1 . The nurse is establishing a therapeutic nurse-client relationship.

In
what order will the nurse progress through initiating and ending the
therapeutic relationship?
A. Termination phase
B. Working phase
C. Preinteraction phase
D. Conclusion of relationship
E. Orientation phase

ANSWER: C, E, B, A, D

C. Preinteraction phase is the first phase, before the nurse meets the client. In the phase the nurse
gathers information about the client.

E. Orientation phase is next. Introductions are made during an initial meeting, the relationship is
defined, and the purpose of the visit is established.

B. The working phase occurs next, which is the active part of the relationship in which techniques of
therapeutic communication are used to discuss the issues of importance.

A. Termination phase. After the working phase is completed, the termination phase begins, and the
relationship is reviewed and summarized.

D. Conclusion of relationship is the final phase in which the relationship with the client comes to an end.

2. While collecting information from the 16-year-old who is in the first

trimester of pregnancy, the nurse learns that the client drinks four to six
alcoholic beverages three to four times a week. Based on the client’s
current developmental stage, what should be the nurse’s initial focus of
care?
A. Establish a trusting relationship with the client
B. Educate the client about the risk for developing fetal alcohol syndrome (FAS)
C. Inform the client about the personal health risks of continuing with excessive drinking
D. Seek clarification about her home life and the friends with whom she spends time

ANSWER: A

A. The nurse should first establish a trusting relationship with the client to be able to counsel the
client about the effects of alcohol on the developing fetus and the client’s health. According to
Erikson’s theory of development, adolescents are very egocentric, and peers are a strong
 influence. Because it is very important to be a part of a group, many will do whatever is
necessary, believing that “nothing bad will ever happen” to them.
B. Teaching about FAS is premature; the client may not be ready to hear the information. The
nurse first needs to establish a trusting relationship.
C. The nurse must first establish a trusting relationship. The short-term effects of drinking with
friends may far outweigh concerns about the physiological effects of alcohol.
D. Only with a trusting relationship will the nurse be able to gather more information about the
client’s home life and friends.

3. When the nurse is completing the history of the 16-year-old client at a

clinic, the client says, “I think that I might be pregnant.” What is the
nurse’s best response?
A. “How long have you been sexually active?”
B. “Why do you think you are pregnant?”
C. “Who have you spoken to about this?”
D. “When was your last menstrual cycle?”

ANSWER: D

A. Although determining sexual activity of a teenager is important for client teaching, the nurse’s
best response should be obtaining information pertaining to the pregnancy.
B. Asking a “why” question may make the client defensive.
C. This is an acceptable question, but the nurse needs to begin with the facts.
D. A direct question related to the client’s menstrual cycle is best and is necessary prior to
obtaining other information.

4. The nurse is to obtain a medical history for the client who has a
tracheostomy. The client’s spouse states that the client does not use a
speaking valve. Which actions should be taken by the nurse to
communicate with the client? Select all that apply.
A. Make eye contact and speak to the client directly.
B. Ask only the spouse for information about the client.
C. Provide the client with a writing board and pen.
D. Place a speaking valve over the client’s tracheostomy.
E. Assess the client’s preferred communication method.
F. Ask the client only “yes” and “no” questions.

ANSWER: A, C, E
 A. Making eye contact and speaking to the client directly convey an interest in the client
and are essential to facilitate communication.
B. Asking only the spouse information excludes the client from the conversation and does
not facilitate trust between the nurse and client.
C. Supplying the client with a writing board allows the client to answer and ask questions
about care.
D. Placing a speaking valve over the tracheostomy should not occur until the client has
been assessed for the ability to tolerate cuff deflation Without aspiration or respiratory
distress.
E. Assessing the client’s preferred communication method allows the client to participate
in care and shows that the client’s needs are valued.
F. Asking the client only “yes” and “no” questions does not allow the client to provide any
descriptions, can be frustrating for the client, and does not allow the client to ask any
questions.

5. The nurse is having a conversation with the client who is beginning

hemodialysis. How many different therapeutic communication
techniques does the nurse use in conversing with the client?
 A. One technique
B. Two techniques
C. Three techniques
D. Four techniques

ANSWER: D

A. There is more than one therapeutic communication technique being used by the nurse.
B. There are more than two therapeutic communication techniques being used by the
nurse.
C. There are more than three therapeutic communication techniques being used by the
nurse.
 D. There are four therapeutic communication techniques being used by the nurse. In
interaction 1, the nurse uses a broad opening. In interaction 2, the nurse is asking for
clarification. In interaction 3, the nurse is reflecting. In interaction 5, the nurse is using
silence to allow time to think about what to say next or to allow the client to further
express concerns. The nurse uses nontherapeutic techniques in the remaining
interaction. In interaction 4, the nurse is “parroting.” If it were restating, the nurse
would paraphrase the message back to the client. ln interaction 6, the nurse is advising.
In interaction 7, the nurse is belittling the client’s feelings by telling the client not to
worry.

6. The 94-year-old client, who has been on chronic hemodialysis for 8

years, states to the dialysis nurse upon arrival, “I no longer want to
continue dialysis. I have had a good life, and now I am ready to let go-”
Which intervention by the nurse is best?
A. Dialysis should be started as scheduled; address the concern later.
B. Obtain a psychiatric consult regarding suicidal ideations.
C. Restate to the client, “You no longer want to continue dialysis?”
D. Ask the client, “Why do you want to stop dialysis?”

ANSWER: C

A. Starting dialysis without first addressing the concern ignores the client’s feelings and
violates the client’s Wishes regarding care. Time needs to be allowed for communication
to take place to provide a therapeutic nurse-client relationship.
B. Obtaining a psychiatric consult regarding suicidal ideations is inappropriate as the client
is preparing for death, which would be appropriate at the client’s current
developmental stage.
C. Restating the comment regarding discontinuing dialysis relays concern and active
listening to the client. This is the best response to facilitate further communication.
D. Asking the client “Why” questions suggests criticism of the client’s decision; the client
may become defensive and withdrawn.

