the following should the nurse institute in this
patient's care?
A. Keep the room door open to allow flow of fresh air.
B. The nurse should put on a facemask that extends under the chin.
C. Limit movement of the patient outside of the room to medically necessary purposes.
Rationale: For a patient on airborne precautions, limit transport and movement outside of the room to medically necessary
purposes. A patient on airborne precautions should wear a surgical mask when outside the room to help prevent microbe
transmission. The patient should be placed in an airborne infection isolation room (AIIR) and the door should remain closed to
decrease the potential spread of microbes into the hallway. The nurse should put on a fit-tested, NIOSH-approved, N95 or higher
level respirator before entering the room.
48. While rounding you find that the alarms on a patient's cardiac monitor have been silenced. The patient states, "That noise just
kept going and going, and my daughter works in health care, so she turned it off so I could sleep." What is your best response?
A. “The alarms are there for your safety. I would be happy to talk to your daughter about the importance of these alarms.”
B. “I am so glad your daughter cares about your sleep, but she does not have the knowledge or permission to turn off the alarms.”
C. “It sounds like your daughter knows what she is doing. Those alarms can get very annoying sometimes.”
Rationale: Explain to the patient and the daughter that the alarms are set to keep the patient safe. Telling the patient that her
daughter does not have knowledge degrades the daughter and does not contribute to therapeutic communication. Condoning the
daughter’s actions goes against hospital policy and patient safety.
49. When assessing a patient who received narcotic analgesia in the post-anesthesia recovery unit (PACU) and has just been
transferred to your unit, you note a heart rate of 52 bpm, respiratory rate of 10, and SpO2 of 89%. The patient briefly opens his
eyes and mumbles in response to verbal stimuli. When notifying the provider, which order should you anticipate?
A. Administer intravenous diphenhydramine
B. Administer intravenous epinephrine
C. Administer intravenous naloxone
Rationale: This patient most likely is having an adverse reaction to a narcotic analgesic. A narcotic analgesic can cause
respiratory depression, a slowed heart rate, and a decreased level of consciousness. Naloxone is used to reverse the effects of
opioid narcotics. Diphenhydramine is more often used for an allergic reaction to medication. Epinephrine is generally used to
treat anaphylaxis and cardiac arrest.
51. Which statement by a new nurse is most appropriate when communicating a practice concern to a more experienced nurse?
A. "I noticed the way you manage IV ports isn't the way I was shown during orientation. Can you help me understand more about
this practice?"
B. "Why didn't you cap the IV port? I thought that was the policy."
C. "In school we learned that there is a better way to manage IV ports than the way you are doing it."
Rationale: Asking a question about a practice, then asking to discuss it further opens up a nonthreatening conversation in which
both nurses may learn something valuable. Asking “Why didn’t you…?” can put the other nurse on the defensive and impair
good communication. Telling an experienced nurse that things have changed and there are now better ways may be true, but this
degrades the collegial relationship.
52. You are providing discharge education to a patient with diabetes mellitus. Which response by the patient demonstrates
understanding of the discharge teaching?
A. Nodding in agreement when the nurse explains how insulin works.
B. Stating, “I will start walking 30 minutes each day.”
C. The patient states they will read insulin dosing instructions once they get home.
Rationale: Using the teach-back method by having the patient restate the information taught demonstrates that the patient has
heard and understood the teaching—in this case, the need for daily exercise. Nodding does not confirm patient understanding.
Written resources can be very beneficial, but the nurse must go beyond hearing that the patient will read the information. The
nurse needs to ensure that the patient can read and understand the information and wants to incorporate these recommendations
into the plan of care.
53. A patient who was admitted to the medical-surgical unit one day ago for dehydration and malnutrition reports that he is
nauseous, has a headache, and his hands are starting to shake. You observe diaphoresis and tremors. What condition do you
suspect the patient may be experiencing?
