Question 1

The nurse is completing a percutaneous endoscopic gastrostomy (PEG) feeding on a patient who had the PEG tube placed one week ago. The nurse notices that the tube has become dislodged. What is the priority action?

Accepted Answer

Answer reason: A newly placed PEG (about 1 week old) has an immature tract, so blind reinsertion risks creating a false tract, perforation, and peritonitis. The priority is rapid provider notification for timely replacement and confirmation of correct placement before use, because the stoma can begin to close quickly after dislodgement. Nursing actions like attempting reinsertion or placing a Foley catheter are not appropriate without an order and can worsen harm in an immature tract. Using an NGT may be needed later for temporary access, but it does not address the immediate risk of tract closure and potential complications from improper replacement.

Question 2

A client, diagnosed with severe depression, asks a nurse about taking St. John’s wort as an alternative to prescription antidepressants. Which is the best response by the nurse?

Accepted Answer

Answer reason: "Severe depression requires coordinated, evidence-based treatment planning because inadequate therapy increases the risk of worsening symptoms and suicidality. An herbal product can have clinically significant drug interactions (notably serotonergic toxicity risk with antidepressants and reduced effectiveness of many medications via enzyme induction), so changing therapy should be medically supervised. The safest nursing response is to promote interprofessional evaluation rather than endorsing an alternative or giving specific dosing/efficacy claims. Saying it is automatically safe because it is “herbal” is a common misconception and can lead to harm due to adverse effects and interactions.

Question 3

The nurse is planning care for a client with a low serum albumin level. Which of the following interventions should the nurse include in the client’s plan of care?

Accepted Answer

Answer reason:  Low serum albumin most commonly reflects inadequate protein intake/absorption, increased losses (e.g., nephrotic syndrome), or decreased hepatic synthesis, and it increases risks such as edema, impaired wound healing, and poor overall nutrition status. A targeted nutrition assessment and protein-calorie optimization are appropriate nursing interventions, and a dietician is the key collaborator to individualize dietary plans and supplementation. Checking capillary glucose is not a direct response to hypoalbuminemia unless diabetes/hypoglycemia is otherwise suspected. Seizure precautions and strict bed rest are not indicated by a low albumin level and could add unnecessary restrictions and complications.

Question 4

A 65 year old male patient is being examined, and the nurse notes a pulsatile mass in the abdomen. The patients vital signs are BP: 98/60 mmHg, Pulse: 122 bpm, Respirations: 18/min, Temp: 99.0 °F. What should the nurse do next?

Accepted Answer

Answer reason: A pulsatile abdominal mass with hypotension and tachycardia is highly concerning for an abdominal aortic aneurysm with possible impending/active rupture, which is an emergent, life-threatening condition. The priority nursing action is rapid escalation to the provider/rapid response to activate definitive evaluation and surgical management while maintaining close monitoring and readiness for resuscitation. Rechecking the blood pressure delays treatment and does not address the high-risk assessment finding. Initiating an IV bolus may be performed per protocol, but it is not the best single next step without urgent notification because definitive management requires immediate medical/surgical intervention.

Question 5

What does the R in SBAR stand for?

Accepted Answer

Answer reason: The final step prompts the communicator to state what they think is needed next (e.g., orders, evaluation, transfer level of care), which closes the loop and supports timely decision-making. This aligns with safe interprofessional collaboration by translating assessment findings into an actionable plan. A common error is stopping after the assessment without explicitly stating what is being requested or proposed, which can delay interventions and increase risk.

Question 6

Which of the following conflict management strategies produces the best outcome?

Accepted Answer

Answer reason: It uses open communication, problem-solving, and shared decision-making to address the underlying issues rather than just reducing tension. This typically improves team relationships, patient-care coordination, and safety outcomes because all stakeholders buy into the plan. By contrast, compromising often results in each side giving up something important, and accommodating/smoothing may temporarily reduce conflict but can leave core problems unresolved.

Question 7

The nurse is administering medications and a 48-year-old has 20 mg Labetalol IV push ordered. The nurse verifies the last documented blood pressure as 128/67. What is the best course of action?

Accepted Answer

Answer reason: g., indication, target BP, and hold criteria). A BP of 128/67 is not hypertensive and could become dangerously low if an IV push beta-blocker is given without a clear reason or threshold. Nursing practice does not support independently altering an ordered IV push dose without an explicit protocol or provider direction. Contacting the provider to clarify the indication and specific hold parameters best prevents iatrogenic hypotension/bradycardia and aligns with safe medication administration standards.