7. The clinic nurse is caring for four clients. Which interaction

demonstrates the use of the communication technique of reflection?
A. Child: “Don’t turn out the light. I don’t like the dark.” Nurse: “1 will have your mommy
hold you while I turn out the light to check your eye."
B. Adolescent: “My mom won’t let me pierce my tongue.” Nurse: “What would it be like to
have a pierced tongue?”
C. Adult: “My blood sugar was really out of control yesterday.” Nurse: “Was your blood
sugar high or low yesterday?”
 D. Older Adult: “My life means nothing anymore.” Nurse: “Socializing more allows you to
reflect back on good times and will help you feel better about your life.”

ANSWER: B

A. Option 1 is presenting reality but offering support to the child to boost confidence in
handling the dark
B. When using reflection as a communication technique, the nurse selects one or two of
the client’s words to reflect back to the client for consideration. This technique
strengthens client confidence.
C. Option 3 seeks clarification.
D. Option 4 demonstrates advising, a nontherapeutic communication technique.

8. The nurse is completing the final visit with the client being discharged
from home-care services. Each time that the nurse attempts to leave, the
client otters a new subject and attempts to delay the nurse’s departure
Which is the best action by the nurse?
A. Abruptly tell the client that the session has ended and that the nurse must leave.
B. Set up another appointment for an additional home-care visit.
C. Plan to meet the client for coffee at a time that the client would like.
D. Be finn and clear about the relationship tenninating and seek feedback from the client.

ANSWER: D

A. Abruptly telling the client that the session has ended does not leave room for feedback
from the client and may also leave the client with negative feelings about the
interaction. The client may feel as though he or she did or said something wrong to
cause the nurse to leave abruptly.
B. Setting up an additional home-care visit only pro- longs the termination phase and may
allow the client to become manipulating.
C. Planning to meet the client for a social visit is inappropriate and may violate
professional and ethical codes of conduct.
D. Being firm and clear about the termination of the relationship maintains professional
boundaries, while soliciting feedback helps the client maintain a positive attitude about
the interaction.

9. An adult daughter is sitting at the bedside of her mother, a devout

Baptist, who developed a serious postoperative infection. Which
statement by the nurse to the daughter demonstrates empathy?
A. “I know how you feel. We also prayed at my grandmother’s bedside when she was sick.”
 B. “You’ve been here a long time and look exhausted. Tell me how things are going for
you.”
C. “You might as well go home because your mother is sleepy. Maybe tomorrow will go
better.”
D. “The new antibiotic was started this morning- We will pray that your mother gets well.”

ANSWER: B

A. This statement focuses on the nurse’s feelings, not the daughter’s.

B. The statement focuses on the daughter’s feelings and demonstrates the nurse’s
concern.
C. This statement reinforces the powerlessness of the daughter in the situation and blocks
therapeutic communication.
D. This response offers information and hope, but not empathy.

10. The nurse is setting up supplies to complete a dressing change at

2000 hours on the client’s stump following a right leg BKA. The client
looks away and angrily says, “I don’t want to look at that thing. Can’t you
come back later?” Which is the nurse’s best action?
A. Put the supplies away and reattempt the dressing change in 1 hour.
B. Complete the dressing change because it is pre- scribed for 2000.
C. Ask the client, “Why don’t you want your dressing changed now?”
D. Restate, “You don’t want to look at your leg?” and allow time for a response.

ANSWER: D

A. Putting the supplies away and reattempting in 1 hour avoids discussing the client’s
feelings about the amputation when the client is clearly upset and the opportunity is
there for establishing a relationship.
B. Completing the dressing change despite the client’s request, because it is prescribed for
2000, takes the control away from the client and violates any trust between the nurse
and client.
C. Asking the client a question can be interrogating and does not address the client’s
feelings about the amputation.
D. Restating provides an opportunity for the client to clarify further and encourages
discussion of the client’s feelings about having an amputation.
11 . The nurse and the client are engaged in a conversation. Which
statement made by the nurse best encourages therapeutic
communication?

A. Response 1
B. Response 2
C. Response 3
D. Response 4

ANSWER: C

A. Asking the client “why” questions belittles the client’s feelings and may cause the client
to withdraw from the interaction.
B. Response 2 is an example of restating and clarifying the client’s response, but it does
not further stimulate conversation. Asking the client a “yes/no” question, as in response
2, ends the conversation and does not allow for further opportunity to build a
relationship.
 C. Response 3 uses therapeutic communication techniques of sharing observations and
using an open-ended statement. The statement allows the client to elaborate further
about the client’s feelings and fears while building a trusting nurse-client relationship.
D. Response 4 is an example of restatement. While the statement allows the client to
further elaborate and is therapeutic, response 3 is the best statement because it uses
two therapeutic communication techniques, whereas response 4 uses one.

12. The nurse is caring for the client with Alzheimer’s disease who is
yelling Obscenities at the staff. The client’s spouse tearfully states to the
nurse, “Never would you have heard those things before the Alzheimer’s.
I wish that you would have known my spouse before the sickness.”
Which is the best response by the nurse?
A. “Why do you think that your spouse is acting like this?”
B. “How long has your spouse had Alzheimer’s disease?”
C. “I can see that it is difficult for you to see your spouse like this.”
D. “Tell me about the things your spouse did before the Alzheimer’s was diagnosed.”

ANSWER: C

A. Asking the “why” questions may suggest criticism of the client’s actions, and the spouse
may become defensive.
B. Asking “How long has your spouse had Alzheimer’s disease?” is a closed—ended
question.
C. Response 3 is a statement that uses the therapeutic technique of sharing observations.
This statement validates the spouse’s feelings and allows the client to elaborate further.
D. The statement “Tell me about the things your spouse did before being diagnosed with
Alzheimer’s disease” is inappropriate at this time because the spouse is crying, and
these emotions should be addressed first.

