NURSING-Readiness Benchmark Exam

1. Hepatic Encephalopathy Diet

NURSING-Readiness Benchmark Exam. A client who is 43-years-old is admitted to the medical unit with a diagnosis of hepatic cirrhosis and a provisional diagnosis of hepatic encephalopathy. The client’s laboratory results reveal an ammonia level of 120 mcg/dL (Reference Range 10 to 80 mcg/dL). Which nutritional recommendation should the nurse include in the client’s plan of care?

• High calorie, high carbohydrate diet.
• Encourage a low protein diet.
• Limit intake of leafy green vegetables.
• Increase intake of foods high in potassium.

2. Laissez-Faire Leadership

A nurse manager is using a laissez-faire leadership style. Which action by the nurse manager would be most consistent with this style?

• Direct every action of the staff on the unit.
• Assume a passive role, providing little to no direction to the staff.
• Give minimal guidance to staff on the unit, using a “hands off” approach.
• Consult with the staff to make decisions for the unit.

3. Hypovolemia Management

A client reports vomiting and diarrhea for the past 48 hours. The client’s blood pressure is 90/56 mm Hg, heart rate is 120 beats/min, and the skin is cool and clammy. Which interventions should the nurse anticipate? (Select all that apply.) NURSING-Readiness Benchmark Exam

• Administer ondansetron.
• Place client on fall precautions.
• Establish intravenous access.
• Place the client in a high-Fowler’s position.
• Administer a bolus of 5% dextrose in water.

4. Warfarin and GI Bleeding

A client is admitted to the emergency department with gastrointestinal bleeding. The client has a history of a recent blood clot and is taking warfarin. Which assessment finding is most significant?

• The client’s last bowel movement was 2 days ago.
• Takes over-the-counter nonsteroidal anti-inflammatory drugs for pain.
• The client consumes a diet high in leafy green vegetables.
• The client’s INR is 2.5.

5. Reinforcing Civility

A nurse manager is developing a plan to reinforce civility among staff on the unit. Which action should the nurse manager include in the plan?

• Use role play to demonstrate the influence of civility on staff relationships and communication.
• Allow the staff to handle conflicts independently.
• Implement a policy of zero tolerance for any form of incivility.
• Conduct mandatory monthly meetings to discuss the importance of civility.

6. Infant Iron Deficiency

The nurse is providing education to the parents of a healthy, term, breastfed infant about preventing iron deficiency. Which information should the nurse include?

• Introduce cow’s milk at 9 months of age.
• Iron-fortified infant cereal can be introduced at approximately 6 months of age.
• Administer iron supplements starting at birth.
• Breast milk provides all the iron the infant needs for the first year.

7. Narcotic Diversion Investigation

A nurse manager is suspecting a staff nurse of diverting narcotics. Which statement by the nurse manager to the staff nurse is most appropriate?

• “You are being suspended pending an investigation into missing narcotics.”
• “I have noticed you seem very tired lately. Are you okay?”
• “We have a discrepancy in narcotic administration on the days that you work, and as part of the investigation, we need you to take a drug screen now.”
• “If you have a problem with drugs, you need to tell me so we can help you.” NURSING-Readiness Benchmark Exam

8. Gestational Diabetes Assessment

A nurse is assessing a pregnant client with gestational diabetes. The client’s blood glucose is 75 mg/dL before lunch. Which recommendation is most appropriate?

• Increase the dose of insulin before lunch.
• This is a normal blood glucose level.
• THIS IS LOW; MAKE SURE YOU ARE EATING BEFORE LUNCH EACH DAY.
• Eat a high-sugar snack immediately.

9. Antacid Interaction

A nurse is performing a medication reconciliation for a client who is prescribed antacids daily. Which medication should the nurse identify as having a potential interaction with antacids? NURSING-Readiness Benchmark Exam

• Furosemide.
• Sublingual nitroglycerin.
• Atorvastatin.
• Metoprolol.

