Practice Tests: Practice Exam #4 - 45 questions

All 45 questions are randomized each time you take the test, and do not appear in the same order here.

 

 

Management of Care

1. The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client

A) has had a change in respiratory rate by an increase of 2 breaths
B) has had a change in heart rate by an increase of 10 beats
C) was minimally responsive to voice and touch
D) has had a blood pressure change by a drop in 8 mmHg systolic

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2. A client tells the nurse, "I have something very important to tell you if you promise not to tell.” The best response by the nurse is

A) "I must document and report any information."
B) "I can’t make such a promise."
C) "That depends on what you tell me."
D) "I must report everything to the treatment team."

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3. The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?

A) Test blood sugar every 2 hours by Accu-Check
B) Review with family and client signs of hyperglycemia
C) Monitor for mental status changes
D) Check skin condition of lower extremities

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4. A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with

A) a Dopamine drip IV with vital signs monitored every 5 minutes
B) a myocardial infarction that is free from pain and dysrhythmias
C) a tracheotomy of 24 hours in some respiratory distress
D) a pacemaker inserted this morning with intermittent capture

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5. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?

A) Be with a client who self-administers insulin
B) Cleanse and dress a small decubitus ulcer
C) Monitor a client's response to passive range of motion exercises
D) Apply and care for a client's rectal pouch

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6. The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client’s condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?

A) Encourage oral fluids to prevent dehydration
B) Recheck temperature 15 minutes after removing hot liquids from the bedside
C) Ask the client to drink only cold water and juices
D) Chart this temperature elevation on the flow sheet

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7. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?

A) To observe the type and amount of nasogastric tube drainage
B) Monitor the client for nausea or other complications
C) Irrigate the nasogastric tube with the ordered irrigant
D) Perform nostril and mouth care

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8. A client asks the nurse to call the police and states: “I need to report that I am being abused by a nurse.” The nurse should first

A) focus on reality orientation to place and person
B) assist with the report of the client’s complaint to the police
C) obtain more details of the client’s claim of abuse
D) document the statement on the client’s chart with a report to the manager

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9. When assessing a client, it is important for the nurse to be informed about cultural issues related to the client’s background because

A) normal patterns of behavior may be labeled as deviant, immoral, or insane
B) the meaning of the client's behavior can be derived from conventional wisdom
C) personal values will guide the interaction between persons from 2 cultures
D) the nurse should rely on her knowledge of different developmental mental stages

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10. The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Assigning which of these tasks to a UAP indicates the student needs further teaching about the delegation process?

A) Assist a client post cerebral vascular accident to ambulate
B) Feed a 2 year-old in balanced skeletal traction
C) Care for a client with discharge orders
D) Collect a sputum specimen for acid fast bacillus

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11. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?

A) Assign an RN to provide total care of the client
B) Assign a nursing assistant to help the client with self-care activities
C) Delegate complete care to an unlicensed assistive personnel
D) Supervise a nursing assistant for skin care

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12. A client continuously calls out to the nursing staff when anyone passes the client’s door and asks them to do something in the room. The best response by the charge nurse would be to

A) keep the client’s room door cracked to minimize the distractions
B) assign 1 of the nursing staff to visit the client regularly
C) reassure the client that 1 staff person will check frequently if the client needs anything
D) arrange for each staff member to go into the client’s room to check on needs every hour on the hour

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13. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states “I don’t think I need those medications. They make me too sleepy and drowsy. 1 insist that you explain their use and side effects.” The nurse should understand that

A) a referral is needed to the psychiatrist who is to provide the client with answers
B) the client has a right to know about the prescribed medications
C) such education is an independent decision of the individual nurse whether or not to teach clients about their medications
D) clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

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14. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the practical nurse (PN)?

A) Test a stool specimen for occult blood
B) Assist with the ambulation of a client with a chest tube system
C) Irrigate and redress a leg wound
D) Admit a client from the emergency room

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15. An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions?