13. After falling at home, the 84-year-old client is brought to the ED by

the client’s adult child. Upon assessing the client, the nurse discovers
that the client is aphasic and unable to answer any of the nurse’s
questions. Which intervention should be taken by the nurse initially?
A. Ask the client to nod his or her head “yes” or “no” to questions
B. Consult a speech therapist
C. Give the client a writing board
D. Direct questions to the client’s adult child

ANSWER: A
 A. Asking the client to nod his or her head “yes” or “no” to questions is the best initial
intervention to assess further if the aphasia is expressive (Broca’s aphasia) or also
receptive (Wcrrricke’s aphasia). If the client is able to communicate by head nodding,
the nurse should continue to include the client in the plan of care and preserve any
communication ability that the client retains to prevent the client from becoming
withdrawn.
B. Consulting a speech therapist may be helpful at a later stage, but this is not the best
initial intervention.
C. Giving the client a writing board may only discourage the client, as written deficits
usually parallel speech deficits in clients with Broca’s aphasia.
D. Directing questions to the client’s adult child excludes the client from the conversation
and forces the client to become withdrawn.

14. The newly hospitalized 90-year-old client has difficulty answering

the nurse’s questions and reports progressive hearing loss. Which
nursing action would best aid in communication between the nurse and
client?
A. Overexaggerating facial expressions
B. Using simple sentences
C. Overenunciating longer words
D. Speaking quickly in a higher-pitched voice

ANSWER: B

A. Overexaggerating should be avoided because it will not increase the client’s ability to
hear and may be insulting to the client.
B. Using simple sentences will assist in communicating with the client. There will be fewer
words to decipher and less room for error in interpreting the meaning of the sentences.
C. Overenunciating should be avoided because this will not increase the client’s ability to
hear and may be insulting to the client.
D. Speaking quickly, in a higher-pitched voice, should be avoided because often older adult
clients with presbycusis lose the ability to hear higher-pitched sounds first and are able
to hear lower-pitched sounds better when they are spoken slowly.

15. The nurse is leading a team to develop an evidence-based practice

guideline for preventing skin breakdown in the hospitalized client. To
fully use the databases available to the nurse, which should be the
nurse’s first step in the process for developing the guidelines?
A. Critically appraise the resources for their use in clinical decision making
 B. Formulate the issue into a searchable, answerable question
C. Critically appraise the quantitative and qualitative evidence
D. Determine the model and strategies for the evidence-based practice

ANSWER: B

A. Critically appraising the resource is the second step in the process of looking for
evidence-based research.
B. The formulation of a well-built question will help determine the resources to access for
the best available evidence.
C. Once the research methods have been identified, there should be criteria and a process
in which to evaluate the quantitative and qualitative evidence. This is the third step.
D. Evidence—based practice is the utilization of research knowledge that takes into
consideration factors such as best evidence from a thorough search and critical
appraisal of the research, context, health care resources, practitioner skills, client status
and circumstance, and client references and values. But, this is the fourth step in the
process.

16. The new nurse is told by experienced unit nurses that the nurse
manager is an empowering manager. Which statements made by the
nurse manager should lead the new nurse to agree with the experienced
nurses’ opinions? Select all that apply.
A. “You hardly ever complete your documentation during work hours. I’ll have the charge
nurse work on making better assignments for you.”
B. “The team worked well together on the pain documentation project. Through your
efforts, there were improvements in client satisfaction scores for pain control on client
surveys.”
C. “Today you were timely in your clients’ care, but most days you stay overtime to
complete documentation. Is there something we can do to help you complete all duties
within the scheduled work time?”
D. “The charge nurse told me that you didn’t complete some of your client care today.
What was the problem?”
E. “We are at peak census. For the next shift, I need one more nurse than usual. Our
options include a volunteer, calling in an off-duty staff, or mandating someone. Is there
a volunteer?”
F. “I’ve arranged for a new staffing schedule because no one working part—time will
volunteer for extra shifts and administration won’t allow me to pay nurses overtime
anymore.”

ANSWER: B, C, E

A. This statement uses a variation of “you didn’t,” which is not empowering the nurses.
 B. This statement is empowering because the nurse manager’s statements indicate
personal ownership of beliefs, values, and needs while communicating expectations
about values and goals. The nurse manager uses a variation of “I want” or “I need”
rather than “you must” or “you didn’t.”
C. This statement is empowering because the nurse manager’s statements indicate
personal ownership of beliefs, values, and needs while communicating expectations
about values and goals. The nurse manager uses a variation of “I want” or “I need”
rather than “you must” or “you didn’t.”
D. This statement uses a variation of “you didn’t,” which is not empowering the nurses.
E. This statement is empowering because the nurse manager’s statements indicate
personal ownership of beliefs, values, and needs while communicating expectations
about values and goals. The nurse manager uses a variation of “I want” or “I need”
rather than “you must” or “you didn’t.”
F. This statement uses a variation of “you didn’t,” which is not empowering the nurses.

17. The RN is discharged for jeopardizing client safety by consistently

failing to notify the HCP of changes in clients’ health status. Which
statement by the nurse manager is most appropriate when another
health care facility telephones for a reference check on the RN?
A. “The RN resigned due to safety concerns such as failure to notify the provider when the
health status of clients changed.”
B. “The RN is uncomfortable communicating with providers. Otherwise, the nurse’s work
meets standards of care.”
C. “I need to consult with the hospital attorney to determine if any information can be
provided about a nurse previously employed here.”
D. “The nurse worked at this facility on the telemetry unit but was discharged after 2 years
of employment-”

ANSWER: D

A. Option 1 is incorrect information. The RN was discharged.

B. Option 2 suggests that the employee’s failure to notify is related to discomfort with
communication, which could be an incorrect conclusion.
C. Option 3 is inappropriate. The nurse manager should know the policies of the agency.
D. Only factual information should be provided. The former employee has not consented
to provide additional information.
18. The nurse is providing a change-of—shift report to the oncoming
shift nurse for the client. Besides the client’s name and room number,
which information should the nurse include in a typical shift report?
Select all that apply.
A. Briefmedical history of the client’s current problem
B. Client’s satisfaction with the nursing care provided
C. Client-family dynamics and client psychosocial concerns
D. Surgery, tests, or procedures for the next 24 hours
E. The status of tubes and intravenous (IV) infusions
F. The telephone number of the nurse giving report if questions arise

ANSWER: A, C, D, E

A. A brief medical history of the client’s current problem should be provided at the shift
report so the oncoming shift nurse can provide focused care.
B. A typical end-of-shift report does not include the client’s satisfaction with the nurse’s
care. This information is unnecessary to providing quality care and meeting the client’s
needs.
C. Client-family dynamics and client psychosocial concerns are important to include
because family is part of the client’s support system.
D. Surgery, tests, or procedures scheduled for the next 24 hours should be included in the
report so the nurse can teach and prepare the client for these.
E. Tube and equipment status, including IVS, should be reported so that the nurse can
determine priorities.
F. A typical end—of-shift report does not include the telephone number of the nurse
giving report. If the report is complete, there should be no reason to consult the nurse
whose shift has ended.