A. Substance withdrawal
B. Depression with suicidal ideation
C. Manic episode related to bipolar disorder
Rationale: The patient is most likely experiencing symptoms of substance withdrawal, which warrant early intervention for
patient safety. A patient with depression and suicidal ideation is more likely to be expressing feelings of wanting to kill themself,
hopelessness, or unbearable pain. Bipolar disorder is characterized by mood fluctuations from abnormally elated and excited
during a manic period to periods of depression.
54. You obtain a fingerstick blood glucose level of 37 mg/dL for a patient with diabetes mellitus. The patient is lethargic,
diaphoretic, and trembling. Your medical-surgical unit has protocol orders to treat hypoglycemia. Which action is your priority?
A. Call the charge nurse to bring IM glucagon to the patient's room
B. Call the provider to report the patient's condition
C. Call the nursing assistant to bring some fruit juice
Rationale: Hypoglycemia can be a life-threatening condition requiring immediate treatment. Asking the charge nurse to bring
IM glucagon (while staying with the patient) is the most appropriate treatment to raise the blood glucose level quickly. With
protocol orders in place, you should begin emergency treatment before notifying the provider. Because the patient is lethargic and
may not have an intact gag reflex, do not give oral glucose (fruit juice).
56. You are assessing a patient who has just been admitted to your unit from the emergency department with a urinary tract
infection. Which of the following should alert you to a potential diagnosis of delirium?
A. The patient remembers all the events from last week.
B. The patient states she feels unsafe going to the bathroom and would like assistance.
C. The patient frequently changes the topic and appears agitated.
Rationale: A patient who frequently changes the topic and appears agitated may be showing signs of delirium, which can range
from lethargy and disorientation to hallucinations and combative behavior. An impaired memory and poor judgment are more
likely signs of delirium than accurate recall of events and having the good judgment to ask for assistance to ambulate to the
bathroom.
57. The shared governance staffing committee is reviewing the next month's schedule and sees that a holiday does not have any
nurses scheduled who are qualified to perform a procedure that is common on the unit. Recognizing this problem could lead to a
conflict, which suggestion by a committee member would be most appropriate for healthy conflict management?
A. "Let's see if any of the nurses with these competencies are able to switch this holiday for another day."
B. "We should tell the nurses with the correct competencies that one of them has to work."
C. "Since we're responsible for staffing, one of us should take the shift."
Rationale: Exploring options to switch holiday shifts represents a compromise, which is usually a positive form of conflict
management. An authoritarian approach would be to tell certain nurses that they have to work a particular shift; this will likely
create negative feelings and potentially increase conflict. Having one of the staffing committee members take the shift is an
example of accommodation, which may mean neglecting personal needs in order to satisfy others. Accommodation may be
unhealthy if an individual takes on undue burden.
59. A novice nurse notes that the patient's usual dose of medication may be contraindicated because the patient's serum creatinine
level is elevated. When the nurse provides an SBAR report and recommends a change in dosing, the provider says to give the due
dose and that the team will address a new order during rounds. What is the nurse's best response?
A. Withhold the medication and avoid speaking with the provider during rounds.
B. Give the medication as ordered so as not to cause further conflict with the provider.
C. Talk to the charge nurse about the issue and work together to resolve it and support patient safety.
Rationale: By asking the charge nurse to help resolve this issue, the nurse demonstrates collaboration, which involves a group of
people working together to achieve a common goal. Giving the medication as ordered is accommodation that would be
neglecting the patient's safety in order to satisfy the provider. Withholding the medication without telling the provider is outside
of the nursing scope of practice, and avoiding further discussion with the provider does not resolve the underlying conflict.
60. You are delegating the task of assisting a patient to the bathroom to the UAP. Which of the following is an appropriate
statement?
A. “Please take the man in room 2 to the bathroom. I’m not sure how he walks, but stay with him if you think it is necessary.”
B. “The patient in room 2 needs to go to the bathroom. Please help him for me when you get the chance.”
C. “Please take Mr Jones to the bathroom. His left side is weak, so he will need support. Stay with him, and then help him back to
bed. Let me know how he does.”
