PNLE I Nursing Practice

Scope of this Nursing Test I is parallel to the NP1 NLE Coverage:

  • Foundation of Nursing
  • Nursing Research
  • Professional Adjustment
  • Leadership and Management

1. The registered nurse is planning to delegate tasks to unlicensed assistive personnel (UAP). Which of the following task could the registered nurse safely assigned to a UAP?

  1. Monitor the I&O of a comatose toddler client with salicylate poisoning
  2. Perform a complete bed bath on a 2-year-old with multiple injuries from a serious fall
  3. Check the IV of a preschooler with Kawasaki disease
  4. Give an outmeal bath to an infant with eczema

2. A nurse manager assigned a registered nurse from telemetry unit to the pediatrics unit. There were three patients assigned to the RN. Which of the following patients should not be assigned to the floated nurse?

  1. A 9-year-old child diagnosed with rheumatic fever
  2. A young infant after pyloromyotomy
  3. A 4-year-old with VSD following cardiac catheterization
  4. A 5-month-old with Kawasaki disease

3. A nurse in charge in the pediatric unit is absent. The nurse manager decided to assign the nurse in the obstetrics unit to the pediatrics unit. Which of the following patients could the nurse manager safely assign to the float nurse?

  1. A child who had multiple injuries from a serious vehicle accident
  2. A child diagnosed with Kawasaki disease and with cardiac complications
  3. A child who has had a nephrectomy for Wilm’s tumor
  4. A child receiving an IV chelating therapy for lead poisoning

4. The registered nurse is planning to delegate task to a certified nursing assistant. Which of the following clients should not be assigned to a CAN?

  1. A client diagnosed with diabetes and who has an infected toe
  2. A client who had a CVA in the past two months
  3. A client with Chronic renal failure
  4. A client with chronic venous insufficiency

5. The nurse in the medication unit passes the medications for all the clients on the nursing unit. The head nurse is making rounds with the physician and coordinates clients’ activities with other departments. The nurse assistant changes the bed lines and answers call lights. A second nurse is assigned for changing wound dressings; a licensed practitioner nurse takes vital signs and bathes theclients. This illustrates of what method of nursing care?

  1. Case management method
  2. Primary nursing method
  3. Team method
  4. Functional method

6. A registered nurse has been assigned to six clients on the 12-hour shift. The RN is responsible for every aspect of care such as formulating the care of plan, intervention and evaluating the care during her shift. At the end of her shift, the RN will pass this same task to the next RN in charge. This nursing care illustrates of what kind of method?

  1. primary nursing method
  2. case method
  3. team method
  4. functional method

7. A newly hired nurse on an adult medicine unit with 3 months experience was asked to float to pediatrics. The nurse hesitates to perform pediatric skills and receive an interesting assignment that feels overwhelming. The nurse should:

  1. resign on the spot from the nursing position and apply for a position that does not require floating
  2. Inform the nursing supervisor and the charge nurse on the pediatric floor about the nurse’s lack of skill and feelings of hesitations and request assistance
  3. Ask several other nurses how they feel about pediatrics and find someone else who is willing to accept the assignment
  4. Refuse the assignment and leave the unit requesting a vacation a day

8. An experienced nurse who voluntarily trained a less experienced nurse with the intention of enhancing the skills and knowledge and promoting professional advancement to the nurse is called a:

  1. mentor
  2. team leader
  3. case manager
  4. change agent

9. The pediatrics unit is understaffed and the nurse manager informs the nurses in the obstetrics unit that she is going to assign one nurse to float in the pediatric units. Which statement by the designated float nurse may put her job at risk?

  1. “I do not get along with one of the nurses on the pediatrics unit”
  2. “I have a vacation day coming and would like to take that now”
  3. “I do not feel competent to go and work on that area”
  4. “ I am afraid I will get the most serious clients in the unit”

10. The newly hired staff nurse has been working on a medical unit for 3 weeks. The nurse manager has posted the team leader assignments for the following week. The new staff knows that a major responsibility of the team leader is to:

  1. Provide care to the most acutely ill client on the team
  2. Know the condition and needs of all the patients on the team
  3. Document the assessments completed by the team members
  4. Supervise direct care by nursing assistants

11. A 15-year-old girl just gave birth to a baby boy who needs emergency surgery. The nurse prepared the consent form and it should be signed by:

  1. The Physician
  2. The Registered Nurse caring for the client
  3. The 15-year-old mother of the baby boy
  4. The mother of the girl

12. A nurse caring to a client with Alzheimer’s disease overheard a family member say to the client, “if you pee one more time, I won’t give you any more food and drinks”. What initial action is best for the nurse to take?

