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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank
Chapter 48
Question 1
Type: MCSA
The nurse would function with the greatest degree of autonomy in which of the following community settings?
1. Correctional facility
2. Physician's office
3. Outpatient surgery center
4. Home health
Correct Answer: 4
Rationale 1: The nurse working in home health usually travels from home to home alone, and must provide care
independently and determine when further assistance might be necessary. In the other settings the nurse works as
a member of a team.
Rationale 2: The nurse working in home health usually travels from home to home alone, and must provide care
independently and determine when further assistance might be necessary. In the other settings the nurse works as
a member of a team.
Rationale 3: The nurse working in home health usually travels from home to home alone, and must provide care
independently and determine when further assistance might be necessary. In the other settings the nurse works as
a member of a team.
Rationale 4: The nurse working in home health usually travels from home to home alone, and must provide care
independently and determine when further assistance might be necessary. In the other settings the nurse works as
a member of a team.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify common community nursing care settings.
Question 2
Type: MCSA
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

The nurse working in the physician's office is caring for a client who has a mild allergic response to medication
administered during the visit. The nurse reports the response to the:
1. Medical assistant office manager.
2. Physician.
3. Medical assistant assigned to the same physician as the nurse.
4. Receptionist.
Correct Answer: 2
Rationale 1: The nurse would report the change in the client's status to the physician or RN supervisor. The nurse
does not report to the unlicensed assistive personnel (UAP), in this case the medical assistant, in regard to client.
While the MA may act as the nurse's supervisor in terms of employment, the nurse is not supervised by the MA in
terms of client care and needs.
Rationale 2: The nurse would report the change in the client's status to the physician or RN supervisor. The nurse
does not report to the unlicensed assistive personnel (UAP), in this case the medical assistant, in regard to client.
While the MA may act as the nurse's supervisor in terms of employment, the nurse is not supervised by the MA in
terms of client care and needs.
Rationale 3: The nurse would report the change in the client's status to the physician or RN supervisor. The nurse
does not report to the unlicensed assistive personnel (UAP), in this case the medical assistant, in regard to client.
While the MA may act as the nurse's supervisor in terms of employment, the nurse is not supervised by the MA in
terms of client care and needs.
Rationale 4: The nurse would report the change in the client's status to the physician or RN supervisor. The nurse
does not report to the unlicensed assistive personnel (UAP), in this case the medical assistant, in regard to client.
While the MA may act as the nurse's supervisor in terms of employment, the nurse is not supervised by the MA in
terms of client care and needs.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe the LPN/LVN scope of practice in a physician's office or outpatient surgery center.
Question 3
Type: MCSA
The nurse receives orders from the physician to notify the client of an elevated cholesterol level and inform the
client to increase the dosage of Lipitor (atorvastatin calcium) from 10 mg daily to 20 mg daily, and provides the
nurse with a written prescription for the client. The nurse's priority action is to:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Call the client and leave a message on the answering machine with the information.
2. Call the prescription to the pharmacy.
3. Call the client and leave a message to call the office for information about lab results.
4. Call the client and leave a message to call the office and ask for her.
Correct Answer: 4
Rationale 1: The nurse must first call the client to determine what pharmacy the order will be called to. If the
client is not home, in order to maintain privacy, it is important to ask him only to call the office without explaining
why, unless he has signed a form saying it is okay to leave detailed messages on the answering machine.
Rationale 2: The nurse must first call the client to determine what pharmacy the order will be called to. If the
client is not home, in order to maintain privacy, it is important to ask him only to call the office without explaining
why, unless he has signed a form saying it is okay to leave detailed messages on the answering machine.
Rationale 3: The nurse must first call the client to determine what pharmacy the order will be called to. If the
client is not home, in order to maintain privacy, it is important to ask him only to call the office without explaining
why, unless he has signed a form saying it is okay to leave detailed messages on the answering machine.
Rationale 4: The nurse must first call the client to determine what pharmacy the order will be called to. If the
client is not home, in order to maintain privacy, it is important to ask him only to call the office without explaining
why, unless he has signed a form saying it is okay to leave detailed messages on the answering machine.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe the LPN/LVN scope of practice in a physician's office or outpatient surgery center.
