OUR LADY OF MERCY COLLEGE 4.

A client is brought to the emergency department by the police after

BORONGAN CITY, E. SAMAR having lacerated both wrists in a suicide attempt. The nurse should
take which initial action?
SEMI FINALS in NCM419
a) examine and treat the wound sites
A. MULTIPLE CHOICE
b) obtain and record a detailed history
1. You are the charge nurse. A client with chronic pain reports to you
c) encourage and assist the client to ventilate feelings
that the nurses have not been responding to requests for pain
d) administer an anti-anxiety agent
medication. What is your initial action
5. A client with diabetic neuropathy reports a burning, electrical-type
a. check the MAR for the past several days
pain in the lower extremities that is worse at night and not
b. ask the nurse educator to provide in-service training about pain
responding to NSAIDs. Which medication will you advocate for first?
management
a. Gabapentin
c. perform a complete pain assessment on the client and take a pain
b. corticosteroids
history
c. hydromorphone (Dilaudid)
d. have a conference with the nurses responsible for the care of this
d. lorazepam (Ativan)
client
6. As the charge nurse, you are reviewing the charts of clients who
2. A nurse is caring for a client with preeclampsia who suddenly
were assigned to the care of a newly graduated RN. The RN has
progresses to an eclamptic state. The initial nursing action would be
correctly charted dose and time of medication, but there is no
to:
documentation regarding nonpharmaceutical measures. What
a) check the fetal heart rate
action should you take first?
b) check the maternal blood pressure
a. make a note in the nurse's file and continue to observe clinical
c) maintain an open airway
performance
d) administer oxygen to the mother by face mask
b. refers the new nurse to the in-service education department
3. A registered nurse (RN) has delegated care of a newly postoperative
c. quiz the nurse about knowledge of pain management and
client to a licensed practical nurse (LPN). The LPN notifies the RN
pharmacology
that the client's blood pressure and respirations are elevated from
d. give praise for correctly charting the dose and time and discuss
the baseline readings and that the client is complaining of pain and
the deficits in charting
dyspnea. The RN takes which action next?
7. A client is 3 hours postoperative following a right upper lobectomy.
a) the RN need not to carry out further assessment because the LPN
The collection chamber of the closed pleural drainage system
is very experienced and trustworthy
contains 400 ml of bloody drainage. The client's vital signs are blood
b) the RN requests that the LPN offer the client a opioid analgesic,
pressure 100/50 mmHg, heart rate of 100 beats per minute, and
which has ordered postoperatively
respiratory rate 26 breaths per minute. There is intermittent
c) the RN places a call to the attending surgeon and reports that the
bubbling in the water seal chamber. One hour following the initial
client is having pain and dyspneic
assessment, the nurse notes that the bubbling in the water seal
d) the RN assesses the client, checks the client's surgical notes, and
chamber is now constant and the client appears dyspneic. The nurse
gathers addition data before calling the surgeon
should first check:
 a) lung sounds
b) vital signs
c) the chest tube connections
d) the amount of drainage
8.  A nurse manager is planning the client assignments for the day.
Which of the following clients would the nurse assign to the nursing
assistant?
a) a 2-day postoperative client who had a below-the-knee
amputation
b) a client on a 24-hour urine collection who is on strict bedrest
c) a client scheduled to be discharged after coronary artery bypass
surgery
d) a client scheduled for a cardiac catheterization
9.  A registered nurse (RN) must determine how best to assign
coworkers (another RN and one licensed practical nurse LPN) to
provide care to a group of clients. Which of the following is the
appropriate assignment?
a) the RN is assigned to care for an unemployed 26-year old woman,
newly diagnosed with acquired immunodeficiency syndrome (AIDS),
who has four school-age children
b) the LPN is assigned to care for a 41-year old male, postresection
of an acoustic neuroma 2 days ago, transferred from the intensive
care unit (ICU) this morning
c) the LPN is assigned to provide discharge teaching about
medications and maintenance of nephrostomy tube to a 35-year old
man
d) the RN is assigned to care for a 65-year old woman hospitalized
because of chest pain, being discharged today to home with no
medication
10.  A nurse manager of a medical-surgical unit returns to work after
being on vacation for a week. It is the beginning of the shift, and the
nurse manager is faced with several activities that need attention.
