READINESS BENCHMARK 1

Question 1

A nurse is providing education to the parents of a newborn about infant safety and security. Which of the following instructions should the nurse include? (Select all that apply.)

• The parent should check the photo ID of any person who comes to the room.
• The parent should request that a second staff member verify the identity of any questionable person.
• Because of infant security systems, the baby can be left unattended in the client’s room.
• Parents should use caution when posting photos of their infant on the internet.
• The baby should be carried in the parent’s arms from the room to the nursery.

Correct Answers:

1. The parent should check the photo ID of any person who comes to the room.
2. The parent should request that a second staff member verify the identity of any questionable person.
3. Parents should use caution when posting photos of their infant on the internet.
4. The baby should be carried in the parent’s arms from the room to the nursery.

Question 2

The nurse is providing education on lifestyle modifications to a client with hypertension. Which of the following recommendations should the nurse include? (Select all that apply.)

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

Correct Answers:

1. Avoid smoking, vaping, or use of any type or form of tobacco products.
2. Reduce sodium intake to less than 2,000 mg per day.
3. Increase dietary potassium intake through fruits and vegetables.
4. Engage in 90-150 minutes of aerobic and resistance training activity per week.

Question 3

A 62-year-old female client reports a palpable firm area in her right breast that has grown and is associated with localized redness and dimpling. Complete the following sentences by choosing the correct options.

The nurse anticipates the provider will first recommend a(n) [Option 1] to further evaluate the client’s complaints. If malignancy is suspected, the nurse anticipates the provider will then recommend a(n) [Option 2] to confirm the diagnosis.

• Option 1: Mammogram / MRI imaging / Genetic testing
• Option 2: Core biopsy / Lymph node biopsy / BRCA1 evaluation / Hormone receptor testing

Correct Answers:

1. Option 1: Mammogram
2. Option 2: Core biopsy

Question 4

The nurse is caring for a client who has just received a diagnosis of breast cancer. Classify each nurse statement as either therapeutic or non-therapeutic communication.

• “Let’s identify your family and friends who will be your support system through your treatment.”
• “Now you can participate in those breast cancer walks and wear beautiful pink ribbons!”
• “There are many support groups for women with breast cancer. I can provide you with contact information.”
• “Tell me what’s worrying you right now regarding your recent diagnosis.”
• “At least we caught the cancer before it spread to other organs. That would be more difficult to treat.”
• “Let me explain exactly what is involved in the recovery after surgery so you are well prepared.”

Correct Classification:

1. Therapeutic: “Let’s identify your family and friends…”
2. Non-Therapeutic: “Now you can participate in those breast cancer walks…”
3. Therapeutic: “There are many support groups…”
4. Therapeutic: “Tell me what’s worrying you right now…”
5. Non-Therapeutic: “At least we caught the cancer before it spread…”
6. Therapeutic: “Let me explain exactly what is involved…”

Question 5

The client is scheduled for a lumpectomy followed by high-dose brachytherapy. Which of the following topics should the nurse include or not include in the client education?

• “Your right breast will be removed. Once you are healed, you can plan reconstructive surgery.”
• “The surgeon will biopsy sentinel lymph nodes during your surgery to assess for metastasis of the cancer.”
• “We will insert radioactive seeds through the catheters surgically placed in your breast to deliver high-dose radiation to the target area.”
• “The external radiation will take up to four weeks to complete. You may experience uncomfortable changes to your skin exposed to the radiation.”
• “You will need to clean the catheter insertion sites with soapy water daily and monitor for signs of infection.”
• “The surgeon will attempt to remove the tumor and surrounding healthy tissue to eliminate all malignant cells in your breast.”

Correct Classification:

1. Do Not Include: “Your right breast will be removed…”
2. Include: “The surgeon will biopsy sentinel lymph nodes…”
3. Include: “We will insert radioactive seeds…”
4. Do Not Include: “The external radiation will take up to four weeks…”
5. Include: “You will need to clean the catheter insertion sites…”
6. Include: “The surgeon will attempt to remove the tumor…”

Question 6

A client is starting chemotherapy treatment. Which of the following potential complications should the nurse discuss with the client? (Select all that apply.)