Question 4
Type: MCSA
The nurse admits a client to the surgical center who is to have surgery in two hours. After obtaining data for the
admission paperwork, the client is assisted into a hospital gown and asked:
1. If he has any second thoughts about the procedure.
2. If he needs to use the restroom.
3. If he has any allergies.
4. Who has accompanied him to the center.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Correct Answer: 2
Rationale 1: After the client changes, he should be asked to void to empty the bladder. This is not the proper time
to question him about second thoughts. Allergies and family present are obtained during the admission paperwork.
Rationale 2: After the client changes, he should be asked to void to empty the bladder. This is not the proper time
to question him about second thoughts. Allergies and family present are obtained during the admission paperwork.
Rationale 3: After the client changes, he should be asked to void to empty the bladder. This is not the proper time
to question him about second thoughts. Allergies and family present are obtained during the admission paperwork.
Rationale 4: After the client changes, he should be asked to void to empty the bladder. This is not the proper time
to question him about second thoughts. Allergies and family present are obtained during the admission paperwork.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe the LPN/LVN scope of practice in a physician's office or outpatient surgery center.
Question 5
Type: MCSA
The nurse working in a school health office is visited by a student complaining of menstrual cramps and
requesting Motrin (ibuprofen). The nurse's best action is to:
1. Administer the medication.
2. Inform the student that the nurse cannot prescribe medication.
3. Administer the medication only if the school has a standing order allowing administration.
4. Assess the student.
Correct Answer: 4
Rationale 1: Before administering any medication, the student must be assessed to determine level and location
of pain, presence of other signs or symptoms, history of medical problems, and allergies. Once this information is
collected, the nurse can administer the medication only with a physician's order, which may be in the form of a
standing order.
Rationale 2: Before administering any medication, the student must be assessed to determine level and location
of pain, presence of other signs or symptoms, history of medical problems, and allergies. Once this information is
collected, the nurse can administer the medication only with a physician's order, which may be in the form of a
standing order.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 3: Before administering any medication, the student must be assessed to determine level and location
of pain, presence of other signs or symptoms, history of medical problems, and allergies. Once this information is
collected, the nurse can administer the medication only with a physician's order, which may be in the form of a
standing order.
Rationale 4: Before administering any medication, the student must be assessed to determine level and location
of pain, presence of other signs or symptoms, history of medical problems, and allergies. Once this information is
collected, the nurse can administer the medication only with a physician's order, which may be in the form of a
standing order.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: List important aspects of nursing care in a school health office or clinic.
Question 6
Type: MCSA
The nurse working in home care is about to knock on the client's door when shouting is heard through the door.
The client and spouse are shouting at each other, and the nurse hears the spouse tell the client to put the gun down
before someone gets hurt. The nurse's priority action is to:
1. Enter the apartment and help the spouse calm the client.
2. Call the police and put some distance between the nurse and the apartment.
3. Call the police and wait for them by the door of the apartment.
4. Go to the next client to be seen and notify the agency why this client wasn't visited.
Correct Answer: 2
Rationale 1: The nurse should call the police and get away from the door to prevent self-injury until the police
arrive. Entering the apartment only places the nurse in jeopardy along with the spouse.
Rationale 2: The nurse should call the police and get away from the door to prevent self-injury until the police
arrive. Entering the apartment only places the nurse in jeopardy along with the spouse.
Rationale 3: The nurse should call the police and get away from the door to prevent self-injury until the police
arrive. Entering the apartment only places the nurse in jeopardy along with the spouse.
Rationale 4: The nurse should call the police and get away from the door to prevent self-injury until the police
arrive. Entering the apartment only places the nurse in jeopardy along with the spouse.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Analyzing
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify nursing responsibilities in home care and hospice.