Rationale: Giving specific direction (patient name, specific task, risk factors involved) promotes clear communication. Asking
for feedback after the task allows for evaluation. Referring to a patient by room number can be confusing if there are more than
one patient in the room. Saying “when you have the chance” to the UAP does not meet the patient’s immediate need, and may
cause an injury if the patient tries to get out of bed by himself. Asking the UAP to make a clinical assessment (whether the
patient is safe enough to not need her to stay) is inappropriate.
61. When collaborating with a patient, the family, and members of the interprofessional team, which actions best demonstrate
professional nursing standards?
A. Create a plan of care based on the family's preferences
B. Expect the provider's expertise-based orders to be paramount in the plan of care
C. Base the care plan on the patient's goals and evidence-based interventions
Rationale: Patient and family centered care, based on the patient's goals and evidence-based treatments, reflect professional
nursing standards. Although clinician expertise may be part of an evidence hierarchy, the patient's goals should be paramount.
The family's preferences should also be considered, but not placed above the patient's goals for care.
62. A patient admitted with chest pain has an initial troponin I of 0.03 ng/mL and an ECG that shows a pattern of ST depression.
The patient calls you because the pain has suddenly increased. Following ordered chest pain protocols, which of the following
should you do first?
A. Administer sublingual nitroglycerin
B. Increase the oxygen administration to 6L/minute
C. Assess the patient’s vital signs
Rationale: With a change in the patient's condition, before intervening you should first assess vital signs. Sublingual
nitroglycerin might be administered, but you must first check a heart rate and blood pressure to make sure they are within the
ordered parameters for administration. Oxygen should not be increased unless the oxygen saturation level is lower than the
ordered goal as excess oxygen could cause oxygen toxicity.
63. In the middle of the night a patient with a diagnosis of post-traumatic stress disorder (PTSD) stands in the corner of the room
shouting. Which is the nurse's most appropriate intervention?
A. Turn on all of the lights and speak loudly so the patient can hear you.
B. Tell the patient to calm down and stop disturbing other patients.
C. Orient the patient using a calm and quiet tone of voice.
Rationale: For a patient displaying signs of distress related to PTSD, the best intervention for deescalating the situation is acting
in a calm and quiet manner. Turning on lights and speaking loudly may create more distressing stimuli and may escalate the
patient’s behavior. The nurse's focus should be on helping deescalate the patient's distress without expecting a patient in distress
to consider the needs of other patients.
64. You are discharging a patient with chronic obstructive pulmonary disease (COPD) to home. Which statement by the patient
demonstrates an understanding of the discharge instructions?
A. “I got a flu shot last year, so I am still protected against the flu.”
B. “I will use the patch the doctor prescribed to try to stop smoking.”
C. “If I have increased shortness of breath, I will lay flat and try to rest.”
Rationale: Smoking cessation is a positive step for a patient to decrease the incidence of a COPD exacerbation. Patients should
be vaccinated yearly for influenza. Influenza complicates COPD and increases the potential for hospital admission related to
respiratory failure. The patient should be educated on methods to help decrease dyspnea, such as using the tripod stance and
pursed-lip breathing, not lying flat, and instructed to call the provider or go to the hospital if dyspnea worsens.
65. A trauma nurse is caring for a teenage victim of a car accident. While at work, her 15-year-old son calls to ask her if he can
go out with his friends. She tells him the roads are not safe tonight, and then tells him about the trauma patient for whom she is
caring. At what point would this nurse potentially violate ethical principles?
A. She warns her son that drinking and driving is very unsafe practice.
B. She asks her son to avoid the specific road where the accident happened.
C. She shares with her son the patient’s first name, age, and school affiliation.
Rationale: By sharing specific demographic information with her son, the nurse is potentially violating the ethical principle of
protecting the privacy rights of the patient. Warning her son about unsafe practices does not violate any ethical principles. Asking
her son to avoid a specific road does not reveal any information that would violate ethical principles.