A) "How long have you been a UAP and what units you have worked on?"
B) "What type of care do you give on the surgical unit and what ages of clients?"
C) "What is your comfort level in caring for children and at what ages?"
D) "Have you reviewed the list of expected skills you might need on this unit?"

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16. A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client’s mental status and adjustment. The appropriate response of the nurse should be which of these statements?

A) "I am sorry. Referral information can only be provided by the client’s providers"
B) "I can never give any information out by telephone. How do I know who you are?"
C) "Since this is a referral, I can give you this information"
D) "I need to get the client’s written consent before 1 release any information to you"

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17. A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse’s response should be to

A) ask to not be assigned to this client or to work on another unit
B) tell the client that such behavior is inappropriate
C) inform the client that hospital policy prohibits staff to date clients
D) discuss the boundaries of the therapeutic relationship with the client

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18. Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?

A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand."
B) "If the client is dizzy on standing, ask him to take some deep breaths."
C) "Assist the client to the bathroom at least twice on this shift."
D) "After you assist him to the chair, let me know how he feels."

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19. After working with a client, an unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that demanding client. I just can’t do anything that pleases him. I’m not going in there again." The nurse should respond by saying

A) "He has a lot of problems. You need to have patience with him."
B) "I will talk with him and try to figure out what to do."
C) "He may be scared and taking it out on you. Let's talk to figure out what to do."
D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day."

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20. A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP?

A) A 76-year-old client with severe depression
B) A middle-aged client with an obsessive compulsive disorder
C) An adolescent with dehydration and anorexia
D) A young adult who is a heroin addict in withdrawal with hallucinations

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Delegation


1. Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to help a client ambulate for the first time after a colon resection?

A) "Have the client sit on the side of the bed before helping the client to walk.”
B) "If the client is dizzy ask the client to take some slow, deep breaths."
C) "Help the client to walk in the room as often as the client wishes."
D) "When you help the client to walk, ask if any pain occurs."

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2. The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?

A) Ask the client and family if they are satisfied with the care given
B) Determine if the home health aide's care is consistent with the plan of care
C) Investigate if the home health aide is prompt and stays an appropriate length of time for care
D) Check the documentation of the aide for appropriateness and comprehensiveness

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3. Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?

A) Assess and document skin turgor and color changes
B) Test stool for occult blood and urine for glucose and report results
C) Suggest foods high in iron and those easily consumed
D) Report mental status changes and the degree of mental clarity

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4. The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)?

A) A client with peripheral vascular disease and an ulceration of the lower leg.
B) A pre-operative client awaiting adrenalectomy with a history of asthma
C) An elderly client with hypertension and self-reported non-compliance
D) A new admission with a history of transient ischemic attacks and dizziness

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5. A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate?

A) A client admitted with multiple trauma with a history of a newly implanted pacemaker
B) A new admission with left-sided weakness from a stroke and mild confusion
C) A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial infarction
D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident

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6. The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client’s blood pressure on
the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client’s left arm. Which of these statements is most immediately accurate?

A) The RN has no accountability for this situation
B) The RN did not delegate appropriately
C) The UAP is covered by the RN’s license
D) The UAP is responsible for following instructions

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7. As the RN responsible for a client in isolation, which can be delegated to the practical nurse (PN)?

A) Reinforcement of isolation precautions
B) Assessment of the client's attitude about infection control
C) Evaluation of staffs' compliance with control measures
D) Observation of the client's total environment for risks

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8. A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which staff member should the charge nurse assign the client?

A) Unlicensed assistive personnel (UAP)
B) Senior nursing student
C) PN
D) RN

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9. The charge nurse on a cardiac step-down unit makes assignments for the team consisting of a registered nurse (RN), a practical nurse (PN), and an unlicensed assistive personnel (UAP). Which client should be assigned to the PN?

A) A 49 year-old with new onset atrial fibrillation with a rapid ventricular response
B) A 58 year-old hypertensive with possible angina
C) A 35 year-old scheduled for cardiac catheterization
D) A 65 year-old for discharge after angioplasty and stent placement

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10. The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to?

