Situation: One important legal and safe nursing responsibility is concerned with administration of medications.
1. A pediatric client has been diagnosed with conjunctivitis. The nurse is to administer eye drops 4 times a day. The nurse should administer the medication on to which of the following areas?
a. Center of the cornea
b. Sclera by the inner canthus
c. C. Sclera by the outer canthus
d. Lower conjunctival sac
2. While assessing the client’s intravenous (IV) line, the nurse notes that the area is swollen and cool, causing the client discomfort. The nurse suspects which of the following problems:
d. Air embolism
3. The client is receiving a 5% dextrose in 0.45% NaCl intravevenously (IV) and report pain at the site, the nurse assesses the site and notes erythema and edema. What would be the appropriate action for the nurse to take?
a. Slow the infusion rate
b. Discontinue the IV and apply a warm compress to the IV site
c. Apply antibiotic ointment to the IV site
d. Gently pull back the IV access device to reposition it within the vein
4. A patient’s medication order is to take digoxin 0.125 mg p.o. q.i.d. The nurse has on hand Lanoxin 0.25 mg tablet. The best course of action is to:
a. Dispense 1 ½ tab
b. Dispense ½ tab
c. Dispense 2 tablets
d. Return the medication to the pharmacy
5. The patient is ordered 2000 ml of Lactated Ringer’s over 12 hours. The drop factor is 15gtts/ml. The nurse will regulate the IV to how many gtts/min?
a. 28 gtts/min
b. 42 gtts/min
c. 56 gtts/min
d. 14 gtts/min
Situation: The nurse is caring for a group of hospitalized patients.
6. What should the nurse do first to prevent patient infections?
a. Provide small bedside bags to dispose of used tissues
b. Encourage staff to avoid coughing near patients
c. Administer antibiotics as ordered
d. Identify patients at risk
7. The nurse must collect the following specimens. Which specimen collection does not require the use of surgical aseptic technique?
a. Stool for ova and parasites
b. Specimen for a throat culture
c. Urine from a retention catheter
d. Exudate from a wound for culture and sensitivity
8. The nurse identifies that the greatest risk for a wound infection exists for a patient with a:
a. Surgical creation of a colostomy
b. First degree burn on the back
c. Puncture of a foot by a nail
d. Paper cut on the finger
9. The nurse understands that the factor that places a patient at the greatest risk for developing an infection is:
a. Implantation of a prosthetic device
b. Presence of an indwelling catheter
c. Burns more than twenty percent of the body
d. Multiple puncture sites from laparascopic surgery
10. The nurse is caring for a patient with high fever secondary septicemia. When the physician orders a cooling blanket, the nurse understands that it is used to achieved heat loss via:
Situation: The nurse is caring for Mrs. Estrada who has recently diagnosed with advanced cancer.
11. Which statement reflects Kubler-Ross stage of denial in the grief process?
a. “Why this have to happen to me now?”
b. “My daughter will live with my sister after I am gone”
c. “Maybe they mixed up my records with someone else’s”
d. “How could this happen to me when I quit smoking cigarettes?”
12. After the physician has informed Mrs. Estrada that her cancer is inoperable and the prognosis is poor, the patient begins to cry. The nurse should:
a. Touch the patient’s hand to provide support
b. Leave the room to give the patient privacy to cry
c. Telephone the patient’s family to inform them of the diagnosis
d. Ask the patient how she feels to encourage ventilation of feelings
13. Mrs. Estrada became withdrawn and depressed. The nursing action that is most therapeutic is:
a. Assisting the patient to focus on positive thoughts daily
b. Explaining that the patient still accomplish goals
c. Accepting the patient’s behavioral adaptation
d. Offering the patient advice when appropriate
14. Which is the most appropriate inference made by the nurse when a patient says, “I’m the same age as my father when he died. Am I going to die of my cancer?” The patient is experiencing:
a. Grieving associated with perceived impending death
b. Powerlessness associated with feelings of loss of control
c. Fear associated with perceived threat to biological integrity
d. Ineffective coping associated with inadequate psychological resources
15. Mrs. Estrada is now willing to try new therapies. The nurse identifies that the patient is in what stage of Kubler-Ross’ stages of grieving?
Situation: The nurse should be aware of the legal principles associated with nursing practice.
16. Licensure of Registered Professional Nurses is required necessarily to protect:
c. Common law
d. Health care agencies
17. A patient falls while getting out of bed unassisted. When completing and Incident Report, the nurse understands that it main purpose is to:
a. Ensure that all parties have an opportunity to document what happened
b. Help establish who is responsible for the incident
c. Make available data available for quality control analysis
d. Document the incident on the patient’s chart
18. The nurse says. “If you do not let me do this dressing change, I will not let you eat dinner with other residents in the dining room”. This is an example of :
19. An anxious patient repeatedly uses the call bell to get the nurse to come to the room. Finally the nurse says to the patient, “If you keep ringing, there will come a time I won’t answer the bell.”This is an example of:
20. A patient asks the nurse, “What is a Living Will?” the nurse should respond that it is a document that:
a. Instructs a physician to withhold/withdraw life-sustaining procedures if death is near
b. Enables a person to request medication to end life in a humane and dignified manner
c. Gives consent to perform life-sustaining medical intervention during an emergency
d. Wills ones organs to help others who need a transplant to sustain life
Situation: As a nurse you must be responsible for the needs of your client.
21. Ms. R has been medicated for her surgery. The operating room (OR) nurse, when going through the client’s chart, realizes that the consent form has not been signed. Which of the following is the best action for the nurse to take?
a. Assume it is emergency surgery and the consent is implied
b. Give the consent form and have the client sign it
c. Tell the physician that the consent form is not signed
d. Have a family member sign the consent form
22. Ms. R is a client on your medical-surgical unit. His cousin is a physician and wants to see the chart. Which of the following is the best response for the nurse to take?
a. Hand the cousin the client’s chart to review
b. Ask Ms. R to sign an authorization, and have someone review the chart with the cousin
c. Call the attending physician and have the doctor speak with his cousin
d. Tell the cousin that the request cannot be granted
23. Ms. R has had both wrists restrained because she is agitated and pulls out her IV lines. Which of the following would the nurse observe if Ms. R is not suffering any ill effects from the restraints? That:
a. She has difficulty moving her fingers and making a fist
b. Her skin is reddened where the limits were tied around her wrist
c. Ms. R’s capillary refill is less than two seconds
d. The client complains of numbness and tingling in her hand
24. The nurse is in the hospital’s public cafeteria and hears two nursing assistants talking about Ms. R in 406. They are using her name and discussing intimate details about her illness. Which of the following actions is best for the nurse to take?
a. Go over and tell the nursing assistants that their actions are inappropriate, especially in public place
b. Wait and tell the assistants later that they were overheard discussing the client. Otherwise, they might be embarrassed.
c. Tell the nursing assistants’ supervisor about the incident. It is the supervisor’s responsibility to address the issue
d. Say nothing. It is not the nurse’s job and she is not responsible for the assistants’ actions
25. A nurse comes up a motor vehicle accident when driving to work. The nurse administers care to the people involved. Under the Good Samaritan Act, the nurse could be liable:
a. For nothing, any action is covered
b. For gross negligence
c. For not providing the standard care found in the hospital
d. For not stopping and offering care