66. A patient who is one day post-op from hip surgery complains of significantly increased pain at the incision site, stating, "I
never had this kind of pain when I got my other hip done last year." You note redness and swelling around the incision. Which
action is most important for you to perform?
A. Check the condition of the patient's other hip
B. Check neurovascular status in the affected extremity
C. Review the patient's pain management history in the chart
Rationale: Surgical site infection can lead to neurovascular compromise distal to the surgical site. Therefore, you should first
check the patient's neurovascular status in the affected extremity. The patient's history of pain management and recovery from a
similar surgery can help with creating a plan of care, but is not the priority action at this time.
67. A patient complains of increased shortness of breath with any type of activity. On assessment, you note pitting peripheral
edema. The patient has an oxygen saturation of 92%, an ejection fraction of 23%, and a BNP value of 729 pg/mL. Which of the
following should you implement for this patient?
A. Administer oxygen to achieve an SaO2 of 97%
B. Initiate intravenous fluids at a rate of 100 ml/hr
C. Help the patient sit up and assess vital signs
Rationale: The patient has signs and symptoms of systolic heart failure. Sitting upright will assist with oxygenation and work of
breathing, and keeping the legs dependent will reduce pulmonary capillary pressure. Current vital signs will help inform the need
for other interventions. Oxygenation goals for patients with heart failure are usually to keep the oxygen saturation above 90%. A
saturation of 97% is likely not achievable, and may require a high concentration of supplemental oxygen. This patient has
peripheral edema, a sign of fluid overload, which is affecting cardiac and respiratory status. Therefore, IV fluids are more likely
to worsen, rather than improve, the patient's condition.
68. You are assessing the severity of a patient's chronic back pain. You know that which method is most accurate to assess the
patient's pain?
A. The visual analog scale for pain assessment
B. The patient’s self-report of pain
C. The Brief Chronic Pain Screening Tool
Rationale: The patient’s self-report is the gold standard of determining the severity of pain. The visual analog scale is a
quantitative measure of the level of pain, and the Brief Chronic Pain Screening Tool is a qualitative measure of the patient’s
description of pain.
69. Which question is most likely to be included in a computer-based algorithm to screen patients for risk of self-harm?
A. “What brought you into the hospital?”
B. “Do you have any thoughts of hurting yourself?”
C. “What difficulties are you having at home?”
Rationale: The question most likely to occur in an algorithm to assess for risk of self-harm is a direct question, such as “Do you
have any thoughts of hurting yourself?” Other, more general questions may also be part of a patient admission assessment, but
would not prompt a patient clearly enough to discuss thoughts of self-harm, thus limiting the healthcare team's ability to keep the
patient safe.
70. A patient who is recovering after a percutaneous coronary intervention is being treated for pain with a nonsteroidal antiinflammatory (NSAID) medication. With baseline vital signs of 128/84 mmHg, heart rate of 76 bpm, respiratory rate of 16 bpm,
and a pain level goal of 3 on a 0 to 10 analog scale, which finding is a priority for the nurse to address?
A. Creatinine level 2.4
B. Pain level of 2 at the incision site
C. Blood pressure of 124/83 mmHg
Rationale: NSAIDs can impair renal function. Communicating the elevated creatinine level of 2.4 to the provider is a priority. A
pain level of 2 when the patient's goal is a 3 should be acceptable for the patient. NSAIDs can cause a rise in blood pressure;
however, the blood pressure of 124/83 mmHg is below the patient's baseline blood pressure, so does not warrant further action at
this time.
71. The family member of a dying patient who has elected hospice care expresses gratitude to you for helping the patient retain
dignity near the end of life. Which action is most likely to contribute to the patient's dignity?
A. Supporting a family member's optimism that the patient will return to health
B. Arranging for grooming that the patient requests, including shampooing the hair
C. Limiting visitors to visiting hours so the patient has more time to rest
Rationale: The principles of hospice and palliative care include providing comfort and support. By arranging for grooming the
nurse is supporting what the patient has defined as most important near the end of life and supports the patient's self-worth.