  1. Take no action because it is the family member saying that to the client
  2. Talk to the family member and explain that what she/he has said is not appropriate for the client
  3. Give the family member the number for an Elder Abuse Hot line
  4. Document what the family member has said

13. Which is true about informed consent?

  1. A nurse may accept responsibility signing a consent form if the client is unable
  2. Obtaining consent is not the responsibility of the physician
  3. A physician will not subject himself to liability if he withholds any facts that are necessary to form the basis of an intelligent consent
  4. If the nurse witnesses a consent for surgery, the nurse is, in effect, indicating that the signature is that of the purported person and that the person’s condition is as indicated at the time of signing

14. A mother in labor told the nurse that she was expecting that her baby has no chance to survive and expects that the baby will be born dead. The mother accepts the fate of the baby and informs the nurse that when the baby is born and requires resuscitation, the mother refuses any treatment to her baby and expresses hostility toward the nurse while the pediatric team is taking care of the baby. The nurse is legally obligated to:

  1. Notify the pediatric team that the mother has refused resuscitation and any treatment for the baby and take the baby to the mother
  2. Get a court order making the baby a ward of the court
  3. Record the statement of the mother, notify the pediatric team, and observe carefully for signs of impaired bonding and neglect as a reasonable suspicion of child abuse
  4. Do nothing except record the mother’s statement in the medical record

15. The hospitalized client with a chronic cough is scheduled for bronchoscopy. The nurse is tasks to bring the informed consent document into the client’s room for a signature. The client asks the nurse for details of the procedure and demands an explanation why the process of informed consent is necessary. The nurse responds that informed consent means:

  1. The patient releases the physician from all responsibility for the procedure.
  2. The immediate family may make decision against the patient’s will.
  3. The physician must give the client or surrogates enough information to make health care judgments consistent with their values and goals.
  4. The patient agrees to a procedure ordered by the physician even if the client does not understand what the outcome will be.

16. A hospitalized client with severe necrotizing ulcer of the lower leg is schedule for an amputation. The client tells the nurse that he will not sign the consent form and he does not want any surgery or treatment because of religious beliefs about reincarnation. What is the role of the RN?

  1. call a family meeting
  2. discuss the religious beliefs with the physician
  3. encourage the client to have the surgery
  4. inform the client of other options

17. While in the hospital lobby, the RN overhears the three staff discussing the health condition of her client. What would be the appropriate nursing action for the RN to take?

  1. Tell them it is not appropriate to discuss the condition of the client
  2. Ignore them, because it is their right to discuss anything they want to
  3. Join in the conversation, giving them supportive input about the case of the client
  4. Report this incident to the nursing supervisor

18. A staff nurse has had a serious issue with her colleague. In this situation, it is best to:

  1. Discuss this with the supervisor
  2. Not discuss the issue with anyone. It will probably resolve itself
  3. Try to discuss with the colleague about the issue and resolve it when both are calmer
  4. Tell other members of the network what the team member did

19. The nurse is caring to a client who just gave birth to a healthy baby boy. The nurse may not disclose confidential information when:

  1. The nurse discusses the condition of the client in a clinical conference with other nurses
  2. The client asks the nurse to discuss the her condition with the family
  3. The father of a woman who just delivered a baby is on the phone to find out the sex of the baby
  4. A researcher from an institutionally approved research study reviews the medical record of a patient

20. A 17-year-old married client is scheduled for surgery. The nurse taking care of the client realizes that consent has not been signed after preoperative medications were given. What should the nurse do?