Question 8

Situation : You are assigned to take care of a group of patients across the lifespan. In conflict management, the win-win approach occurs when?

Accepted Answer

Answer reason: This requires shared commitment to openly communicate, generate options, and agree on a mutually beneficial plan rather than trading concessions. Option B describes compromise (each side gives up something), which is not necessarily win-win because both may lose part of what they value. Options A and D do not reflect collaborative resolution between the parties and are inconsistent with standard conflict-management styles used in nursing leadership.

Question 9

The nurse assesses that the client with delirium tremens is becoming increasingly agitated. The nurse notes that IV doses of diazepam, lorazepam, and propofol are prescribed for the client, but is unclear regarding which medication would be most effective. Which action by the nurse will best improve the client’s outcome?

Accepted Answer

Answer reason: The nurse recognizes a knowledge gap and appropriately seeks expert consultation. Pharmacists are key members of the interprofessional team and can provide detailed guidance on medication selection, dosing, and safety—especially in complex cases like delirium tremens where benzodiazepines are typically first-line and propofol carries higher risks. This action supports safe, evidence-based care and improves outcomes. Option A is unsafe and not evidence-based. Option B is incorrect because the listed medications can be effective. Option C involves administering a high-risk sedative without adequate understanding, which could cause respiratory depression or require airway support.

Question 10

The nurse case manager knows case management is an example of which client care model?

Accepted Answer

Answer reason: Case management is fundamentally based on coordination of care across multiple disciplines, including nurses, physicians, social workers, and other healthcare professionals. The goal is to ensure continuity, efficiency, and optimal outcomes through collaborative planning and communication. This aligns directly with the interdisciplinary care management model rather than models focused solely on protocols, outcomes, or risk assessment.

Question 11

The nurse is talking with the parents of a 3-day-old client with Edwards syndrome (trisomy 18) who is receiving mechanical ventilation. The parents ask when the client will be able to breathe without the ventilator. The nurse should?

Accepted Answer

Answer reason: A structured interdisciplinary meeting supports consistent messaging, clarifies goals of care (life-prolonging vs comfort-focused), and allows parents to ask questions about realistic expectations and next steps. This approach also ensures palliative care involvement for symptom management and psychosocial support while aligning treatment with the family’s values. By contrast, offering “curative” options is misleading because trisomy 18 is not curable, and providing inaccurate survival predictions undermines trust and informed decisions.

Question 12

Which of the following would be the best example of an appropriate SBAR report?

Accepted Answer

Answer reason: SBAR communication should be concise and structured, clearly stating the situation, relevant background, objective assessment data, and a specific recommendation. This report includes key objective findings (oxygen delivery method and rate, SpO2 of 88%, crackles) that support clinical urgency and demonstrates nursing assessment rather than vague concern. It also ends with a clear, actionable request, which improves provider response and patient safety. By contrast, statements focused mainly on anxiety, nonspecific “unstable vitals,” or unrelated history do not provide sufficient assessment data to guide immediate clinical decisions.

Question 13

Which of the following power refers to the ability of a leader to influence a follower because of the follower’s loyalty and admiration?

Accepted Answer

Answer reason: Referent power is based on admiration, respect, and loyalty toward a leader. Followers comply because they identify with or respect the leader, which supports effective collaboration and team dynamics in care delivery.

Question 14

When assessing a child’s cultural background, the nurse in charge should keep in mind that?

Accepted Answer

Answer reason: This makes intergenerationally shared behavior patterns a key concept for nurses when assessing how families understand illness, prevention, and treatment. In contrast, assuming culture has little impact on health practices risks missed preferences and nonadherence due to unaddressed beliefs. Physical traits do not reliably define culture, and “heritage” alone does not rigidly determine values because individuals vary within cultural groups.

Question 15

Her former manager demonstrated passion for serving her staff rather than being served. She takes time to listen, prefers to be a teacher first before being a leader, which is characteristic of?

Accepted Answer

Answer reason: The stem describes a leader who serves first, listens, and frames leadership as teaching and developing people, which aligns directly with servant-leader principles. Transformational leadership focuses more on inspiring a shared vision and motivating change rather than explicitly putting followers’ needs first. Transactional leadership is primarily exchange-based (rewards/penalties), and charismatic leadership centers on personal charm/influence, neither of which best fits the “serve others first” theme.