Which activity will the nurse manager attend to first?
a) a crash cart needs checking
b) client assignments for the day
c) a phone message that indicates that the charge nurse of the next
shift is ill and will not be reporting to work
d) a stack of mail from the education department and
administrative services
11. The nurse is providing community education to a group of clients
about the prevention of type 2 diabetes mellitus. Which client
would be at highest risk for the development of diabetes mellitus?
A - A middle-age woman who delivers mail
B - A young adult who plays basketball regularly
C - A middle-age man with a basal metabolic rate within normal
limits
D - An elderly woman who is sedentary
12. The nurse is ambulating a client. The client experiences chest pain
after ambulating 50 feet. What is the nurse's priority intervention?
A - Sit the client down
B - Get the client back to bed
C - Administer the ordered sublingual nitroglycerin
D - Obtain an electrocardiogram (ECG)
13. A few minutes after you have given an intradermal injection of an
allergen to a patient who is undergoing skin testing for allergies, the
patient reports feeling anxious, short of breath, and dizzy. Which
action included in the emergency protocol should you take first?
a. Start oxygen at 4 L/ min using a nasal cannula.
b. Obtain IV access with a large-bore IV catheter.
c. Give epinephrine (Adrenalin) 0.3 mL intramuscularly.
d. Administer 3 mL of nebulized albuterol (Proventil) 0.083%
14.  You are working with a student nurse to care for an HIV-positive
patient with severe esophagitis caused by Candida albicans. Which
action by the student indicates that you need to intervene most
quickly?
a. Putting on a mask and gown before entering the patient's room
b. Giving the patient a glass of water after administering the
ordered oral nystatin (Mycostatin) suspension
c. Suggesting that the patient should order chile con carne or
 chicken soup for the next meal A. State nursing practice act
d. Placing a "No Visitors" sign on the door of the patient's room B. Professional nursing organization
15.  The client's nursing diagnosis is Deficient Fluid Volume related to C. Institutional policies
excessive fluid loss. Which action related to fluid management D. National Council of the State Boards of Nursing
should be delegated to a UAP? 20. An RN is supervising a team consisting of an LPN and a NAP. Which
a. Administering IV fluids as prescribed by the physician of the following patients should the RN see first?
b. Providing straws and offering fluids between meals A. A patient on an insulin drip requiring hourly blood glucose checks
c. Developing a plan for added fluid intake over 24 hours B. A terminally ill cancer patient complaining of pain radiating
d. Teaching family members to assist the client with fluid intake throughout the abdomen
16. You have been floated to the telemetry unit for the day. The C. A patient diagnosed with chronic obstructive pulmonary disease
monitor watcher informs you that the client has developed (COPD) who has become confused
prominent U waves. Which laboratory value should you check D. A patient with a serum potassium of 4.0
immediately? 21. . The nurse is making assignments for the patient care team. Which
a. Sodium of the following tasks should the RN complete herself?
b. Potassium A. Blood glucose testing for a diabetic patient
c. Magnesium B. Feeding a client with dementia
d. Calcium C. Administering the scheduled oral beta blocker to a patient with
17. A staff nurse informed the charge nurse that she was 6 weeks hypertension
pregnant. The charge nurse rearranged patient assignments so the D. Providing medication to a patient complaining of pain after
pregnant nurse would not be caring for highly infectious patients. surgery
This scenario is an example of which relationship-oriented concern? 22. A nurse is caring for a patient diagnosed with acute exacerbation of
A. Health COPD. Which of the following is the RN's priority assessment?
B. Appropriateness A. Breath sounds
C. Fairness B. Pedal pulses
D. Staff preference C. Location and intensity of pain
18. The charge nurse assigns a patient with a rare diagnosis to a newer D. Cardiac rate and rhythm
nurse. This is an example of which relationship-oriented concern in 23. When organizing work for the day, which of the following should
making assignments? take priority?