19. The nurse is notifying the HCP of the client’s change in status using
the SBAR format. In which order should the nurse place the statements?
A. “I suggest that the client be transferred to the critical care unit, and I would like you to
come evaluate the client.”
B. “The client is deteriorating, and I’m afraid the client is going to arrest.”
C. “I am calling about {client name and location}. Vital signs are BP=100/50, P=120, RR=30,
T=100.4°F (38°C).”
D. “The client is becoming confused and agitated. The skin is pale, mottled, and
diaphoretic. The client is very dyspneic with an oxygen saturation of 85% despite placing
a nonrebreather mask.”

ANSWER: C, D, B, A
C. “I am calling about {client name and location}. Vital signs are BP=100I50, P=120, RR=30, T=100.4°F
(38°C)” describes the situation and what is happening at the present time. This represents the S of SBAR.

D. “The client is becoming confused and agitated. The skin is pale, mottled, and diaphoretic. The client is
very dyspneic with an oxygen saturation of 85% despite placing a nonrebreather mask” describes the
background of what has occurred leading 11p to the situation. This represents the B of SBAR.

B. “The client is deteriorating, and I’m afraid the client is going to arrest” is an assessment of the primary
problem and represents the A of SBAR.

A. “I suggest that the client be transferred to the critical care unit, and I would like you to come evaluate
the client” describes the recommendations for correcting the problem, which is the R of SBAR.

20. The client is scheduled for an MRI scan. Which is most important for
the nurse to include prior to the client’s MRI scan?
A. SBAR-format report to the receiving unit
B. Accurate documentation of the client’s vital signs
C. Accurate documentation of the client’s intake and output
D. Inclusion ofa discharge planning report

ANSWER: A

A. For the safety of the client and continuity of care, the nurse should communicate with
the receiving department (radiology) using the SBAR-formatted report (situation,
background, assessment, and recommendation). SBAR is a standardized, widely adopted
reporting format.
B. Vital signs, if pertinent, should be included in the SBAR report.
C. 1&0 or fluid status, if pertinent, should be included in the SBAR report.
D. Because the client is not being discharged, this information is not pertinent to the
radiology department.

21 . A hospital implemented computerized provider order entry (CPOE).

Which additional task related to CPOE is required for the nurse to
provide safe care?
A. Checking the computer periodically for new orders
B. Checking the computer every hour for medications due
C. The HCP telephoning the nurse about the new computer orders
D. Documenting blood sugars in the computer for HCP viewing

ANSWER: A
 A. With CPOE, the HCP can enter orders from any location, and the nurse must check for
these periodically (usually every half hour).
B. The nurse may check the computer at the beginning of the shill and note the
medications due during the shift; this does not require hourly checking.
C. When new orders are placed in the computer, it is the responsibility of the nurse to
check the computer for the new orders. Usually the HCP does not telephone the nurse
about these unless it is a STAT order.
D. Documentation of blood sugars is unrelated to checking for new orders.

22. The experienced nurse is reviewing a new nurse’s documentation in

the client’s EMR. Which abbreviation should be corrected by the new
nurse because it appears on The Joint Commission’s published list of “Do
Not Use” abbreviations? Place an X on the abbreviation that should be
corrected.
M.S. should be corrected. It appears on the The Joint Commission’s published list of “Do Not Use”
abbreviations. M.S. could mean either morphine sulfate or magnesium sulfate.

23. The nurse hears a thud and, upon entering a room, finds the client on
the floor beside a wheel- chair. Which notations are most appropriate
for the nurse to make in the client’s EMR regarding the incident? Select
all that apply.
A. The client stated, “I was trying to reach for my water and fell from the wheelchair.”
B. The client refirsed to lock the wheelchair when told to do so.
C. A loud noise was heard from the client’s room, and the client was found on the floor.
D. The client stated, “Nothing hurts. I don’t think I have any injuries.”
E. An incident report has been completed and filed; a copy is in the client’s chart.

ANSWER: A, C, D

A. The documentation should be factual and objective. Quoting the client’s statements of
how the fan happened is appropriate.
 B. This notation lays blame on the client. If prior to the fall the nurse had repeatedly
instructed the client to leave the wheelchair locked, and the nurse found the wheelchair
in the unlocked position, a notation as to the observations and interventions would be
appropriate. But the notation must be in a nonaccusatory manner and not as a result of
the incident.
C. This is a factual statement based on what the nurse observed.
D. The nurse’s assessment and client’s statements may be placed in the medical record.
E. An incident report should be completed. However, stating it has been completed is
never documented in the medical record because it then becomes discoverable
evidence if litigation ensues.

24. The new nurse is working in an agency that uses only narrative
documentation. Which entries made by the new nurse in multiple
clients’ medical records would earn praise from the charge nurse? Select
all that apply.
A. “Client being difficult, refusing suggestions for improving appetite.”
B. “Alert, oriented x3, responds to verbal stimuli. See assessment flowsheet.”
C. “Furosemide 40 mg IV given over 4 minutes through NS maintenance infusion.”
D. “On commode to void after first attempting to use the bedpan.”
E. “Client up, out of bed, walked down hallway with Assistance, tolerated well.”

ANSWER: B, C

A. Documentation should include objective data unless directly quoted from the client.
B. Specific information was included in the documentation.
C. The documentation is specific and detailed identifying the medication, dose, route, and
administration rate.
D. Documentation is incomplete; does not indicate whether or not the client was able to
void.
E. Document incomplete and does not describe the distance ambulated. The phrase
“tolerated well” is vague and does not describe what the nurse had been observing to
make this determination.