Question 16

The nurse is caring for a client who recently immigrated from Southeast Asia and is being treated for hypertension. During medication teaching, the client states, “I prefer to use herbal teas and traditional remedies instead of pills.” What is the nurse’s best next action?

Accepted Answer

Answer reason: When clients use herbal remedies alongside prescribed medications, the nurse should ensure safety by verifying potential interactions and coordinating care with appropriate team members. This approach supports a safe, individualized plan while respecting the client’s preferences. Other responses are dismissive, create unnecessary ultimatums, or fail to address potential safety risks.

Question 17

During the morning rounds, Nurse AJ accompanied the physician in every patient’s room. The physician writes orders for the client with diabetes mellitus. Which order would the nurse validate with the physician?

Accepted Answer

Answer reason: Insulin glargine is a long-acting “basal” insulin designed to provide relatively flat 24-hour coverage and is typically ordered once daily. Ordering it BID increases overlap of action and raises hypoglycemia risk, so it warrants clarification for intent (e.g., split dosing rationale) and patient-specific factors. In contrast, rapid-acting insulin (lispro) is appropriate for correction/sliding scale, and regular insulin is appropriately timed about 30 minutes before meals. Metformin 1000 mg/day in divided doses is a common, acceptable total daily dose depending on renal function and tolerance.

Question 18

During a staff meeting the nurse manager presents his own analysis of problems and proposal for actions to the staff, inviting critique and comments. Which answer indicates the manager’s leadership style?

Accepted Answer

Answer reason: Presenting an analysis and proposed actions, then explicitly inviting critique and comments, reflects shared problem-solving rather than unilateral control. This differs from autocratic leadership, which minimizes staff input and expects compliance with the leader’s decisions. It also differs from laissez-faire leadership, where the leader provides little guidance and staff largely direct themselves. The described approach supports collaboration, buy-in, and improved implementation of agreed-upon plans.

Question 19

Which of the following is often associated with the concept of decentralized decision making in management?

Accepted Answer

Answer reason: Aligns with councils/committees where nurses participate in policy, practice standards, and quality decisions rather than relying solely on top-down administrative control. The correct choice reflects a formal structure that supports autonomy, engagement, and shared accountability for outcomes. A common distractor is team nursing, which is primarily a care delivery assignment model and does not inherently define how organizational decisions are decentralized. Shared governance most directly captures the management concept being tested.

Question 20

Some decisions are best made by a group rather that by the nurse alone. What is an advantage of group decision making?

Accepted Answer

Answer reason: Pooling input tends to improve the completeness and safety of care plans, especially for complex patients requiring interdisciplinary coordination. This advantage is distinct from simply having “different ideas,” because the benefit is the synthesis into a more comprehensive decision. Options describing influence by others or fostering dependency reflect potential disadvantages (groupthink, reduced autonomy), not advantages.

Question 21

Situation: Maria, 48 years old, is a known diabetic type 1. She has often consulted her internist for medication. She asks you if she can get well. 1. If Maria asks you what to take for medication, you would answer that she;?

Accepted Answer

Answer reason: For chronic conditions like type 1 diabetes, safe medication management depends on coordinated, prescriber-directed therapy and adherence to an individualized regimen (e.g., insulin dosing, monitoring, and adjustments). The nurse’s appropriate guidance is to reinforce following the prescribed plan and to consult the treating provider before making changes, because unsupervised changes increase risk of hypo/hyperglycemia and complications. Advising “alternative” approaches or switching providers without a clinical reason undermines continuity and coordinated management. A blanket statement that all herbal medicines are prohibited is less precise than emphasizing prescriber guidance, assessment for interactions, and adherence to the ordered regimen.

Question 22

Which of the following is the best guarantee that the patient's priority needs are met?

Accepted Answer

Answer reason: A collaboratively developed nursing care plan translates assessed needs into measurable outcomes and tailored nursing actions, and it is continually updated based on the patient’s responses. Input from family, the physician, and the interprofessional team can be valuable, but none replaces direct partnership with the patient in setting priorities. This approach also supports autonomy, improves adherence, and reduces missed or misaligned care priorities.

Question 23

The charge nurse in the telemetry unit has delegated the task of giving a bed bath to a male Arab client. Which communication to the female nursing assistant demonstrates appropriate cultural sensitivity?