Supporting an unrealistic idea that the patient's health will improve does not convey truthful information and may belittle the
patient's wishes for dignity at the end of life through hospice care. Limiting visiting hours may hinder the patient's ability to
spend time with family and does not contribute to the patient’s quality of life.
72. During the early stages of shock (compensatory stage), the nurse should expect to find which assessment result in the patient?
A. Decreased heart rate
B. Normal blood pressure
C. Warm skin temperature in the fingers
Rationale: During the compensatory stage of shock, blood pressure may be normal or slightly increased or decreased. The heart
rate and contractility are increased in an attempt to circulate more oxygenated blood. Blood is shunted away from the peripheral
vessels, causing coolness to the distal extremities.
73. A patient continues to have pain, even though he is receiving intravenous morphine after having leg surgery. After notifying
the provider, you anticipate an order for which adjuvant therapy?
A. An antidepressant
B. A muscle relaxant
C. A nerve block
Rationale: A muscle relaxant is an adjuvant therapy that may be used. Adjuvant therapy medications have another primary use,
but have properties that help reduce pain. Antidepressants and nerve blocks both affect stages of the pain pathway: an
antidepressant is given to alter the pain modulation; a nerve block is given to prevent pain transmission.
74. You are caring for a patient who has diabetes mellitus and is hospitalized to treat an infection of the right toes with
intravenous antibiotics. Which of the following interventions is most appropriate in preventing the patient's condition from
worsening?
A. Perform hand hygiene at recommended intervals.
B. Recommend that the medical team place a central venous catheter for antibiotic administration since the patient has poor
vascular access.
C. Measure the patient’s blood glucose every 24 hours.
Rationale: This patient is at risk of a hospital-acquired infection. Good hand hygiene is an essential factor in preventing further
infection. Central venous catheters are a common source of healthcare-associated infections, and other routes of delivery should
be investigated before recommending this type of access. A patient with diabetes mellitus and an active infection likely requires
blood glucose monitoring more often than every 24 hours to prevent elevated glucose levels that can contribute to the infection
risk.
75. Which patient should you recommend that the medical team urgently investigate for possible sepsis?
A. A patient with late-stage, severe Alzheimer dementia has been crying uncontrollably after falling and sustaining a 1-inch
laceration to the lower leg.
B. A patient with a temperature of 38 degrees C, a heart rate of 117 bpm, a large number of white blood cells in the urine, and
confusion.
C. A patient with diabetes mellitus and an infected left great toe, temperature of 37.4 degrees C, heart rate of 77 bpm, and blood
pressure of 127/81 mmHg.
Rationale: The patient with confusion, a large number of white blood cells in the urine, and elevated temperature and heart rate
should be most urgently investigated for possible sepsis. The patient's dysregulated host response may lead to life-threatening
organ dysfunction. The patient with a localized laceration may also be at risk for sepsis, but would require further evaluation to
determine if other signs besides crying are present. The patient with diabetes currently has vital signs which do not point to lifethreatening organ dysfunction and a dysregulated response to infection that characterizes sepsis.
77. When assessing the safety needs of the unit, the nurse manager may consider data from which of the following nursesensitive indicators?
A. Patient perspectives on care
B. Physician rounding frequency
C. Nursing hours per patient day
Rationale: Nursing hours per patient day is a nursing quality indicator that may affect the safety of the nursing unit. Nursingquality indicators are unit-specific, nurse-sensitive data collected from over 2,000 hospitals so that nurse leaders can compare
data to improve quality and nurse engagement. Patient perspectives on care and physician rounding frequency can also impact
quality, but are not nursing quality indicators.
78. A patient is being discharged home with a prescription for opioids. Which statement by the patient demonstrates the need for
additional education?
A. "I will not drink any alcohol while I am taking these pills."
B. "If I don't need all of the pills in my prescription I'll return them to the pharmacy."
C. "I'll share the extra pills with my dad, who has a prescription for them, but often can't afford them."
Rationale: Medication should never be shared with anyone for whom it is not prescribed. This statement should alert you that the
patient needs further education. The patient is correct that alcohol should not be consumed while taking opioid medication. If the
medication is no longer needed, it should be disposed of safely, according to local laws, which often require pharmacies to accept
unused medication for safe processing.
