10). Which statement by the patient during a focused nutritional assessment provides the RN with the most accurate information about diet?

a. “I eat cereal for breakfast; a sandwich and fruit for lunch; meat and potatoes for dinner.”

b. “Here is a list of what I ate, including between meal snacks, for the past few days.”

c. “I have eggs 4 times a week; I eat fish a few times a week; salads and soups every day.”

39). During an outpatient physical assessment, the RN sits the older adult client in a chair and performs the Get up and Go Test. The client uses the arms of the chair to push off to a standing position and is unsteady when sitting back down. What is the initial action by the RN?

a. Assess the client’s muscle strength.

b. Complete a Safety Assessment Scale.

c. Perform a comprehensive fall evaluation.

d. Conduct a follow-up assessment.

39). An infant with bronchiolitis has a radiological procedure ordered. Which nursing team member is most appropriate to accompany the infant to radiology?

The nurse with the most pediatric experience.

The nurse in charge of the unit.

The nurse assigned to care for the child.

The nurse with the least busy assignment.

45). A patient with the nursing diagnosis of Risk for Impaired Skin Integrity has the outcome of patient will not develop redness in the sacral area during hospital stay. The nursing intervention identified was to reposition the patient frequently. A day later, the patient’s sacral area was reddened. What areas should the RN explore when the outcome was not met?Select all that apply.

a. The reassessment of patient specific risk factors.

b. The ability of staff to follow the plan of care for all patients.

c. Determine if the unit was adequately staffed.

d. Review if the nursing order was clear and specific.

e. Documentation reflects the nursing actions taken.

48). A patient, who experienced a traumatic amputation of the leg, tells the RN “I’ll never be the same without my leg.” The RN identifies Grieving as a nursing diagnosis. Which considerations are necessary for establishing an outcome for this patient?Select all that apply.

a. Inquire about the patient’s cultural and religious beliefs.

b. Ask about the personal meaning of the loss.

c. Collaborate on an outcome realistic for the patient.

d. Provide examples of outcomes previously useful with other patients.

e. Describe the desired resolution of the problem.

52). The patient with Impaired gas exchange has an expected outcome of maintaining oxygen saturation at 95% or greater. The patient’s oxygen saturation is 95% on 2 liters via nasal cannula but drops to 92% when the patient removes the oxygen. What nursing intervention is helpful to meet the patient outcome?

a. Identify the need for more patient education.

b. Continue the plan of care as the goal was partially met.

c. Revise the plan of care with a different outcome.

d. Explore barriers to achievement of the outcome with the patient.

54). During a well-child visit, a parent voices concern about possible side effects from the recommended immunizations. What is an appropriate intervention by the RN?

a. Review the current evidence-based research with the parent.

b. Refer the parent to immunization information on the internet.

c. State that side effects only occur with live attenuated viruses.

d. Share that many vaccinations have been given without incident.

55). The RN assesses a patient who was admitted 2 hours ago with atrial fibrillation and congestive heart failure. The RN records the following data

Vital Signs

• Temperature 98 °F (37°C) oral

• Pulse 96 (apical) beats per minute; irregularly irregular.

• Respiratory Rate 30 breaths per minute

• Blood Pressure 100/72 mmHg (manual)

• Pain 0 on Numeric Rating Scale

• Oxygen Saturation 92% on 2 liters nasal cannula.

• Weight 159 pounds (72 kilograms) increase of 9 pounds (4 kilograms) from baseline

• Respiratory Assessment

• Breath sounds Crackles in bilateral lower lobes, clear in bilateral upper lobes.

• Verbalizes difficulty breathing with all activity

• Which nursing diagnoses are appropriate for this patient?Select all that apply.

a. Ineffective Breathing Pattern

b. Impaired Gas Exchange

c. Excess Fluid Volume

d. Activity Intolerance

e. Imbalanced Nutrition more than body requirements

56). A patient with chronic pulmonary disease is admitted with pneumonia. Which of the following cues is considered insignificant and does not impact the patient’s current health concern?

a. Weight loss of 5 pounds (2.3 kilograms) within the previous week.

b. Family history of reactive airway disease.

c. Bronchial breath sounds heard over bilateral lung fields.

d. Contraction of abdominal muscles during inspiration.

