Basic Nursing Essentials for Practice 7th Edition by Potter – Test Bank
Chapter 01: Health and Wellness
- When planning care a nurse wants to use the goals of Healthy People 2010 because these goals:
|A.||aim to increase both quality and years of life by eliminating the nation’s health disparities.|
|B.||increase the life expectancy of all Americans.|
|C.||reduce the percentage of communicable diseases in childhood.|
|D.||identify gaps among ethnic minorities in regard to health promotion and disease prevention.|
- The health-illness continuum can be used to:
|A.||define health and illness as absolute.|
|B.||understand the relationships between attitudes toward health and health practices.|
|C.||compare one patient’s health to another patient’s health.|
|D.||consider a patient’s risk factors when identifying levels of health.|
- After assessing a patient’s risk factors, a nurse understands that risk factors are:
|A.||direct indicators of the presence of disease.|
|B.||more common in adolescents than adults.|
|C.||modifiable traits that can assist a patient with changing.|
|D.||variables that increase vulnerability to develop illness or accident.|
- To evaluate a patient’s external variables, a nurse understands that health beliefs and practices can be influenced by a patient’s:
- A nurse uses the concept of primary prevention when instructing a patient to:
|A.||get a flu shot on a yearly basis.|
|B.||take blood pressure medication every day.|
|C.||explore hiring a patient with a known disability.|
|D.||undergo physical therapy following a cerebrovascular accident.|
- A married father of four has recently been diagnosed with emphysema resulting from a long history of smoking. At a family counseling session a nurse helps the family to understand that this diagnosis is classified as a(n):
- Which of the following is the best definition of health?
|A.||State of complete well-being|
|B.||Absence of disease|
|C.||Vital signs within normal range|
|D.||Maintenance of a normal weight|
- Mrs. Kitchene, a 64-year-old patient with newly diagnosed diabetes, is concerned about her risk for developing foot ulcers because her mother had a foot amputated as a result of the disease. This an example of which of the following?
- A 53-year-old patient with diabetes is diligent about taking his blood sugar before meals. This is an example of the third component of which model?
|A.||Basic Human Needs|
- Which of the following will best assist a nurse in understanding a patient’s use of tying a silver dollar to the stomach of her newborn infant to heal an umbilical hernia?
|A.||Health Belief Model|
|B.||Maslow’s Hierarchy of Needs|
|C.||World Health Organization’s definition of “health”|
- A 32-year-old construction worker smokes a pack of cigarettes per day. This is an example of which of the following?
|C.||Negative health behavior|
|D.||Basic human need|
- When teaching a 15-year-old patient with diverticulitis about foods that he should avoid, a nurse takes into consideration his stage of growth and development. This is an example of which of the following?
- A nurse working in a rural public health clinic is developing a smoking cessation program for patients in her county. This corresponds with Healthy People 2010’s efforts to provide direction for health care efforts on what level?
- The husband of a 90-year-old patient with terminal cancer is refusing pain medication for her because he fears she will become addicted like some of the soldiers he knew in World War II. A nurse will need to focus on which of the following internal variables when approaching this situation?
- When considering what influences a person’s health beliefs and practices, a nurse should consider both internal and external variables. Which of the following is an example of an external variable?
- A nurse should emphasize health promotion, wellness strategies, and illness prevention activities as important forms of health care. Which of the following is considered a health promotion strategy?
|B.||Stress management class|
- A nurse who works in an inner-city health clinic is scheduling a day for student nurses to assist with a flu immunization clinic. Which of the following best describes this type of activity?
- Mr. and Mrs. Fedor are visiting Judy, a registered nurse and the diabetic educator. Mrs. Fedor is concerned that because her husband has diabetes, their 25-year-old daughter will also develop it. What is the nurse’s best response?
|A.||“Just because your husband has diabetes doesn’t mean that your daughter will get it.”|
|B.||“Your daughter has an increased risk for developing diabetes because your husband has it.”|
|C.||“Your daughter should see an endocrinologist to prevent her from developing the disease.”|
|D.||“People don’t usually develop type 2 diabetes until they are elderly.”|
- Which of the following would NOT be considered a physiological risk factor?
- A 75-year-old man has been diagnosed with hypertension. The nurse knows that he would benefit from changing his diet to reduce his sodium intake. How can the nurse best determine his readiness to change?
|A.||Asking the patient what stage of change best describes him|
|B.||Asking his wife what she normally does to get him to change behavior|
|C.||Explaining the effects of hypertension to him and watching his reaction|
|D.||Providing him with low sodium food choices|
- Which of the following modifiable risk factors are responsible for the highest actual cause of death in the United States?
|C.||Motor vehicle accidents|
- According to the latest best practice, the efficacy of smoking cessation interventions for hospitalized patients are most effective when patients receive support for a minimum of how long?
|A.||1 week after discharge|
|B.||2 weeks after discharge|
|C.||3 weeks after discharge|
|D.||1 month after discharge|
- A systematic review of the research regarding nursing interventions for smoking cessation suggests that it is most effective when a nurse:
|A.||is familiar with the patient.|
|B.||is not too direct with the patient regarding smoking.|
|C.||is an ex-smoker.|
|D.||takes a main role of health promotion or smoking cessation.|
- What is the most appropriate first step in health promotion, wellness education, and illness prevention activities?
|A.||Exploring available support groups|
|B.||Identifying risk factors|
|C.||Providing patient teaching|
|D.||Implementing risk factor modification|
- A 34-year-old smoker has confided to his nurse that he feels like a failure because he began smoking again after not having had a cigarette for more than a week. What is the nurse’s best response?
|A.||“Let’s discuss what triggered you to start smoking again so you can avoid it in the future.”|
|B.||“You understand that smoking is the number one cause of death in the United States, correct?”|
|C.||“Did you know that your insurance premiums will increase if you continue to smoke?”|
|D.||“My mother died last year of lung cancer?”|
- Which of the following best describes the stages of change?
|A.||Precontemplation, contemplation, preparation, action, maintenance|
|B.||Contemplation, preparation, action, maintenance, postmaintenance|
|C.||Contemplation, procrastination, preparation, action, maintenance|
|D.||Precontemplation, contemplation, preparation, action, engagement|
- A nurse who is caring for a patient who smokes two packs a day knows that the patient is in the contemplation stage regarding smoking cessation. According to change theory, which of the following is the best statement for the nurse to tell the patient?
|A.||“You need to stop smoking as soon as possible.”|
|B.||“Smoking is a very expensive habit.”|
|C.||“The negative effects of smoking can be reversed.”|
|D.||“Tobacco use killed 435,000 people in 2000.”|
- Which of the following patients should a nurse consider as being the most ill?
|A.||A 25-year-old patient with cystic fibrosis who is attending yoga classes|
|B.||A 12-year-old adolescent with newly diagnosed diabetes who is concerned about checking his blood sugar at school|
|C.||A 43-year-old patient with breast cancer who has recently adopted a vegetarian diet|
|D.||A 77-year-old patient with AIDS and hepatitis who attends weekly AA meetings|
- A registered nurse is working in a community clinic that provides services for chronically ill patients. Which of the following would be considered a chronic condition?
- The major cause of death and disability in the United States are a result of which of the following?
- A public health nurse understands that is best to prevent chronic diseases such as chronic obstructive pulmonary disease (COPD). She knows that for those patients who already have a chronic disease, she can best help them manage their illness to reduce the occurrence of symptoms by doing which of the following?
|A.||Providing holistic patient education|
|B.||Consulting with a disease specialist|
|C.||Reviewing their long-term health insurance policy|
|D.||Providing disease-specific patient education|
- Keith, a registered nurse in a rehabilitative unit, is working with Mr. Miles, a 25-year-old veteran with chronic back pain that was caused as a result of an injury he received while in military service in Iraq. Keith’s goal is to assist Mr. Miles to learn self-management skills to help him promote health within his illness. Which of the following statements to Mr. Miles best supports Keith’s goal?
|A.||“Do you have plans to return to active duty?”|
|B.||“You need to take your pain medication as prescribed.”|
|C.||“Perhaps you need to consider going to a different health care provider.”|
|D.||“Why don’t you keep a log of what causes the pain to become worse?”|
- A pregnant 31-year-old mother of two children has been experiencing severe morning sickness and fatigue. Her friends and family members have been providing her family with meals, and her husband has been taking responsibility for the housework. This is an example of which of the following behaviors?
- A patient asks a nurse if smoking, alcohol use, and weight gain have a direct effect on cardiovascular functioning. The nurse informs the patient that these risk factors are ____________________.
- Using the health promotion model while rendering care enables a nurse to do which of the following? Select all that apply.
|A.||Encourage wellness in the patient.|
|B.||Detect the presence of illness.|
|C.||Promote health behaviors.|
|D.||Assess a family’s response to illness.|
|E.||Plan interventions that can assist a patient with achieving self-actualization.|
Potter: Basic Nursing, 7th Edition
Chapter 02: The Health Care Delivery System
- A nurse is teaching the importance of self-breast examination to a group of 20-year-old women. The nurse is promoting _____ care.
- A patient who needs nursing and rehabilitation after a stroke would benefit most by receiving care at a(n):
|A.||primary care center.|
|B.||restorative care setting.|
|C.||assisted living center.|
- A patient states that he cannot afford health care insurance. What is the best form of insurance available to him?
|D.||A managed care organization|
- A managed care system focuses on:
|A.||customer service and patient choices.|
|B.||admissions, diagnostic testing, and treatments.|
|C.||control over primary health services of a defined population.|
|D.||comprehensive rather than fragmented approaches to health.|
- A nurse admits an older adult patient who states that she has no living relatives and only friends of her own age. One of the nurse’s immediate considerations for this patient will be to implement a:
|C.||patient-focused care model.|
|D.||resource utilization group.|
- Technological advances in health care:
|A.||make a nurse’s job easier.|
|B.||depersonalize bedside patient care.|
|C.||threaten the integrity of the health care industry.|
|D.||do not replace sound personal judgment.|
- In 1983 Congress established the Prospective Payment System (PPS) to:
|A.||establish cost-based reimbursement for health care.|
|B.||provide reimbursement for patient medications.|
|C.||establish reimbursement rates based upon diagnosis-related groups (DRGs).|
|D.||establish quality improvement measures.|
- A 74-year-old man was admitted to the hospital with diabetic ketoacidosis. The hospital where he was admitted will be reimbursed by Medicare according to:
|A.||his diagnostic-related group.|
|B.||the cost of his care.|
|C.||his length of stay.|
|D.||his clinical outcome.|
- Capitation is the payment mechanism in which health care providers receive a fixed amount of money for each patient. What is the purpose of capitation?
|A.||To balance the quality of care with the cost of providing care|
|B.||To provide the least expensive care for patients|
|C.||To build a payment plan that includes professional standards of care|
|D.||To ensure that all patients receive the same care for the same cost|
- A single mother with three children utilizes the public health department services in her county to immunize her children. Which of the following best describes this level of health care?
|C.||Secondary acute care|
- A registered nurse working as a school nurse for a small poor rural school district has noticed an increase in children arriving at school without having eaten breakfast. She has discussed this issue with the school principle and is working on a proposal to ask the school district to explore a school breakfast program. This is an example of which of the following?
- A small business owner has consulted with an occupational health nurse regarding health promotion activities for his employees. The registered nurse explores with him the possibility of providing an area outside the new office complex where employees can walk during their breaks. This an example of which of the following?
- A 43-year-old grocery store clerk does not have a family health care provider. She has had a sore throat for the past week and recently began running a fever. Her husband takes her to the local community hospital’s emergency room for treatment. This is an example of what level of care?
- A retired high school teacher has been admitted to the hospital with complications of his diabetes. The hospital where he has been admitted uses a case management model to coordinate care. His discharge planning will be coordinated by which of the following?
|B.||Insurance company representative|
- Discharge planning is a centralized, coordinated, multidisciplinary process that ensures that a patient has a plan for continuing care after leaving a health care agency. What is the most appropriate time to begin discharge planning?
|A.||The day of patient discharge from the health care agency|
|B.||As soon as the insurance provider has been identified|
|C.||When the health care provider writes the discharge order|
|D.||When the patient is admitted to the health care agency|
- Which of the following patients is most in need of discharge planning?
|A.||29-year-old mother with a healthy newborn|
|B.||59-year-old patient after appendectomy|
|C.||43-year-old patient with heart failure|
|D.||56-year-old patient after hysterectomy|
- Which of the following is considered the most expensive place to deliver care?
|B.||Long-term care facility|
|C.||Intensive care unit|
|D.||Private hospital room|
- A 23-year-old college student with severe depression was recently admitted to the psychiatric ward of a local hospital. His family is concerned about him finishing his college term. Which of the following is the best information for the nurse to give regarding how long psychiatric patients are typically hospitalized?
|A.||A relatively short inpatient stay is followed by outpatient treatment.|
|B.||A long inpatient hospitalization is normal.|
|C.||Patients with emotional or behavioral problems generally are not hospitalized.|
|D.||Most are automatically placed in a long-term care facility.|
- A 17-year-old girl was seriously injured in a motor vehicle accident and has been transferred from an acute care hospital to a rehabilitation facility. Which of the following options will ensure the best outcome for her?
|A.||Making sure that she gets enough rest|
|B.||Pushing her beyond her limits|
|C.||Requesting that the family not visit for the first few days|
|D.||Involving her family early in the rehabilitation process|
- A 54-year-old businessman who experienced a stroke four days ago has been discharged from the hospital and will be undergoing outpatient rehabilitation. He should expect which of the following with this level of care?
|A.||Admission to the rehabilitative unit of the hospital|
|B.||Scheduled appointment times for therapy|
|C.||Home visits from all members of the multidisciplinary team|
|D.||House calls from his primary health care provider|
- The Omnibus Budget Reconciliation Act of 1987 is also referred to as the _____ Act.
|B.||Nursing Home Reform|
|C.||Diagnostic Related Group|
- A new registered nurse who recently began working in a nursing center has been asked to complete a Resident Assessment Instrument (RAI) on a newly admitted resident. She knows the purpose of this instrument is to:
|A.||provide a database to better understand the healthcare needs of this population.|
|B.||provide the nursing staff with an overall physical assessment of the resident.|
|C.||provide statistical evidence to support a universal healthcare policy.|
|D.||determine how many health care resources this population consumes.|
- Gladys, an 81-year-old widow with dementia, recently moved in with her daughter Cecilia, a 46-year-old working mother with three children. In considering how to have care for her mother when she is working, what is the most appropriate option?
|A.||A rehabilitation center|
|B.||A nursing center|
|C.||An adult day care center|
- A 78-year-old widow needs assistance with her medications, housekeeping, and laundry. She would like to maintain her independence. Of the following, which is the best option for her to consider?
- Which of the following patients is most suitable for admission into a hospice?
|A.||63-year-old man with a fractured femur|
|B.||45-year-old woman with end-stage renal failure|
|C.||14-year-old patient with leukemia|
|D.||78-year-old patient with dementia|
- A registered nurse has been working for an oncology unit for the past year. She has a passion for caring for oncology patients undergoing chemotherapy. Whose responsibility is it for the nurse to become competent in administering chemotherapy?
|A.||The hospital where she works|
|B.||The charge nurse|
|D.||The oncologist who admits patients to the unit where she works|
- Changes in the health care delivery system are being driven by _____________________.
- A registered nurse working in a restorative care setting will focus on which of the following? Select all that apply.
|A.||Providing extensive supportive care|
|B.||Providing one-on-one care to patients|
|C.||Promoting patient self-care|
Potter: Basic Nursing, 7th Edition
Chapter 03: Community-Based Nursing Practice
- A student nurse is beginning her community health rotation. She anticipates that her assignment in community-based health care will most likely be at which of the following organizations?
|A.||Acute care hospital|
- What is the primary characteristic of a community health nurse?
|A.||Providing care to subpopulations|
|B.||Providing care in existing services|
|C.||Being a specialist in public health science|
|D.||Having a case management certification|
- Which of the following is considered the overall goal of Healthy People 2010?
|A.||To increase the life expectancy of people in the United States|
|B.||To increase the health status of people throughout the world|
|C.||To eradicate HIV/AIDS|
|D.||To reduce health care costs|
- The teen pregnancy rate in one community significantly increased, and, as a result, the school system was seeing an increase in the drop-out rate of teenage mothers. A student nurse recently worked with the local school system to develop a day care program for the children of high school students so that they could return to school. This is an example of which of the following?
|A.||Building a relationship with pregnant teens|
|B.||Responding to changes within the community|
|C.||Influencing community environmental factors|
- The most cost-effective health care is which of the following?
|A.||Acute care hospital|
|C.||Community-based nursing center|
patient speaks English very well. The community health nurse knows that she may be a vulnerable patient because of which of the following?
|B.||Her immigration status|
- The most important competency in community nursing is which of the following?
- Community-based nursing provides services that will improve the health of specific populations; in contrast, public health practice ____________________.
- A nurse in community-based practice needs a variety of skills and talents while rendering care to patients in the community, which includes which of the following? Select all that apply.
- Vulnerable populations of patients are those who are more likely to develop health problems as a result of which of the following? Select all that apply.
|A.||Living at home|
- A community assessment involves components to identify needs for health policy, health program development, and services, which include assessing which of the following? Select all that apply.
Potter: Basic Nursing, 7th Edition
Chapter 04: Legal Principles in Nursing
- The State Nurse Practice Act is an example of which of the following?
|A.||A federal senate bill|
|B.||A law enacted by the federal government|
|C.||A statute enacted by state legislature|
|D.||A judicial decision|
- A student nurse has been studying hard throughout her nursing program to prepare for the licensure examination. This is an examination that she must pass before she can practice nursing in her state. NCLEX® stands for __________ Examination.
|A.||Nursing Council of Licensing|
|B.||Nightingale Code of Licensure|
|C.||Nursing Code of Licensure|
|D.||National Council Licensure|
- A registered nurse was accused of patient abandonment when she became angry, quit her job, and left the hospital before the end of her shift. This is an example of violating guidelines set by which of the following?
|A.||State Department of Health|
|B.||The Joint Commission|
|C.||State Board of Nursing|
|D.||National League of Nursing|
- A RN suffers from chronic back pain that was the result of an injury she suffered when pulling a patient up in bed. She is addicted to pain medication and has recently been accused of stealing narcotics. This is an example of which of the following violations of the law?
- A registered nurse was pulled from her normal unit to fill in for a pediatric unit. She is caring for a 16-year-old patient who refuses to cooperate for a dressing change. The nurse tells the patient that she will tie the patient down if she does not hold still. This threat is an example of which of the following?
- A wrong-site surgery is considered a sentinel event for a health care organization. In addition to the hospital being at fault for this situation, the health care provider could also be considered guilty of committing which of the following?