25. At 1000, the client states, “I can’t get enough air,” and the nurse
assesses fine crackles in the client’s bilateral lung bases. At 1010 the
nurse increases the client’s oxygen from 2 liters per nasal cannula (NC)
to 4 liters per protocol. Which is the most appropriate nursing
documentation?
 A. 1010: Increased oxygen to 4 L/NC.
B. 1010: Client dyspneic. Lung sounds bilat crackles in bases. Incr. 02 to 4LfNC per protocol.
C. 1000: Client dyspneic. Left message for health care provider to return call; will wait for
orders.
D. 1020: Client dyspneic. Oxygen to 4L/rnask. 02 saturation improved, and client denies
dyspnea.

ANSWER: B

A. This is incomplete documentation of the events; there is no reason provided for the
increase of oxygen administration.
B. The documentation is complete and reflects that the nurse identified the problem
(client reports), sought a solution (reviewed protocol), and implemented the solution to
the problem (action taken).
C. The nurse did not document any action taken with the client. The nurse should have
checked the orders and intervened accordingly. This would be viewed as a failure to
rescue.
D. There is no indication that oxygen was administered via mask or that the oxygen
saturation was improved.

26. The hospitalized infant had five wet diapers during an 8-hour period
that weighed 22 g, 24 g, 38 g, 34 g, and 21 g. The weight of a dry diaper is
15 g. What amount in milliliters (mL) should the nurse document for the
infant’s total urine output for the 8 hours?

___________ mL (Record your answer as a whole number.)

ANSWER: 74

First, add the five wet diaper weights: 22 + 24 + 38 + 34+ 21 = 139. Next determine the weight of 5 dry
diapers (15 g X 5 = 75). Next, subtract the weight of the 5 dry diapers from the weight of the wet diapers
to determine the urine output (139 — 75 = 64). Finally, convert grams to milliliters. One milliliter of
urine output equals 1 g of body weight. Thus, 64 g equals 64 mL of urine output.

27. The adult client is being transferred from a hospital to a

rehabilitation facility. Which information should the nurse include in the
transfer note documentation? Select all that apply.
 A. Reason for the transfer
B. Name of person receiving a verbal report
C. Condition of the client
D. Medication and food allergies
E. Client’s ability to pay for expenses

ANSWER: A, B, C, D

A. The reason for the transfer is needed to provide continuity of the client’s care and to
protect the client from injury.
B. Verbal report should be given to the transferring facility, and the name of the person
receiving the report should be documented for legal protection of both nurses and for
follow-up if needed.
C. The condition of the client is important so that the receiving nurse can anticipate the
type of care the client will need and any immediate needs.
D. Medication, food, and environmental allergies Should be included in the transfer note to
protect the client from injury.
E. Insurance information is included in records that are prepared for transfer, but not the
financial status or client’s ability to pay for expenses. If a social worker has been
assigned for follow-up due to financial concerns, this should be noted in the transfer
note.

28. The nurse manager learns that the LPN employed by the agency
documented and signed the client’s EMR with the nurse’s name and
credentials of LPN when the LPN was providing care as a student in an RN
program. Based on this information, which action should be taken by the
nurse manager?
A. Report the incident to the student’s clinical instructor and request that the clinical
instructor assist the LPN in correcting the documentation
B. Discuss the incident with the LPN and advise the LPN to leave the medical record
untouched because it is a legal document
C. Advise the LPN to delete the incorrect entry and use the registered student nurse log-in
ID to reenter the information
D. Make a notation in the client’s medical record that the LPN was functioning in the
registered nurse student role

ANSWER: A

A. While in the student nurse role, the LPN is not considered an employee of the agency.
The nurse manager should inform the clinical instructor who is responsible for clinical
supervision.
B. The nurse’s credentials are in error on the day of care. A notation and correction should
be made in the client’s medical record.
 C. Although the LPN should be instructed to make a correction entry, the person discussing
the incident with the LPN should be the clinical instructor.
D. The nurse manager should not make a notation in the client’s medical record but should
ensure that an incident (unusual occurrence) report is completed by the nurse who
found the documentation error.

29. The new nurse is being oriented to the EMR on a nursing unit. Which
points should be included in the new nurse’s orientation session? Select
all that apply.
A. Any entries into the computer will be credited to the person who is logged in to the
computer.
B. Leaving a computer without first logging off can be a breach of client confidentiality.
C. For the experienced EMR user, the EMR enhances time efficiency and accuracy of data.
D. An incorrect entry can be opened and edited, thus keeping the original date and time.
E. Most agencies using EMR incorporate a system for tracking computer printouts.

ANSWER: A, B, C, E

A. The log-in access includes an electronic signature with the name of the person to whom
the log-in access is assigned.
B. Information displayed on the monitor can be viewed by others. This may lead to a
breach in client confidentiality.
C. Studies have shown that EMR enhances time efficiency, direct client care time, user
satisfaction, accuracy of data, and completeness of the medical record.
D. If a correction is made in an incorrect entry, the current date and time are entered. An
incorrect entry should be corrected by making a new entry. The date of the entry will be
the log-in date at the time of the correction entry.
E. Both computer printouts and log-ins are tracked by most agencies. Computer printouts
are tracked to prevent indiscriminate duplication or distribution.

30. The experienced nurse is orienting the new nurse to essential

documentation when caring for clients through a home health care
agency. Which statement should be made by the experienced nurse
regarding home health documentation?
A. “During each visit, an assessment is performed and then documented similarly to
hospital documentation.”
B. “Your documentation must show the need for professional medical services.”
C. “Reimbursements for visits are directly related to the accuracy and wording of
documentation.”
 D. “The assistance you provide with activities of daily living (ADLs) can be documented on a
flowsheet.”

ANSWER: C

A. This statement is very broad. Only a focused physical assessment may be completed
during a home care visit, and documentation usually will not include a complete physical
assessment. Assessment of the home environment may be included if it impacts the
client’s ability to care for himself or herself.
B. Nurses justify the need for nursing, not medical services.
C. With each visit, the need for a professional nurse must be noted. Reimbursement for a
visit is directly related to the documentation showing a need for professional assistance.
D. The professional nurse would not be performing ADLs during a visit. These are
completed by a home health aide.