A. Staff preference A. Clustered activities
B. Learning opportunities B. Activities that are time specific
C. Compatibility C. Delegating of assignments
D. Fairness D. Peak energy time
19. A new nurse is reviewing the legal constraints of nursing practice. 24. A nursing manager participates on a committee reviewing approved
Which of the following should the nurse review to determine legal assignments for LPNs. Which of the following best describes this
boundaries to practice? situation?
 A. Direct delegation
B. Supervision
C. Indirect delegation
D. Assignment
25. 1. A client who was involved in a motor vehicle accident is admitted
through the emergency department. He has an IV of 0.9% NS @ 100
mL/hr, BP 92/58, and complains of weakness, fatigue, and
abdominal pain. On assessment, the nurse discovers that Mr.
Reynolds is nauseated and just vomited 560 milliliters of green
emesis with flecks of "coffee grounds." The nurse delegates client
care activities to the nursing assistive personnel. Which activity
should the nurse keep?
A. Taking and recording vital signs every 15 minutes
B. Recording accurate intake and output
C. Obtaining a baseline weight to guide therapy
D. Increasing the IV rate to 250 mL/hr if the blood pressure drops to
85/50
26.  A client recovering from congestive heart failure (CHF)is being
discharged this afternoon. The client needs teaching to be
reinforced. Who should complete this task?
A. An LPN/LVN
B. A UAP/NAP
C. A unit secretary
D. A second-year nursing student working as a nurse tech on the
unit
27. A nurse is caring for several clients. , Which client could be assigned
to a UAP/NAP?
A. A client with a recent head injury
B. A client for the removal of an ovarian cyst post-laparoscopy
C. A client with stable angina
D. A client with a sepsis
28.  The RN who is the team leader gives assignments to all the team
members. How should the nurse base this decision?
A. The number of staff willing to work
B. The age and desires of the team members
C. The RN needing to take orders and write client outcomes
D. The condition and needs of each client
29. An RN is setting up the day's assignments. A newly licensed RN has
been floated to the unit. What should the RN consider when making
the assignment for the newly licensed nurse?
A. The nurse's age
B. The nurse's knowledge of the institution's standards of practice
C. The nurse's nursing degree
D. The nurse's level of skill
30.  What two legal responsibilities should the RN take into
consideration when delegating to others?
A. Knowing the job requirements and evaluating the outcomes
B. Assessing how much supervisory time is necessary and assessing
the competence of each staff member
C. Writing job descriptions and communicating them to all staff
members
D. Making sure the supervisor and employee strengths are matched
and giving adequate supervision
31. An RN arrives at work and the nurse manager tells her that the ICU
needs more help. The RN is the most experienced nurse on this unit.
The RN tells the nurse manager she has never worked in the ICU and
shares her concerns regarding the lack of familiarity with the
technical equipment and protocols of the ICU. The nurse manager
states that she understands the RN's concern but is to go to the ICU.
How should the RN respond to the situation?
A. Refuse to go to the ICU
B. Go to the ICU and tell the charge nurse that she is ill and needs to
go home
C. Go to the ICU and inform the charge nurse of the tasks she is able
to perform and those tasks with which she feels she needs
assistance
D. Call the nurse manager's supervisor and report her for unsafe
delegation
32. Delegation is defined as:
A. Reassigning the responsibility of performing a job from one
person to another.
B. Explaining how you want a job done.
C. Telling other people what to do.
D. Developing ways to classify people into job categories to learn
what they are capable of doing.
33. An RN has worked in labor and delivery for 15 years with a total RN
staff. The nurse is presently an associate nurse manager of a busy
postpartum unit and has RNs and UAPs. What should the nurse
consider when making assignments to members of the health-care
team?
A. Length of service
B. Scope of practice
C. Ability to perform the task
D. Job title
34.  A nurse is caring for a client who has dementia and urinary
incontinence. Which nursing action is appropriate to delegate to a
UAP/NAP?