  1. Call the surgeon
  2. Ask the spouse to sign the consent
  3. Obtain a consent from the client as soon as possible
  4. Get a verbal consent from the parents of the client

21. A 12-year-old client is admitted to the hospital. The physician ordered Dilantin to the client. In administering IV phenytoin (Dilantin) to a child, the nurse would be most correct in mixing it with:

  1. Normal Saline
  2. Heparinized normal saline
  3. 5% dextrose in water
  4. Lactated Ringer’s solution

22. The nurse is caring to a client who is hypotensive. Following a large hematemesis, how should the nurse position the client?

  1. Feet and legs elevated 20 degrees, trunk horizontal, head on small pillow
  2. Low Fowler’s with knees gatched at 30 degrees
  3. Supine with the head turned to the left
  4. Bed sloped at a 45 degree angle with the head lowest and the legs highest

23. The client is brought to the emergency department after a serious accident. What would be the initial nursing action of the nurse to the client?

  1. assess the level of consciousness and circulation
  2. check respirations, circulation, neurological response
  3. align the spine, check pupils, check for hemorrhage
  4. check respiration, stabilize spine, check circulation

24. A nurse is assigned to care to a client with Parkinson’s disease. What interventions are important if the nurse wants to improve nutrition and promote effective swallowing of the client?

  1. Eat solid food
  2. Give liquids with meals
  3. Feed the client
  4. Sit in an upright position to eat

25. During tracheal suctioning, the nurse should implement safety measures. Which of the following should the nurse implements?

  1. limit suction pressure to 150-180 mmHg
  2. suction for 15-20 seconds
  3. wear eye goggles
  4. remove the inner cannula

26. The nurse is conducting a discharge instructions to a client diagnosed with diabetes. What sign of hypoglycemia should be taught to a client?

  1. warm, flushed skin
  2. hunger and thirst
  3. increase urinary output
  4. palpitation and weakness

27. A client admitted to the hospital and diagnosed with Addison’s disease. What would be the appropriate nursing action to the client?

  1. administering insulin-replacement therapy
  2. providing a low-sodium diet
  3. restricting fluids to 1500 ml/day
  4. reducing physical and emotional stress

28. The nurse is to perform tracheal suctioning. During tracheal suctioning, which nursing action is essential to prevent hypoxemia?

  1. aucultating the lungs to determine the baseline data to assess the effectiveness of suctioning
  2. removing oral and nasal secretions
  3. encouraging the patient to deep breathe and cough to facilitate removal of upper-airway secretions
  4. administering 100% oxygen to reduce the effects of airway obstruction during suctioning.

29. An infant is admitted and diagnosed with pneumonia and suspicious-looking red marks on the swollen face resembling a handprint. The nurse does further assessment to the client. How would the nurse document the finding?

  1. Facial edema with ecchymosis and handprint mark: crackles and wheezes
  2. Facial edema, with red marks; crackles in the lung
  3. Facial edema with ecchymosis that looks like a handprint
  4. Red bruise mark and ecchymosis on face

30. On the evening shift, the triage nurse evaluates several clients who were brought to the emergency department. Which in the following clients should receive highest priority?

  1. an elderly woman complaining of a loss of appetite and fatigue for the past week
  2. A football player limping and complaining of pain and swelling in the right ankle
  3. A 50-year-old man, diaphoretic and complaining of severe chest pain radiating to his jaw
  4. A mother with a 5-year-old boy who says her son has been complaining of nausea and vomited once since noon

31. A 80-year-old female client is brought to the emergency department by her caregiver, on the nurse’s assessment; the following are the manifestations of the client: anorexia, cachexia and multiple bruises. What would be the best nursing intervention?

  1. check the laboratory data for serum albumin, hematocrit, and hemoglobin
  2. talk to the client about the caregiver and support system
  3. complete a police report on elder abuse
  4. complete a gastrointestinal and neurological assessment

32. The night shift nurse is making rounds. When the nurse enters a client’s room, the client is on the floor next to the bed. What would be the initial action of the nurse?