Question 7
Type: MCSA
The nurse visits the client in his home and finds him with a temperature of 100.2F oral. The nurse's priority
action is to:
1. Notify the physician that the client has a fever and obtain an order for antipyretics.
2. Assess the client further to determine possible cause of the fever.
3. Talk with the family members to get information about the client's condition.
4. Obtain a rectal temperature for increased accuracy.
Correct Answer: 2
Rationale 1: The nurse should assess the client before implementing any nursing care or notifying the physician.
The reason for the temperature might not be immediately assessed but the physician will need the nurse to provide
as much data as possible when notified.
Rationale 2: The nurse should assess the client before implementing any nursing care or notifying the physician.
The reason for the temperature might not be immediately assessed but the physician will need the nurse to provide
as much data as possible when notified.
Rationale 3: The nurse should assess the client before implementing any nursing care or notifying the physician.
The reason for the temperature might not be immediately assessed but the physician will need the nurse to provide
as much data as possible when notified.
Rationale 4: The nurse should assess the client before implementing any nursing care or notifying the physician.
The reason for the temperature might not be immediately assessed but the physician will need the nurse to provide
as much data as possible when notified.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify nursing responsibilities in home care and hospice.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Question 8
Type: MCSA
The nurse working in a physician's office admits a client and gathers information about the client's reason for
visiting. While the client talks, the nurse:
1. Writes down exactly what the client says.
2. Listens actively and observes the client as she talks.
3. Measures vital signs.
4. Performs hand hygiene.
Correct Answer: 2
Rationale 1: The nurse should employ active listening and observe the client as she talks to assess general mental
status and overall condition. Vital signs are not measured while the client is talking, hand hygiene is performed
before entering the room, and information should be documented after the client finishes speaking.
Rationale 2: The nurse should employ active listening and observe the client as she talks to assess general mental
status and overall condition. Vital signs are not measured while the client is talking, hand hygiene is performed
before entering the room, and information should be documented after the client finishes speaking.
Rationale 3: The nurse should employ active listening and observe the client as she talks to assess general mental
status and overall condition. Vital signs are not measured while the client is talking, hand hygiene is performed
before entering the room, and information should be documented after the client finishes speaking.
Rationale 4: The nurse should employ active listening and observe the client as she talks to assess general mental
status and overall condition. Vital signs are not measured while the client is talking, hand hygiene is performed
before entering the room, and information should be documented after the client finishes speaking.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe the client admission process and preparation of a client for examination in a
physician's office or clinic.
Question 9
Type: MCSA
After collecting data from the client admitted to the physician's office, the nurse documents:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Chief complaint, present illness, and vital signs.


2. Chief complaint, past medical history, and medication administration.
3. History of present illness, social history, and demographic data.
4. Chief complaint, present illness, and demographic data.
Correct Answer: 1
Rationale 1: The nurse documents chief complaint, or purpose of the visit; history of the present illness; and vital
signs. Past medical history is obtained from the client in the waiting room, and the receptionist gathers
demographic data at the same time.
Rationale 2: The nurse documents chief complaint, or purpose of the visit; history of the present illness; and vital
signs. Past medical history is obtained from the client in the waiting room, and the receptionist gathers
demographic data at the same time.
Rationale 3: The nurse documents chief complaint, or purpose of the visit; history of the present illness; and vital
signs. Past medical history is obtained from the client in the waiting room, and the receptionist gathers
demographic data at the same time.
Rationale 4: The nurse documents chief complaint, or purpose of the visit; history of the present illness; and vital
signs. Past medical history is obtained from the client in the waiting room, and the receptionist gathers
demographic data at the same time.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe the client admission process and preparation of a client for examination in a
physician's office or clinic.
Question 10
Type: MCSA
The nurse admits a client to the gynecologist's office for a routine annual examination. When preparing the client
for the examination, the nurse:
1. Instructs the client to put on an examination gown, with the opening in the back.
2. Obtains a signed consent for performance of the examination.
3. Assists the client into the supine position.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

4. Places the chart outside the examination room and notifies the physician.
Correct Answer: 4
Rationale 1: When the client is ready for the examination, the nurse indicates this by placing the chart outside the
examination room and notifying the physician. The nurse assists the client into the lithotomy position for the
pelvic examination. The gown is placed with the opening in the front, not the back. A signed consent is not
required, and all clients admitted to the physician's office sign a general consent for treatment.