31 . The nurse makes an error by documenting the wrong VS in the

client’s written medical record. Which action would be best to correct
the error?
A. Draw a line through the error, initial and date the line, and then document a corrected
entry.
B. Circle the incorrect entry, write “error” above the entry, and then date and initial the
entry.
C. Highlight the error in yellow, write the correct VS on the line, and date and initial the
line.
D. Cover the incorrect VS with the correct VS in such a manner that these are clearly
readable.

ANSWER: A

A. Common agency policy includes drawing a single line through the error, adding the date,
and then initialing the entry. Writing “void” in the space above the entry is sometimes
included in agency policy. The vital signs should be documented in the correct client’s
medical record.
B. While agency policy may include circling the error, writing “error” in a medical record
should be avoided. This option does not include entering the correct vital signs.
C. If medical records are copied for any reason, the highlighted information may not show
up as being highlighted.
D. Writing over (covering) an existing entry is not permitted because of the implication of
covering up an error or mistake.
32. The client is admitted with a suspected stroke. What information
should the nurse document about the client’s admission? Select all that
apply.
A. Orientation to the room including use of the call light
B. Admitting medical diagnosis of possible ischemic stroke
C. Nurse’s physical and other assessment findings
D. Allergies to foods, medications, and other substances
E. That the client is wearing a 1-carat diamond ring

ANSWER: A. C, D

A. The client should be oriented to the room and use of the call light for the client’s safety.
This information should be documented.
B. There is no information indicating that the client had an ischemic stroke.
C. Physical assessment findings should be documented on admission for baseline
information and for comparison if the condition of the client changes.
D. All allergies should be documented on admission to protect the client from harm.
E. Valuables such as jewelry should be described in general terms, such as a “yellow ring
with a clear stone.”

33. The nurse is planning prenatal classes for pregnant adolescents

intending to keep their babies. Which teaching strategy would be most
effective for the adolescents?
A. Inviting mothers and daughters for one-to-one teaching sessions
B. Preparing group sessions for teaching the pregnant adolescents together
C. Offering open sessions for the pregnant adolescents and anyone else who wants to
attend
D. Designing poster boards that may be viewed individually in the school nurse’s office

ANSWER: B

A. Inviting mothers and daughters for individual teaching sessions may be effective for
teaching the adolescent mothers, but less effective for the pregnant adolescents.
B. Peer groups are important for adolescents, so utilizing group teaching sessions is the
most effective teaching strategy.
C. Prenatal teaching, especially the topic of body changes with pregnancy, could threaten
the adolescent’s self-esteem and body image if it is discussed in open sessions where
anyone could attend.
D. Poster boards could be an effective strategy for young adults, but not adolescents.
34. The nurse is teaching the client who is hard of hearing and wears
bilateral hearing aids. Which action by the nurse would best evaluate the
teaching on how to change a urinary drainage bag?
A. Have the client demonstrate how to change the bag
B. Ask during the teaching if the client has any questions
C. Ask the client to state the steps for changing the bag
D. Provide a handout with instructions of the procedure

ANSWER: A

A. Having the client demonstrate how to change a urinary drainage bag is the best way to
assess that the client understands the teaching. If the client is unable to return the
demonstration, the client will need further teaching, possibly with a different nonverbal
method if the client’s hearing loss is a barrier to understanding.
B. Asking if the client has any questions about the procedure does not evaluate whether
learning has occurred. The client may state that he or she has no questions, especially if
the client is unable to hear the information or is embarrassed by the hearing loss or
subject matter.
C. Although having the client state the procedure may be one method of evaluating
information, for a psychomotor skill the best method of evaluation is having the client
perform the skill.
D. Providing a handout with instructions would be helpful and is a teaching strategy, but it
does not aid in evaluating the client’s understanding of the teaching.

35. The nurse is instructing parents of Mexican origin about

administering their toddler’s oral medication. What method is best to
ensure that the toddler will get the prescribed amount of medicine at the
appropriate times?
A. Have an interpreter available to translate information to the parents.
B. Have a parent demonstrate the medication administration process prior to discharge.
C. Initiate a referral to a home health care agency for a follow-up visit.
D. Provide written instructions to the parents on how to administer the medication.

ANSWER: B

A. Having an interpreter may be warranted, but there is no indication that the parents are
unable to speak English.
B. In adult learning theory, return demonstration or demonstrating ability to do the task is
the most effective means of evaluating performance.
C. lnitiating a referral would not be warranted unless there are other health care or
parenting concerns.
 D. Providing written instructions is a supplemental resource for the parents but would
require evaluation of reading and comprehension skills.

36. When preparing a class to teach children, the nurse reviews Piaget’s
stages of development. With which age group do concrete operations
roughly correspond?
A. Toddlerhood
B. Preschool-age children
C. School-age children
D. Adolescence

ANSWER: C

A. Toddlers, 12 to 24 months, are in the sensorimotor phase of cognitive development.

B. Preschool children, 2 to 4 years, are in the preconceptual phase, where everything is
significant and relates to “me."
C. Concrete operations occur between the ages of7 and 11 years.
D. Adolescents are in the formal operations phase and are able to use rational thinking and
deductive and futuristic reasoning.