Accepted Answer

Answer reason: In many Arab/Middle Eastern cultural contexts, modesty norms and gender interactions may make direct eye contact between unrelated men and women feel uncomfortable, particularly during intimate care. Minimizing eye contact while maintaining respectful, professional communication supports privacy and reduces perceived impropriety during a bed bath. Requiring the wife’s presence is not an appropriate assumption and may violate privacy or be impractical in the hospital. Claims about not talking or that touching the head is disrespectful are not broadly reliable across Arab cultures and risk stereotyping rather than promoting individualized care.

Question 24

Which is the philosophy of CULTURALCARE?

Accepted Answer

Answer reason: Culturally congruent nursing care is grounded in the principle that health beliefs, values, and practices shape how patients define health, interpret symptoms, and accept treatments. This option directly reflects cultural care by emphasizing holistic care tailored to a person’s cultural traditions and needs to improve communication, trust, and adherence. By contrast, focusing primarily on technology/science or broad prevention goals describes other healthcare philosophies but does not address cultural meaning and patient-centered cultural context. Aligning care with the patient’s cultural framework supports safer, more effective planning and shared decision-making.

Question 25

A neonate on ventilator support is diagnosed with trisomy 18 (Edwards syndrome). What would be an appropriate action by the nurse?

Accepted Answer

Answer reason: Coordinating an interdisciplinary meeting supports shared decision-making, aligns interventions (including ventilator use) with family values, and ensures symptom management and psychosocial support. This is within the nurse’s role to initiate collaboration and advocate for appropriate resources, rather than independently implying recovery or a weaning trajectory. Options that focus only on generic treatment information or distributing results are incomplete for the urgency and ethical complexity of prognosis and decision-making in this scenario.

Question 26

A nurse in a community health clinic is caring for four clients who each have a communicable disease. Which of the following conditions is considered a nationally notifiable infectious disease?

Accepted Answer

Answer reason: Chlamydial infection is a nationally notifiable sexually transmitted infection in the U.S., so identifying it triggers mandatory reporting and partner notification/public health follow-up. In contrast, RSV is not typically a nationally notifiable condition, and MRSA and C. difficile reporting requirements are generally institution- or jurisdiction-specific rather than universally nationally notifiable in routine clinical settings. This makes the STI the most clearly reportable condition among the options.

Question 27

The nurse is assigned to a client who does not have any brain function. Which referral is appropriate at this time?

Accepted Answer

Answer reason: This referral supports coordinated end-of-life and donation processes and ensures required protocols, consent processes, and preservation measures are initiated appropriately. Hospice is intended for patients with terminal illness who are still alive and focuses on comfort care rather than post–brain death organ donation. Home health and funeral director referrals are not the immediate clinical priority at the time brain death is identified.

Question 28

The nurse is approached by a friend who has a lesion on her neck. The lesion is dark brown/black in color. It is irregularly shaped and is described as having enlarged in size over the last few months. What advice should the nurse give in regards to this lesion?

Accepted Answer

Answer reason: " An enlarging, irregularly shaped, dark pigmented lesion is concerning for melanoma using the ABCDE warning signs (asymmetry, border irregularity, color variation/darkness, diameter/change, evolution). The safest nursing guidance is prompt referral for expert evaluation and possible biopsy, since early diagnosis markedly improves outcomes. “Watch and wait” and reassurance with topical creams can delay detection of a potentially malignant lesion. Covering from sun can be good prevention advice, but it does not address the urgent need for diagnostic assessment.

Question 29

A woman has been admitted to the labor and delivery unit with a macular rash and lymphadenopathy. Lab tests reveal WBC count of 11,000, a platelet count of 200,000, creatinine of 0.9, and the nontreponemal antibody test is positive. What should the nurse do next?

Accepted Answer

Answer reason: A positive nontreponemal test with rash and lymphadenopathy in pregnancy is concerning for active syphilis, which requires prompt provider evaluation and treatment to reduce the risk of congenital infection. The nurse’s priority is to escalate care for timely confirmatory testing, staging, and initiation of penicillin therapy and fetal risk management. The other findings (WBC, platelets, creatinine) are not the urgent issue driving next-step action here. Interventions like increasing fluids or positioning do not address the infectious risk to the fetus, and asking about illicit drug use does not change the immediate need for treatment coordination.

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