79. You are providing discharge teaching for a patient who was admitted for heart failure. Which statement by the patient
demonstrates understanding of the teaching?
A. “I should weigh myself every day while I am taking the water pill.”
B. "So I don't interrupt my sleep, I should take my water pill before bedtime.”
C. “I can continue smoking, now that I am on medications for my heart failure.”
Rationale: To estimate fluid retention, patients with heart failure are usually instructed to weigh themselves every day and report
a weight gain of 2 or more pounds over a few days. Because diuretics cause frequent urination, patients should be taught to take
these medications at a time that will not disrupt sleep. The patient should be taught about smoking cessation since smoking
increases the risk of complications for patients with heart failure.
80. You are caring for a patient with a surgical site infection. After two days of treatment, which finding indicates the need for
further intervention?
A. Heart rate of 126 beats per minute
B. Decreased drainage on the dressing
C. Pink skin color around the surgical site
Rationale: A heart rate of 126 may indicate early sepsis, which requires immediate intervention. Decreased drainage on the
dressing and pink skin color around the surgical site are both positive signs of healing, and do not require further intervention.
81. One week after delivery a postpartum patient with a newborn was admitted to the medical surgical unit after an emergency
open appendectomy. The patient is medically stable and is receiving IV antibiotics. The patient's primary goal is to bond with and
breastfeed her baby. She is demanding discharge if she cannot see her baby. However, the unit's infection control visitation rules
prohibit children from visiting the unit. Which is your best action to improve the patient's quality of care?
A. Collaborate with the provider to facilitate visitation with the baby outside of the patient unit.
B. Allow the family to bring the baby onto the unit after visiting hours have ended.
C. Request a psychiatric consult to prevent the patient's departure against medical advice.
Rationale: Since the patient's primary goal is to bond with and breastfeed the baby, you should collaborate with the provider to
find a solution to meet this need. This could involve an order for off-unit privileges and finding a safe location off the unit, such
as a consultation or visitors lounge, where the patient can nurse and bond with the baby. The patient's goal could also be safely
met by collaborating with the provider for transfer to a maternal-child unit with infection control precautions or potentially
discharging the patient to home with IV antibiotics. Bringing the baby on to the unit violates ethical principles and infection
control safety policies. The patient may benefit from mental health support for distress and disrupted bonding, but this is not the
patient's primary need.
82. A patient reports feeling distressed about their prognosis and ability to manage a chronic health disorder. Which of the
following statements demonstrates the best approach to achieving optimum patient outcomes?
A. “The medical team knows best how to manage your chronic illness and will order appropriate care."
B. “You are going to be fine. Just take your medications, do what the home health nurse tells you, and keep all of your scheduled
appointments."
C. “This situation must be very difficult. Tell me about some coping mechanisms that you use in stressful situations like this.”
Rationale: One goal of patient-centered care is for the patient to be able to improve their coping abilities. You should
acknowledge the patient’s distress and help explore ways to cope using open-ended questions and prompts. Telling the patient
not to bother with the details undermines the patient’s right to make informed decisions about the chronic disorder. Telling a
patient that they will be fine is providing false hope and breaking trust. Giving directions to follow home health orders limits
patient autonomy and does not appropriately support optimum patient outcomes.
83. Which of the following orders would you anticipate as part of the plan of care for a patient with a surgical site infection when
the wound has purulent and bloody exudate?
A. Apply positive-pressure wound therapy
B. Remove dressing every four hours to inspect the wound
C. Intravenous antibiotics
Rationale: Intravenous antibiotics based on the results of wound cultures will most likely be part of the plan of care for a patient
with a surgical site infection. Negative-pressure (not positive-pressure) wound therapy may be ordered to draw out fluid from the
wound and increase blood flow. For a wound with purulent and bloody drainage, it is likely that the ordered dressing material
will be antimicrobial, absorbent, hydrocolloid or have a low-adherent contact layer. These types of dressings should be removed
and changed based on the drainage and condition of the wound and the manufacturer's instructions, rather than disrupting the
healing environment every four hours.