37. The nurse is preparing a campaign for seventh- and eighth-grade

teachers. The purpose of the campaign is to decrease and subsequently
eliminate bullying at school. Which strategy should the nurse utilize to
most effectively present this information to the teachers?
A. Panel presentation with small-group discussion
B. Case studies with time for discussion of the cases
C. Lecture presentation with assignments before classes
D. Educational videos that students can View independently

ANSWER: A

A. Adults see themselves as doers; therefore, inter- active sessions are most effective when
dealing with issues in which the targeted audience has variable knowledge and/or
experience. Panel presentation with small-group discussion would be most effective.
B. Case studies may be useful, but they are not as interactive as a panel presentation and
small-group discussion.
C. A lecture may be useful, but it is not as interactive as a panel presentation and small-
group discussion.
D. Educational videos may be useful, but they are not as interactive as a panel presentation
and small- group discussion.
38. The nurse is preparing to educate parents who are extremely
anxious because their infant has a physical disability. What is the initial
purpose of this education?
A. Ensure that the parents who are being educated can perform a repeat demonstration
B. Assist the parent to understand that there are multiple causes for their infant’s disability
C. Reduce the parents’ anxiety to effect change in the parents’ knowledge, attitudes, and
skills
D. Understand family factors that may influence their ability to live with their infant’s
disability

ANSWER: C

A. Repeat demonstrations are good for skills; however, they do not necessarily indicate a
change in the cognitive or affective domains of learning.
B. Knowing the causes of their infant’s disease may increase, not decrease, the parents’
anxiety and may be a barrier to learning.
C. The purpose of education with extremely anxious parents is to reduce the parents’
anxiety and provide information to prepare the family to live with the child.
D. Understanding causes and how to live with the condition are the products of education;
however, they are not the purpose of education.

39. The pediatric nurse is planning time for teaching. The nurse assesses
that which parent and child should be most ready to learn?
A. A mother sitting with her 4-year-old daughter who has just learned that the child has
leukemia
B. A father who is sitting with his 10-year-old daughter who just returned from physical
therapy
C. A father with his 2-year-old son who received an analgesic prior to a wound dressing
change
D. A mother and her 3-year-old son who are reading a story about being sick in the hospital

ANSWER: D

A. Preoccupation with the illness or grieving as in option 1 is a barrier to learning.

B. Child fatigue and pain are barriers to learning.
C. Analgesics are a barrier to learning.
D. Clients most ready to learn are those who are experiencing the least amount of stress
and would be the least preoccupied with other concerns. Reading a book, seeking out
information, and asking questions are indicators of readiness to learn.
40. The nurse completes teaching on insulin self-administration for the
client newly diagnosed with diabetes. The nurse will document that the
teaching is effective if the client demonstrates which injection technique
for insulin administration?
ANSWER: C

A. Insulin is administered as a subcutaneous injection. This illustration shows an

intraderrnal administration technique.
B. Insulin is administered as a subcutaneous injection. This illustration shows an
intramuscular Z-track administration technique.
C. Insulin is administered as a subcutaneous injection, which is shown in this illustration.
D. Insulin is administered as a subcutzureous injection. This illustration shows an
intravenous administration technique.
41 . The nurse is completing discharge teaching for the older adult client
who is fully dressed and watching a television program. The nurse sits in
a chair facing the client and shows the client a handout. The client
squints while reading the paper and periodically looks at the television.
Nearing completion of the teaching, the family arrives. The nurse should
determine that the client may need additional teaching due to which
barriers to learning? Select all that apply.
A. The client is watching a television program.
B. The client is an older adult.
C. The client is fully dressed.
D. The client squints to read the handout.
E. The family arrives during teaching.

ANSWER: A, D, E

A. The television is a distracter and can affect learning.

B. Just because the client is elderly does not mean that the client cannot comprehend the
information being taught. There is no indication that the client may have a cognitive
dysfunction.
C. Just because the client is frilly dressed does not mean that the client cannot
comprehend the information being taught.
D. The client squinting suggests that the lettering is too small or that the client does not
understand the information in the handout.
E. The family entering the room is a distraction and can affect learning.

42. When attempting to teach the client about medications, the client
states, “Just tell my wife. She gives me all my pills.” Which is the nurse’s
best response?
A. “You need to learn about your medications. What will you do if your wife isn’t around?”
B. “I will write out a list for her with instructions about how and when they should be
given.”
C. “When will your wife be visiting next? I can go over the medications with both of you
then.”
D. “Having your wife set up your medications is a good plan; this avoids making mistakes.”

ANSWER: C

A. The statement in option 1 is nontherapeutic and challenging.

B. While the nurse may also write out a list of medications, the list of medications should
be reviewed with the client and his wife and not given to the wife.
 C. If the wife will be administering the medications, then both the husband and wife
should be included in the teaching. Psychological and situational stressors can interfere
with concentration and learning.
D. Option 4 addresses only setting up the medications and does not reflect the client’s
comment regarding the wife giving the client the pills.

43. The nurse is providing discharge teaching to the client newly

diagnosed with type 2 DM. Prioritize the nurse’s actions by placing each
step of the teaching process in the correct order.
A. Implement the teaching plan.
B. Collect and analyze information about the client’s knowledge of type 2 DM.
C. Formulate an educational nursing diagnosis and client outcomes for teaching.
D. Develop a teaching plan for the client, including content and teaching strategies.
E. Evaluate client learning based on the established outcomes.
F. Identify the client’s learning needs.

ANSWER: B, F, C, D, A, E

B. Collect and analyze information about the client’s knowledge of type 2 DIVI to identify learning needs.

F. Identify the client’s learning needs.

C. Formulate an educational nursing diagnosis and client outcomes for teaching.

D. Develop a teaching plan for the client, including content and teaching strategies.

A. Implement the teaching plan.

E. Evaluate client teaming based on the established outcomes.

44. The nurse teaches the postoperative adult client how to perform
incision care. Prior to discharge, how should the nurse best evaluate the
client’s learning?
A. Ask the client questions and discuss the steps for performing incision care
B. Have the client return-demonstrate cleansing and dressing the incision
C. Reinforce the teaching with a handout at the time of the client’s discharge
D. Ask a family member to be present when the client is being discharged

ANSWER: B
 A. Discussion encourages active participation, but it is not the best method for teaching
motor skills involved in incision care.
B. Demonstration is the best method for teaching motor skills. Learning can be exhibited
and reinforced by having the client return- demonstrate the incision care.
C. Reinforcing teaching is not evaluating whether the client has learned.
D. A family member’s presence does not ensure that client learning has occurred.