10. Difficile Precautions

A nurse is caring for a client suspected of having Clostridium difficile. Which actions should the nurse take? (Select all that apply.)

• Don a gown and gloves during client care.
• Place on contact precautions.
• Wash hands with soap and water.
• Use an alcohol-based hand sanitizer after care.
• Place the client in a room with negative pressure.

11. Type 1 Diabetes Education

A nurse is providing education to a client with type 1 diabetes mellitus. Which statements by the client indicate a need for additional instruction? (Select all that apply.)

• “I will not take my insulin if I am sick and not eating.”
• “I can eat whatever I want as long as I take additional insulin.”
• “I will check my blood glucose levels before each meal and at bedtime.”
• “I will carry a source of fast-acting carbohydrate with me at all times.”

12. Short-Staffed Unit Causes

A nurse manager is investigating why a unit is consistently short-staffed. Which factors should the nurse manager identify as likely causes? (Select all that apply.)

• Charge nurse relieves unit nurses for breaks but not the nurses floated to the unit.
• The nurse manager on the unit assigns fewer clients to unit staff than to float staff.
• Clients with the highest acuity are assigned to staff who float to the unit.
• The unit has a low turnover rate among staff nurses.

13. Preoperative Problem Identification

A client is admitted for a femur fracture. The client is NPO and signed the consent after the preoperative workup. Midazolam was given at 1125, and the consent was signed at 1200.

Situation	Problem	Not a Problem
Chlorhexidine wipes were not used this morning.	X
Metoprolol was administered to the client.		X
Midazolam was given prior to informed consent.	X
Family is not in the family waiting room.		X
Consent was signed after the preop workup.		X

14. Fear of Labor Response

A client who is 39 weeks pregnant expresses fear about the impending labor and how to manage. The client’s birth plan includes insertion of an epidural catheter for anesthesia. Which response by the nurse is most appropriate?

• “It’s normal to be anxious about labor. Let’s discuss what makes you afraid.”
• “Labor is scary to think about, but the actual experience isn’t.”
• “You are going to have an epidural. You won’t feel anything.”
• “Don’t worry, you’ll do fine. Women have been having babies for a long time.”

15. Medication Error: Insulin

A 76-year-old client is cared for in the medical-surgical unit. Nursing notes state: 0730 Fasting fingerstick glucose 224 mg/dL. Breakfast trays passed and client eating. 0815 Morning meds given. The MAR shows Insulin aspart 5 units given at 0815, prescribed “Before meals and at bedtime.”

• The nurse recognizes that an error has been made in the administration of insulin aspart because the nurse did not recheck the client’s glucose.

16. Increased Intracranial Pressure Care

The nurse plans care for a client with increased intracranial pressure. What should the nurse include in the plan of care?

• Position the client in a supine position and provide pillows for comfort.
• Encourage coughing and deep breathing to clear the airway.
• Manually disimpact the client if they did not have a recent bowel movement.
• Administer prescribed antiseizure medications to prevent seizures.

17. Placental Abruption Finding

A client presents to the emergency department with suspected placental abruption. Which assessment finding is most concerning to the nurse?

• Increase in maternal blood pressure.
• Decrease in fundal height.
• Decrease in reports of abdominal pain.
• Hard, board-like abdomen.

18. Cirrhosis and Pain Management

A 68-year-old client is admitted to the orthopedic unit with a diagnosis of shoulder dislocation. The client has a history of alcohol abuse, advanced cirrhosis, and a previous hip fracture. Orders include Acetaminophen 500 mg every 4 hours PRN pain. Client reports 9/10 pain. What is the most appropriate intervention?

• Administer the acetaminophen as prescribed for the client’s pain.
• Encourage the client to use non-pharmacological pain interventions.
• Administer half of the acetaminophen dose to the client.
• Call the health care provider to verify the acetaminophen prescription.

