Asepsis
1. The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or
health care providers, the nurse emphasizes interventions that do which of the following?
a. Eliminate the reservoir.
b. Block the portal of exit from the reservoir.
c. Block the portal of entry into the host.
d. Decrease the susceptibility of the host.
2. Which is the most effective nursing action for controlling the spread of infection?
a. Thorough hand hygiene
b. Wearing gloves and masks when providing direct client care
c. Implementing appropriate isolation precautions
d. Administering broad-spectrum prophylactic antibiotics
3. When caring for a single client during one shift, it is appropriate for the nurse to reuse only which of the
following personal protective equipment?
a. Goggles
b. Gown
c. Surgical mask
d. Clean gloves
4. The nurse determines that a field remains sterile if which of the following conditions exist?
a. Tips of wet forceps are held upward when held in ungloved hands.
b. The field was set up 1 hour before the procedure.
c. Sterile items are 2 inches from the edge of the field.
d. The nurse reaches over the field rather than around the edges.
Safety
1. An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker
& takes a diuretic. Which intervention is most important to protect him from injury?
a. Leave the bathroom light on.
b. Withhold the client’s diuretic medication.
c. Provide a bedside commode.
d. Keep the side rails up.
2. A 75-year-old client, hospitalized with a CVA, becomes disoriented at times & tries to get out of bed,
but is unable to ambulate without help. What is the most appropriate safety measure?
a. Restrain the client in bed.
b. Ask a family member to stay with the client.
c. Check the client every 15 minutes.
d. Use a bed exit safety monitoring device.
3. Which nursing intervention is the highest in priority for a client at risk for falls in a hospital setting?
a. Keep all of the side rails up.
b. Review prescribed medications.
c. Complete the “get up and go” test.
d. Place the bed in the lowest position.
Hygiene
1. The client is unresponsive and requires total care by nursing staff. Which assessment does the nurse
check first before providing special oral care to the client?
a. Presence of pain
b. Condition of the skin
c. Gag reflex
d. Range of motion
2. The client is in surgery and will be returning to his bed via a stretcher. Which bed option reflects that the
nurse appropriately planned ahead for this client?
a. Open bed in low position
b. Occupied bed in low position
c. Closed bed in high position
d. Surgical bed in high position
3. The nurse is observing the unlicensed assistive personnel (UAP) perform perineal care for a client.
Which action indicates that the nurse needs to discuss additional teaching with the UAP?
a. Uses a clean portion of the washcloth for each stroke.
b. Wipes from the pubis to the rectum.
c. Uses clean gloves.
d. Does not retract the foreskin.
4. The nurse is discussing foot care with a client who was recently diagnosed with diabetes. Which
statement by the client indicates a need for further teaching?
a. “I am going to use a mirror to check my feet.”
b. “I enjoy walking barefoot around the house.”
c. “I will file my nails.”
d. “I will increase the time that I wear new shoes each day.”
Critical Thinking & Clinical Judgment
1. A client reports feeling hungry, but does not eat when the food is served. Using critical-thinking skills,
the nurse should perform which of the following?
a. Assess why the client is not eating.
b. Leave the food at the bedside.
c. Notify the primary care provider.
d. Perform an abdominal assessment
Vital Signs
1. For a 40 yo male which of the following sets of VS would be considered normal?
a. BP 130/72, P 73, RR 16
b. BP 90/60, P 70, RR 32
c. BP 100/50, P 44, RR 10
d. BP 180/100, P 72, RR 20
2. Which of the following is the highest priority to report to the physician in regard a 25 yo female
admitted with R/O ectopic pregnancy?
a. Temp 39C
b. HR 110 BPM
c. RR 18 BPM
d. BP 145/65 mm/hg
3. A nursing diagnosis of Ineffective Peripheral Tissue Perfusion would be validated by which one of the
following?
a. Bounding radial pulse
b. Irregular apical pulse
c. Carotid pulse stronger on the left side than the right
d. Absent posterior tibial & pedal pulses
4. Which client meets the criteria for selection of the apical site for assessment of the pulse rather than a
radial pulse?
a. A client is in shock
b. The pulse changes with body position changes
c. A client with an arrhythmia
d. It is less than 24 hours since a client's surgical operation
5. The client’s oral temperature at 8:00 AM is 36.1°C (97.2°F). If the respiration, pulse, and blood pressure
were within normal range, what would the nurse do next?
a. Wait 15 minutes and retake it.
b. Check what the client’s temperature was the last time.
c. Retake it using a different thermometer.
d. Chart the temperature; it is normal.
Health & Wellness
1. Which of the following is an example of secondary prevention?
a. Routine immunizations
b. Fitness courses
c. Mammograms
d. Rehabilitation therapies for disabled patients
2. Which of the following external variables effects an individuals health belief and practices?
a. Spiritual factors
b. Socioeconomic factors
c. Developmental stage
d. Intellectual background
3. Which individual appears to have “taken on” the sick role?
a. An obese client states, “I deserve to have a heart attack.”
b. A mother is ill and says, “I won’t be able to make your lunch today.”
c. A man with low back pain misses several physical therapy appointments.
d. An elder states, “My horoscope says I will be well again.”
4. A client recently diagnosed with diabetes mellitus is confident that he can control his blood sugar. He
checked out a video on the management of diabetes. The client’s actions are most representative of
which model?
a. Health belief model
b. Clinical model
c. Role performance model
d. Agent-host-environment model
Physical Assessment
1. Which of the following assessment findings would you report to the physician?
a. Hypo-active bowel sounds
b. Normo-active bowel sounds
c. Hyper-active bowel sounds
d. No bowel sounds
e. Hyper-active bowel sounds over the ileocecal valve
2. After auscultating the lungs, the nurse would be concerned with which finding?
a. Bruit over the femoral artery
b. Absence of bowel sounds for 60 seconds
c. Vesicular lung sounds in the peripheries
d. Continuous expiratory wheezing
e. Expiration lasting longer than inspiration
3. If unable to locate the client’s popliteal pulse during a physical examination, what should the prudent
nurse execute next?
a. Check for a pedal pulse.
b. Check for a femoral pulse.
c. Take the client’s blood pressure on that thigh.
d. Ask another nurse to try to locate the pulse.
e. Notify the physician
Stress & Coping
1. After the death of several long-term clients, which action indicates the nurse is demonstrating ineffective
coping?
a. The nurse talks at length to her partner about the deaths.
b. The nurse keeps busy with other actions & doesn’t think about the deaths for several days.
c. The nurse offers to work extra shifts for several weeks.
d. Several nurses schedule a group session with the agency clergy to discuss the deaths.
2. The nurse helps a 50-year-old client with diabetes who is to begin giving insulin injections identify
previously successful coping strategies that may be useful in the current situation. Which stressor is
closely related to the new stressor?
a. Interviewing for a new job
b. Death of a pet while the person was a teenager
c. The person’s partner filing for a divorce
d. Starting to wear eyeglasses at age 30
3. A client who was informed of a cancer diagnosis assures the nurse he is fine. Which of the following is
the most indicative physical evidence to the nurse of the client’s stress?
a. Denies pain
b. Dilated peripheral blood vessels
c. Hyperventilation
d. Decreased heart rate