1. A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse
recommend for treatment first?
a. A client who has a neck injury and is unable to breathe spontaneously
b. A client who has two open chest wounds with a left tracheal deviation
c. A client who has major burns over 75% of her body surface area
d. A client who has bipolar disorder and is exhibiting signs of hallucination (Class 3)
2. A client is brought to the emergency department following a motor-vehicle crash. Drug use is suspected in
the crash, and a voided urine specimen is ordered. The client repeatedly refuses to provide the specimen.
Which of the following is the appropriate action by the nurse?
a. Tell the client that a catheter will be inserted.
b. Document the client’s refusal in the chart.
c. Assess the client for urinary retention.
d. Obtain a provider’s prescription for a blood alcohol level.
3. A nurse is making shift assignments in a hospital. Which of the following tasks is appropriate to assign to a
licensed practical nurse?
a. Pick up the meal trays after lunch.
b. Administer a nasogastric tube feeding.
c. Plan break times for assistive personnel.
d. Determine adequacy of ventilator settings.
4. A nurse preceptor is evaluating a newly licensed nurse’s competency in assisting with a sterile procedure.
Which of the following actions indicates the newly licensed nurse is maintaining sterile technique? (SATA)
a. Places sterile items within a 1.25 cm (0.5 in) border around the edges of the sterile field
b. Opens the sterile pack by first unfolding the top flap away from her body
c. Prepares a container of sterile solution on the field after putting on sterile gloves
d. Removes the outside packaging of a sterile instrument before dropping it onto the sterile
field
e. Holds the sterile solution bottle with the label facing up
5. A nurse enters a client’s room and identifies that the client is receiving too much IV fluid because the IV
pump is not working properly. Which of the following actions should the nurse take first?
a. Auscultate the client’s lungs.
b. Notify the provider.
c. Place a faulty equipment tag on the pump.
d. Complete an incident report.
6. A nurse is planning care for a group of clients and can delegate care to a licensed practical nurse (LPN) and
an assistive personnel. Which of the following tasks should the nurse assign to the LPN?
a. Reinforcing teaching with a client who is learning to self-administer insulin
b. Ambulating a client who is scheduled for discharge later in the day
c. Administering morphine IV bolus to a client who is hr postoperative
d. Admitting a new client who has chronic back pain to the unit
7. A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile
gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic
technique?
a. The nurse applies goggles.
b. The nurse turns her back to the sterile field.
c. The nurse holds her hands above her waist.
d. The nurse puts on a face mask.
8. A nurse who is caring for a group of clients delegates collection of vital signs to an assistive personnel
(AP). Which of the following actions should the nurse take to evaluate the delegated task?
a. Review vital sign trends at the end of the shift.
b. Recheck vital signs that are outside the expected reference range.
c. Ask the AP to write a summary of the delegated tasks during the shift.
d. Compare the vital signs the AP obtained with those taken by another AP on a previous shift.
9. A nurse is caring for four clients. Which of the following tasks can be delegated to an assistive personnel?
a. Obtaining a stool sample from a client who has renal failure
b. Monitoring a client who has a fluid restriction
c. Assessing a client who just returned from hemodialysis
d. Reviewing dietary instructions for a client who has kidney stones
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