1.Easy
Which finding is an airway problem?
- ASwelling of the tongue and lips with a hoarse voice
- BA weak, thready radial pulse
- CFine crackles heard at the bases of both lungs on inspiration
- DAbdominal pain rated 8/10
2.Easy
What does a “STAT” order mean?
- ACarry it out immediately
- BCarry it out only if the patient asks for it
- CCarry it out within the next 24 hours
- DCarry it out at the next routine round
3.Easy
In a three-level triage system, a patient with a twisted ankle, normal vital signs and mild pain is usually classified as:
- AUrgent
- BNon-urgent
- CExpectant
- DEmergent
4.Medium
A patient wants to leave the hospital against medical advice. What should the nurse do?
- AHide the patient’s clothes and belongings until the provider arrives
- BInform the provider, explain the risks and document the discussion
- CLock the door so the patient cannot leave the unit
- DLet the patient leave without telling anyone
5.Medium
A registered nurse tells a nursing assistant, “Check on the patient in room 12.” Which right of delegation is missing?
- ARight task for the setting
- BRight directions and communication
- CRight person for the task
- DRight circumstance
6.Medium
A pregnant nurse is on the unit. Which patient should the charge nurse avoid assigning to her?
- AA patient with a fractured wrist
- BA patient with type 2 diabetes who needs insulin teaching before discharge
- CA patient with a sealed radioactive implant for cervical cancer
- DA patient after a hip replacement
7.Hard
A team has an RN, an LPN/LVN and a nursing assistant. Which task is the best one to assign to the LPN/LVN?
- AGiving a scheduled subcutaneous anticoagulant injection to a stable patient
- BWriting the discharge teaching plan for a patient with new diabetes
- CMeasuring the vital signs and weights of every patient on the unit before breakfast
- DAssessing a patient who returned from surgery 30 minutes ago
8.Hard
A patient with Guillain-Barré syndrome has weakness that is spreading up from the legs. Which assessment has the highest priority?
- AThe patient’s mood and coping
- BMuscle strength in the feet and ankles at the start of each morning
- CSkin condition over the heels
- DBreathing strength, such as vital capacity and the ability to cough
Answer key
- 1. A · Swelling of the tongue and lips with a hoarse voice
- 2. A · Carry it out immediately
- 3. B · Non-urgent
- 4. B · Inform the provider, explain the risks and document the discussion
- 5. B · Right directions and communication
- 6. C · A patient with a sealed radioactive implant for cervical cancer
- 7. A · Giving a scheduled subcutaneous anticoagulant injection to a stable patient
- 8. D · Breathing strength, such as vital capacity and the ability to cough
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