  1. chart that the patient fell
  2. call the physician
  3. chart that the client was found on the floor next to the bed
  4. fill out an incident report

33. The nurse on the night shift is about to administer medication to a preschooler client and notes that the child has no ID bracelet. The best way for the nurse to identify the client is to ask:

  1. The adult visiting, “The child’s name is ____________________?”
  2. The child, “Is your name____________?”
  3. Another staff nurse to identify this child
  4. The other children in the room what the child’s name is

34. The nurse caring to a client has completed the assessment. Which of the following will be considered to be the most accurate charting of a lump felt in the right breast?

  1. “abnormally felt area in the right breast, drainage noted”
  2. “hard nodular mass in right breast nipple”
  3. “firm mass at five ‘ clock, outer quadrant, 1cm from right nipple’
  4. “mass in the right breast 4cmx1cm

35. The physician instructed the nurse that intravenous pyelogram will be done to the client. The client asks the nurse what is the purpose of the procedure. The appropriate nursing response is to:

  1. outline the kidney vasculature
  2. determine the size, shape, and placement of the kidneys
  3. test renal tubular function and the patency of the urinary tract
  4. measure renal blood flow

36. A client visits the clinic for screening of scoliosis. The nurse should ask the client to:

  1. bend all the way over and touch the toes
  2. stand up as straight and tall as possible
  3. bend over at a 90-degree angle from the waist
  4. bend over at a 45-degree angle from the waist

37. A client with tuberculosis is admitted in the hospital for 2 weeks. When a client’s family members come to visit, they would be adhering to respiratory isolation precautions when they:

  1. wash their hands when leaving
  2. put on gowns, gloves and masks
  3. avoid contact with the client’s roommate
  4. keep the client’s room door open

38. An infant is brought to the emergency department and diagnosed with pyloric stenosis. The parents of the client ask the nurse, “Why does my baby continue to vomit?” Which of the following would be the best nursing response of the nurse?

  1. “Your baby eats too rapidly and overfills the stomach, which causes vomiting
  2. “Your baby can’t empty the formula that is in the stomach into the bowel”
  3. “The vomiting is due to the nausea that accompanies pyloric stenosis”
  4. “Your baby needs to be burped more thoroughly after feeding”

39. A 70-year-old client with suspected tuberculosis is brought to the geriatric care facilities. An intradermal tuberculosis test is schedule to be done. The client asks the nurse what is the purpose of the test. Which of the following would be the best rationale for this?

  1. reactivation of an old tuberculosis infection
  2. increased incidence of new cases of tuberculosis in persons over 65 years old
  3. greater exposure to diverse health care workers
  4. respiratory problems are characteristic in this population

40. The nurse is making a health teaching to the parents of the client. In teaching parents how to measure the area of induration in response to a PPD test, the nurse would be most accurate in advising the parents to measure:

  1. both the areas that look red and feel raised
  2. The entire area that feels itchy to the child
  3. Only the area that looks reddened
  4. Only the area that feels raised

41. A community health nurse is schedule to do home visit. She visits to an elderly person living alone. Which of the following observation would be a concern?

  1. Picture windows
  2. Unwashed dishes in the sink
  3. Clear and shiny floors
  4. Brightly lit rooms

42. After a birth, the physician cut the cord of the baby, and before the baby is given to the mother, what would be the initial nursing action of the nurse?

  1. examine the infant for any observable abnormalities
  2. confirm identification of the infant and apply bracelet to mother and infant
  3. instill prophylactic medication in the infant’s eyes
  4. wrap the infant in a prewarmed blanket and cover the head

43. A 2-year-old client is admitted to the hospital with severe eczema lesions on the scalp, face, neck and arms. The client is scratching the affected areas. What would be the best nursing intervention to prevent the client from scratching the affected areas?

  1. elbow restraints to the arms
  2. Mittens to the hands
  3. Clove-hitch restraints to the hands
  4. A posey jacket to the torso

44. The parents of the hospitalized client ask the nurse how their baby might have gotten pyloric stenosis. The appropriate nursing response would be:

  1. There is no way to determine this preoperatively
  2. Their baby was born with this condition
  3. Their baby developed this condition during the first few weeks of life
  4. Their baby acquired it due to a formula allergy

45. A male client comes to the clinic for check-up. In doing a physical assessment, the nurse should report to the physician the most common symptom of gonorrhea, which is:

  1. pruritus
  2. pus in the urine
  3. WBC in the urine
  4. Dysuria

46. Which of the following would be the most important goal in the nursing care of an infant client with eczema?

  1. preventing infection
  2. maintaining the comfort level
  3. providing for adequate nutrition
  4. decreasing the itching

47. The nurse is making a discharge instruction to a client receiving chemotherapy. The client is at risk for bone marrow depression. The nurse gives instructions to the client about how to prevent infection at home. Which of the following health teaching would be included?