45. The 78-year-old client who has arthritis is being discharged from the
hospital with a Jackson- Pratt (JP) wound drainage system. In order to
teach the client, the nurse should plan to take which action? Select all
that apply.
A. Assess the client’s manual dexterity in compressing the device and replacing the
stopper.
B. Provide a group teaching session with younger and older adults who have JP drains.
C. Provide Web-based references for additional reading on emptying and caring for JP
drains.
D. Provide sufficient opportunities for the client to return-demonstrate emptying the
reservoir.
E. Evaluate the client’s learning, and if unable to manage the drain, initiate a home care
referral.

ANSWER: A, D, E

A. Arthritis can affect manual dexterity, preventing the client from being able to empty and
care for the JP drain.
B. The teaching strategies for younger adults may vary from those of older adults; a mixed-
age-group teaching session is not advised. Older adults may need large-print materials,
aids to manual dexterity, and repeated opportunities for practice, whereas younger
adults may learn more quickly.
C. Providing Web-based references is an unnecessary detail that can lead to confusion with
irrelevant in- formation.
D. An older person may need more time to process information and perform psychomotor
skills.
E. Regardless of age, if a person is unable to perform a task related to self-care such as
managing the drain, a referral should be initiated.

46. The new nurse is planning to change a central-line dressing. Which

statement by the new nurse to the experienced nurse indicates that
further teaching is needed?
 A. “I will wash my hands immediately before and right after the dressing change.”
B. “I will put on a pair of clean gloves only before I start to remove the dressing.”
C. “I will ask that the client face away from the dressing while I am changing it.”
D. “I will cleanse the site with an antiseptic solution before applying the new dressing.”

ANSWER: B

A. Washing hands before and after the dressing change limits the spread of
microorganisms.
B. The nurse should put on sterile gloves prior to removing the dressing on a central line to
prevent contamination of the catheter and site. Once the dressing is removed, the nurse
should don a new set of sterile gloves to complete the dressing change. This statement
indicates that further teaching is needed.
C. Asking the client to face away from the site helps prevent catheter-related bloodstream
infections from the client’s expired air.
D. Cleaning the site with an antiseptic solution helps prevent microorganisms on the
client’s skin from entering the catheter insertion site.

47. The nurse is preparing teaching materials for highly educated, self-
directed adult clients on a cardiac step-down unit. Which methods of
instruction should the nurse consider when preparing the instruction
materials? Select all that apply.
A. Computer-assisted instruction
B. Closed-circuit television programs
C. Group sessions presented by hospitalized clients
D. Printed materials for handouts
E. Poster boards strategically placed on the unit

ANSWER: A, B, D, E

A. Computer-assisted instruction is an appropriate learning strategy. The nurse will need to

consider whether the client would have access to a hospital-based computer.
B. Closed-circuit television programs allow for individual or group learning.
C. Professionals should lead group sessions and not hospitalized clients, who are in the
hospital for health reasons.
D. Handouts allow learners to learn at their own pace and can be reviewed at a later time.
E. Poster boards allow visual learning and can be read at the learner’s own pace.
48. The hospitalized client, who smokes two packs of cigarettes per day,
voices concerns about not being able to smoke. Which actions should be
taken by the nurse to educate the client about the effects of cigarette
smoking and smoking cessation? Select all that apply.
A. Obtain smoking-cessation information for client education on the hospital’s Web site.
B. Find the latest evidence on the Internet about smoking cessation during hospitalization.
C. Inform the client that cigarette smoking during hospitalization is prohibited by hospital
policy.
D. Check the American Lung Association Web site for current guidelines on smoking
cessation.
E. Go to the hospital library, conduct a literature search, and write a policy on smoking
cessation.

ANSWER: A, B, D

A. The hospital Web site should provide information that is in a format and at a reading
level appropriate for educating the client.
B. Latest evidence found on the Internet may provide strategies to assist the client in
smoking cessation.
C. Discouraging the client from smoking by citing agency policy is not a supported strategy
for smoking cessation.
D. The American Lung Association is a reputable source for obtaining smoking cessation
information.
E. Conducting a literature search and writing a policy will not be done in time to assist this
client.

49. The nurse plans medication teaching for the hospitalized, literate
client who is taking multiple new medications. Which actions should be
taken by the nurse to ensure that the client understands the newly
prescribed medications? Select all that apply.
A. Notify the client’s health care provider that the client needs teaching on medications
B. Provide information leaflets to the client on the medications, their use, and when to
take them
C. Use pictures that illustrate how and when to take the newly prescribed medications
D. Have the client practice opening the unit dose medication packets before discharge
E. Ask the client to write the medication information as the nurse presents it to the client

ANSWER: B, C

A. Medication teaching is a nursing responsibility; it is unnecessary to notify the HCP.

 B. The client can use the leaflets containing information about the medications during the
teaching and have these for later reference.
C. Visual teaching materials, such as using pictures and illustrations, enhance learning.
D. Because of costs, prescriptions are ordinarily not filled with unit doses. Bringing packets
to have the client practice opening these can cause confusion.
E. Writing is unnecessary if using patient information leaflets and can be frustrating for the
client.

50. The nurse is obtaining health information from a Web site for the
parents of a child diagnosed with sickle cell anemia. Prior to printing
information for the parents, the nurse should take which actions? Select
all that apply.
A. Check the URL domain for the publishing author, such as a Web address ending in “.gov”
B. Determine when the Web page and links were last updated and whether information is
current
C. Evaluate the author credentials and whether information is appropriate for the parents
D. Use a search engine to find blogs for providing facts about the disease to the parents
E. Provide the Web address for a pharmacy so the parents can check on new medications
F. Evaluate the content of the document to ascertain whether contents are fact or opinion

ANSWER: A, B, C, F

A. The URL domain provides clues as to the author and institution. The URL of .gov
indicates a U.S. government Web site and would be an acceptable site if information is
appropriate for the client.
B. Checking for an updated Web page and links will help ensure that only current
information is provided to the parents.
C. The credibility of the author should be evaluated to determine if the author has the
credentials and qualifications to speak on the topic.
D. Blogs generally describe a person’s experiences and may not contain factually correct
information.
E. Information about medications should be obtained from resources developed for
teaching clients.
F. The document should be at the educational and reading level appropriate for the client
and based on facts, research, or expert knowledge, and not on opinion.