- Malpractice is sometimes referred to as “professional negligence.” To establish the elements of malpractice, which of the following must be proven by the patient?
|A.||The patient must have been harmed as a result of the injury.|
|B.||The patient must have paid for the health care services.|
|C.||The patient must show evidence of malicious intent.|
|D.||The patient must demonstrate personal accountability.|
- Which of the following is the best way for a nurse to avoid being liable for malpractice?
|A.||Purchasing quality malpractice insurance coverage|
|B.||Practicing nursing that meets the generally accepted standard of care|
|C.||Not sharing his or her last name with patients and families|
|D.||Not delegating any tasks to unlicensed assistive personnel|
- Which of the following is an example of a nursing standard of care?
|A.||World Health Organization guidelines|
|B.||State Department of Health guidelines|
|C.||Health care facility’s written procedure|
|D.||Department of Health and Human Services guidelines|
- If accused of malpractice, which of the following is the best proof that a nurse acted responsibly?
|A.||The nurse supervisor’s memory of the event|
|B.||The physician’s memory of the event|
|C.||The nurse’s memory of the event|
|D.||Recorded documentation of nursing care|
- A registered nurse is caring for a 45-year-old patient 2 days after a colon resection. The patient called for assistance to go to the bathroom. Instead of waiting for help, the patient decided to get up on her own. She fell but did not injure herself. After contacting the patient’s health care provider, which of the following is most important for the nurse to do?
|A.||Nothing; the patient wasn’t injured.|
|B.||Call the Risk Management Department.|
|C.||Submit an incident report.|
|D.||Insist that the patient have a radiograph done.|
- After witnessing a patient fall, a nurse fills out an occurrence report. Which of the following is the best way for the nurse to document this occurrence?
|A.||“Patient found lying on right side on floor. No noted injuries, patient stated, ‘I slipped on a wet spot on the floor. I don’t think I am injured.’”|
|B.||“Patient slipped on a wet spot on the floor. No noted injuries, physician notified.”|
|C.||“Patient in too much of a hurry and was walking too fast and fell. Was not injured. Patient instructed to slow down and not be in such a hurry. Health care provider notified.”|
|D.||“Patient fell while going outside to smoke. Patient denied any injuries. Health care provider notified. Patient counseled.”|
- A new registered nurse who recently passed board examinations was on his way home from the STD clinic where he was working since graduating from nursing school. He stopped at an automobile accident to see if he could assist. There was one victim who was not breathing. The nurse provided CPR at the scene, but the victim died. The victim’s family sued the nurse. Which of the following provides the best protection to the nurse in this case?
|A.||STD clinic’s malpractice insurance policy|
|B.||Good Samaritan Law|
|C.||The State Board of Nursing|
|D.||Institute of Medicine|
- A registered nurse has recently started working as a surgical nurse. Within his orientation he was instructed that he would be responsibility for verifying that the Consent for Surgery form was signed. He understands that the person signing the form must be competent. Which of the following patients would be considered competent to give informed consent?
|A.||27-year-old unconscious patient|
|B.||16-year-old emancipated minor|
|C.||43-year-old patient who has been drinking alcohol|
|D.||33-year-old patient who has received preanesthesia medication|
- A nurse works for a unit caring for patients after open heart surgery. A patient is confused and is attempting to get out of bed. The nurse is tired after working for more than 10 hours and is concerned for the patient’s safety. What is the best action that the nurse should take to prevent the patient from harm?
|A.||Restrain the patient with wrist restraints.|
|B.||Restrain the patient with a belt restraint in a chair.|
|C.||Sedate the patient with medication.|
|D.||Ask a family member to sit with the patient.|
- A registered nurse is admitting a 65-year-old patient into the hospital for acute pancreatitis. As part of the admission process she asks if the patient has an advance directive. The patient states that he is not sure. Which of the following is considered an advance directive?
|A.||Power of attorney|
|D.||Organ donation card|
- Which of the following examples demonstrates a breach of confidentiality and a violation of HIPAA?
|A.||Giving a report to the oncoming nurse in a conference room|
|B.||Discussing a patient’s diagnosis with the patient’s health care provider|
|C.||Providing patient information to the nursing assistant caring for the patient|
|D.||Sharing with other nurses on the unit that a patient is HIV-positive|
- Crystal, a RN, has been caring for a patient of Dr. Hoover. Crystal received an illegible order for a medication. Dr. Hoover has a reputation for impatience and irritability. Knowing Dr. Hoover’s surly nature, which of the following would be the most appropriate action by Crystal?
|A.||Clarify the order with the pharmacy.|
|B.||Clarify the order with the nursing supervisor.|
|C.||Clarify the order with Dr. Hoover.|
|D.||Ask another nurse to look at the order to try to clarify it.|
- During an evening shift, Clara, a senior student nurse, was working as a nursing assistant in the local hospital where she does her school clinical rotations. One of the nurses she was working with was extremely busy and asked Clara to assist her. The nurse knew that Clara would be graduating soon and had good clinical skills. Which of the following tasks would be appropriate for Clara to independently perform?
|A.||Distributing medications to patients|
|B.||Administering insulin injections|
|C.||Collecting intake and output data|
- Only one nurse was scheduled to care for 12 postsurgical patients with a nursing assistant. He is concerned for the safety of the patients and his nursing license. What is the most appropriate first step in this situation?
|A.||Contacting the nursing supervisor and documenting the action|
|B.||Refusing to care for the patients without appropriate help and leaving|
|C.||Contacting the State Board of Nursing and documenting the action|
|D.||Contacting the hospital administrator on call to complain and documenting the action|
- A nurse administered the wrong medication to a patient. As a result, the patient received a large cash settlement. What did the nurse commit?
|D.||Violation of criminal law|
- If a patient falls out of bed because the side rails were not raised, this action would constitute:
- Nurses may place a patient in restraint devices to:
|A.||ensure staff convenience.|
|B.||retaliate against poor behavior.|
|C.||punish a patient.|
|D.||ensure the patient’s safety.|
- An employee’s institution’s malpractice insurance covers the nurse for incidences that occur:
|A.||while driving to work.|
|B.||driving home from work.|
|C.||while tending to people in the neighborhood.|
|D.||while working within the scope of employment.|
- A state with abuse legislation requires a nurse who suspects child abuse or neglect to:
|A.||report it to the proper legal authority.|
|B.||inform the parents that their actions are illegal.|
|C.||call the security department to handle the problem.|
|D.||prevent the parents from seeing the child during hospitalization.|
- A student nurse employed as a personal care assistant may perform patient care:
|A.||learned in school.|
|B.||expected of a nurse at that level.|
|C.||identified in the position’s job description.|
|D.||requiring technical rather than professional skills.|
- A nurse is caring for a patient who states, “I just want to die.” For the nurse to comply with this request the nurse and the patient should discuss the benefits of:
|A.||a living will.|
- Good Samaritan laws encourage health care providers to render assistance in accidents because these laws ____________________.
- A nurse is about to administer a medication and notices that the physician’s or health care provider’s order looks incorrect regarding the amount of the medication. What should the nurse do? Select all that apply.
|A.||Notify the physician or health care provider.|
|B.||Withhold the medication.|
|C.||Document the suspicion that the dosage is incorrect.|
|D.||Administer the medication.|
|E.||Observe the patient for untoward side effects.|
|F.||Write a progress note explaining why the medication was withheld.|
Potter: Basic Nursing, 7th Edition
Chapter 05: Ethics
- A 73-year-old patient with hypertension is awaiting a triple cardiac bypass surgery. Robert is hard of hearing and did not understand what the surgeon told him regarding the surgery. His daughter is concerned that he does not understand the risks of the surgery. If not clarified, this would be a violation of what principle?
- A 45-year-old mother of two children has cirrhosis of the liver and is on a waiting list for a liver transplantation. She had to meet certain criteria to be eligible to receive a liver. She has been waiting for seven months for a donor liver and fears that she is running out of time. She understands that she is next on the list for a donor liver that matches. This is an example of which of the following principles?
- A registered nurse who works on an oncology unit discussed pain control options that the health care provider had ordered with a patient undergoing treatment for pancreatic cancer. The patient requested that they be given prn intravenous (IV) pain medication on a regular basis. The nurse agreed to provide the prn IV pain medication as requested. This is an example of which of the following principles?
- A registered nurse knows that an oncology patient undergoing a bone marrow transplant will spend weeks in isolation in the hospital. During that time the patient will be at an increased risk for infection and other complications. There is the possibility that the patient may not recover from the complications of the procedure. The nurse has a duty to ensure that the patient has been given information regarding the risks and potential benefits of the procedure. This is an example of which of the following principles?
- A registered nurse is working on a pediatric oncology unit and caring for four children undergoing chemotherapy. Today she has a new nursing assistive personnel (NAP) assigned to assist her. Although she has never worked with this person, she understands that the NAP had to pass a basic competency examination before he was allowed to work on the unit with patients. She will delegate a portion of the fundamental nursing tasks to the NAP during the shift. This is an example of demonstrating which of the following?
|B.||Code of ethics|
- The mother of a 45-year-old patient is a retired physician and requests to discuss her daughter’s plan of care with the nurse caring for the patient. What is the nurse’s best response to this request?
|A.||“I will need to ask permission from my supervisor before I can share that information.”|
|B.||“I cannot share that information with you. I would suggest you ask your daughter.”|
|C.||“I would suggest that you discuss that with your daughter’s physician.”|
|D.||“I will have to get your daughter’s permission before I can share that information.”|
- A RN has been a nurse for 35 years. During that time she has become very intolerant to patients who are smokers. This is a violation of __________ standards.
- A registered nurse has recently been reassigned to the gynecology unit at her hospital. She is a devout Catholic and is strongly against abortion. She contacts the nursing supervisor regarding her assignment because the unit cares for women who are undergoing abortions. With which of the following is she having a conflict?
- A 9-year-old patient was severely burned and has been undergoing whirlpool treatments to debride her wounds. She is crying and does not want to go to the physical therapy department for the treatment. The registered nurse caring for the girl knows that, even though it is uncomfortable, she needs to have the therapy for the wounds to heal properly. The nurse is demonstrating which of the following principles?
- Although a registered nurse has been working for several years as a staff nurse on an adult oncology unit, he recently transferred to a pediatric unit in the hospital. He will be in orientation for several days to learn about the different systems, and he will need to demonstrate proficiency in various pediatric areas such as medication administration. This is because he will need to demonstrate which of the following?
- A code of ethics provides the foundation for professional nursing. A nurse’s use of ethical responsibility can best be exemplified when the nurse:
|A.||delivers competent care.|
|B.||applies the nursing process.|
|C.||forms interpersonal relationships.|
|D.||evaluates new computerized technologies.|
- A nurse decides to withhold a medication because it will further lower a patient’s respiratory rate. In this case, the nurse is practicing what principle?
- A patient is about to undergo a new, controversial bone marrow transplant procedure. The procedure may cause periods of pain and suffering. Although nurses agree to do no harm, this procedure may be necessary to promote health. This is an example of which of the following ethnical principles?
- A community health nurse states, “I wish we had just a portion of the dollars spent repairing atherosclerotic hearts to teach the community about cardiovascular risk factors.” This statement stems from what philosophy?
|D.||Ethics of care|
- A nurse decides to tell adult children that they need to decide how to advise their father about taking narcotics during the terminal phase of his illness. This critical processing step of an ethical dilemma:
|A.||articulates the problem.|
|B.||evaluates the action.|
|C.||negotiates the outcome.|
|D.||determines values surrounding the problem.|
- The code of ethics for nursing sets forth ideals of nursing conduct and provides a common foundation for nurses’ training, which was developed by what organization?
|A.||Board of Registered Nurses|
|B.||American Medical Association|
|C.||National League for Nursing|
|D.||American Nurses Association|
- Nursing staff members strive to advocate for their patients. When a nurse practices patient advocacy, he or she will ____________________.
- A nurse is working with the parents of a seriously ill newborn. Surgery has been proposed for the infant, but the chances of success are unclear. To help the parents resolve this conflict, the nurse will begin to analyze this ethical dilemma by doing which of the following? Select all that apply.
|A.||Identifying people who can solve this dilemma|
|B.||Gathering all relevant information surrounding this dilemma|
|C.||Clarifying the values related to the cause of this dilemma|
|D.||Consulting a professional ethicist regarding how to proceed with this dilemma|
|E.||Considering possible courses of action|
Potter: Basic Nursing, 7th Edition
Chapter 06: Evidence-Based Practice
- Which of the following nurses was the first to use evidence-based practice?
- A registered nurse has been a nurse for 3 years. She questioned the nurses on the neonatal intensive care unit where she works about the practice of kangaroo care for neonates. She had read literature supporting the practice, but the nurses she works with told her that they had never done anything like that at their institution. She continued to ask questions and began a literature review. Which of the following behaviors was she demonstrating?
|B.||Problem solving methodology|
- A registered nurse wants to review the latest information regarding prevention of a health care acquired infection. The best place for her to obtain the latest information is which of the following?
|A.||Latest edition of a nursing textbook|
|C.||Peer-reviewed nursing journal|
|D.||Most recent edition of a nursing magazine|
- A 15-year-old male patient was admitted to the hospital with a bowel obstruction. He underwent surgery and was experiencing postoperative pain. The nurse caring for him had recently read a research article in which a study had been done with neonatal patients and the use of therapeutic touch to assist with pain control. Which of the following is most important for the nurse to consider in this case when applying research to clinical practice?
|C.||Stage of patient growth and development|
- Evidence-based practice is a systematic approach to determine the most current and relevant information from which to make patient care decisions. Choose the first step in the evidence-based care process.
|A.||Collecting the most relevant and best evidence|
|B.||Integrating evidence with one’s clinical expertise|
|C.||Critically appraising the evidence gathered|
|D.||Asking a clinical question|
- The nurse manager of a 30-bed medical surgical unit has noticed that the fall rate of postoperative patients has increased in the past 2 months. This is a clinical situation that he believes should be addressed using evidence-based practice. The clinical question that he is formulating has come about because of which of the following?
- A registered nurse who works for a surgical intensive care unit (ICU) has recently read several articles in professional nursing journals about the use of quiet time in the ICU to enhance patient outcomes. He would like to apply the research findings to his unit. The clinical question he formulated was generated by which of the following?
- A nurse’s manager has suggested that she formulate a PICO question to clarify her topic before doing a literature review. The acronym PICO stands for which of the following?
|A.||Policy, information, comparison, outcome|
|B.||Patient, information, collection, outcome|
|C.||Patient, intervention, comparison, outcome|
|D.||Patient, intervention, communication, outcome|
- A nurse working on a PICO question has found a large amount of literature available on the topic that she is interested in. There have been multiple studies that have been published. Which of the following types of studies should have the best evidence?
|A.||Meta-analysis of randomized control trials|
|B.||Opinion of an expert committee|
|C.||One well-designed randomized control trial|
|D.||Systematic review of descriptive and qualitative studies|
- A registered nurse is concerned about the quality of life that patients experience after a diagnosis of liver cancer. The most appropriate type of research study from which to gather information about this is which of the following?
|D.||Case controlled study|
- The National Data Base for Nursing Quality Indicators (NDNQI) collects information regarding patient falls, pressure ulcer incidence, and nursing satisfaction. Which of the following organizations require affiliated health care organizations to collect and report this information?
|A.||The Joint Commission|
|B.||Magnet Recognition Program|
|C.||Centers for Disease Control and Prevention|
|D.||Department of Health and Human Services|
- A student nurse is looking for research articles that she can use to complete her research paper. Where can she look to quickly find out if an article is research or clinically based?
|D.||Results or conclusions|
- As a nurse working in an acute care setting, Greta wanted to determine the most accurate way to take patient’s temperatures. She noticed that the tympanic thermometers used by her unit were often not accurate. Greta wrote a PICO question and reviewed the literature. She found that the literature showed tympanic thermometers were not the most accurate method of obtaining a temperature. Greta wanted to change the nursing practice of her unit. What is the most logical next step?
|A.||Discuss the findings with a physician to gain support.|
|B.||Gain the support of a multidisciplinary team.|
|C.||Share the findings with the nursing practice council.|
|D.||Discuss the findings with an administrator.|
- After a practice change has taken place, the final step in the application of evidence-based practice is to do which of the following?
- The most effective way to evaluate the effectiveness of an evidence-based practice change is to do which of the following?
- At a health care organization, patients are turned every two hours to help prevent pressure ulcers. Because of this nursing intervention, patients exhibit far fewer pressure ulcers than the national average. This is known as what?
- The most important thing that a nurse can do to ensure outcome measurements are accurate is to:
|A.||communicate results to all clinicians.|
|B.||train all clinicians who are involved in collecting data.|
|C.||maintain a small group of patients in the study.|
|D.||collect all data on the same day.|
Potter: Basic Nursing, 7th Edition
Chapter 07: Critical Thinking
- A registered nurse is caring for a 68-year-old patient in the trauma unit who had been involved in a motor vehicle accident. Although the patient denied pain, during the nurse’s assessment, she observed that he groaned when moving and was protective of his right arm. She believed the patient had pain and reported it to the health care provider who ordered a radiograph of his right arm. The radiograph revealed a fractured humerus. This is best described as which of the following?
- A registered nurse is caring for a postoperative patient whose systolic blood pressure has dropped 10 points during his shift. He remembers that this was similar to a situation that happened in the past when the patient developed an internal bleed. The nurse’s thoughts are best described as which of the following?
- Blair, a student nurse, is assisting a nurse with admitting a 73-year-old woman with a fractured ulna and radius to the trauma unit of the hospital. The patient’s daughter and son-in-law are with her. Blair notices that the patient does not make eye contact when answering questions and she feels that something is not right about the situation. This can best be explained by which of the following?
- A student nurse is with a medical unit during this clinical rotation. She is administering an enema with her instructor in the room. The patient states that they can no longer hold the enema solution. The student nurse acknowledges the patient’s request and begins to tell the patient that he can go to the bathroom to expel the enema. The instructor suggests that the patient wait a few minutes to give the enema solution time to be absorbed into the bowel. In this situation the student nurse demonstrates what level of critical thinking according to Kataoka-Yahiro and Saylor’s model?
|A.||Level 1: Basic|
|B.||Level 2: Complex|
|C.||Level 3: Commitment|
|D.||The student nurse is not demonstrating critical thinking.|
- A novice nursing student will most likely practice nursing at level _____ of critical thinking according to Kataoka-Yahiro and Saylor’s model.
- A nursing student learning about the critical thinking process begins with which of the following?
|B.||Identifying a problem|
|C.||Formulating a question|
|D.||Evaluating the results|
- A registered nurse is explaining to a 35-year-old woman about what she can expect when her peripherally inserted central line is inserted. Which of the following is the best way for the nurse to explain the procedure?
|A.||“A PICC line is about the same as a needle in your arm.”|
|B.||“A triluminal catheter will be inserted into your basilic vein.”|
|C.||“The PICC line will be threaded through your superior vena cava.”|
|D.||“A PICC is a catheter that will be inserted in a vein in your arm.”|
- A 56-year-old patient receiving blood after an abdominal surgery notified the nurse that her IV pump was alarming. The nurse checked the pump and determined that the tubing was kinked. The tubing was straightened out and the nurse left the room. Five minutes later the IV pump again alarmed. The nurse returned to find the tubing was again kinked. On further investigation, the nurse discovered that the IV tubing had become twisted. This is an example of which of the following on the part of the nurse?
|A.||Effective problem solving|
|D.||Commitment level of critical thinking|
- A 16-year-old patient on a pediatric unit who underwent an appendectomy for a ruptured appendix 3 days ago complains of acute pain and has a high fever. The nurse is concerned that she may have an infection and notifies the health care provider of the change in her condition. This concern is based on the nurse’s experience as a pediatric nurse. Her ability to make a tentative conclusion regarding this patient’s situation based on observed data is known as what?
|C.||Effective problem solving|
- Roger, a 34-year-old patient with cancer, is undergoing outpatient chemotherapy. Nancy, the nurse caring for him at the clinic where he goes for his treatments notes that Roger’s white blood cell count is very low and he has little energy. Roger’s plan of care is based upon the nursing diagnosis Risk for infection. Nancy provides patient teaching in order to reduce Roger’s risk for infection. Nancy is using which skill in this situation?
- Stacie, a nursing student, is caring for Mrs. Thames, an elderly lady who recently experienced a stroke. Stacie notices that Mrs. Thames coughs after she eats or drinks. Stacie knew that Mrs. Thames was at risk for aspiration because of the stroke that she had experienced and was concerned that Mrs. Thames may have impaired swallowing. Stacie develops a care plan for Mrs. Thames based on the nursing diagnosis Impaired swallowing. Which of the following is Stacie using to make this nursing diagnosis?