84. Two nurses have called out sick for a shift on a medical-surgical unit. After the charge nurse has made assignments to best
meet the patients' acuity and staff mix, the bed-control supervisor calls to admit two patients with exacerbation of heart failure
from the emergency department. During a team huddle to discuss the admissions, which response to the charge nurse best reflects
professional nursing ethics?
A. "Can they assign an additional nurse to our unit or send the admissions to another unit?"
B. "My patients' high acuity probably makes it unsafe, but I'll do the best I can to admit one more patient."
C. "I don't think we should accept any more patients, no matter how sick they are."
Rationale: Nurses can support the charge nurse to weigh the unit's nursing personnel's abilities and patient safety to make an
ethical choice. Requesting an additional nurse who has the required competencies for the unit is the best approach to keep nursing
personnel and patients safe. Accepting an additional patient to an assignment with high acuity may put both personnel and
patients at risk. Supporting the charge nurse by suggesting solutions is a more ethical choice than not accepting any additional
admissions as this may also put the patients' safety at risk.
85. A patient with opioid use disorder who was admitted for diarrhea and pain developed an acute kidney injury (AKI). Which
nursing action should be included in this patient's plan of care?
A. Monitor laboratory results and call the provider to report abnormal values.
B. Plan to provide up to the maximum dose of nonsteroidal anti-inflammatory medications (NSAIDS) to treat the patient’s pain.
C. Plan to administer potassium sparing diuretics to treat oliguria.
Rationale: Abnormal laboratory results can indicate worsening kidney injury and should be reported to the provider. NSAIDS
are nephrotoxic, and should be limited for a patient with kidney disease. Patients with acute kidney injury are at risk for
hyperkalemia, so medications that block renal excretion of potassium should not be given.
87. You are caring for a postoperative patient. Which action helps prevent pneumonia in this patient?
A. Placing the patient in supine position
B. Instructing the patient to suppress any urge to cough
C. Washing your hands before and after caring for the patient
Rationale: Good hand hygiene is one of the primary tools for preventing infection such as pneumonia. Place a post-operative
patient in semi-Fowler’s position, if possible, to allow for better expansion of the chest. Encourage the patient to cough and deep
breathe to expel any secretions and help to expand the lungs.
88. A patient has just been admitted to the unit with chest pain. What should be your priority action?
A. Call the discharge planner to meet with the patient about continuation of care after the hospital stay.
B. Start an IV and hang fluids as ordered by the provider.
C. Ask the patient about the location and quality of the pain.
Rationale: The first step of the nursing process is assessment. Therefore, begin the nursing process by assessing the patient,
including the patient's pain. Assessment data will help you determine and prioritize actions. Starting the IV and beginning
discharge planning are both important interventions that should happen after patient assessment.
90. An unlicensed assistive personnel (UAP) offers to apply oxygen for a patient who is having shortness of breath. The UAP
states that this was common practice at the UAP's former place of employment. Which response is most appropriate?
A. “I need to assess the patient and check the provider orders, so I can't safety delegate that activity to you."
B. “If you applied oxygen at your last hospital, then you should be fine. It’s all about experience! Let me know how the patient
does with it.”
C. “I need to check the hospital policy to see if that’s a procedure that you are allowed to do.”
Rationale: The authority to delegate and scope of nursing practice both come from the State Nursing Board. Although the
hospital sets policies in line with the State Board’s regulations, the nurse needs to know when activities such as assessing the
patient's need for oxygen are outside the parameters of safe delegation. The UAP's prior experience in another setting does not
provide enough information to the nurse to evaluate the UAP's ability to perform a delegated activity.