Rationale 2: When the client is ready for the examination, the nurse indicates this by placing the chart outside the
examination room and notifying the physician. The nurse assists the client into the lithotomy position for the
pelvic examination. The gown is placed with the opening in the front, not the back. A signed consent is not
required, and all clients admitted to the physician's office sign a general consent for treatment.
Rationale 3: When the client is ready for the examination, the nurse indicates this by placing the chart outside the
examination room and notifying the physician. The nurse assists the client into the lithotomy position for the
pelvic examination. The gown is placed with the opening in the front, not the back. A signed consent is not
required, and all clients admitted to the physician's office sign a general consent for treatment.
Rationale 4: When the client is ready for the examination, the nurse indicates this by placing the chart outside the
examination room and notifying the physician. The nurse assists the client into the lithotomy position for the
pelvic examination. The gown is placed with the opening in the front, not the back. A signed consent is not
required, and all clients admitted to the physician's office sign a general consent for treatment.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe the client admission process and preparation of a client for examination in a
physician's office or clinic.
Question 11
Type: MCSA
The nurse notifies the physician that the client is ready for the gynecological examination, and does what when
the physician enters the client room?
1. Accompanies the physician and remains in the room throughout the exam.
2. Prepares the next client for examination.
3. Documents data gathered from the client currently being examined.
4. Uses the opportunity to take a break and get a cup of coffee.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Correct Answer: 1
Rationale 1: The nurse must stay in the room during the examination.
Rationale 2: The nurse must stay in the room during the examination.
Rationale 3: The nurse must stay in the room during the examination.
Rationale 4: The nurse must stay in the room during the examination.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe the client admission process and preparation of a client for examination in a
physician's office or clinic.
Question 12
Type: MCSA
The nurse is assisting the physician with a minor office procedure when the doctor is called away and asks the
nurse to finish suturing the small wound created by the procedure. The nurse:
1. Sutures the wound, applies a dressing, and instructs the client how to perform wound care.
2. Tells the physician that nurses are not allowed to suture because it is outside the scope of practice.
3. Asks the physician to demonstrate by placing the first suture, and then performs the remainder of the procedure.
4. Notifies the nurse supervisor of the physician's request, and asks for permission to perform the procedure.
Correct Answer: 2
Rationale 1: The nurse is not allowed to suture a wound, according to the nurse practice act, so the nurse must
inform the physician that the task is outside his scope of practice.
Rationale 2: The nurse is not allowed to suture a wound, according to the nurse practice act, so the nurse must
inform the physician that the task is outside his scope of practice.
Rationale 3: The nurse is not allowed to suture a wound, according to the nurse practice act, so the nurse must
inform the physician that the task is outside his scope of practice.
Rationale 4: The nurse is not allowed to suture a wound, according to the nurse practice act, so the nurse must
inform the physician that the task is outside his scope of practice.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: List ways the LPN/LVN can assist with office surgical procedures.
Question 13
Type: MCSA
The nurse admits a client to the physician's office who requires excision of a small mole on the forearm. The nurse
establishes a sterile field, and places the needed equipment and supplies while maintaining sterility. After the tray
is prepared, the nurse, while waiting for the physician to arrive:
1. Covers the tray with a sterile drape, and admits another client.
2. Tells the client not to touch anything on the tray, and notifies the doctor the client is ready.
3. Remains in the room.
4. Moves the sterile tray out into the hallway while admitting another client.
Correct Answer: 3
Rationale 1: Once the sterile field is established, it must be observed at all times, because contamination cannot
be seen.
Rationale 2: Once the sterile field is established, it must be observed at all times, because contamination cannot
be seen.
Rationale 3: Once the sterile field is established, it must be observed at all times, because contamination cannot
be seen.
Rationale 4: Once the sterile field is established, it must be observed at all times, because contamination cannot
be seen.
Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Explain how to perform or assist with office screening and testing procedures.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.