- A nurse who is demonstrating clinical decision-making is:
|A.||collecting information about a patient and coming to a conclusion about his or her health problems.|
|B.||clarifying the problem and analyze possible causes.|
|C.||developing a new idea based on experience and knowledge over time.|
|D.||selecting appropriate treatment after forming a nursing diagnosis.|
- A new registered nurse working for a busy unit of an acute care teaching hospital begins her shift with four patients. She needs to prioritize care. Which of the following patients should she attend to first?
|A.||Patient who needs assistance in ambulating the hall|
|B.||Patient whose blood pressure suddenly drops and who passes out|
|C.||Recovering surgical patient whose family has just arrived|
|D.||Patient who was just diagnosed with cancer and is alone|
- The critical thinking competency that is unique to nurses is the nursing process. Which of the following includes all steps of the nursing process in the correct order?
|A.||Assessment, diagnosis, planning, implementation, and evaluation|
|B.||Diagnosis, assessment, planning, implementation, and evaluation|
|C.||Planning, assessment, diagnosis, implementation, and evaluation|
|D.||Evaluation, diagnosis, planning, implementation, and assessment|
- A new nurse is working for a surgical unit. One of the postoperative patients has been experiencing a great deal of pain. She notified the surgeon who wrote an order for pain medication. Upon checking the order, she noticed that the dosage was more than three times the normal range for this medication. She called the surgeon to question the order. This is primarily an example of which of the following critical thinking attitudes?
- A nurse for 6 years has always worked for the oncology unit of a hospital. Recently, however, there were cutbacks because more patients are being treated on an outpatient basis, so the nurse transferred to an orthopedic unit where he is caring for a patient who underwent an above-the-knee amputation, something for which he has never provided care. He is to do a dressing change for the amputated leg, so he asks another nurse to help him. He is demonstrating which of the following critical thinking attitudes?
- A student nurse in her last semester of nursing school found that keeping a journal of her experiences helped her to understand why she took a certain action and to evaluate whether there was a better way of approaching the task. She has found that this has helped her to grow into the role of a nurse. Which of the following critical thinking attitudes is she demonstrating?
- A new nurse who has just begun working for an oncology unit is frustrated with trying to figure out the relationships between a patient’s problems and appropriate nursing interventions. The best tool that she can use to synthesize data into meaningful information is which of the following?
|C.||Plan of care|
- A nurse walks into a room and finds a patient to be incoherent. As the nurse examines and observes the patient closely, searches for ideas, and considers scientific principles to plan the patient’s care, the nurse is using:
- Last night a nurse spent time instructing a patient on how to monitor his pulse while taking digoxin. The next day the nurse asks the patient to recount the details of this skill. The nurse is using:
- A patient is admitted with dependent edema. As a nurse assesses the patient for the presence of jugular vein distention, the nurse is using the process of:
|D.||testing the hypothesis.|
- When using critical thinking, nurses need to incorporate their cognitive skills and:
- The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done in what way?
|D.||In a vacuum|
- The nursing process organizes the approach to delivering nursing care. To provide the best professional care to patients, a nurse needs to incorporate the nursing process and:
|D.||critical thinking skills.|
- While a nurse is assessing a patient’s chest pain, the patient states, “The pain hurts in the middle of my chest.” The nurse asks, “Can you tell me where the pain is exactly and describe what it feels like?” This scenario most accurately depicts application of:
|C.||critical thinking attitudes.|
|D.||critical thinking standards.|
- Learning how to correctly administer a bed bath adds to a patient’s comfort. Additional factors contribute to the concept of comfort. Tying together these concepts demonstrates ____________________.
Potter: Basic Nursing, 7th Edition
Chapter 08: Nursing Process
- A nurse is collecting data on a patient he is admitting into hospice care. He collects data from both the patient and the family so that he has a clear picture of the patient status. Which step of the nursing process is the nurse currently involved in?
- This is a registered nurse’s first day back to work since she has been on vacation. She is admitting a patient to the unit. She asks the patient about his health history. Which of the following components of the nursing process is she engaged in?
- Harry, a registered nurse, has responded to a call light in a patient’s room. Mr. Greene is a postoperative patient who is continuing to have incisional pain. As part of Harry’s assessment, he notes that Mr. Greene is grimacing when he changes position. Mr. Greene’s grimace can be useful in Harry’s assessment and can be described as which of the following?
- Mr. Greene, the postoperative patient, has denied the need for pain medication. Harry, his nurse, has assessed Mr. Greene and has noted that he describes his pain as an “1” on a 0 to 10 scale. Harry notes that Mr. Greene grimaces when he changes position and guards his incision. Harry believes that Mr. Greene is experiencing pain based on the information he gathered in his assessment. What is this phenomena known as?
- A student nurse is collecting data during the assessment of her patient. During the assessment, she collects both subjective and objective data. Which of the following would be considered subjective data?
|A.||Heart rate of 96|
|C.||Emesis of 150 mL|
|D.||Pain rating of 5|
- A student nurse is in a clinical rotation on a medical unit in an acute care hospital. He has just completed an assessment on a 31-year-old patient with a fractured right femur. Which of the following data are objective?
|A.||Patient’s toes of right foot are warm and pink.|
|B.||Patient rates pain as 7 on 0 to 10 scale.|
|C.||Patient requests pain medication.|
|D.||Patient is concerned about insurance coverage.|
- John, a student nurse, is responsible for assessing a patient, who is abrupt with John and requests that the assessment be done later by a nurse. As John charts the interaction, which of the following statements is the best way for John to document what happened?
|A.||Appears to be in pain as evidenced by his grouchy behavior|
|B.||Behavior is inappropriate, requests registered nurse do the assessment|
|C.||States, “I would prefer a registered nurse to do my assessment”|
|D.||Is grumpy, registered nurse notified|
- Mrs. Falstaff, a 29-year-old mother of five children, is admitted to the hospital for abdominal pain. As a nurse admits Mrs. Falstaff, she asks a series of questions before performing a physical assessment. When asking Mrs. Falstaff about the history of her illness, Mr. Falstaff, who has accompanied his wife, answers all the nurse’s questions. As the admission process progresses and the nurse gathers subjective data, the nurse requests that Mr. Falstaff allow his wife to answer the questions. The nurse does this because she believes that:
|A.||Mr. Falstaff is exhibiting abusive behavior.|
|B.||Mr. Falstaff is being obnoxious.|
|C.||Mrs. Falstaff is the best source of information.|
|D.||Mr. Falstaff is too controlling of his wife.|
- A 4-year-old girl is being admitted to the outpatient surgery for a tonsillectomy. Which of the following will provide the best primary source of information for what comforts her when she is stressed?
- A student nurse is interviewing a patient being admitted to the hospital for a mastectomy. During the interview, she introduces herself as a student nurse and explains that she will be gathering some information. Which phase of the interview is this?
- Which of the following are the three phases of the interview process?
|A.||Orientation, working, termination|
|B.||Orientation, assessment, evaluation|
|C.||Introduction, assessment, termination|
|D.||Planning, assessment, evaluation|
- One of the best ways to gather information about a patient’s health history is to use open-ended questions. Which of the following questions would be best to gather the most information during a health history assessment?
|A.||“How long have you been ill?”|
|B.||“When did you first discover that you were having problems?”|
|C.||“Tell me about the problems you are having.”|
|D.||“Do you have a family history of this problem?”|
- As a student nurse is obtaining a health history from his patient, he shows that he has heard what the patient has said by giving positive comments such as “go on.” This is known as:
- A 73-year-old patient with a history of seizures was being admitted to the hospital after a grand mal seizure took place at a shopping mall. Her husband accompanied her to the hospital and was being interviewed by the nurse. Which question should the nurse ask to quickly focus on her symptoms?
|A.||“Tell me about your wife’s history of seizures.”|
|B.||“How long did the seizure last?”|
|C.||“Tell me how Jenalee’s seizure disorder has affected her lifestyle.”|
|D.||“Tell me why you brought Jenalee to the hospital today.”|
- A 17-year-old patient was admitted to the hospital after a motorcycle accident. The nurse in the emergency room is assessing vital signs, general appearance and behavior, and performing a head to toe examination of all body systems. Which of the following best describes what the nurse is doing?
- When admitting a woman to the hospital, the nurse asks if she has problems feeding herself since she had a stroke. She denies any problems and states that she does not require assistance. After lunch, the nurse notes that she has not eaten most of her food and has spilled much of what she did attempt to eat. These cues lead the nurse to believe that she is not functioning at the level she indicated upon admission. The nurse was using which of the following to make this deduction?
- Mr. LaMar, a 67-year-old patient of French heritage, was recently admitted to the hospital. He was interviewed by Yung Kim, a student nurse from a Korean family. Yung Kim did not make eye contact with Mr. LaMar while conducting the interview. This disturbed Mr. LaMar because he thought that Yung Kim might be trying to hide something. This behavior was most likely the result of differences in:
- A 23-year-old Jamaican mother took her 18-month-old child to a clinic because the child was lethargic. She was perplexed when the nurse asked how long the child had diarrhea, a term with which she was unfamiliar. Many Jamaicans refer to diarrhea as “runny belly.” The nurse could have prevented the confusion at the beginning of the interview. Which of the following is the most culturally sensitive statement to begin the interview?
|A.||“What do you call this problem?”|
|B.||“How long has your child had the runs?”|
|C.||“When did the loose stools begin?”|
|D.||“Has anyone else in your family had diarrhea?”|
- Which of the following is the final step in a complete assessment?
|A.||Reviewing diagnostic data|
|C.||Documentation of findings|
- A 63-year-old patient with bilateral pneumonia was admitted to the intensive care unit. The nurse who initially prepared her plan of care identified that she had the collaborative problem of Potential complications: hypoxemia. This is considered a collaborative problem because it requires:
|A.||monitoring for signs of acid-base imbalance.|
|B.||ensuring adequate hydration.|
|C.||evaluating the effects of positioning on oxygenation.|
|D.||both nursing and physician-prescribed interventions.|
- A patient states, “I’m burning up, and I have a fever.” The nurse takes the patient’s temperature, observes the skin for flushing, and feels the skin temperature. This is an example of __________ subjective data.
- A heart rate of 66 beats per minute, a respiratory rate of 12 breaths per minute, and a blood pressure (BP) of 120/80 mm Hg represents __________ data.
- Assessment reveals that a patient has lost 10 pounds in the last 2 months. Weight loss is one of the three defining characteristics of the diagnostic category Imbalanced nutrition: less than body requirement. Knowing this, the nurse should:
|A.||restate the nursing diagnosis as Imbalanced nutrition: less than body requirements related to poor dietary habits.|
|B.||examine the assessment data to see if other signs and symptoms of altered nutrition exist.|
|C.||ignore the data regarding the weight loss because 10 pounds is not that much.|
|D.||restate the nursing diagnosis as Weight loss related to decreased food intake.|
- The identification of nursing diagnoses allows a nurse to:
|A.||compete with physicians or health care providers.|
|B.||develop an individualized plan of care.|
|C.||treat nursing problems and medical problems.|
|D.||manage patient care for the entire health team.|
- A patient is suffering from shortness of breath. How is the goal statement correctly written?
|A.||“The patient will be comfortable by the morning.”|
|B.||“The patient will breathe unlabored at 14 to 18 breaths per minute by the end of the shift.”|
|C.||“The patient will not complain of breathing problems within the next 8 hours.”|
|D.||“The patient will have a respiratory rate of 14 to 18 breaths per minute.”|
- Nurse-initiated interventions are:
|A.||determined by state nursing practice acts.|
|B.||supervised by the entire health care team.|
|C.||made in concert with the plan of care initiated by the physician or health care provider.|
|D.||developed after evaluating the interventions for the recent medical diagnoses.|
- A nurse is writing a care plan for a newly admitted patient. Which of the following outcome statements is written correctly?
|A.||“The patient will eat 80% of all meals.”|
|B.||“The nursing assistant will set up the patient for a bath every day.”|
|C.||“The patient will have improved airway clearance by May 30.”|
|D.||“The patient will identify the need to increase dietary intake of fiber by July 4.”|
- As a nurse works with a patient in the achievement of goals, an appropriate action would be to:
|A.||keep the plan of care flexible.|
|B.||discover ways to improve health care.|
|C.||adhere to the plan of care written for the patient.|
|D.||encourage the patient to quickly move toward being discharged.|
- A patient has received several nursing interventions. To evaluate the interventions, the nurse needs to examine the:
|A.||appropriateness of the interventions and the correct application of the implementation process.|
|B.||nursing diagnoses to ensure they are not medical diagnoses.|
|C.||care planning process for errors in other health care team members’ judgment.|
|D.||interventions of each nurse to enable the nurse manager to correctly evaluate their performance.|
- When caring for a patient who has multiple health problems and related medical diagnoses, a nurse can best illustrate nursing diagnoses and nursing interventions by developing a:
|C.||nursing care plan.|
- A patient has met the goals set for improvement of ventilatory status. The nurse should now:
|A.||modify the care plan.|
|B.||discontinue the care plan.|
|C.||create a nursing diagnosis that states goals have been met.|
|D.||reassess the patient’s response to care and evaluate the implementation step of the nursing process.|
- The use of standing orders gives the nurse ____________________.
Potter: Basic Nursing, 7th Edition
Chapter 09: Informatics and Documentation
- Regulations from agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services require the monitoring and evaluation of the quality and appropriateness of patient care. What is the best method for demonstrating that an organization is providing quality patient care?
|A.||Cost of care per patient day|
|B.||Number of registered nurses on staff|
|C.||Absence of sentinel events|
- Sadie, a registered nurse was caring for Mr. Harris, an older adult patient with lung cancer. His daughter, a nurse, asked Sadie to let her look at Mr. Harris’ chart. Sadie’s best reply should be:
|A.||“I’m sorry; you will have to wait until I am done with my documentation to look at the chart.”|
|B.||“I’m sorry; this information is confidential.”|
|C.||“Let me ask my supervisor if it is okay.”|
|D.||“You should know better than to ask me that.”|
- A nursing student is working on his clinical assignment. He knows that he must maintain patient confidentiality. Which of the following is acceptable for him to write on the clinical care plan that he will give to his instructor?
|A.||Patient room number|
|B.||Patient date of birth|
|C.||Patient medical record number|
|D.||Patient nursing diagnosis|
- Which of the following agencies have standards that require a nurse’s documentation to be within the context of the nursing process?
|A.||Centers for Disease Control and Prevention|
|B.||World Health Organization|
|C.||The Joint Commission|
|D.||Public Health Department|
- Practitioners from many disciplines use the medical record to document data. The most important purpose of the medical record is to:
|A.||invoice the patient or insurance company for reimbursement.|
|B.||protect the clinician in case of a malpractice suit.|
|C.||ensure everyone is working toward a common goal of providing safe care.|
|D.||contribute to a databank for medical and nursing research.|
- A nurse is frustrated about what she feels is a lack of staff on her shift. When one of the patients fell and broke his hip, she documented the incident in the patient’s chart. Which of the following is the best way that she should document what happened?
|A.||“Fell while going to the bathroom. Physician notified.”|
|B.||“Nobody available to answer call bell; patient got up on own and fell.”|
|C.||“Patient fell due to unsafe staffing levels on unit.”|
|D.||“Patient waited as long as he could; nobody there to help him and he fell.”|
- A registered nurse is documenting her patient assessment. Which of the following examples of documentation is most clear?
|A.||“Seems comfortable at this time.”|
|B.||“Is asleep, appears not to be experiencing pain.”|
|C.||“Apparently is not in pain because he didn’t rate it high on the scale.”|
|D.||“States pain is a 2 on a 0 to 10 scale.”|
- A patient states that she is experiencing pain in her lower back. What is the best way for the nurse to document this subjective information?
|A.||“States her back is hurting.”|
|B.||“States ‘My lower back hurts.‘”|
|C.||“Grimaces when moving; I believe she has lower back pain.”|
|D.||“Appears to be uncomfortable with lower back pain.”|
- Which of the following examples of documentation best describes the data?
|A.||“Small amount of clear yellow urine voided.”|
|B.||“Voided 220 mL clear yellow urine.”|
|C.||“A small amount of urine voided into absorbent pad.”|
|D.||“Patient incontinent of urine.”|
- Which of the following demonstrates the most accurate and safe documentation?
|A.||“Sm. amt. of emesis.”|
|B.||“150 mL of cloudy dark yellow urine.”|
|C.||“15.00 mL of blood collected.”|
|D.||“.5 L of fluid administered.”|
- Which of the following documentation samples is most appropriate?
|A.||“The patient states he would except moving to a semi-private room.”|
|B.||“Patient stated he developed aspiration pneumonia due to dysphasia.”|
|C.||“Bruise noted on right side over fractured ileum.”|
|D.||“Right jugular vein distended.”|
- A student nurse is documenting her last entry for the day. It is 3:15 PM and she needs to document her entry using military time. Which of the following is the correct way to document the time?
- The Joint Commission requires that a plan of care be written for patients in all the following areas except for those patients in a(n):
|B.||acute care hospital.|
|D.||extended care facility.|
- A registered nurse recently went to work for a health care organization that uses the SOAP format for documentation. Which of the following most accurately describes what SOAP stands for?
|A.||Status, Observation, Assessment, Plan|
|B.||Subjective data, Objective data, Assessment, Plan|
|C.||Subjective data, Objective data, Assimilation, Plan|
|D.||Subjective data, Objective data, Assessment, Priority|
- A student nurse as been scheduled to do her clinical rotation this semester for a busy medical unit in an acute care hospital. This is the first time she has been at this hospital, and she is told during orientation that the organization is very patient focused and that it uses a documentation system with the acronym PIE. What does PIE stands for?
|A.||Problem, Intervention, Evaluation|
|B.||Patient, Intervention, Evaluation|
|C.||Population, Intervention, Evaluation|
|D.||Plan, Intervention, Evaluation|
- A new registered nurse is working on a pediatric unit in a large teaching hospital that uses focus charting with the acronym DAR. What does this stand for?
|A.||Data, Assessment, Reaction|
|B.||Data, Assessment, Response|
|C.||Data, Actions, Response|
|D.||Data, Actions, Reaction|
- A registered nurse recently changed jobs and is now working in home health. She understood that the reason for accurate documentation in the acute care setting where she had previously worked was to provide an accurate record for safe patient care. Working in home health, she now has learned that in addition to providing an accurate record for safe patient care, this documentation is also used by Medicare, Medicaid, and private insurance companies for which of the following?
|A.||Justification for prescribed medications|
|B.||Data for nursing research|
|C.||Justification for home care reimbursement|
|D.||Data to support social security benefits for the disabled|
MSC: Client Needs: Safe and Effective Care Environment
- The nurse manager of a large medical unit in a busy urban teaching hospital reviews the unit trends for staffing, which are determined by an acuity system. Which of the following statements is true about an acuity-based staffing model?
|A.||More staff are needed for a low acuity level.|
|B.||More staff are needed for a high acuity level.|
|C.||Less staff are needed for a high acuity level.|
|D.||Acuity levels are never used to determine staffing levels.|
- When a student nurse began working at a local hospital this past summer, she learned that the hospital had just instituted a “hand-off” protocol. Which of the following is the best example of a hand-off report?
|B.||IV fluid flow sheet|
|C.||Documentation in the nurse’s notes of the patient chart|
- One communication strategy that health care providers have adopted to improve patient safety is SBAR. The acronym SBAR stands for which of the following?
|A.||Situation, Background, Action, Recommendation|
|B.||Summary, Behavior, Allergies, Recommendation|
|C.||Situation, Background, Assessment, Recommendation|
|D.||Situation, Background, Action, Recommendation|
- A nurse records that a patient states his abdominal pain is worse now than last night. Of what is this an example?
|D.||Charting by exception|
- A nurse completes an incident report on a patient who fell while walking in the hallway. The purpose of this documentation is to:
|A.||exchange information among health care members.|
|B.||provide information about patients on one unit to another.|
|C.||ensure proper care for the patient.|
|D.||aid in the hospital’s quality improvement program.|
- After a nurse receives a medication telephone order for a patient, what is the proper action?
|A.||Withholding the medication until the physician or health care provider is able to write the prescription in person|
|B.||Verifying the physician’s or health care provider’s order with the pharmacy|
|C.||Documenting the new medication order in the patient’s chart|
|D.||Clarifying the new medication order with another registered nurse|
- During a change-of-shift report the nurse who is going off duty is expected to:
|A.||exchange judgments made about the patient’s attitudes.|
|B.||include a description of how to perform procedures.|
|C.||provide a concise and organized description of the patient’s status and needs.|
|D.||make walking rounds with the nurse coming on duty to review the patient’s plan of care.|
- Multidisciplinary team members use a critical pathway to monitor the patient’s progress. This is an example of using a critical pathway as a:
|B.||method to track changes.|
|C.||way to format the nursing process.|
|D.||substitute for a Kardex form.|
- The discharge summary deals with important elements pertaining to the patient’s problems and health care after discharge. When preparing the summary, the nurse needs to include:
|A.||the specific teaching plan.|
|B.||deviations from the plan of care.|
|C.||the standardized nursing care plan.|
|D.||a detailed description of nursing procedures.|
- Information about a patient’s status may not be disclosed to non–health care team members because:
|A.||legal and ethical obligations require health care team members to keep information strictly confidential.|
|B.||regulations require health care institutions to document evidence of physical and emotional well-being.|
|C.||reimbursement issues relating to patient care and procedures may be of concern.|
|D.||a fragmentation of nursing and medical care procedures may be identified.|
- A nursing unit is conducting a trial on a computerized documentation system. The nurse is anxious to implement this type of system because it:
|A.||maximizes the need to duplicate records.|
|B.||can be used to document all aspects of care.|
|C.||alters the need to document on a regular basis.|
|D.||has a much narrower scope than current charting systems.|
- A nurse has just admitted a patient with a medical diagnosis of Rule out myocardial infarction. When completing the paperwork the nurse needs to record:
|A.||an interpretation of patient behavior.|
|B.||objective data that are observed.|
|C.||lengthy entries using lay terminology.|
|D.||abbreviations familiar to the nurse.|
- Although each clinical agency may use different documentation formats, nurses need to realize that the purpose of documentation is which of the following? Select all that apply.
|A.||To aid in clinical research|
|B.||To maintain a legal and financial record of care|
|C.||To include a step-by-step description of how to perform procedures|
|D.||To guide professional and organizational performance improvement|
Potter: Basic Nursing, 7th Edition
Chapter 10: Communication
- A student nurse who works for an oncology unit is preparing to bathe a patient who recently underwent surgery to remove an abdominal tumor. Before beginning the bath, the student nurse explains what she intends to do. Which of the following best describes her communication role?