A. Teaching the client to use the call bell when needing the bed pan
B. Offering the bed pan to the client every 2 hours
C. Obtaining a sterile urine sample for culture and sensitivity
D. Assessing the client for skin breakdown
35. A nurse is assigned to care for the following patients. Which patient
should the nurse assess first?
a. A 60 y/o patient on a ventilator for whom sterile sputum
specimen must be sent to the lab
b. A 55 y/o with COPD and a pulse oximetry reading from the
previous shift of 90% saturation
c. A 70 y/o with pneumonia who needs to be started on IV
antibiotics
d. A 50 y/o with asthma who complains of shortness of breath after
using a bronchodilator
36. An assistant nurse manager is making assignments for the next shift.
Which patient should the assistant nurse manager assign to a nurse
with 6 months of experience and who has been floated from a
surgical unit to the medical unit?
a. A 58 y/o on airborne precautions for TB
b. A 68 y/o who just returned from bronchoscopy and biopsy
c. A 69 y/o with COPD who is ventilator dependent
d. A 72 y/o who needs teaching about the use of incentive
spirometry
37. A mother reports that her school-age child has been reprimanded
for daydreaming during class. The mother is concerned because her
other child has been diagnosed with absence seizures. This behavior
is new, and the child's grades are dropping. What is the most
appropriate action by the nurse?
A - Refer the child to the primary health care provider to assess for
absence seizures
B - Refer the child to an audiologist for a hearing assessment
C - Refer the child to the primary care provider to assess for
attention deficit hyperactivity disorder (ADHD)
D - Refer the child to the special education department to assess for
a learning disability
38. The nurse is caring for a client in the post anesthesia care unit
(PACU) following an adrenalectomy. What is the nurse's priority
action?
A - Assessing serum potassium
B - Administering opioids
C - Administering dextrose in water
D - Assessing blood pressure
39. The nurse is caring for a neonate diagnosed with diabetes insipidus.
Which assessment finding would warrant an immediate
intervention?
A - Weight loss
B - Increased head circumference
C - Increased feeding
D – Edema
40. A client has received an infusion of antibiotics and is now
experiencing an anaphylactic reaction. What is the most important
 intervention by the nurse? 45. The high-pressure alarm on a patient's ventilator goes off. When
A - Administer epinephrine you enter the room to assess the patient, who has ARDS, the oxygen
B - Maintain a patent airway saturation monitor reads 87% and the patient is struggling to sit up.
C - Monitor vital signs Which action should you take next?
D - Administer a bolus of normal saline solution A. Reassure the patient that the ventilator will do the work of
41. The nurse is caring for a client with terminal lung cancer. What is breathing for him.
the priority nursing intervention for this client? B. Manually ventilate the patient while assessing possible reasons
A - Provide pain control. for the high-pressure alarm.
B - Provide nutritional support. C. Increase the fraction of inspired oxygen on the ventilator to 100%
C - Prepare the client's will. in preparation for endotracheal suctioning.
D - Provide emotional support. D. Insert an oral airway to prevent the patient from biting on the
42. A 30-year-old multiparous client in active labor is admitted to the endotracheal tube.
labor and delivery unit. She has received no prenatal care for this B. 46-50.
pregnancy. Which data would the nurse obtain first? 1. What are the responsibilities of the professional nurse when
A - Family history of sexually transmitted infection (STIs) delegating tasks to an LPN/LVN or NAP?
B - Name of insurance provider
C - Date of last menstrual period (LMP)
D - Number of and ages of previous children WRITE YOUR ANSWER AT THE BACK OF YOUR ANSWER SHEET
43. A client is admitted to the labor and delivery unit in labor with blood
flowing down her legs. What would be the priority nursing
intervention?
A - Monitor fetal heart tones
B - Place an indwelling catheter
C - Perform a cervical examination
D - Prepare the client for cesarean birth
44. A 16-year-old patient with cystic fibrosis is admitted with increased
shortness of breath and possible pneumonia. Which nursing activity
is most important to include in the patient's care?
A. Perform postural drainage and chest physiotherapy every 4
hours.
B. Allow the patient to decide whether she needs aerosolized
medications.
C. Place the patient in a private room to decrease the risk of further
infection.
D. Plan activities to allow at least 8 hours of uninterrupted sleep.