• Alopecia
• Weight loss
• Myelosuppression
• Thrombocytopenia
• Extravasation at IV site
• Neutropenia
• Anemia
• Stomatitis

Correct Answers:

1. Alopecia
2. Myelosuppression
3. Thrombocytopenia
4. Extravasation at IV site
5. Neutropenia
6. Anemia
7. Stomatitis

Question 7

A client presents 10 days post-chemotherapy with a fever of 101.5°F, sore throat, and productive cough. Which provider order should the nurse question?

• Admit to oncology unit.
• Blood culture and sensitivity.
• Sputum culture.
• Labs: CBC with differential, CMP.
• Maintenance IV fluids.
• Ondansetron 4 mg IVPB q 8 hours PRN nausea.
• Cefazolin 1 g IVPB BID, start if positive culture.
• Filgrastim 5 mcg/kg subq daily.

Question 8

The nurse in the acute oncology unit is assigning a roommate to a 62-year-old female client admitted for fever of unknown origin and resolving neutropenia. Which of the following potential admissions is the most appropriate roommate?

• 66-year-old female with pancreatic cancer on chemotherapy, TPN initiated. Blood counts WNL.
• 88-year-old male admitted from skilled nursing facility following a fall. X-ray confirms forearm fracture. Soft cast applied in ED. Scheduled for ORIF today.
• 94-year-old female admitted after stroke. DNR. End of life care ordered.
• 44-year-old female with resolved pneumonia, admitted for dehydration and frequent watery stools x 4 days. C-diff culture pending.

Question 9

A parent calls the clinic reporting that their child may have received an extra dose of acetaminophen. The child is alert, oriented, and not in distress. Which question should the nurse ask first?

• What color was the acetaminophen liquid that you gave your child?
• Did your child drink all of the acetaminophen that you gave them?
• What device did you use to measure the acetaminophen?
• Would you measure the child’s temperature now and tell me what it is?

Correct Answer:

1. What device did you use to measure the acetaminophen?

Question 75

A client comes to the clinic for an annual visit and reports ongoing sleep difficulties. Which measures are appropriate for the nurse to suggest to improve the client’s sleep? Select all that apply.

• Nap as often wanted during the day.
• Watch television when falling asleep.
• Keep a sleep log of times asleep.
• Exercise before bed to become tired.
• Minimize light when going to sleep.

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Question 76

Based on the information in the client’s electronic health record, what assessment information should be identified by the staff as the reason for the client’s poor oral intake of meals today?

• The client prays 3 times daily.
• The client is non-verbal.
• The client is of the Muslim faith.
• The client has pneumonia.

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Question 77

A client with an estimated blood loss of 1,000 mL, an open femur fracture, and multiple lacerations has the following cardiac rhythm. Which statement by the nurse is appropriate?

• “Your heart has an irregular rhythm due to the injuries you sustained.”
• “Your heart is beating quickly because of your blood loss and pain.”
• “Your heart is beating in a rhythm that needs to be treated with medications.”
• “Your injuries are severe, and your heart is not reacting well.”

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Question 78

The nurse is providing discharge education to an older adult client. The client is distracted, confused, and states, “I don’t understand a word you’re saying.” Which changes in the nurse’s communication approach are appropriate? Select all that apply.

• Use proper pacing because the nurse spoke rapidly and didn’t always speak the words clearly.
• Use clarity and brevity because the nurse spoke in long sentences and used several filler words.
• Change the facial expression because the nurse’s words did not always match the facial expression.
• Use correct gestures because the nurse used gestures at the wrong time and in an inappropriate way.
• Change time of teaching because the client was watching television during the education session.

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Question 79

The nurse is reviewing the predisposing factors for chronic renal failure. Which factors should the nurse identify as causing or accelerating the development of the disease?

• Increased age, obesity, and hypotension.
• Cardiovascular disease, diabetes, and emphysema.
• Hypertension, diabetes, and osteoporosis.
• Diabetes, increased age, and hypertension.

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Question 80

The nurse is reviewing the cardiac rhythms of assigned clients. Which rhythm requires immediate nursing action?

• Strip 1: Sinus Tachycardia
• Strip 2: Ventricular Fibrillation (Chaotic wavy line)
• Strip 3: Ventricular Tachycardia (Wide, rapid QRS complexes)
• Strip 4: Normal Sinus Rhythm

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Question 81

The nurse is teaching a client about conscious sedation. Which information should the nurse include in the teaching?