- A patient is being cared for by a student nurse. The patient has questions regarding what time her surgery is scheduled. When the student nurse responds to the question, she is assuming which of the following communication roles?
- A registered nurse is a new nurse manager who needs to council an employee regarding her attendance. Because the nurse manager is new to the position, she is rehearsing what she plans to say to the employee before the meeting. Which of the following best describes this form of communication?
- A student nurse is working in a busy emergency department of an urban hospital. The family of a patient brought in by ambulance asks the student nurse what the doctor meant when she said that the patient was “coding.” In this situation, the word “coding” is an example of which of the following?
- Mrs. Bath asked a student nurse when she could expect her health care provider to make rounds. The student nurse was on her way to take a patient for a stat test and replied very quickly, “I have no idea.” Mrs. Bath most likely interpreted the student nurse as uncaring due to which of the following?
- A 9-year-old patient who is hospitalized for bowel surgery appeared very frightened. To appear less threatening to the child, which of the following would be best for the nurse to do?
|A.||Stand over his bed when talking to him.|
|B.||Sit in a chair next to his bed when talking to him.|
|C.||Maintain constant eye contact with him.|
|D.||Stay within 12 inches of him when talking to him.|
- Mary, a student nurse, went into Mrs. Doer’s room at 0900, shortly after she was told that she had liver cancer. Mrs. Doer asked Mary if she had a few minutes because she did not want to be alone. Mary stood very close to Mrs. Doer, held her hand and told her she had plenty of time. A few minutes later, Mary thought she should check the time on her watch because she was supposed to take another patient for a test at 0945. Mrs. Doer saw Mary look at her watch and told Mary that she now was okay to be alone. Why did Mrs. Doer most likely request to be alone?
|A.||Invasion of personal space|
- A registered nurse is caring for a postoperative patient who is experiencing respiratory distress after the administration of pain medication. The nurse called the patient’s health care provider immediately. The information regarding the patient was conveyed using the SBAR format. What does SBAR stand for?
|A.||Situation, background, assessment, recommendation|
|B.||STAT, background, assessment, recommendation|
|C.||Status, background, analysis, recommendation|
|D.||Situation, belief, assessment, requirement|
- A student nurse is considered to project a professional image by her peers. Which of the following behaviors would be considered most professional?
|A.||Addressing a patient by “dear”|
|B.||Wearing small earrings|
|D.||Avoiding troublesome patients|
- When caring for a patient from another culture, what is the best strategy for the nurse to use in communicating with the patient?
|A.||Using a cultural joke to break the ice|
|B.||Stereotyping the patient within their culture|
|C.||Considering the context of the patient’s background|
|D.||Assuming the patient speaks English|
- A 67-year-old patient had a stroke that left her aphasic. A student nurse is working on a plan of care. What is the best nursing diagnosis to use for the patient’s aphasia?
|A.||Impaired verbal communication|
|C.||Impaired social interaction|
- A 67-year-old patient recently had a stroke that left her aphasiac. The nurse has planned to take a multidisciplinary approach to her care. Who would be most appropriate for the nurse to collaborate with regarding the patient’s aphasia?
|D.||Psychiatric nurse specialist|
- Marsha, a student nurse, is spending time with her patient, Mrs. James, who has recently been diagnosed with breast cancer. Mrs. James expresses that she is frightened about the diagnosis and feels overwhelmed. Marsha’s responds, “It sounds to me like you are feeling very scared right now.” This is an example of which of the following?
- A patient has just been admitted to the hospital with a broken hip from a fall in her home. She is concerned that she might not be able to return home after surgery because she lives in a second-floor apartment without an elevator. The nurse admitting her is practicing active listening. Which of the following behaviors best conveys to the patient that the nurse is listening to her?
|A.||Keeping arms crossed|
|B.||Sitting facing the patient|
|C.||Leaning away from the patient|
|D.||Standing facing the patient|
- Graham is a nursing student who is working evenings for a busy medical unit. He is caring for one patient who is having abdominal pain and is experiencing difficulty sleeping. Graham sits at the bedside of this patient and takes her hand. The patient quickly pulls back her hand. What is the most likely cause for this behavior?
|A.||She is uncomfortable with being touched.|
|B.||She is in too much pain to be touched.|
|C.||She has impaired social skills.|
|D.||She has difficulty with nonverbal communication.|
- A student nurse who is assisting in the admission of a patient to the orthopedic unit of the hospital is obtaining information for the database. She is using therapeutic communication to gain information from the patient. Which of the following is the best way for the student nurse to obtain information from the patient?
|A.||Asking personal questions in order to show interest|
|B.||Using medical vocabulary to appear competent|
|C.||Asking why he waited so long to get his knee replaced|
|D.||Using silence while he gathers his thoughts|
- A nurse decides to talk with another staff nurse about a patient for which they are caring. This type of communication constitutes:
- When a nurse tells a patient “I will return in 15 minutes,” the nurse is using the technique of:
- A 22-year-old female model recently had a bowel resection resulting in a colostomy. When the nurse enters the room to begin teaching the patient about the care of the ostomy, she finds the patient crying. The nurse decides to delay this teaching session due to the:
|A.||pacing of the conversation.|
|B.||timing and relevance of the information.|
|C.||environmental setting of the conversation.|
|D.||possible differences in connotative meaning.|
- Contracts for a therapeutic helping relationship are formed during the _____ stage.
- A nurse enters a patient’s room and sees the patient grimacing with each movement. When questioned the patient states that he “feels fine.” Nonverbal communication by the patient:
|A.||adds cues and meaning to verbal communication.|
|B.||ensures the patient will send the message intended.|
|C.||is an indirect communication technique to ensure their needs are met.|
|D.||conveys contextual factors such as attitudes, values, beliefs, and self-concept.|
- While a patent is being interviewed, a family member states, “My father really means that he doesn’t know what the physician meant about the medical diagnosis.” The communication style the family member used is:
- A nurse is experiencing problems understanding a dysarthric patient. When dealing with patients who experience impaired communications, a nurse can:
|A.||vary the tone, pitch, and intonation of the voice.|
|B.||facilitate methods that help the patient communicate more clearly.|
|C.||shift from subject to subject until the patient responds.|
|D.||speak through another staff member who has more experience dealing with dysarthric patients.|
- When a staff nurse plans a teaching session for a patient diagnosed with postmyocardial infarction, an important aspect to incorporate is the message component of the teaching session. The message component:
|A.||uses methods unique to the situation.|
|B.||conveys a message within a message.|
|C.||pays attention to each aspect of the message.|
|D.||is clear, organized, and expressed in a familiar method.|
- A nurse has just admitted a 5-year-old child for a suspected appendicitis. A therapeutic communication technique to use while talking with this child includes which of the following? Select all that apply.
|A.||Allowing the child time to talk|
|B.||Using simple, direct language|
|C.||Sitting at the child’s eye level|
|D.||Telling the child exactly what he or she can do|
Potter: Basic Nursing, 7th Edition
Chapter 11: Patient Education
- A nursing student has been asked to prepare patient education for Spanish-speaking patients regarding diabetes. This information will be available to patients in the diabetes clinic. The goal of this patient education is to:
|A.||assist Spanish-speaking patients to reach optimal health.|
|B.||teach Spanish-speaking patients some English.|
|C.||provide information so they can make a decision between oral and injectable medications.|
|D.||reduce the legal liability of the clinic.|
- A patient with newly diagnosed diabetes is being discharged from the hospital. She will be going to an outpatient diabetic center to learn more about diet, exercise, disease management, and insulin administration. Which of the following statements made by the patient indicates that effective teaching can take place?
|A.||“I am thankful that my doctor figured out what was wrong with me because I don’t want to get sick again.”|
|B.||“I am so happy to be going home so I don’t have to eat hospital food anymore.”|
|C.||“I will be glad when they find a cure for diabetes.”|
|D.||“I don’t think I will need to take insulin for very long because I already feel better.”|
- The parents of a 3-month-old infant are preparing to take their child home from the hospital after she was hospitalized after she stopped breathing. Before being discharged, they must be educated on infant CPR. The most appropriate learning objective for this situation is which of the following?
|A.||Parents will be able to successfully prevent SIDS.|
|B.||Parents will demonstrate infant CPR skills.|
|C.||Baby will not require further hospitalization.|
|D.||Parents will prevent child from having another near-SIDS event.|
- A nurse is evaluating if the patient teaching she has completed with a patient was effective. Which of the following would best demonstrate the effectiveness of the teaching?
|A.||The patient understands how to change abdominal dressing.|
|B.||The patient acknowledges understanding of the principles of abdominal dressing change.|
|C.||The patient correctly demonstrates an abdominal dressing change as taught.|
|D.||The patient states the steps of the abdominal dressing change as taught.|
- A patient recently had a stroke and suffered right-sided weakness as a result. He is being discharged from a rehabilitation hospital after learning to use a walker. Which of the following learning domains was primarily used to teach him to be independent with his walker?
- Which of the following patients is the most likely to be motivated to learn?
|A.||23-year-old smoker being taught about smoking cessation|
|B.||45-year-old man being taught about importance of prostate cancer screening|
|C.||63-year-old knee replacement patient being taught post-surgical care|
|D.||15-year-old being taught about safe sex|
- A 47-year-old postsurgical patient is being taught about wound care before being discharged from the hospital. She is in a semiprivate room with another patient who is upset with a family member and is crying. The television is on to try to provide some distraction from the roommate, and her husband has just arrived to pick her up from the hospital. Which of the following should the nurse do to best facilitate her patient education?
|A.||Explain to the patient that everything she needs to know is on the handout she has been given.|
|B.||Take the patient to a quiet area to do the patient teaching.|
|C.||Ask the roommate to please be considerate of the patient because she is receiving her patient education.|
|D.||Request that a home health nurse follow up with the patient at home to teach her about wound care.|
- A nurse has just recently received certification to teach prepared childbirth. She will be teaching a prepared childbirth class for the first time at a neighborhood church. She has gone to the church to determine which room would be best suited to teach a group of six couples. Which of the following room configurations would be most appropriate for teaching this group?
|A.||A small carpeted room with no furniture|
|B.||A large auditorium with a stage and theatre-style seating|
|C.||A lunchroom with stationary tables and chairs|
|D.||A Sunday-school classroom with tables and chairs|
- Mrs. Cisco is a 34-year-old patient who is a migrant farm worker. She did not graduate from high school and speaks English as a second language. Becky, a student nurse, will be providing Mrs. Cisco’s discharge teaching after a hysterectomy. Becky is concerned about Mrs. Cisco’s ability to understand her discharge instructions. Which of the following should be of most concern in this situation?
- A patient was recently diagnosed with heart failure. Her health care provider has ordered a low-sodium diet. A student nurse is planning her patient education. When organizing the patient teaching what is the most logical thing to teach first?
|A.||How much daily intake of sodium is recommended|
|B.||How to read food labels|
|C.||How to understand the metric system of measurement|
|D.||How much sodium is in a serving of potato chips|
- A nurse who works in a diabetes clinic has been asked to help a 12-year-old patient learn to give his own insulin injections. The nurse demonstrates the technique on a teaching manikin and then asks the patient to demonstrate the task on the manikin. This is best described as what teaching approach?
- A pediatric nurse who works evenings on a surgical floor in a children’s hospital has been working with a 5-year-old patient who has undergone abdominal surgery. She gives him a sticker each time he uses his incentive spirometer. This is an example of what type of reinforcement?
- A nursing student is preparing to take a 5-year-old child’s blood pressure. The best way for the nursing student to reduce the girl’s anxiety about this procedure is to do which of the following?
|A.||Do nothing because the more fuss that is made about a procedure, the more anxiety it causes the patient.|
|B.||Explain to the patient that the blood pressure is a vital sign that her doctor has ordered.|
|C.||Tell the child that the blood pressure cuff will “hug” her arm.|
|D.||Ask the girl’s mother to step outside the room because children frequently do better when alone.|
- An 8-year-old boy has been diagnosed with diabetes. A nurse is teaching his mother how to plan meals that are appropriate for him. The nurse asks the mother to put together a 24-hour meal plan for her son and then reviews the plan with her. What is this type of teaching?
- A nurse is discharging a patient who required teaching about how to change the dressing on his foot. The nurse wants to ensure that the patient understands the signs and symptoms of infection and is preparing written materials for him to take home to refer to. Because the nurse does not know the patient’s reading ability, she should prepare written materials to be read at the _____ grade level.
- Mrs. Beasley is a 75-year-old patient who is being discharged home after a stroke left her with left-sided weakness. The nurse who is planning the patient teaching is determining the best approach for Mrs. Beasley, given her age. Of the following strategies, which is the best for the nurse to use?
|A.||Provide all the teaching at once, immediately before going home so Mrs. Beasley will remember it.|
|B.||Teach Mrs. Beasley with the aid of a computer to demonstrate that the discharge instructions are on the hospital webpage.|
|C.||Provide Mrs. Beasley with generic patient discharge information about strokes.|
|D.||Provide information based on Mrs. Beasley’s needs in frequent sessions.|
- A nurse needs to begin diabetic teaching with a 14-year-old boy. The nurse remembers that health education should focus on:
|A.||motivating the patient to comply with a given health care regimen.|
|B.||preventing diseases and learning good health promotion activities.|
|C.||allowing the entire health care team to give a variety of strategies for the patient to follow.|
|D.||determining the patient’s level of knowledge and perception of what learning is needed.|
- A patient needs to take daily injections of a blood thinner for 7 days after hospital discharge. The nurse observes the patient’s self-administration technique. Administration of a blood thinner constitutes __________ learning.
- A 40-year-old man suffered a myocardial infarction 4 days ago. The patient appears anxious about how this event will affect his future. The nurse knows that an effective principle to incorporate in a teaching session is:
|D.||special needs for this age-group.|
- A nurse is teaching a 74-year-old patient how to apply an ostomy pouch to a new colostomy. A technique this nurse can use is:
|B.||using discovery learning techniques.|
|C.||presenting information in short frequent sessions.|
|D.||creating a comprehensive teaching/learning plan.|
- A nurse tells a patient with a recent back injury that damage to the nerves is comparable to a water hose that has been pinched off and that time is needed to allow normal nerve transmission. During this teaching session, the nurse is using the process of:
- A nurse is beginning diabetic teaching for a 52-year-old patient with newly diagnosed type 1 diabetes. An ideal environment for promoting learning is a room that __________________.
- A patient is unable to apply a lower leg orthotic device because of a minor paralysis of the right upper extremity. On observation the nurse determines that the physical capability necessary for learning this psychomotor skill relates directly to which of the following? Select all that apply.
Potter: Basic Nursing, 7th Edition
Chapter 12: Managing Patient Care
- Brenda is a new nurse who is applying for a job as a registered nurse. One of the hospitals where she is interested in working has a Nursing Practice Council, which comprises nurses who write the nursing policies and procedures for the organization. The Nursing Practice Council is an example of which of the following?
|C.||Nursing code of ethics|
- A registered nurse has been practicing as an operating room nurse for the past 6 years. She is a member of the Association of Perioperative Registered Nurses (AORN) and attends the national conference annually to keep abreast of the latest research in that field of nursing. This is an example of maintaining which of the following American Nurses Association Standards of Performance?
|A.||Quality of practice|
- A nurse manager in an outpatient oncology center is responsible for the management of 23 registered nurses, four clerical associates, and three nurse practitioners who work at the center. He requires all staff to review the performance of their peers on an annual basis. This is an example of which of the American Nurses Association Standards of Practice?
|A.||Quality of practice|
- Gwen is a registered nurse who works on a busy orthopedic unit. She is responsible for caring for six patients on her day shift with the help of Mike, a nursing assistive personnel (NAP). Gwen begins her shift by discussing patients with Mike and delegating appropriate tasks that are in Mike’s job description. This is an example of which of the following American Nurses Association Standards of Practice?
|C.||Quality of Practice|
- A registered nurse who works in postanesthesia care is caring for a 54-year-old patient who has just had an appendectomy. The patient has arrived in the postanesthesia care unit with a heart rate of 88, respiratory rate of 14, and blood pressure of 134/78. The nurse notes that the patient’s mucus membranes are dusky, and she retakes the vital signs. This is an example of which of the following American Nurses Association Standards of Practice?
- A patient admitted to the intensive care unit was placed on ventilator support. The nurse caring for this patient identified on the plan of care that one of the outcomes was that the patient would not develop ventilator-acquired pneumonia. This is an example of which of the following American Nurses Association Standards of Practice?
- An 83-year-old patient was admitted to the hospital for hip replacement surgery after falling at home and breaking her hip. She has developed pneumonia while in the hospital. The nurse caring for the patient is concerned about her hip healing but is more concerned about her ineffective airway clearance related to pain, increased tracheobronchial secretions, and fatigue. The nurse encourages the patient to breathe deeply and cough during her shift. This is an example of which of the following American Nurses Association Standards of Practice?
- Katie is a student nurse completing her final semester of nursing school. This semester she is caring for patients in a wound clinic. One of the patients, Mr. Theim, is a 67-year-old man with a varicose ulcer in his right lower leg. Katie has been caring for Mr. Theim for the past month and is taking off the bandages from the leg to see how it is healing. The ulcer no longer had exudates and appeared to be healing as expected. This is an example of which of the following American Nurses Association Standards of Practice?
- A senior nursing student is applying to several hospitals where she would like to work after she graduates. She would like to work where her clinical performance is valued and in an environment that uses evidence-based practice. Given her goals, she should concentrate on applying to which of the following organizations?