93. You are caring for a patient who suffered an ischemic stroke 24 hours ago. Which of the following assessments will alert you
to possible deterioration of the patient's status?
A. The patient is increasingly more drowsy and unable to maintain a conversation
B. The patient’s mood is light and elated
C. The patient describes increased visual acuity
Rationale: One sign of neurologic decline and deterioration of patient status is a decreased level of consciousness. A
deteriorating patient may also experience irritability or delirium, but will generally not have an elated mood. Visual disturbances,
not increased visual acuity, are also associated with patient deterioration after an ischemic stroke.
95. When caring for a patient whose stool culture was positive for clostridium difficile (c. difficile), you should use which
protective equipment?
A. Non-permeable gown
B. Face mask with shield
C. Alcohol-based hand sanitizer
Rationale: When caring for a patient with a c. difficile infection, use contact precautions. These precautions call for a nonpermeable gown and gloves. A face mask with shield is not usually needed to care for a patient with a c. difficile infection unless
there is a possibility of splashing. Since alcohol-based hand sanitizer is not effective against c. difficile, use soap and water for
hand hygiene.
96. You are caring for a patient who is reporting a high level of pain, crying out, and moaning. Which response by the nurse
impedes culturally congruent care?
A. “No matter how bad your pain is, patients are not allowed to be so loud because it is disruptive to the unit."
B. “Is there anything you have tried in the past that helps this kind of pain?”
C. “You appear to be in a lot of pain. How can I best help?”
Rationale: Projecting your beliefs and values about the patient's expression of pain impedes culturally congruent care. A
response that does not address the patient's pain but is focused on the unit's culture shows insensitivity to the patient’s beliefs and
values. Asking what has worked in the past shows respect for the patient’s input and beliefs. Affirming the patient’s complaint
shows respect and a desire to view the situation from the patient’s perspective.
98. While caring for patients during your shift, which activity demonstrates attention to preventing infection?
A. Washing your hands before putting on gloves to change a dressing.
B. Leaving in a patient's peripheral intravenous catheter, even though it has not been used in 24 hours.
C. Inserting an indwelling urinary catheter as an intervention for incontinence.
Rationale: The most effective infection control strategy is to wash your hands every time you enter and leave a patient's room,
before putting on gloves and after removing them, and before performing any procedure. If a peripheral intravenous catheter is
left in when not necessary, it becomes a potential port for infection. Inserting an indwelling urinary catheter to manage
incontinence rather than using a non-invasive solution creates a potential route for infection.
99. The nurse tells a patient that physical therapy is schedule for 0900. The patient responds that this is the time the patient is
required to perform prayers. Which statement by the nurse demonstrates culturally congruent care?
A. “We will try to make time for your prayers after you return from physical therapy.”
B. “I will call the physical therapy department and have the appointment time switched.”
C. "You really need the physical therapy to be discharged, so if I were you I wouldn't miss the appointment."
Rationale: You demonstrate cultural congruence by respecting the patient’s religious rituals and altering the care schedule to
accommodate them. Therefore, work with the patient and the physical therapy team to schedule therapy around the patient's
prayer time. Stating that the patient really needs physical therapy and providing advice about your own personal values decreases
a trusting relationship and undermines the patient’s religious beliefs by implying that the nurse’s beliefs are superior to those of
the patient.
100. You are caring for a patient with suspected sepsis related to a urinary tract infection. Which orders do you expect to be part
of the initial plan of care?
A. Obtain blood cultures
B. Administer intravenous vasopressors
C. Obtain a portable echocardiogram
Rationale: The initial care for a patient with suspected sepsis includes measuring the lactate level, obtaining blood cultures
before administering antibiotics, administering antibiotics, and administering crystalloid fluid intravenously for hypotension or
lactate level greater than 4 mmol/L. Intravenous vasopressors may be necessary later if the patient does not respond to initial
fluid resuscitation efforts. A portable echocardiogram may also be used later to assess the fluid balance and adequacy within the
heart and great vessels but is not a priority in the initial treatment and evaluation for urosepsis.