19. Hip Replacement Delegation

The nurse is caring for a client who is post-operative following a total hip replacement. Which task is most appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?

• Assess the client’s surgical incision for signs of infection.
• Assist the client to perform deep breathing and coughing exercises.
• Provide education to the client on the use of an incentive spirometer.
• Determine the client’s level of pain using a numeric scale.

20. Placental Abruption Contraindication

The nurse is caring for a client with suspected placental abruption. Which intervention should the nurse avoid?

• Perform a vaginal examination.
• Monitor fetal heart rate continuously.
• Administer oxygen via non-rebreather mask.
• Initiate a large-bore intravenous access.

21. Hypoglycemia Action

A client with diabetes mellitus received the prescribed doses of regular and NPH insulin at 0800. At 1200, the client reports feeling shaky, lightheaded, and faint. Which action should the nurse take next? NURSING-Readiness Benchmark Exam

• Prepare the next dose of regular insulin.
• Obtain capillary blood glucose.
• Prepare to administer 50% dextrose IV.
• Call the rapid response team.

22. Non-Reassuring FHR

An experienced nurse teaches new perinatal nurses to interpret uterine and fetal heart monitoring. The nurse explains that fetal heart rates that are tachycardic, bradycardic, or include late decelerations or loss of variability are non-reassuring. Which should the nurse instruct the new nurses to anticipate?

• Assess and intervene for fetal exposure to opiates due to maternal drug use.
• Provide interventions to relieve maternal hypotension.
• Institute measures to relieve fetal cord compression.
• Plan interventions that relieve fetal hypoxemia. NURSING-Readiness Benchmark Exam

23. Homeless Student Plan

A teacher is concerned about a student who was attentive and used to perform well. Lately, the student is doing poorly, looks disheveled, and falls asleep in class. The nurse suspects the family is homeless. What is most important for the nurse to include in the plan?

• A note to the parents giving them a week to get shelter or they will be reported.
• A letter to the parents stating the student’s behaviors and offering to help in any way possible.
• A call to Child Protective Services to report that the student is homeless.
• Allowing the student to have meals in the cafeteria and sleep in the gymnasium.

24. Inappropriate Communication

The nurse enters the room of a client labeled disagreeable by staff. The client says, “I haven’t seen you since I have been here. Are you new? I’m not taking that pill right now, either.” Which responses would be inappropriate? (Select all that apply.)

• “Oh, no problem. You don’t have to take it now; take it anytime you wish.”
• “Tell me what’s preventing you from taking it now.”
• “I’m not the one who needs this pill. You’re not hurting me by not taking it.”
• “I suggest you take this pill now, because you will die if you keep refusing to take it.”
• “Yes, I hear you are disagreeable, and I don’t take foolishness either, so take your pill.”

25. Herbal Laxative

A client was given a laxative this morning. Today, the client has had 5 bowel movements and reports abdominal cramping. The client admits to taking a small amount of an herbal drug in the morning. Which herb did the client most likely take?

• Aloe
• Ginger root
• Garlic

26. Pre-Op Lifestyle Modifications

A client who is 55 years old and has a history of hypertension is attending a pre-operative appointment for elective surgery. Which recommendations does the nurse include? (Select all that apply.)

• Reduce sodium intake to less than 2,000 mg per day.
• Avoid smoking, vaping, or use of any type or form of tobacco products.
• Increase dietary potassium intake through fruits and vegetables.
• Engage in 90-150 minutes of aerobic and resistance training activity per week.
• Increase foods high in trans-fatty acids to maintain energy levels.
• Limit alcohol intake to no more than 3 drinks per day.

27. Autism Plan of Care

A seven-year-old child with autism is hospitalized with asthma exacerbation. Which factor associated with the preferences held by many children with autism should be included in the plan of care?

• During the hospitalization, parents’ expectations are met.
• Parents need not be at the hospital or room-in with the client.
• Child’s routine habits and preferences are maintained.
• Child is supported throughout the autistic crisis.