- Margaret is a nurse of 15 years. Her husband is in the army and they have recently relocated to a new city. Margaret has worked in a variety of nursing areas and would like to find a unit within the hospital that mirrors her professional values. The best way for Margaret to find a unit that would be a good fit is for her to examine which of the following documents?
|A.||Hospital mission statement|
|B.||Unit scope of practice|
|C.||Unit philosophy of care|
|D.||Hospital vision statement|
- A registered nurse works on a unit with other registered nurses, a licensed practical nurse (LPN), and a nursing assistive technician. He does all the dressing changes, the technician gives all the baths, and the LPN administers medications. This model of care is best described as:
|D.||total patient care.|
- A nurse works at a community hospital in a rural area. She typically cares for six patients during a day shift and is accountable for all their care. There is a licensed practical nurse who works on the same unit to whom she delegates specific tasks, such as bathing. This model of care is best described as:
|D.||total patient care.|
- A registered nurse who works in a women’s hospital assumes care for the same patients from the time they are admitted to when they are discharged home. This model of nursing can best be described as:
|B.||primary care nursing.|
- A registered nurse has a patient assignment of caring for six postoperative patients in the orthopedic unit. He completes the patient assessments, distributes medications, and provides care to the patients as outlined within his job description. What term best describes this behavior?
- A nurse works in a trauma intensive care unit in a busy urban hospital. Once a week, staff from all the disciplines caring for the trauma patients get together to discuss their progress. As the team meets in the patient room, the patient’s family can be included in the discussion if it is approved by the patient. This is best described as which of the following?
- A nursing student has just started her first clinical rotation. She is seeing a patient for the first time this morning. Which of the following should she do first?
|A.||Focused patient assessment|
|B.||Patient health history|
- A registered nurse is prioritizing his care for four patients on his shift. Which of the patients should he see first?
|A.||44-year-old woman 1 day postoperative|
|B.||64-year-old man who had a stroke 2 days ago|
|C.||56-year-old woman with acute asthma|
|D.||67-year-old man with a fractured hip|
- A first-year nursing student is learning how to prioritize her time. One of the best ways that this can be accomplished is for her to focus on which of the following?
- Jenny is a staff nurse who works on a busy medical unit in a community hospital. She is caring for six patients on her shift and is working with Nancy, a nursing assistive personnel. Which of the following tasks can she safely delegate to Nancy?
|B.||Patient discharge teaching|
|C.||Patient bed bath|
- Joann, a registered nurse, requested that Heather, a student nurse, give Mrs. Harris a bath in the morning because she was going to surgery. As Joann prepared Mrs. Harris for surgery, she noted that she had not yet had her bath, and it was too late to give her one because surgery was calling for the patient. Joann needed to give feedback to Heather. Where would be the most appropriate place for Joann to provide Heather this feedback?
|A.||In the hallway|
|B.||At the nurse’s station|
|C.||In the patient’s room|
|D.||In the conference room|
- As a profession, nursing requires that members possess a significant amount of education. Nurses know that education provides:
|A.||a consumer-focused and service-based practice.|
|B.||the autonomy necessary for the performance of nursing skills.|
|C.||methods to decentralize medical and nursing care.|
|D.||a foundation for practice responding to changes created by scientific and technological advances.|
- Nurses use professional standards of nursing practice while rendering care to patients. These nursing practice standards are essential because they:
|A.||provide guidelines for active participation in clinical care management.|
|B.||provide a theoretical framework for how to practice.|
|C.||identify nursing competencies and evaluative criteria.|
|D.||offer guidelines for how to perform professionally, exercise care, cure, and coordination.|
- A nurse is working in a health care facility where she assumes responsibility for a caseload of patients over a period of time. The nurse is practicing:
- A nurse is working in a busy university-centered medical center. The nurse works in a system where tasks are divided among the registered nurse, licensed vocational nurse/licensed practical nurse, and assistive personnel. The nurse recognizes this nursing care delivery model as ____________________.
- A nurse has been promoted to nurse manager. This new nurse manager can foster the decentralized decision-making model by ____________________.
- A newly graduated nurse has been assigned to a team consisting of her and one assistive personnel staff member. When delegating skills the nurse needs to do which of the following? Select all that apply.
|A.||Assign only bed-making skills and feeding tasks.|
|B.||Assess the knowledge of assistive personnel.|
|C.||Remind the staff member that she is working under the license of the RN.|
|D.||Allow the staff member to perform only skills that the RN is able to teach assistive personnel to perform.|
|E.||Assign only feeding tasks.|
|F.||Assess skill levels of assistive personnel.|
- Nurses working at a progressive health care organization participate in a decentralized decision-making framework where they are actively involved in nursing unit decisions. These nurses know that the key elements of decentralization include which of the following? Select all that apply.
- A senior nursing student is assigned to a nurse caring for a group of patients. Leadership skills a student should use when caring for patients include which of the following? Select all that apply.
Potter: Basic Nursing, 7th Edition
Chapter 13: Infection Prevention and Control
- Beth is a nurse who has found that MRSA has colonized in her nasal cavity, although she has not been ill from the bacteria. How is Beth’s nasal cavity best described?
|C.||Portal of entry|
|D.||Mode of transmission|
- Brenda is an assistive nursing personnel working on a busy pediatric unit in a hospital. She has a cut on her hand that has not been kept covered. It hurts her to wash her hands or sanitize them, so she has been providing patient care without performing hand hygiene. Several of the patients on the pediatric unit have suffered hospital associated infections of rotavirus. This was thought to be a result of Brenda’s lack of hand hygiene. This type of disease transmission can best be described as __________ transmission.
- There was an outbreak of Salmonella poisoning at a nursing home. Several residents were hospitalized as a result of their infections. What is the best term to describe this health care–acquired infection?
- Peggy is a senior nursing student who is working on a community health project for the local homeless shelter. There are several indigent men who come to the shelter in cold weather to sleep for the night. Peggy knows that these men do not bathe on a regular basis. One of the men has been sick several times recently with skin infections. Which of the following is the best way for Peggy to explain the importance of personal hygiene to this individual?
|A.||“You need to take a shower to help you stay healthy.”|
|B.||“If you don’t take a shower, you will continue to get sick.”|
|C.||“Taking a shower will help your body remove germs that can cause skin infections.”|
|D.||“You are compromising your body’s defense mechanism by your poor personal hygiene.”|
- Which of the following situations is most likely to contribute to a health care–acquired infection?
|A.||Patient in a semiprivate room|
|B.||Old drainage on a dressing|
|C.||Foley catheter drainage bag touching the floor|
|D.||Patient in acute pain|
- Bruce is a nurse working for a postsurgical unit. He is caring for five postsurgical patients, and one patient who is awaiting surgery. About which of the following patients should he be most concerned regarding a health care-associated infection?
|A.||78-year-old man with bacterial growth in his urine|
|B.||19-year-old man with a white blood cell count of 10,000/mm3|
|C.||23-year-old woman one day postoperative with redness at incision site|
|D.||35-year-old woman with temperature of 99.3° F and complaints of malaise|
- Gene is a student nurse who is developing a plan of care for Harry, a 67-year-old postoperative patient who underwent abdominal surgery to remove a tumor. Gene has chosen Risk for infection as a nursing diagnosis. Which of the following is the most appropriate goal for this diagnosis?
|A.||Patient’s wound drainage will decrease in 2 days.|
|B.||Patient will report decrease in incisional pain by discharge.|
|C.||The progression of infection will be controlled or decreased.|
|D.||Patient will describe signs/symptoms of wound infection.|
- Mary is a student nurse caring for Alma, a 45-year-old postsurgical patient. Mary is prioritizing her care based on Alma’s needs. Alma has developed a health care–acquired wound infection that has become systemic. Which of the following should be Mary’s top priority?
|A.||Changing the surgical dressing|
|C.||Providing patient education|
|D.||Providing personal hygiene|
- Alton is an 89-year-old patient who lives in a nursing home. He has been admitted to the hospital for observation after falling and exhibiting confusion and malaise in the nursing home. He had a urinary catheter inserted 2 weeks ago when he complained of difficulty urinating. Alton’s health care provider ordered laboratory work. The nurse notes that his neutrophil count is low. She knows that this, combined with the other clinical signs and symptoms, most likely indicates what condition?
- Wanda is a nursing student who is working for a surgical unit in the hospital. Included in her job description is to assist in the cleaning and disinfection of equipment stored on the unit. Which of the following is the best explanation of disinfection?
|A.||Removing organic material|
|B.||Removing inorganic material|
|C.||Eliminating almost all pathogenic organisms|
|D.||Destroying all forms of microbial life|
- Misty is a surgical nurse and is very concerned about infection control in the Surgery Department. Recently she provided education to the surgery staff on ways to eliminate transient hand flora. The most precise description for this is hand:
- A patient with a history of poor nutrition and chronic illness is admitted to the medical unit. As a nurse is caring for this patient, the nurse recalls that normal body flora:
|A.||assist with the formation of antibodies.|
|B.||assist with the digestion and absorption of nutrients.|
|C.||participate in maintaining a person’s health by inhibiting the multiplication of microorganisms.|
|D.||resist infection by releasing antibacterial substances and inhibiting multiplication of pathogenic microorganisms.|
- Standard precautions involve using personal protective equipment with all patients regardless of the presence of infections. Therefore, when obtaining a blood sample, the nurse must wear:
|C.||gloves and a mask.|
|D.||gloves, a mask, and a gown.|
- A patient is admitted for treatment of a home-acquired pressure ulcer. The patient is incontinent of urine and has Alzheimer disease. A Foley catheter is inserted. The nurse identifies a link in the infection chain as:
|C.||the Foley catheter bag.|
- A nurse is concerned with the chain of infection when taking care of contaminated care items. Semicritical items that require disinfection include:
|C.||blood pressure cuffs.|
- A nurse is coaching a student on the proper method of applying surgical gloves. One step in the proper donning of sterile gloves requires the nurse to:
|A.||grasp the inside of one gloved hand with the other gloved hand.|
|B.||tuck the glove under the wrist of the sterile gown with fingers of the bare hand.|
|C.||grasp the outside of the cuff with the nongloved hand to adjust the fit.|
|D.||carefully pull the glove over the dominant hand, leaving a cuff and being sure the cuff does not roll up over the wrist.|
- A nurse is caring for a patient who had an appendectomy 48 hours ago. On physical assessment the nurse notices that the wound looks red and swollen. The patient’s white blood cell count is increased. The nurse should:
|B.||notify the physician or health care provider.|
|C.||document the findings and reassess in 4 hours.|
|D.||place the patient on strict isolation regimen.|
- A nurse is assigned to multiple patients on a busy surgical unit. The nurse knows actions that contribute to causing health care–acquired infections include:
|A.||washing hands before applying a dressing.|
|B.||taping a paper bag to the bed rail for tissue disposal.|
|C.||hanging a Foley bag in a dependent position on the side of the bed.|
|D.||using an iodine preparation to cleanse the skin before starting an intravenous line.|
- The infection control nurse is presenting an in-service presentation on infection prevention and control. A participating nurse identifies what patient as most susceptible to acquiring an infection?
|A.||81-year-old patient with a fractured hip|
|B.||10-month-old patient with a first-degree burned hand|
|C.||40-year-old patient with a recent uncomplicated laparoscopic cholecystectomy|
|D.||16-year-old athlete with a repair of the medial collateral ligament|
- An emergency department nurse is caring for a patient with a laceration on the lower leg that has become infected. On assessment the nurse realizes that a sign of an inflammatory response consists of:
|B.||a decrease in the number of white blood cells.|
|C.||a vascular reaction that delivers fluid, blood, and nutrients to the area.|
|D.||instantaneous replacement of mature, healthy newly created cells.|
- A nurse sets up a sterile field. A break in the sterile field occurs when the nurse does which of the following? Select all that apply.
|A.||Wears a double mask because she has a cold|
|B.||Spills solution onto the sterile field|
|C.||Keeps the top of the table above waist level|
|D.||Keeps sterile objects within a 1-inch border of the field|
Potter: Basic Nursing, 7th Edition
Chapter 14: Vital Signs
- Lucas is a nursing student who is obtaining Mrs. Elliott’s vital signs. Mrs. Elliott has gone to the clinic seeking help because she is having chest pain. Which of the following vital signs are most important for Lucas to obtain?
|A.||Temperature, pulse, respirations|
|B.||Temperature, pulse, respirations, oxygen saturation|
|C.||Temperature, pulse, respirations, blood pressure, oxygen saturation|
|D.||Temperature, pulse, respirations, blood pressure, oxygen saturation, pain|
- Upon a patient’s admission to the nursing unit, the registered nurse delegated to the nursing assistive personnel to take her vital signs. What is the registered nurse’s responsibility regarding delegating this task?
|A.||This is inappropriate delegation, the nurse should always take the vital signs.|
|B.||The nurse should ask the nursing assistive personnel to report any abnormalities in the measurements.|
|C.||The nurse should review and interpret the vital sign measurements.|
|D.||This task has been delegated so the nurse is not responsible.|
- A 36-year-old African American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98. Which of the following should the nurse do next?
|A.||Call the physician to report the blood pressure.|
|B.||Retake the blood pressure with an electronic device.|
|C.||Ask the patient what his blood pressure normally measures.|
|D.||Do nothing; this is within a normal range.|
- A man has been taken to the emergency department after passing out while repairing the roof on his house. The temperature outside is 96° F and his skin is warm and dry. How should the nurse obtain his temperature?
- Nancy is a 6-year-old who was taken into the hospital after having a seizure at home. Nancy’s mother tells the nurse that she has been ill for the past week and has had a fever with nausea and vomiting. Nancy’s mother believes that the seizure was caused by a fever of 99.5° F, which Nancy had during the course of her illness. What is the nurse’s best response?
|A.||“It probably was a febrile seizure; let’s see what the health care provider thinks.”|
|B.||“Has Nancy ever had a seizure in the past?”|
|C.||“Febrile seizures are common in children Nancy’s age.”|
|D.||“Has Nancy been exposed to anyone with the flu?”|
- Gwen, a nursing assistive personnel, has told Jane, a registered nurse, that Mrs. Roger’s temperature has reached 103.4° F. Mrs. Roger is a patient who was admitted earlier in the shift with a fever of unknown origin. Jane asks Gwen to help her gather the equipment to draw a blood culture on Mrs. Roger. What is the best reason for Jane to draw a blood culture before giving an antipyretic medication?
|A.||The causative organism is most prevalent during a spike in temperature.|
|B.||An antipyretic could cause Mrs. Roger’s stomach to become upset.|
|C.||An antipyretic will kill the causative organism.|
|D.||The antipyretic may interfere with blood clotting.|
- A nurse is working on a medical unit in an acute care hospital. One of the patients she is caring for has a fever of 100.3° F. The nurse is not going to administer an antipyretic at this time. Which of the following is the best reason why the patient should not receive an antipyretic at this time?
|A.||A temperature of 100.3° F is within the normal range.|
|B.||Antipyretics do not work until the body’s temperature is at least 101° F.|
|C.||Antipyretics may make the patient drowsy.|
|D.||Mild fevers are an important defense mechanism of the body.|
- A 56-year-old grandmother has been admitted to the hospital with a fever of 103.2° F after caring for her 5-year-old granddaughter who also developed a fever. The health care provider has ordered blood cultures, antibiotics, antipyretics, a clear liquid diet, and a chest radiograph. Which of the orders should the nurse do first?
|C.||Draw blood cultures.|
|D.||Obtain chest radiograph.|
- A 4-year-old child was taken to the after-hours pediatric clinic with a fever and a rash. She had been seen by her pediatrician earlier in the day for a sore throat and had been given a prescription for an antibiotic. Later that evening she developed a fever and a rash on her abdomen. The nurse who assesses the child in the clinic suspected the symptoms are associated with which of the following?
|A.||Common symptoms of strep throat|
|B.||An allergic response to the prescribed medication|
|C.||An undiagnosed illness|
|D.||A food allergy|
- Jenny, a nursing student working on a medical unit in a pediatric hospital, was caring for Helen, a 5-year-old child who was admitted with meningitis. Helen was admitted to the hospital with a fever of 104.5° F and nuchal rigidity. She responded to antipyretics that were ordered. In addition, Jenny instructed Helen’s mother to help reduce the fever by limiting the number of blankets covering Helen. Jenny recognized that additional teaching was necessary when Helen’s mother made which of the following statements?
|A.||“Helen is more comfortable now that her fever is dropping.”|
|B.||“I will call you if Helen feels warm.”|
|C.||“Helen’s fever is dropping because she is shivering.”|
|D.||“I will replace Helen’s heavy sleeper with lighter-weight pajamas.”|
- Hal is a 26-year-old man who works in construction. He was helping a friend replace a roof on his backyard shed after work on a hot July afternoon. Hal and his friend had a few beers as they worked on the roof. Hal’s friend took him to the hospital after Hal had severe muscle cramps and became confused. Which of the following should the admitting nurse do first when assessing Hal?
|A.||Draw a specimen to check for blood alcohol level.|
|B.||Take Hal’s temperature.|
|C.||Ask Hal how long he had been sick.|
|D.||Start an intravenous line.|
- A registered nurse is caring for a patient who was admitted to the hospital after being involved in a motor vehicle accident. The patient has undergone two surgeries and now has a health care–acquired infection. Multiple medications were ordered. Which of the following would be least appropriate for the nurse to administer to reduce the fever?
- A 15-year-old girl was taken to a small rural hospital by her mother. The family had been camping, and it had become very cold during the night. The mother had difficulty waking her daughter in the morning, and she was shivering uncontrollably. Which of the following interventions should the admitting nurse do first?
|A.||Take a detailed health history.|
|B.||Wrap the girl in warm blankets.|
|C.||Start an intravenous line.|
|D.||Draw blood to check for drug overdose.|
- Catherine is a student nurse who volunteers twice a month in an inner city clinic. The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girl’s temperature rectally and obtaining a reading of 100.4° F. The mother was concerned that her daughter might be ill. Which of the following is the best response from Catherine?
|A.||“Babies usually run lower rather than higher temperatures when ill.”|
|B.||“Because the temperature is low-grade, it is probably a viral infection.’|
|C.||“Rectal temperatures are higher than temperatures obtained in other sites.”|
|D.||“Because the temperature is low-grade, it is probably a bacterial infection.”|
- A senior nursing student is doing her community clinical rotation. When visiting a young family to whom she has been assigned, the mother of the 3-year-old child states that her daughter does not feel well. The nursing student feels her skin, which is warm. She asks the mother if she has taken her temperature to which the mother replies, “Yes, I used the same thermometer that was my great-grandmother’s; it has been used by my family for years. Her oral temperature was 102.3° F.” The most important patient teaching for the nursing student to perform is to discuss:
|A.||the potential for a febrile seizure with this fever.|
|B.||the need to contact the health care provider as soon as possible.|
|C.||the dangers of using a mercury thermometer.|
|D.||isolating the child from her siblings to prevent the spread of infection.|
- Roberta is a nursing student who works for a busy postanesthesia unit in a same day surgery center. A 38-year-old postoperative patient who had just undergone a unilateral oophorectomy began developing problems. The nurse asked Roberta to continue to monitor the vital signs while she contacted the surgeon. The best place for Roberta to monitor the patient’s pulse is which of the following sites?