  1. “Get a weekly WBC count”
  2. “Do not share a bathroom with children or pregnant woman”
  3. “Avoid contact with others while receiving chemotherapy”
  4. “Do frequent hand washing and maintain good hygiene”

48. The nurse is assigned to care the client with infectious disease. The best antimicrobial agent for the nurse to use in handwashing is:

  1. Isopropyl alcohol
  2. Hexachlorophene (Phisohex)
  3. Soap and water
  4. Chlorhexidine gluconate (CHG) (Hibiclens)

49. The mother of the client tells the nurse, “ I’m not going to have my baby get any immunization”. What would be the best nursing response to the mother?

  1. “You and I need to review your rationale for this decision”
  2. “Your baby will not be able to attend day care without immunizations”
  3. “Your decision can be viewed as a form of child abuse and neglect”
  4. “You are needlessly placing other people at risk for communicable diseases”

50. The nurse is teaching the client about breast self-examination. Which observation should the client be taught to recognize when doing the examination for detection of breast cancer?

  1. tender, movable lump
  2. pain on breast self-examination
  3. round, well-defined lump
  4. dimpling of the breast tissue
Answers and Rationales
  1. D. Bathing an infant with eczema can be safely delegated to an aide; this task is basic and can competently performed by an aid.
  2. B. The RN floated from the telemetry unit would be least prepared to care for a young infant who has just had GI surgery and requires a specific feeding regimen.
  3. C. RN floated from the obstetrics unit should be able to care for a client with major abdominal surgery, because this nurse has experienced caring for clients with cesarean births.
  4. A. The patient is experiencing a potentially serious complication related to diabetes and needs ongoing assessment by an RN
  5. D. It describes functional nursing. Staff is assigned to specific task rather than specific clients.
  6. B. Case management. The nurse assumes total responsibility for meeting the needs of the client during her entire duty.
  7. B. The nurse is ethically obligated to inform the person responsible for the assignment and the person responsible for the unit about the nurse’s skill level. The nurse therefore avoids a situation of abandoningclients and exposing them to greater risks
  8. A. This describes a mentor
  9. B. This action demonstrates a lack of responsibility and the nurse should attempt negotiation with the nurse manager.
  10. B. The team leader is responsible for the overall management of all clients and staff on the team, and this information is essential in order to accomplish this
  11. C. Even though the mother is a minor, she is legally able to sign consent for her own child.
  12. B.  This response is the most direct and immediate. This is a case of potential need for advocacy and patient’s rights.
  13. D.  The nurse who witness a consent for treatment or surgery is witnessing only that the client signed the form and that the client’s condition is as indicated at the time of signing. The nurse is not witnessing that the client is “informed”.
  14. C. Although the statements by the mother may not create a suspicion of neglect, when they are coupled with observations about impaired bonding and maternal attachment, they may impose the obligation to report child neglect. The nurse is further obligated to notify caregivers of refusal to consent to treatment
  15. C. It best explains what informed consent is and provides for legal rights of the patient
  16. B. The physician may not be aware of the role that religious beliefs play in making a decision about surgery.
  17. A. The behavior should be stopped. The first step is to remind the staff that confidentiality may be violated
  18. C. Waiting for emotions to dissipate and sitting down with the colleague is the first rule of conflict resolution.
  19. C. The nurse has no idea who the person is on the phone and therefore may not share the information even if the patient gives permission
  20. A. The priority is to let the surgeon know, who in turn may ask the husband to sign the consent.
  21. A. Phenytoin (Dilantin) can cause venous irritation due to its alkalinity, therefore it should be mixed with normal saline.
  22. A. This position increases venous return, improves cardiac volume, and promotes adequate ventilation and cerebral perfusion
  23. D. Checking the airway would be a priority, and a neck injury should be suspected
  24. D. Client with Parkinson’s disease are at a high risk for aspiration and undernutrition. Sitting upright promotes more effective swallowing.