• Clients are completely unconscious during the entire procedure.
• The client will be awake and able to talk during the entire procedure.
• The client will maintain spontaneous respirations during the procedure.
• Most clients require intubation for a short time during the procedure.

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Question 82

A client is receiving their first infusion of packed red blood cells. The infusion began 10 minutes ago. The client reports a new onset of low back pain and is appearing restless. What is the priority nursing action?

• Obtain the client’s vital signs.
• Stop the transfusion.
• Review the MAR for PRN pain medications.
• Assist the client to take a walk in the hallway.

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Question 83

An older adult client is being evaluated during an annual physical examination. The client has decreased in height by 1.5 inches. Which diagnostic test does the nurse anticipate will be prescribed for the client?

• CT (computed tomography) scan.
• DEXA (Dual-energy X-ray absorption) scan.
• MRI (magnetic resonance imaging) scan.
• Routine X-ray studies.

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Question 84

Complete the following sentence by choosing from the list of options.

The nurse suspects the client is experiencing alcohol withdrawal. When calling the health care provider, the nurse anticipates a prescription for a benzodiazepine.

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Question 85

A client is postoperative day one following an open reduction and internal fixation (ORIF) of a right tibia fracture. The client reports pain as “really bad, way more than yesterday” and requests pain medication one hour after the last dose. On assessment, the client cannot move his toes, and the toes are cool to the touch and dusky in color. What is the priority nursing action?

• Apply a new bag of ice to the affected area.
• Elevate the leg on pillows above heart level.
• Call the health care provider immediately.
• Administer the prescribed pain medication.

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Question 86

The nurse is assessing the environment of a client who is practicing a spiritual ritual. Which observation indicates the ritual is being practiced safely?

• Lights the candles and burns them for only five minutes.
• Uses flameless candles instead of lighting real ones.
• Burns the candles in the bathroom to avoid bothering the roommate.
• Lights one candle at a time instead of all at the same time.

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Question 87

The nurse is caring for a client with a history of COPD who is using a corticosteroid inhaler. The client reports a sore, irritated throat. Which questions should the nurse ask the client? Select all that apply.

• “Are you ensuring that you inhale the medication as slowly as possible?”
• “Are you rinsing your mouth with water and gargling each time you use the inhaler?”
• “Have you been drinking any hot beverages after inhaling the drug?”
• “When you rinse and gargle after using the inhaler, are you swallowing the water?”
• “Are you spraying your throat with a numbing spray before each inhaled dose?”

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Question 88

Based on the client findings, complete the following diagram by selecting from the list of options.

ACTIONS TO TAKE

• Initiate enteral feedings via nasogastric tube
• Administer isotonic IV fluids

CONDITION MOST LIKELY EXPERIENCING

• Acute respiratory distress syndrome

PARAMETERS TO MONITOR

• Hourly urinary output
• Head of bed position 45 degrees or higher

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Question 89

Two nurses approach the nurse manager and report they suspect the charge nurse is stealing narcotics. What is the nurse manager’s priority action?

• Ask the nurses to provide the proof needed to confront the charge nurse about the allegation.
• Schedule a meeting with the charge nurse and the two nurses together to discuss the allegation.
• Meet with the charge nurse to discuss the issue but do not divulge the source of the information.
• Send an email to the charge nurse demanding to know why narcotics are being stolen.

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Question 90

A client presents to the clinic with an itchy throat and a temperature of 101.9 F. The nurse reviews the client’s record and administers a live attenuated influenza vaccine (LAIV). Which information was overlooked that should have prevented the client from receiving the vaccine?

• Client’s subjective report.
• Blood pressure and heart rate.
• Husband’s illness and oxygen saturation.
• Temperature and health history.

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Question 91

A client at 32 weeks gestation (G2 P1) presents with sudden onset of acute abdominal pain and frank vaginal bleeding. Which additional assessment findings are most concerning to the nurse? Select all that apply.

• Average FHR of 126 beats/min.
• Blood oozing from IV site.
• Late decelerations.
• Change in fundal height over 1 hour.
• Moderate variability.
• Accelerations with fetal movement.