- A man has been admitted to the hospital with lethargy. He was placed on the telemetry unit and is being continuously monitored. He is due to receive his dose of digoxin. The nurse knows that the medication is to be held if the pulse rate is less than 70 beats per minute. Which of the following is the best site to get his pulse reading?
|D.||Off the telemetry monitor|
- A new nursing student is learning how to take vital signs. He is having difficulty hearing his patient’s apical pulse with his stethoscope. Which of the following would best maximize the sound quality of what he hears through the stethoscope?
|A.||Positioning the diaphragm very lightly on the area he is listening to|
|B.||Placing the stethoscope chestpiece directly on the patient’s skin|
|C.||Placing the stethoscope on the patient’s back, directly behind the heart|
|D.||Using a stethoscope with the longest tubing that he can find|
- A nursing student is learning to take vital signs. He is practicing taking a pulse at home on his mother. He carefully counts the beats per minute and determines the rhythm. He finds that his mother’s heart rate is 58 beats per minute. He knows that this is considered:
|C.||a normal heart rate for an adult.|
- Michael is a nursing student volunteering at a health screening for hypertension. Mrs. English, a 63-year-old woman who has gone to the clinic, has had her blood pressure taken. Her blood pressure reading was 140/90 mm Hg. Mrs. English is concerned with this reading. Which of the following statements should Michael make to provide Mrs. English with the most accurate information regarding hypertension?
|A.||“You should have your health care provider check your blood pressure again within 2 months.”|
|B.||“You have hypertension and should be seen by your health care provider immediately.”|
|C.||“Your blood pressure reading is normal for a person your age.”|
|D.||“If you don’t seek treatment for your high blood pressure, you could have a stroke.”|
- Mrs. Tensley is a 45-year-old mother of three children who recently found out that she has high blood pressure when she was hospitalized for a hysterectomy. Heather, as a student nurse, was caring for Mrs. Tensley during her hospitalization. Mrs. Tensley confided to Heather that she did not want to have to take medication for the high blood pressure. Heather’s best response to Mrs. Tensley is which of the following?
|A.||“Although you need to take your medication, you may be able to lower your blood pressure by maintaining an ideal body weight and reducing stress.”|
|B.||“You will always need medication to control your hypertension.”|
|C.||“You need to continue to take your medication because you have a family history of hypertension.”|
|D.||“You can most likely wean yourself off your medication a little at a time.”|
- Mrs. Hyatt just returned to the postsurgical unit after undergoing surgery to remove a lung tumor. During one of the postoperative vital sign checks, the student nurse noted that Mrs. Hyatt’s systolic blood pressure had dropped by 10 points within 30 minutes. In addition to the drop in systolic blood pressure, Mrs. Hyatt’s skin was pale. Which of the following should the student nurse do first?
|A.||Report the findings to the nurse.|
|B.||Retake the blood pressure with an automatic blood pressure machine.|
|C.||Check Mrs. Hyatt’s dressing.|
|D.||Nothing; this is a normal occurrence following a thoracic surgery.|
- Mr. Johnson is a patient who was admitted to the hospital with chronic obstructive pulmonary disease. He has smoked cigarettes for 33 years and is currently trying to quit his two packs-a-day habit. Upon admission to the hospital, Marsha, a registered nurse is taking his vital signs and is obtaining a pulse oximetry reading. Mr. Johnson asks Marsha what this reading tells her. What is Marsha’s best answer?
|A.||“This tells me what your heart rate is.”|
|B.||“This tells me how well your lungs are perfusing.”|
|C.||“This is a way for me to measure your respiratory rate.”|
|D.||“This reading tells me how deeply you are breathing.”|
- A woman has been hospitalized with pneumonia. She has had oxygen on via nasal cannula at a rate of 2 L per minute. A nursing student is taking her vital signs. She notes that her respirations are labored and the rate is 22 respirations per minute. The nursing student recognizes this as:
|A.||a normal respiratory rate for an adult.|
- A registered nurse is volunteering at a health fair in an African American urban neighborhood. She is working at the blood pressure booth and has noted that many of the clients having blood pressure checks have elevated blood pressure readings. She remembers that this is most likely because:
|A.||African Americans have a higher rate of hypertension than the general population.|
|B.||African Americans are under more stress than the general population.|
|C.||fewer African Americans take hypertensive medications.|
|D.||people in urban settings generally have higher blood pressure readings than people who live in rural areas.|
- A patient is obese. The nursing assistant takes the patient’s blood pressure with a standard-size cuff. The nurse educates the assistant by stating that the use of this cuff will affect the reading with values that are:
- A nurse delegates the task of obtaining vital signs to a nursing assistant. The nurse reminds the nursing assistant that blood pressure of an infant:
|A.||will be lower than an adult’s.|
|B.||is essentially the same as an adult’s.|
|C.||is labile during the first months of life.|
|D.||is highly sensitive to changes in nursing personnel.|
- A nursing assistant asks the nurse why she needs to bathe a febrile patient. The best response is that this intervention increases heat loss through:
- A nurse is ready to take the temperature of an adult patient who has just ingested a hot cup of tea. The nurse’s most appropriate action would be to:
|A.||take a rectal temperature.|
|B.||take the oral temperature as planned.|
|C.||ask the patient to rinse her mouth out with cold water.|
|D.||wait 30 minutes and take the oral temperature at that time.|
- A nurse notices that a patient has an irregular pulse. To best assess an irregularity in pulses the nurse should:
|A.||determine the rate of the pulse.|
|B.||take the apical pulse for one full minute.|
|C.||auscultate for the strength of the apical pulse.|
|D.||ask if the patient feels a palpation or abnormality of the pulses.|
- A nurse assesses a patient who has developed a febrile state. The nurse recalls that chills and shivers involve an alteration of the set point located in the:
- A patient is breathing rapidly. The nurse’s most appropriate response would be to:
|A.||take the patient’s radial pulse.|
|B.||count the patient’s respirations.|
|C.||take a measurement of the patient’s oxygen saturation level.|
|D.||ask the patient if any situations have contributed to this response.|
- A postoperative patient is shivering. The nurse recalls that this mechanism is ____________.
- A postoperative patient stands up and begins to feel faint. The nurse should do which of the following? Select all that apply.
|A.||Have the patient lie down.|
|B.||Have the patient try to stand again later.|
|C.||Attempt to listen to the Korotkoff sounds.|
|D.||Listen to the patient’s apical pulse with the bell of a stethoscope.|
|E.||Expect the sitting blood pressure to be lower than the standing blood pressure.|
Potter: Basic Nursing, 7th Edition
Chapter 15: Health Assessment and Physical Examination
- Harriett is a nursing student who is performing a physical examination on Jarred, a 6-year-old patient who is being admitted to the pediatric unit with abdominal pain. When would be the most appropriate time in the examination to palpate Jarred’s abdomen?
|A.||Palpate tender areas last.|
|B.||Palpate tender areas first to get it over.|
|C.||Palpate tender areas between other portions of the exam.|
|D.||Do not palpate tender areas.|
- Debra is a registered nurse who works on a pulmonary unit in an urban hospital. She is precepting Thomas, a first-year nursing student. Debra is demonstrating to Thomas how to appropriately auscultate. Auscultation is defined as:
|A.||listening with a stethoscope to sounds produced by the body.|
|B.||tapping the body with the fingertips to produce a vibration.|
|C.||becoming familiar with the nature and source of body odors.|
|D.||using the hands to touch body parts to make a sensitive assessment.|
- A nurse is preparing to do a physical examination on a patient. What is the most important thing that the nurse should do to prepare for the examination?
|A.||Gathering all the necessary equipment|
|B.||Making sure the equipment is in working order|
|C.||Performing thorough hand hygiene|
|D.||Having the appropriate forms available for documentation|
- A registered nurse is preparing to perform a physical examination on a 5-year-old child. What can the nurse do to make the child feel safer during the examination?
|A.||Examining his fingernails before listening to his breath sounds|
|B.||Asking the child to put on a gown before the examination|
|C.||Using medical language to demonstrate her competence|
|D.||Inviting the child’s siblings to be present for the examination|
- A nurse is admitting a 79-year-old woman with a fractured hip to the orthopedic unit. The patient states that she broke her hip when she tripped in her garden. Upon examination, the nurse notes purple, green, and yellow bruises on the back and arms. The patient states that those were received when she fell. The nurse is concerned because she knows that this can be a sign of:
- Joy is a student nurse who has been assigned to the pediatric unit for her clinical training this semester. She is assisting with the admission of a 5-month-old infant. The child is being admitted with pneumonia. As part of the admission process, Joy is responsible for taking the child’s vital signs and weighing and measuring the child. The infant’s mother is very concerned when Joy tells her that the baby weighs 14 pounds. The mother states that the baby has lost a significant amount of weight because the previous week she weighed 16 pounds at home. What is Joy’s best response to the mother’s concern?
|A.||“When babies are sick they can lose weight.”|
|B.||“I wish I could lose two pounds in one week.”|
|C.||“What was her birth weight?”|
|D.||“Weight measurements can vary with different scales.”|
- Mrs. Johnson is an older adult African American who has gone to the clinic where a RN volunteers twice a week. Mrs. Johnson is a diabetic and has some skin breakdown on the calf of her right leg. Mrs. Johnson’s skin is very darkly pigmented. In order to best examine Mrs. Johnson’s skin, the nurse should use:
- A nurse is preparing to perform a physical exam on a patient. She has found that it is best to perform the physical with a head-to-toe approach. Why is this important?
|A.||People develop in a cephalo-caudal direction.|
|B.||It is a methodical way to include all body systems.|
|C.||It is less threatening.|
|D.||It is better to start with a body part that is uncovered.|
- A patient is being seen in the health clinic for abdominal pain. The nurse will be doing a physical assessment. Which part of the assessment should the nurse do last?
|A.||Palpation of the abdomen|
|B.||Auscultating breath sounds|
|C.||Vital sign measurement|
|D.||Height and weight measurement|
- A young mother of two children is concerned about her children getting enough exercise and fresh air. She has taken her two young children with her to the community pool on several occasions over the summer. A student nurse who works in the pediatrician’s office can help the mother prevent her children from developing melanomas in the future by offering what advice?
|A.||“Don’t let your children eat the high-fat food in the snack bar at the local pool.”|
|B.||“It is best to restrict your children’s exposure to pool chemicals to once a week.”|
|C.||“Make sure your children get enough fiber in their diets.”|
|D.||“Make sure that the children don’t get a sunburn.”|
- A 41-year-old man recently had a cast applied to his left lower leg after a football injury in which he broke his tibia. After the application of the cast, the nurse felt the toes of his left and right feet. The nurse was assessing:
|A.||pain in the left foot.|
|B.||neurostatus to see if he is ticklish in both feet.|
|C.||skin temperature to see if he has impaired circulation.|
- An RN is assessing an 87-year-old patient who has gone to the clinic to see the health care provider for a follow-up appointment. The nurse notes that the patient looks tired and has dark circles under her eyes. She assesses her skin turgor, which is poor. She is concerned because she knows that poor skin turgor can predispose the patient to which of the following?
- William is a student nurse who is helping admit Mr. Farley, a 77-year-old man, to the surgical floor of an acute care hospital. Mr. Farley has an abdominal tumor that is scheduled to be removed; he has had nothing by mouth (NPO) since midnight in preparation for his surgery. As William is assessing Mr. Farley, he notes that his skin is very dry and scaly. Which of the following should William investigate further as the most likely cause for Mr. Foley’s dry skin?
|A.||Dehydration from being NPO|
|B.||The use of excessive soap when bathing|
|C.||The onset of psoriasis due to anxiety about the surgery|
|D.||Drinking too many caffeinated beverages|
- A single mother with three school-age children has recently noticed that the second child has been scratching his head and complains that it itches. She asks the school nurse to examine him. The school nurse notes that the child has head lice. Which of the following is the best description of head lice?
|A.||Lice look like little white crabs.|
|B.||Lice are difficult to see, but their eggs are small oval particles.|
|C.||Lice and their eggs are on the hair shafts and look like dandruff.|
|D.||Lice suck blood and spread disease.|
- A nursing student who is assessing an older adult who has smoked for the past 47 years and has been diagnosed with chronic obstructive pulmonary disease. Which of the following would the nursing student expect to see upon physical examination of the patient?
|B.||Petechiae on the skin|
|D.||Pitting edema in the lower extremities|
- A 47-year-old patient is being treated for hyperthyroidism. When she goes to the health care provider for a check-up, the student nurse doing his clinical rotation in the clinic expects to see which of the following physical symptoms?
- A 17-year-old was taken to the emergency department when his mother found him unresponsive. Upon examination, his pupils were found to be pinpoints. This is a common sign of:
|C.||ingestion of hallucinogenic mushrooms.|
- An 18-month-old child was taken to the pediatric after-hours clinic by her mother. The child had been fussy for the past 2 days and had developed a fever earlier in the day, which did not respond well to antipyretics. The mother of the child was concerned that she had an ear infection and requested the nurse to examine the child’s ears. On examination the nurse found the right eardrum pink and bulging. How should a normal eardrum appear?
- A 55-year-old woman went to the public health clinic with a fever that had persisted for several days. Upon palpation of the neck, a registered nurse found several large lymph nodes. What is the nurse’s best response to this patient upon palpating her lymph nodes?
|A.||“There is no need to worry; enlarged lymph nodes are normal findings.”|
|B.||“Enlarged lymph nodes sometimes indicate an infection.”|
|C.||“Most people have a few enlarged lymph nodes.”|
|D.||“We need to follow up because the last patient with enlarged nodes had cancer.”|
- A 45-year-old gay man who lives with a partner of 19 years recently has developed a persistent cough and night sweats from which he wakes up soaked. The nurse who is caring for the man should be most concerned about which of the following conditions?
- A nurse is meeting a patient for the first time. The importance of establishing baseline data is that it will enable the nurse to assess:
|A.||physiological outcomes of care.|
|B.||the normal range of physical findings.|
|C.||a pattern of findings identified when the patient is first assessed.|
|D.||clinical judgments made about a patient’s changing health status.|
- An adolescent is embarrassed to be examined by the nurse. What is the most appropriate response by the nurse?
|A.||“We need to do this examination, so just lie still.”|
|B.||“Don’t worry, we can defer this part of the examination.”|
|C.||“This is a necessary part of your assessment, but I will keep you covered up as much as possible.”|
|D.||“Just tell me if you have any unusual conditions or if any of your parts look different.”|
- A nurse is assisting with a female genitalia examination. The nurse will assist the patient to assume a __________ position.
- While auscultating a patient with pneumonia, a nurse hears low-pitched, continuous sounds over the bronchi. These sounds can best be described as:
|D.||a friction rub.|
- An older adult patient complains of thirst, headache, and weight loss. The patient appears emaciated. On physical assessment the nurse finds that the patient’s skin does not return to normal shape after being assessed. This finding is consistent with:
|D.||poor skin turgor.|
- At a point during the admission process of a young female patient, a nurse asks the patient about her menstrual history and self-breast examination. The patient asks about the best time of the month to perform this examination. What is the best response?
|A.||“Anytime you think about it.”|
|B.||“At the same time every month.”|
|C.||“On the first day of your menstrual cycle.”|
|D.||“On the last day of your menstrual cycle.”|
- A day shift nurse is caring for a patient with a repair of a rotator cuff. What is the ideal time for the nurse to assess respiratory status?
|A.||During the patient’s bath|
|B.||Anytime during the shift|
|C.||At the beginning of the shift|
|D.||This patient does not need a respiratory assessment.|
- A nurse uses four basic skills during a physical assessment. While assessing the abdomen the nurse must begin with the skill of:
- A nurse inspects the thorax of an older adult patient. An age-related finding in an older adult patient is characterized by a(n):
|C.||symmetrical anteroposterior diameter.|
|D.||asymmetrical posterolateral diameter.|
- A nurse can best auscultate the point of maximum impulse (PMI) in a teenager at the _____ intercostal space, _____ midclavicular line.
- A patient is admitted from the emergency department. The nurse notices that the patient and family are anxious. During the admission process the nurse should do which of the following? Select all that apply.
|A.||Stereotype the patient concerning his or her admission diagnosis.|
|B.||Disregard racial differences in the physical qualities of the patient.|
|C.||Provide a thorough explanation of the purpose of each assessment.|
|D.||Provide a thorough explanation of the steps of each assessment.|
|E.||Continue to ask questions, even if the interview obviously makes the patient and family members uncomfortable.|
- A patient is complaining of nonspecific abdominal pain. The technique the nurse uses to assess tenderness is ____________________.
Potter: Basic Nursing, 7th Edition
Chapter 16: Administering Medications
- A patient who underwent a minor procedure in an outpatient clinic has requested pain medication. His nurse has an order to give 1 g of acetaminophen PO every 4 hours for pain. Which of the following is the brand name for the drug that has been ordered?
|D.||None of the above|
- A patient has an order for 1 g of acetaminophen every 4 hours for pain after oral surgery. Because he is having difficulty swallowing after the surgery, the nurse will give him the medication in his rectum. The appropriate form of acetaminophen for this route of administration is which of the following?
- A registered nurse for more than 15 years was concerned when she learned that her hospital was going to let unlicensed nursing assistants start IVs on patients. She knew that this was in violation of the scope of nursing practice in her state. Which of the following organizations define the scope of nursing’s professional functions and responsibilities?
|A.||The Joint Commission|
|B.||State Board of Health|
|C.||U.S. Department of Health and Human Services|
|D.||State Nurse Practice Acts|
- A 34-year-old mother of two children told her nurse that she has been on morphine for 6 months after back surgery and has gone to multiple health care providers to obtain prescriptions. Medication __________ best describes this situation.
- Mrs. Morris is a 78-year-old patient whose physician has prescribed daily eye drops for her glaucoma. Mrs. Morris does not always use the eye drops because she has difficulty affording them on her fixed income. This situation is best described as medication:
- A nursing student has been reviewing her patient’s medications. She has found that promethazine is an H1 receptor blocking agent. In addition to its antihistaminic action, it provides sedative and antiemetic effects. It is well absorbed from the gastrointestinal tract, clinical effects are apparent within 20 minutes of oral administration, and it is metabolized by the liver. Which of the following terms best describes the information that the student nurse has gathered?
- A 12-year-old patient has undergone knee surgery. She has an order for pain medication, which can be given by several different routes. The nurse wants to give her the medication by the route that will provide the fastest relief. Which of the following routes of administration will provide the fastest absorption?
- A nurse is working with the pharmacist to determine when a patient’s medications should be given. She has several medications that are due to be given in the morning. What is the most important reason to appropriately schedule the patient’s medications?
|A.||Some medications are absorbed more quickly on an empty stomach.|
|B.||Medications all need to be given at the same time for efficiency.|
|C.||It does not make a difference about when medications are scheduled.|
|D.||Medications should be scheduled around when the pharmacist is available.|
- Melissa is a 19-year-old patient who is being hospitalized with a central nervous system infection that needs to be treated with antibiotics. The medications will be instilled into the subarachnoid space via an epidural catheter. Why is this the best route of administration for this patient?
|A.||The antibiotic can’t pass through the blood-brain barrier.|
|B.||An epidural has a lower complication rate than an IV.|
|C.||The epidural can remain in place for several days.|
|D.||It is a more cost-effective route of administration.|
- Which of the following patients is most at risk for theophylline toxicity?
|A.||45-year-old man with diabetes and asthma|
|B.||59-year-old man with chronic obstructive airway disease|
|C.||53-year-old woman who smokes and has asthma|
|D.||49-year-old woman with chronic obstructive airway disease and hepatitis|
- Which of the following patients is most at risk for digoxin toxicity?
|A.||56-year-old man with coronary artery disease|
|B.||24-year-old woman with cystic fibrosis|
|C.||53-year-old woman with renal disease|
|D.||57-year-old man with a hemorrhagic stroke|
- A woman has been prescribed a daily iron supplement by her health care provider. She recently became constipated, which is most likely caused by the iron supplement. Which of the following best describes this response?
- A patient states that aspirin upsets her stomach. This is known as a(n):
- A postoperative 14-year-old patient is undergoing antibiotic therapy. She has never had any problems taking medications in the past. When the nurse hung the second dose of IV antibiotics, the patient suddenly had shortness of breath and had difficulty breathing. The nurse recognized this was most likely which of the following?
|C.||Side effect of the antibiotic|
- Henry, a 17-year-old patient with a respiratory infection, asks the nurse why some antibiotics are prescribed to be taken every 12 hours and some have to be taken 4 times a day. What is the best response?
|A.||“Antibiotics have different strengths.”|
|B.||“Some antibiotics are more efficient than others.”|
|C.||“Newer antibiotics don’t have to be taken as frequently.”|
|D.||“Some antibiotics stay in your system longer than others.”|
- A patient has an order for subcutaneous injection of insulin. The nurse will prepare to give this injection into which of the following tissues?
- A patient’s health care provider gave her a prescription for her sore throat. The prescription was written using the apothecary system. Which of the following prescription dosages uses the apothecary system?
|A.||1 ounce twice daily|
|B.||15 mL three times a day|
|C.||1 g twice daily|
|D.||25 mg three times a day|
- A patient’s health care provider wrote a prescription for an antibiotic for her upper respiratory infection. According to safe medication practice standards, which of the following is the most appropriate way to write a dosage?