  25. C.  It is important to protect the RN’s eyes from the possible contamination of coughed-up secretions
  26. D. There has been too little food or too much insulin. Glucose levels can be markedly decreased (less than 50 mg/dl). Severe hypoglycemia may be fatal if not detected
  27. D. Because the client’s ability to react to stress is decreased, maintaining a quiet environment becomes a nursing priority. Dehydration is a common problem in Addison’s disease, so close observation of the client’s hydration level is crucial.
  28. D.  Presuctioning and postsuctioning ventilation with 100% oxygen is important in reducing hypoxemia which occurs when the flow of gases in the airway is obstructed by the suctioning catheter.
  29. B. This is an example of objective data of both pulmonary status and direct observation on the skin by the nurse.
  30. C.  These are likely signs of an acute myocardial infarction (MI). An acute MI is a cardiovascular emergency requiring immediate attention. Acute MI is potentially fatal if not treated immediately.
  31. D. Assessment and more data collection are needed. The client may have gastrointestinal or neurological problems that account for the symptoms. The anorexia could result from medications, poor dentition, or indigestion, and the bruises may be attributed to ataxia, frequent falls, vertigo or medication.
  32. B. This is closest to suggesting action-assessment, rather than paperwork- and is therefore the best of the four.
  33. C. The only acceptable way to identify a preschooler client is to have a parent or another staff member identify the client.
  34. C. It describes the mass in the greatest detail.
  35. C. Intravenous pyelogram tests both the function and patency of the kidneys. After the intravenous injection of a radiopaque contrast medium, the size, location, and patency of the kidneys can be observed by roentgenogram, as well as the patency of the urethra and bladder as the kidneys function to excrete the contrast medium.
  36. C. This is the recommended position for screening for scoliosis. It allows the nurse to inspect the alignment of the spine, as well as to compare both shoulders and both hips.
  37. A.  Handwashing is the best method for reducing cross-contamination. Gowns and gloves are not always required when entering a client’s room.
  38. B. Pyloric stenosis is an anomaly of the upper gastrointestinal tract. The condition involves a thickening, or hypertrophy, of the pyloric sphincter located at the distal end of the stomach. This causes a mechanical intestinal obstruction, which leads to vomiting after feeding the infant. The vomiting associated with pyloric stenosis is described as being projectile in nature. This is due to the increasing amounts of formula the infant begins to consume coupled with the increasing thickening of the pyloric sphincter.
  39. B. Increased incidence of TB has been seen in the general population with a high incidence reported in hospitalized elderly clients. Immunosuppression and lack of classic manifestations because of the aging process are just two of the contributing factors of tuberculosis in the elderly.
  40. D. Parents should be taught to feel the area that is raised and measure only that.
  41. C. It is a safety hazard to have shiny floors because they can cause falls.
  42. D. The first priority, beside maintaining a newborn’s patent airway, is body temperature.
  43. B.  The purpose of restraints for this child is to keep the child from scratching the affected areas. Mittens restraint would prevent scratching, while allowing the most movement permissible.
  44. C. Pyloric stenosis is not a congenital anatomical defect, but the precise etiology is unknown. It develops during the first few weeks of life.
  45. B. Pus is usually the first symptom, because the bacteria reproduce in the bladder.
  46. A. Preventing infection in the infant with eczema is the nurse’s most important goal. The infant with eczema is at high risk for infection due to numerous breaks in the skin’s integrity. Intact skin is always the infant’s first line of defense against infection.
  47. D. Frequent hand washing and good hygiene are the best means of preventing infection.
  48. D. CHG is a highly effective antimicrobial ingredient, especially when it is used consistently over time.
  49. A.  The mother may have many reasons for such a decision. It is the nurse’s responsibility to review this decision with the mother and clarify any misconceptions regarding immunizations that may exist.
  50. D. The tumor infiltrates nearby tissue, it can cause retraction of the overlying skin and create a dimpling appearance.