62). A patient with end-stage kidney disease presents with fatigue, tachypnea, hypertension and pitting edema in the feet and sacral area. Based on the patient’s data cues, what is the etiology for the patient’s current condition?

a. Edema in bilateral lower extremities.

b. Increase in weight.

c. Retention of sodium.

d. Decrease in hemoglobin value.

64). The UAP reports to the RN the vital signs of a client recovering from abdominal surgery who appears anxious. The RN reviews the trend in the client’s vital signs in the electronic medical record. What action by the RN exemplifies safe patient care?

Time	Temperature (T), pulse (P)and respirations (R)	Blood pressure (BP)	Verbal report of pain
8 hours ago	T= 98 °F (36.6°C); P= 80; R=18	126/80	3 on 0-10 scale
4 hours ago	T=98.2°F (36.8°C); P =84; R=20	124/76	1 on 0-10 scale
Current	T=99.4 °F (37.4 °C); P=86; R=24	116/84	2 on 0-10 scale

a. Medicate for pain as the trend shows a slightly elevated pulse.

b. Instruct the client on relaxation techniques due to change in vital signs.

c. Monitor the blood pressure because of minor deviation from baseline.

d. Perform a focused in-depth respiratory assessment.

69). Which would be an expected finding in a patient recovering from an ischemic stroke with the nursing diagnosis of Impaired Physical Mobility?

a. Dyspnea on exertion.

b. Pain with movement.

c. Inability to lie supine.

d. Unsteady gait.

77). A patient with cognitive impairment who experienced a hip fracture one day ago tells the RN “No” to the question “Are you in pain?” The RN notes the patient flinches when touched, rubs the fractured leg, and appears agitated. What is an appropriate nursing intervention?

a. Assess vital signs for elevation from the baseline.

b. Medicate with a low dose of analgesic then reassess.

c. Request a physician order for sedation.

d. Reposition the patient using pillows for support.

78). For the patient with Chronic Obstructive Pulmonary Disease (COPD), which is considered a significant data cue for the nursing diagnosis of Ineffective airway clearance related to retained secretions?

a. Adventitious breath sounds

b. Oxygen saturation level of 93%

c. Pursed-lip breathing

d. Excessive somnolence

66). Which nursing intervention is included in the evidence-based tool or “bundle” of activities that are associated with prevention of ventilator associated pneumonia (VAP)?

Elevate the head of the bed to 15 degrees.

Routine suctioning every 2 to 4 hours.

Brush the patient’s teeth twice a day.

Instill saline in the airway to loosen secretions.

69). A student nurse asks the RN the purpose of asking patients about personal sexual preferences and orientation. How does the RN respond?

“These questions screen for potential risk factors for other diseases.”

“This ensures staff do not make inappropriate remarks.”

“Behaviors that signal sexual dysfunction can be identified that way.”

“The patient assessment data set in the electronic health record requires it.”

72). An RN tells the charge nurse “I’m lucky my client refused to take the medication. I would have made a medication error if it was taken.” Which response demonstrates the charge nurse’s competency in risk reduction?

“An occurrence report needs to be done to help improve our systems.”

“So you don’t have to be disciplined, this event stays between the two of us.”

“No additional action is required as no mistake happened.”

“This is a good example how short staffing causes problems.”

77). Which action indicates the RN applies clinical recommendations to decrease catheter associated blood stream infections (CLABSI)?

Assess the patient’s need for the catheter on a daily basis.

Remove the transparent dressing daily to inspect the insertion site.

Routinely scrub the injection port with povidone-iodine.

Flush the catheter every 12 hours with a 5 mL syringe of normal saline.