- A nurse working in a clinic is teaching a patient how much cough syrup to take. The cough syrup comes in a 250 mL bottle, and the dosage is 10 mL every 4 hours. The nurse needs to convert the medication dose to teaspoons. How many teaspoons should she instruct the patient to take?
- A nurse is working in a newborn special care unit that has numerous premature infants. She recently transferred to this unit from an adult intensive care unit where she worked for the past 4 years. One of the patients is a 2-week-old neonate who was born at 32 weeks’ gestational age and who is to be given an antibiotic. The nurse is very cautious in administering the medication because she knows that children are three times more likely than adults to experience a medication error. Why are premature newborns especially vulnerable?
|A.||They receive more medications than other infants.|
|B.||Their medications are more concentrated.|
|C.||Drug interactions are more frequent with this population.|
|D.||Their livers and kidneys have not matured.|
- A patient has a nasogastric tube because of temporary swallowing difficulties. The nurse needs to administer a medication that is only available in pill form. Using a mortar and pestle to crush this medication, the nurse invokes which one of the six rights of medication administration?
- A postoperative patient is receiving morphine sulfate from a patient-controlled analgesia device. On assessment, the nurse notes that the patient’s respirations are depressed. The nurse realizes the effect of morphine sulfate infusion can be labeled as:
- A patient is to receive a medication that is irritating to muscle tissue. The most appropriate injection technique involves the __________ injection.
|A.||Z-track technique of|
|B.||subcutaneous technique of|
|C.||dorsogluteal technique of|
|D.||deltoid muscle as the site for|
- A patient is to receive two different kinds of insulin. What is the nurse’s most appropriate action?
|A.||Prepare the regular (clear) insulin first.|
|B.||Mix Lantus and Lente insulin in the same syringe.|
|C.||Administer the mixed insulin within 30 minutes of placement in the syringe.|
|D.||Never mix Ultralente insulin with any other insulin because this type is more potent than regular insulin.|
- A nurse is caring for a patient with kidney disease. The nurse needs to make more focused assessments when administering medications to this patient because the patient may experience problems with the process of:
- A nurse is assigned to care for a pediatric patient. When administering medications to children, the most appropriate calculation of the medication dosage is based on the child’s:
|D.||body surface area.|
- A nurse experiences problems reading a physician’s or health care provider’s medication order. What is the most appropriate action?
|A.||Calling the physician or health care provider to verify the order|
|B.||Calling the pharmacist to verify the order|
|C.||Consulting with other nursing staff members to verify the order|
|D.||Withholding the medication until the physician or health care provider makes rounds|
- A nurse is caring for a patient who is to be discharged with a prescription for eye drops. The nurse establishes that the patient understands how to administer eye drops correctly when the patient states that eye drops should be instilled on the:
|D.||opening of the lacrimal duct.|
- Nurses are legally required to document medications administered to patients. The nurse is mandated to document which of the following? Select all that apply.
|A.||Medication after giving it|
|B.||Medication before giving it|
|C.||Rationale for giving a questionable incorrect dosage|
|D.||Prescriber’s intention for prescribing the medication|
- A nurse is to administer a medication by IV bolus through an existing IV line. Before administering the medication, what is the most appropriate order of the following actions? Rank the following in order of priority. (Separate letters by a comma and space as follows: A, B, C, D.)
|A.||Perform hand hygiene and apply gloves.|
|B.||Aspirate for blood return before injecting the medication.|
|C.||Occlude the IV line by pinching the tubing just above the injection port.|
|D.||Verify the specified time recommendation for administration of this medication.|
Potter: Basic Nursing, 7th Edition
Chapter 17: Fluid, Electrolyte and Acid-Base Balances
- A nursing student is caring for a 35-year-old patient who is suffering from kidney failure and is receiving peritoneal dialysis. He remembers that peritoneal dialysis works by instilling a solution into the abdomen that contains dextrose that will pull wastes and extra fluid into the abdominal cavity. What is the name of this process?
- A 9-year-old patient has been admitted to the postsurgical nursing unit after surgery to remove her spleen. The health care provider has ordered the child to have an IV of 0.9% sodium chloride. The nurse who is caring for the patient recognizes this as what type of solution?
|D.||None of the above|
- Aaron and Brittney, two nursing students were having pizza one evening as they were studying. Brittney remarked to Aaron that she noticed whenever she ate pizza, she was incredibly thirsty. Aaron remarked that eating salty foods increases ___________ pressure of body fluids.
- A 26-year-old patient is in a coma after a motor vehicle accident. One of the interventions that were initiated as soon as he was hospitalized was to provide IV access. In addition to the medications that he receives through the IV, he is getting an isotonic IV fluid. The primary purpose for this is to:
|B.||move fluid from intravascular space into cells.|
|C.||pull fluid from cells.|
|D.||expand the body’s intravascular fluid volume.|
- A 15-year-old patient suffered a head injury as the result of a bicycle accident. The nurse is concerned about potential complications caused by the injury to his right temple near his pituitary gland and should be closely monitoring which of the following?
- A 7-year-old patient was admitted to the hospital with a high fever. The student nurse caring for the child knows that she can suffer from increased insensible water loss due to the fever and wants to make sure that she has enough fluid intake to prevent becoming dehydrated. Insensible water loss occurs through what organ?
- A nursing student is in his senior clinical rotation at the local hospital. One of the patients he is assigned to is on furosemide (Lasix). The patient has been weak and complaining of muscle cramps. The nursing student should be most concerned about which of the following?
- A student nurse is completing his senior year of nursing school. He is doing his current clinical rotation in an intensive care unit. The patient he has been assigned to is very ill and is on a ventilator. The health care provider has indicated that he is concerned about the patient’s acid-base status. The student nurse anticipates that the health care provider will determine the acid-base levels with which of the following?
|D.||Arterial blood gas|
- A 76-year-old patient is hospitalized with pneumonia. She has become increasingly confused throughout the shift. The nurse becomes concerned about her condition and contacts the health care provider who orders arterial blood gasses. The blood gasses show a pH of 7.33, PaCO2 of 47, PaO2 of 78 and bicarbonate of 26. This indicates which of the following?
- A college freshman has bulimia. She vomits after eating and has recently noticed tingling of her fingers and toes and has had muscle cramps. Her roommate is a nursing student and is concerned about which of the following conditions?
- Of the following patients, who is at the greatest risk for fluid volume deficit?
|A.||4-month-old infant with an intractable fever of 103.2° F|
|B.||17-year-old adolescent with gastroenteritis|
|C.||28-year-old woman with Crohn disease|
|D.||63-year-old man with diverticulitis|
- A 47-year-old patient has heart failure. She is on several medications including an angiotensin-converting enzyme (ACE) inhibitor, a beta blocker, and a diuretic. She is concerned about her fluid volume. What is the single most important indicator of fluid status that should be monitored with this diagnosis?
|A.||Specific gravity of urine|
|C.||Degree of edema on lower extremities|
|D.||Intake and output|
- A student nurse is working for a medical unit in a local hospital. She is responsible for obtaining intake and output measurements for patients. Which of the following should not be counted as parenteral intake?
|A.||IV antibiotic piggyback infusion through a secondary line|
|B.||Continuous IV infusion through a primary line|
|C.||Blood administration through a peripheral IV line|
|D.||Medication administered through jejunostomy tube|
- A man has recently been diagnosed with heart failure and has been put on a low sodium diet. In addition he is on fluid restrictions. When planning patient education for him, the nurse will suggest that half the total oral fluid allotment occur at what between _______ and ________.
|A.||7 AM; 7 PM|
|B.||3 AM; 3 PM|
|C.||7 AM; 3 PM|
|D.||3 PM; 7 AM|
- A 27-year-old patient has seen a health care provider at the local clinic because he has been suffering from diarrhea for the past week. The health care provider has instructed him to drink plenty of fluids, and the nurse clarifies these instructions by advising him to avoid which of the following liquids as long as he has diarrhea?
- A 15-year-old adolescent has been recently diagnosed with cancer. He will be receiving IV chemotherapy for several weeks. Which of the following vascular access devices would be least appropriate for the administration of his IV chemotherapy?
|B.||Peripherally placed IV cannula|
|D.||Peripherally inserted central catheter|
- A new nurse is working for the cardiac unit of the community hospital. The health care provider has ordered 20 mEq of KCl per L to be added to the fluids that the patient is receiving. The patient currently has a bag of D5W IV fluid infusing. Which of the following actions is most appropriate?
|A.||Pushing 20 mEq KCl diluted in 5 mL of fluid in five minutes|
|B.||Estimating the amount of fluid in bag that is infusing and adding KCl to equal 20 mEq/L|
|C.||Replacing bag after it has infused with one containing 20 mEq KCl/L|
|D.||Removing current IV bag and replacing with fluids that have been ordered|
- A nurse is considered an expert on her unit in starting an IV. She is mentoring a new nurse who is learning to start IVs. When beginning an IV on a patient, the nurse tells the new nurse that the best place to initially start the IV, in case the patient needs subsequent venipuncture sites, is which of the following?
|A.||Nondominant antecubital vein|
|B.||Most appropriate distal vein on the nondominant hand|
|C.||Most appropriate proximal vein available|
|D.||Dominant antecubital vein|
- A nursing student who is doing a clinical rotation at an orthopedic unit is caring for a 67-year-old patient who has undergone a knee replacement. The patient is complaining of pain at the IV site. The nursing student assesses the site and finds that the site is cool and pale. He stops the IV and reports the situation to his nurse. What does the nursing student suspect?
|D.||Deep vein thrombosis|
- A woman was admitted to the hospital with dehydration that was a result of gastroenteritis. The nurse caring for her wanted to know if she felt that they had met her expectations of nursing care. Which of the following questions would best assess this?
|A.||“Do you feel less nauseous?”|
|B.||“Have you been satisfied with your nursing care?”|
|C.||“What could I have done to make you more comfortable?”|
|D.||“Do you understand your discharge teaching instructions?”|
- When a nurse is selecting a site for IV placement, what is the most appropriate action?
|A.||Trying the dominant hand first|
|B.||Elevating the extremity|
|C.||Using the most distal part of the vein|
|D.||Locating a vein over a bony prominence|
- A nurse delegates the task of intake and output to a new nursing assistant. The nurse knows that the assistant understands the task when the assistant states:
|A.||“I’ll record the amount of urine.”|
|B.||“I’ll disregard liquid stool as output.”|
|C.||“I won’t include ice cream or sherbet as oral input.”|
|D.||“I’ll note perspiration and record as small or large amount.”|
- A patient presents to the emergency department diaphoretic and with a fever of 104° F. The nurse recalls that these signs indicate:
|B.||sensible water loss.|
|C.||insensible water loss.|
- The body’s fluid and electrolyte balance is maintained partially by hormonal regulation. The nurse conveys an understanding of this mechanism in which of the following statements?
|A.||“The pituitary secretes aldosterone.”|
|B.||“The kidney secretes antidiuretic hormone.”|
|C.||“The adrenal cortex secretes antidiuretic hormone.”|
|D.||“The pituitary gland secretes antidiuretic hormone.”|
- A patient’s arterial blood gas levels indicate a pH of 7.51, PaCO2 of 40 mm Hg, PaO2 of 85 mm Hg, and HCO3 of 32 mEq/L. The patient has been vomiting. The nurse knows the patient is suffering from:
- A patient is on fluid restrictions. The best action for the nurse to take while distributing fluids is to place the largest portion of input during _____ until _____ hours.
- A patient is diagnosed with renal insufficiency. The results of an ABG analysis indicate metabolic acidosis. In metabolic acidosis the nurse would expect the pH to _____________.
- A patient has an infiltrated peripheral IV. The nurse knows that the primary difference between the symptoms of infiltration and phlebitis at the site of infiltration is which of the following? Select all that apply.
- A nurse is caring for a patient after bowel resection. The nurse remembers that body fluids maintain balance through homeostasis, which includes the processes of which of the following? Select all that apply.
- A patient complains of chills, dizziness, and feeling hot during a blood transfusion. The nurse’s most appropriate action is to do which of the following? Select all that apply, and place the correct responses in order of priority. (Separate letters by a comma and space as follows: A, B, C, D.)
|A.||Check the patient’s vital signs.|
|B.||Stop the blood transfusion.|
|C.||Slow the rate of infusion.|
|D.||Notify the blood bank and the physician or health care provider.|
Potter: Basic Nursing, 7th Edition
Chapter 18: Caring in Nursing Practice
- A 72-year-old great-grandmother has always considered herself to be in good health. She has always been a few pounds overweight, so a few months ago when she began losing weight she was delighted, although her daughter thought she ought to seek medical care. About a month ago she also became easily fatigued, which interfered with her active lifestyle. She decided to make an appointment with her health care provider. Which of the following was the most likely reason for the woman to seek health care?
|A.||Her daughter’s urging|
|B.||Her unexplained weight loss|
|C.||Time for her annual checkup|
- Madeleine Leininger identifies the concept of care as setting nursing apart from other health care disciplines. Which of the following examples best demonstrates the concept of caring within nursing?
|A.||Performing a physical assessment|
|B.||Inserting a Foley catheter|
|C.||Measuring vital signs|
|D.||Exploring personal preferences|
- Which of the following statements by a nurse demonstrates attentive reassurance?
|A.||“The procedure you are having done isn’t painful and shouldn’t last more than an hour.”|
|B.||“The machine used to test your pulse-oximetry reading uses two kinds of light.”|
|C.||“I am going to insert a 24-gauge cannula into your basilic vein.”|
|D.||“The automatic blood pressure machine will cycle every 15 minutes.”|
- Dr. Harris was hospitalized with pneumonia. He had always been very healthy and was concerned that now his family had to take care of him. During one conversation that he had with his nurse in which he told her that he was worried that he was a burden to his family, she said to him, “This give the ones who love you a chance to show you how much they care for you.” The comment that the nurse made best demonstrated which behavior?
|D.||Basic human needs|
- A registered nurse who works for an orthopedic unit of an acute care hospital makes hourly rounds to his patients. He also closes the door and pulls the curtains around the beds of patients in private rooms before exposing them for treatments. This is an example of which of the following behaviors?
|D.||Basic human needs|
- A registered nurse who worked in an extended care facility could see that a patient was in the process of dying. The lab technician came to draw his blood. The nurse requested that the blood draw be postponed for a while so that the patient’s wife, who was at his bedside, could spend some quiet time with her husband. This is an example of which caring behavior?
|D.||Basic human needs|
- Mrs. Barnes was admitted to the hospital with advanced-stage cancer. As the nurse was admitting her, Mrs. Barnes told her about how her little dog learned a new trick, and could play dead when she said “bang-bang.” The nurse listened attentively to Mrs. Barnes story because she knew it was a way to:
|A.||pass time until the end of the shift.|
|B.||share stories about her dog.|
|C.||discuss something besides Mrs. Barnes’ cancer.|
|D.||affirm to Mrs. Barnes that she was important.|
- There is a current nursing shortage in the United States. The American Nurses Association (ANA), National League for Nursing (NLN), American Organization of Nurse Executives (AONE), and American Association of Colleges of Nursing (AACN) all advocate strategies to reverse this trend. Which of the following provisions is advocated to create a more desirable work environment?
|A.||More time to demonstrate caring behaviors|
|C.||Ergonomically appropriate work space|
|D.||Evidence-based standards of care|
- A nurse enters a patient’s room and says good morning before starting care. The nurse combines nursing tasks and conversation. An important aspect for the nurse to remember is to:
|A.||establish a relationship.|
|B.||gather assessment data.|
|C.||treat discomforts quickly.|
|D.||assume the patient’s emotional needs.|
- A female patient has just found a large lump in her breast. The physician or health care provider needs to perform a breast biopsy. The nurse assists the patient into the proper position and offers support during the biopsy. The nurse is demonstrating:
|C.||a sense of presence.|
- When individuals become ill, there may be a story about the meaning of the illness. When a nurse listens, the patient is able to:
|A.||break the distress of illness.|
|B.||express emotional needs.|
|C.||share information related to his or her past.|
|D.||keep the nurse in the room for a longer period of time.|
- Nurses care for a variety of patients. What is an activity that best demonstrates the enabling role of a nurse?
|A.||Staying with a patient before a surgery|
|B.||Performing IV insertion with confidence|
|C.||Assessing the patient’s entire health history|
|D.||Teaching the patient how to perform self-injection of insulin|
- Nurses demonstrate caring behaviors when they do which of the following? Select all that apply.
|A.||Address the patient by his or her first name.|
|B.||Inform the family about the patient’s medical problems.|
|C.||Close the curtain while giving a bath.|
|D.||Share information about the patient’s responses with other staff members.|
|E.||Cover the patient while giving a bath.|
- Talking quietly in a soft, gentle voice with a patient during a procedure creates a perception of ____________________.
Potter: Basic Nursing, 7th Edition
Chapter 19: Cultural Diversity
- Martha is a student nurse who is caring for Ileana, a 25-year-old Mexican American woman who has learned that she has cervical cancer. Martha has learned that in the Mexican-American culture, decisions about healthcare are often made by the family group. Martha would like to help Ileana as she makes a decision about her treatment options. The most appropriate way for her to assist in this situation is to do which of the following?
|A.||Suggest the health care provider meet with Ileana privately.|
|B.||Let Ileana know what time the health care provider will make rounds so that she can invite her family to be present.|
|C.||Explain to Ileana what the treatment options are.|
|D.||Have an interpreter present to answer any questions.|
- A student nurse has been learning about cultural awareness. In her own journey to become culturally aware, she should consciously think about which of the following?
|A.||American healthcare policies related to illegal immigrants|
|B.||University policies related to international students|
|C.||Hospital policies related to providing translators for non-English speaking patients|
|D.||Stereotypes of other people|
- Emma is a RN who is caring for Mrs. Loo, a 65-year-old Chinese American patient. Mrs. Loo states that she would like to have her own healer visit her in the hospital. She explains that she uses a shaman when her system is not in balance. Emma knows that a Chinese shaman specializes in which of the following?
|A.||Prayers, singing, and herbs|
|B.||Foretelling the future|
|D.||Plant, animal, and mineral products|
- Harriett has been studying different cultures in relationship to nursing. She understands that transcultural nursing has been developed as a distinct discipline and can be defined as which of the following?
|A.||Understanding one’s own culture within a universal perspective|
|B.||Acknowledging cultural differences among races|
|C.||Understanding cultural similarities and differences among groups of people|
|D.||Respecting cultural differences within an environmental context|
- A student nurse is performing a cultural assessment on an 83-year-old woman from the Appalachian region. Which of the following questions would be most appropriate for the student nurse to ask the patient to help her provide culturally congruent care?
|A.||“Do you have any cultural practices we should know about?”|
|B.||“What characteristics do you value most in your health care providers?”|
|C.||“When is the last time you saw a health care provider?”|
|D.||“How do you intend to pay your bill?”|
- Philip is a 24-year-old graduate student from Jamaica who is enrolled in the local university. Ginny is taking Philip’s blood pressure during a health fair that is being held on campus. After conversing with him, she feels that Philip has developed an affiliation with the local culture. This is known as which of the following?
- A registered nurse works for an intensive care unit caring for acutely ill patients. One of the Muslim patients passed away rather unexpectedly. Because his death was unexpected, it was considered a coroner’s case, which required that an autopsy be performed. The family was distraught by this decision. The most likely cause of this distress is the family:
|A.||did not want the body disfigured.|
|B.||wanted to donate his organs.|
|C.||was concerned about the cost of the autopsy.|
|D.||believed that his death was by natural causes.|
- A nurse is caring for a patient who does not speak English well. The most appropriate action for the nurse to take is to:
|A.||address the patient by his or her first name.|
|B.||use slang terms found in the patient’s language.|
|C.||attempt to interpret nonverbal gestures and mannerisms that may differ.|
|D.||ask the patient preferred manner of address.|
- A nurse working in an ambulatory care center is caring for a patient who requires dressing changes every other day. The family caregiver indicates that the patient does not value adhering to a time schedule. What is the most appropriate action?
|A.||Continue to schedule the appointments.|
|B.||Ask the patient to call the ambulatory care center to cancel appointments.|
|C.||Call every other day to remind the patient of the scheduled appoint.|
|D.||Explain to the patient and family members the importance of wound dressing changes and explore anticipated barriers to time adherence.|
- When developing cultural competence a nurse should develop four practices, which are ____________________.