A) Practical nurse (PN)
B) Registered Nurse (RN)
C) Unlicensed assistive personnel (UAP)
D) Volunteer

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11. Which of these clients would be appropriate to assign to a practical nurse (PN)?

A) A trauma victim with multiple lacerations and requires complex dressings
B) An elderly client with cystitis and an indwelling urethral catheter
C) A confused client whose family complains about the nursing care 2 days after surgery
D) A client admitted for possible transient ischemic attack with unstable neurological signs

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12. Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?

A) Assist with plans for any clients discharged
B) Provide basic hygiene care to all clients on the unit
C) Assess a client after an acute myocardial infarction
D) Gather the vital signs of all clients on the unit

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13. A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?

A) "I will arrange for a conference with you and the UAP within the next week"
B) "I can assure you that I will look into the matter"
C) "I would like for you to approach the UAP about the problem the next time it occurs"
D) I will add this concern to the agenda for the next unit meeting

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14. A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)?

A) Teach the client how to cough up secretions
B) Changes the tracheostomy trach ties
C) Monitor if client has shortness of breath
D) Perform routine tracheostomy dressing care

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15. An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse?

A) A newly diagnosed client with type 2 diabetes mellitus who is learning foot care
B) A client from a motor vehicle accident with an external fixation device on the leg
C) A client admitted for a barium swallow after a transient ischemic attack
D) A newly admitted client with a diagnosis of pancreatic cancer

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16. The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate?

A) "Tell the family they can bring in a pizza if the patient would prefer that."
B) "Make sure the patient gets at least 2 cartons of milk."
C) "Stop the IV if the patient is able to eat solid food."
D) "Encourage the patient to eat slowly to prevent gas."

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17. Which one of these tasks can be safely delegated to a practical nurse (PN)?

A) Assess the function of a newly created ileostomy
B) Care for a client with a recent complicated double barrel colostomy
C) Provide stoma care for a client with a well functioning ostomy
D) Teach ostomy care to a client and their family members

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18. An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions?

A) "How long have you been a UAP?”
B) "What type of care did you give in pediatrics?”
C) "Do you have your competency checklist that we can review?”
D) "How comfortable are you to care for adult clients?”

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19. During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?

A) "What degree of supervision for basic care do you think you need?"
B) "Let’s review your skills check-list for type and level of skill"
C) "Are you comfortable working independently?"
D) "What client care tasks or assignments do you prefer?"

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20. A charge nurse working in a long term care facility is making out assignments. Which assignment made by a registered nurse to an unlicensed assistive personnel (UAP) requires intervention by the supervisor?

A) Provide decubitus ulcer care and apply a dry dressing
B) Bathe and feed a client on bed rest
C) Oral suctioning of an unresponsive elderly client
D) Teaching a family intermittent (bolus) feedings via G-tube before discharge

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21. Which of these clients would be most appropriate to assign to a practical nurse (PN)?

A) A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection
B) A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia
C) A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation
D) A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure
C: A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation

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22. The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?

A) Report signs of redness overlying a joint
B) Monitor the client’s response to ambulatory activity
C) Encouragement for the independence in self-care
D) Assist the client to transfer from a bed to a chair

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23. When walking past a client’s room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?

A) "If we work together we can get all of the client care completed."
B) "Since 1 am late for lunch, would you do this one client's glucose test?"
C) "This client seems confused, we need to watch monitor closely."
D) "I’ll come back and make the bed after I go to the lab."

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24. A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)?

A) Ask the client the degree of relief and document the client’s response
B) Decrease the set rate on the pump by 2 ml/minute
C) Check the IV site for drainage and loose tape
D) Assist the client with ambulation and a gown change with supervision

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25. Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items?

A) "The client has complaints of not sleeping well for the past week"
B) "The family wants to discontinue the home meal service, meals on wheels"
C) "The urine in the urinary catheter bag is of a deeper amber, almost brown color"
D) "The partner says the client has slower days every other day"

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Practice Tests: Practice Exam #4 - 45 questions