- Health disparities are unequal burdens of disease morbidity and mortality rates experienced by racial and ethnic groups that are often exacerbated by which of the following? Select all that apply.
- A nurse is in the process of admitting an ethnically diverse patient. To plan culturally competent care she will conduct a cultural assessment that includes which of the following? Select all that apply.
Potter: Basic Nursing, 7th Edition
Chapter 20: Spiritual Health
- Gerry is a student nurse who is caring for a 78-year-old hospice patient. As the patient is dying, he begins talking to loved ones who have died before him. Gerry feels a sense of peace as his patient quietly dies. What is the best term for this feeling of peace?
- A student nurse is caring for a 54-year-old patient who has been diagnosed with terminal liver cancer. The patient states that he does not believe God, but he has had a meaningful life by contributing to the lives of those around them. This person is most likely which of the following?
- A nurse recently transferred to a cardiac surgery unit. She is caring for a 64-year-old patient who has survived cardiopulmonary resuscitation after a triple coronary artery bypass graft surgery. To help this patient cope with this experience, what is the best thing for the nurse to do?
|A.||To avoid upsetting the patient, this should not be discussed.|
|B.||Discuss the episode if the patient brings it up.|
|C.||Talk to the family about near-death experiences.|
|D.||Explore what happened with the patient.|
- A nurse who works in a neonatal intensive care unit is caring for a critically ill infant with a poor prognosis. She is Christian and feels responsible to care for both the physical and spiritual needs of the infant and his parents. What is the best statement for the nurse to make to the parents of the infant?
|A.||“You should have the child baptized so that its soul will be saved.”|
|B.||“Would you like me to call the chaplain to christen your child at the bedside?”|
|C.||“What can I do to support your spiritual needs?”|
|D.||“I have asked my pastor to stop by and talk to you.”|
- A nurse is caring for a patient with a debilitating chronic illness. The patient mentions several times that faith would guide her healing. The nurse knows that faith can best be defined as a(n):
|A.||awareness of one’s inner self and sense of connection.|
|B.||belief that gives a person meaning and purpose in life.|
|C.||system of organized beliefs and worship.|
|D.||multidimensional concept that gives comfort while a person endures hardship.|
- A patient has been diagnosed with a terminal disease. Hope may be used effectively with this type of patient. Nurses can support a patient’s use of hope because hope provides a(n):
|A.||influence on how a person exercises faith of belief and action.|
|B.||belief in a higher power, spirit guide, God, or Allah.|
|C.||cultural connectedness, structure, and guidance in difficult times.|
|D.||motivation to achieve and the resources to use toward that achievement.|
- When caring for patients a nurse must understand the difference between religion and spirituality. Religious care helps patients maintain their faithfulness to:
|A.||their belief systems and worship practices.|
|B.||a relationship to a higher being or life force.|
|C.||establish a cultural connectedness with the purpose of life.|
|D.||achieve a balance needed to maintain health and well-being.|
- A patient refuses to remove a specific spiritual garment for daily bathing. The most appropriate action for the nurse to take includes:
|A.||removing the article anyway.|
|B.||respecting the patient’s wishes.|
|C.||asking the patient to remove the article just during hospitalization.|
|D.||telling the patient that other patients of the same faith have allowed the item to be removed.|
- A patient informs the nurse that he or she does not eat pork. This statement is most likely an example of a:
|D.||personal belief system.|
- To assess, evaluate, and support a patient’s spirituality the best action a nurse should take includes:
|A.||referring the patient to the health care facility chaplain.|
|B.||assisting the patient with using faith to get well.|
|C.||providing the patient with a variety of religious literature.|
|D.||determining the patient’s perceptions and belief system.|
- As part of the total patient assessment the nurse can use the Spiritual Well-Being (SWB) scale to ____________________.
- Interventions a nurse can use to establish presence with a patient include which of the following? Select all that apply.
|E.||Speaking with the family|
Potter: Basic Nursing, 7th Edition
Chapter 21: Growth and Development
- A student nurse who works in a pediatric clinic is assisting with an assessment on a young child who is not yet walking. She knows that it is considered a delayed gross motor ability if the child does not walk by _____ months.
- According to one growth and development theorist, individuals need to accomplish a particular task before successfully completing the stage of growth and development. Each task is framed with opposing conflicts, such as trust versus mistrust. Who developed this theory?
- This model of personality development is grounded in the belief that two internal biological forces drive the psychological change in a child: sexual (libido) and aggressive energies. Who is responsible for developing this theory?
- Which of the following people developed the theory of cognitive development, which describes children’s intellectual organization and how they think, reason, and perceive the world?
- According to one theorist, moral development depends on the child’s ability to accept social responsibility and to integrate personal principles of justice and fairness. Which of the following individuals is responsible for the theory of moral development?
- Margaret has just found out she is pregnant. The nurse at the clinic told her that she should stop smoking, avoid alcohol, and avoid eating king mackerel because of the high mercury content in the fish. Although this advice should be followed during the entire pregnancy, the fetus is most vulnerable to adverse affects in the _____ trimester.
- A student nurse is in her community health clinical rotation. She is visiting a family with a new baby. Which of the following statements made by the mother of a 1-month-old infant indicates the need for client education?
|A.||“My baby should double his birth weight by the time he is 6 months old.”|
|B.||“I shouldn’t give my baby any cow’s milk until he is at least a year old.”|
|C.||“My baby has been fussy lately; I believe he is probably cutting his teeth.”|
|D.||“I shouldn’t put my baby on a fluffy pillow to sleep.”|
- The mother of a toddler is concerned that her son is not eating enough, although he has not lost any weight. She tells the nurse that her son used to have a very good appetite, but now does not eat as much as he did a couple of months ago. What is the best response for the nurse to provide?
|A.||“You should try to get him to eat, even if it is only cereal.”|
|B.||“He needs a lot of protein for growth during his toddler years.”|
|C.||“Toddlers have periods when they aren’t growing as fast and they don’t need to eat as much.”|
|D.||“Why don’t you let him eat off of your plate instead of making him his own plate.”|
- Kevin is the father of 11-year-old Harry, who is being seen at the clinic for his annual check-up. As part of anticipatory guidance, you instruct Kevin that accidents and injuries are major health problems affecting school age children. Kevin asks what the number one cause of death is in this age group and your response is:
|B.||motor vehicle accidents.|
- Margery is the mother of 8-year-old Bonnie. Margery has brought Bonnie in to the health clinic for her annual check-up. She is concerned about the high blood pressure in her family and asks the nurse if there is some way to know if Bonnie is at risk for hypertension. What is the nurse’s best response?
|A.||“Blood pressure elevation in childhood is the single best predictor of adult hypertension.”|
|B.||“There is no way of knowing because there are so many variables involved.”|
|C.||“If you are concerned about hypertension, you need to keep Bonnie on a low sodium diet.”|
|D.||“Childhood obesity is the single best predictor of adult hypertension.”|
- The transition from childhood to adulthood, in terms of the psychological maturation of the individual, is known as:
- A nurse is caring for a 5-year-old child who is hospitalized for stabilization of asthma. To provide age-specific care, which of the following is the most appropriate action by the nurse?
|A.||Allowing the child to handle medical equipment|
|B.||Responding immediately to the child’s every need|
|C.||Telling the child he has to be good while in the hospital|
|D.||Rationalizing the child’s complaints as part of the developmental process|
- A recent graduate nurse has been assigned to be a primary nurse on a geriatric unit. After completing a review of development and aging, the nurse recalls that changes during the climacteric signify:
|A.||a transition from middle to late adulthood.|
|B.||the ability of the older adult to achieve sexual arousal.|
|C.||a time when cognitive performance begins to peak in middle age.|
|D.||a decline of reproductive capacity caused by a decrease in sexual hormones.|
- A patient is experiencing incisional pain after an operation. When using Maslow’s hierarchy of needs, the nurse realizes that for the patient to return to a prehospitalized status, the patient needs to progress beyond:
|D.||safety and security.|
- A pregnant teenager asks the clinic nurse why she cannot smoke during the first trimester. Remembering growth and development, what is the nurse’s best response?
|A.||“The distribution of body hair can be altered.”|
|B.||“The organ systems are beginning to develop.”|
|C.||“Development of fingers and toes can be affected.”|
|D.||“The sex of the baby is determined in the first 3 months.”|
- A nurse is conducting a community-based education class. A strategy for positive health habits is:
|A.||daily monitoring of blood pressure.|
|B.||adhering to a regular exercise regimen.|
|C.||adhering to a daily exercise regimen and abstaining from alcohol consumption.|
|D.||following the most popular diet to control the effects of weight gain.|
- A patient asks about strategies that can be used to aid in weight reduction. The nurse can inform the patient to follow a well-balanced diet, including selections of low-fat foods such as:
|B.||hot dog with relish.|
|C.||hamburger and French fries.|
|D.||baked potato with bacon and cheese.|
- A 90-year-old patient constantly tells the nurse stories about life many years ago. The nurse encourages this behavior because reminiscence or life review ____________________.
- Postmenopausal women are at risk for skeletal changes. When developing a plan of care, a nurse should remember to teach patients that weight-bearing exercises _________________.
- A pediatric nurse is caring for a group of 6 and 7 year olds. The nurse remembers that, according to Kohlberg, moral development is a component of psychosocial development. Moral development depends on the child’s ability to do which of the following? Select all that apply.
|A.||Integrate social responsibility|
|B.||Have absolute obedience to adults in authority|
|C.||Integrate principles of justice and fairness|
|D.||Integrate decisions of right and wrong|
- A nurse is performing an admission assessment on a middle age patient. A normal change seen in this age-group includes which of the following? Select all that apply.
|A.||Graying and loss of hair|
|B.||Decreased hearing acuity|
|C.||Decreased function of cranial nerves|
|D.||Decreased strength of abdominal muscles|
|E.||Loss of accommodation|
Potter: Basic Nursing, 7th Edition
Chapter 22: Self-Concept and Sexuality
- Kate is caring for Nancy, a 34-year-old abused woman, who was admitted to the hospital with multiple rib fractures that she received from her partner. Nancy states, “I don’t blame Mike for what he did to me; I can be so stupid sometimes.” Kate recognizes this statement as a manifestation of which of the following?
|A.||Body image disturbance|
- Lilly is a 66-year-old patient who has been admitted to the hospital for a stroke. Her health care provider has told her that she should consider retiring from her high-stress position as a hospital administrator. Lilly is distraught over this suggestion. The nurse caring for her recognizes the most likely cause of distress is due to:
- Frank is a nurse who works at a pediatric clinic. Elliott is a 16-year-old patient who is in the clinic for his annual check-up. During the assessment, Frank asks Elliott about his use of tobacco. Although he denies smoking, he tells Frank that he dips snuff. He tells him that he started last year because all his friends do it. Frank recognized this as a stressor of:
- Robert is a 47-year-old patient who has recently undergone surgery to remove a tumor from his colon. As a result of his surgery he has a colostomy. Robert’s nurse is planning his care and would like to incorporate measures to support the adaptation to stress. Which of the following is least likely to support Robert’s adaptation to stress?
|D.||Beginning smoking cessation classes|
- A 35-year-old new mother returned to the clinic for her 6 week postpartum check. As the nurse, you plan to discuss any questions that she might have regarding her sexual health. When is the best time to initiate this discussion?
|A.||As soon as the health care provider completes her pelvic exam|
|B.||As the patient is preparing for the examination|
|C.||After the examination is over and the patient is dressed|
|D.||In the waiting area|
- Kathy is assessing a 27-year-old woman who confides to her in the clinic that she has three sex partners and none of them are aware of the others. Which of the following would be the most appropriate statement that Kathy should make?
|A.||“Don’t you think that is risky behavior?”|
|B.||“Are you practicing safe sex and using condoms?”|
|C.||“Do you think that you are being responsible in your behavior?”|
|D.||“What do you think they would say if they found out about each other?”|
- Bill is a 17-year-old patient who was admitted to the hospital after a motorcycle accident. He has become a paraplegic as a result of his injuries. The nurse recognizes that Bill is ready to have another paraplegic visit him when he says:
|A.||“I am going to spend the remainder of the school year at home.”|
|B.||“I don’t want to go back to school.”|
|C.||“I’m not sure how I will manage going back to school in a wheelchair.”|
|D.||“I don’t want the kids at school to feel sorry for me.”|
- Leigh is a 45-year-old mother of three who recently underwent bladder surgery. She has a Hemovac drain in her abdomen and a urinary catheter in place. The nurse needs to ambulate her, but Leigh doesn’t want to walk down the hall of her hospital unit. She tells the nurse, “I don’t want anyone to see the tubes and the gross drainage bags.” This indicates to the nurse that Leigh is at risk for:
|C.||deep vein thrombosis.|
- Faith, a student nurse, is discussing a 4-year-old patient, Mike, with her nursing instructor. The instructor asks Faith about how Erikson’s Developmental Tasks have an impact on a 4-year-old child’s self-concept and sexuality. What is the best response?
|A.||“Mike says he wants to be a mechanic like his dad when he grows up.”|
|B.||“Mike likes to go to the park to play.”|
|C.||“Mike’s favorite food is hot dogs.”|
|D.||“Mike likes to play video games with his older sister.”|
- The mother of a 7-year-old boy asked the nurse what factors tended to increase self-esteem in boys. According to research, which of the following is the nurse’s best response?
|A.||Positive family communication|
|B.||Parents who have at least 4 years of college|
|C.||Boys with older siblings|
|D.||Boys from two-parent households|
- As a nurse caring for a patient with a colostomy that resulted from the treatment of a benign tumor of the bowel, you most appropriately classify this self-concept component as:
|A.||role performance stressor.|
|D.||body image stressor.|
- A nurse is caring for an adult patient who retired last year. While rendering care, the nurse identifies that the patient is struggling emotionally with this change. This situation is most likely associated with what self-concept component?
|D.||Body image disturbance|
- After a large weight loss a patient tells the nurse, “There still is a fat person inside of me.” This type of statement illustrates a flaw in what self-concept component?
- An older adult patient who recently lost her husband is admitted for surgery. The nurse notices that the patient is experiencing an alteration in psychosocial development when the patient:
|A.||accepts her own limits.|
|B.||voices concerns about the upcoming surgery.|
|C.||expresses her opinions about the quality of care.|
|D.||demands unnecessary assistance from her daughter.|
- To devise a plan of care, when taking a patient’s health history the nurse should always:
|A.||focus only on physical factors that affect sexual functioning.|
|B.||discuss sexual concerns only if the patient raises questions or concerns.|
|C.||use emotionally laden terms when discussing sexual concepts.|
|D.||routinely include a few questions related to sexual functioning.|
- A male patient shares a satisfying relationship with his wife. In addition, he shares close relationships with his male friends. The nurse would most appropriately view these male relationships as:
- A middle-age single woman has breast cancer and needs a mastectomy. She is concerned with future male relationships. She is crying and indicates her life is over. According to Erikson, she occupies which state? ____________________
- A middle-age female model is admitted for a double mastectomy. On admission the nurse notes that she is depressed and withdrawn. The most appropriate patient-centered nursing intervention(s) might include counseling the patient about which of the following? Select all that apply.
|A.||Thinking positively instead of negatively|
|B.||Remaining a positive force in her plan of care|
|C.||Speaking with a support group to explore common coping mechanisms|
|D.||Remaining independent to return to prehospitalization activities|
Potter: Basic Nursing, 7th Edition
Chapter 23: Family Context in Nursing
- Alissa is a nursing student who works in a clinic. She is admitting a 45-year-old patient and asks about her family. Alissa is told that the patient lives with her daughter and son-in-law. Alissa knows that this is an example of which of the following family forms?
|D.||Alternate pattern of relationship|
- Harriett is a student nurse who is working on a community health project with her peers. One of the concerns in her community is the rise in homelessness due to the economy. Harriett understands that the fastest growing segment of the homeless population are:
|C.||families with children.|
- Gene and Jackie are parents of twins. As their daughters have entered high school they have gradually become more independent and the family boundaries have become more flexible. This family is in what developmental stage?
|A.||Unattached young adults|
|B.||Family with young children|
|C.||Family with adolescents|
|D.||Family with young adults|
- Becky and Jack are the parents of Michael, an 18-year-old who joined the military and is being deployed overseas. Becky and Jack discuss with Michael how they plan to stay in touch and purchase a laptop computer for Michael to take with him so they can e-mail and use the webcam to see each other. What is the approach to stress that this family exhibits?
- Harry is a student nurse caring for Jon, a 4-year-old patient who has been admitted to the pediatric unit with acute asthma. As Harry admits Jon, he learns that both parents smoke in the home. Harry plans to discuss with the parents the implications of smoking around Jon and to provide them with information on smoking cessation. This is an example of what approach to family nursing?
|A.||Family as context|
|B.||Family as patient|
|C.||Family as system|
|D.||None of the above|
- Ginny is a nurse who is admitting Mrs. Martinez, a 56-year-old Hispanic patient, to the oncology unit of the hospital. To provide culturally competent care, Ginny needs to determine the influence of culture on Mrs. Martinez’s family. Which of the following questions would best accomplish this?
|A.||“What types of foods do you eat?”|
|B.||“How many children do you have?”|
|C.||“What is your religious preference?”|
|D.||“Do you have an advance directive?”|
- Mark is the nurse admitting Mr. Kern to the neurology unit of the hospital. Mr. Kern is an 82-year-old man who lives at home with his wife of 60 years. His daughter and her family live next door to the Kerns and help care for them. Mrs. Kern has diabetes and hypertension, which are both controlled with medication and diet. As Mark develops a plan of care for Mr. Kern, he should consider which of the following nursing diagnoses?
|A.||Risk for caregiver role strain|
|B.||Disabled family coping|
|D.||Ineffective role performance|
- Sarah is a nurse who works in home care. She is caring for Mr. Jenkins, a 78-year-old patient with liver cancer. Mr. Jenkins lives at home with his wife of 53 years. In addition to caring for Mr. Jenkins, Sarah also assesses caregiver stress in Mrs. Jenkins. Which of the following indicates caregiver stress in Mrs. Jenkins?
|A.||Increased visits from church members|
|B.||Mrs. Jenkins asking her daughter for help with shopping|
|C.||Mrs. Jenkins arranging for Meals-on-Wheels three days a week|
|D.||Mrs. Jenkins contracting pneumonia|
- When evaluating patient expectations of family-centered nursing, it is most important to obtain which of the following?
|A.||Patient outcome information|
|B.||Family’s perspective of nursing care|
|C.||Physician’s perspective of nursing care|
|D.||Health care goals of the patient|
- Rebecca is a student nurse who is talking to her friends about holiday plans with their families. One friend described her family as her mother, brother, and sister-in-law. Another stated her family consisted of her mother, father, grandmother, and her aunt. Rebecca’s family is her mother, stepfather, sister, and stepsister. The uniqueness of these families is known as:
- Geraldine is making plans for her holiday dinner and shares with her butcher that she will be inviting her family. When the butcher asks who will be coming, Geraldine replies, “My two children and their spouses, my ex-son-in-law is bringing my grandson, and my ex-mother-in-law is coming.” This is an example of which of the following?
- Fran is a nursing instructor who is raising her two granddaughters after her daughter and son-in-law were killed in a motor vehicle accident. How is this family form best described?
|D.||Alternative pattern of relationship|
- Chris is a student nurse working in a faith-based health care clinic for the poor. He is preparing Haley, a 14-year-old patient, for the health care provider. Haley’s mother tells Chris that her husband was recently injured and lost his job. The family also lost their health care insurance and the family is now living in a shelter. Chris understands that the fastest growing segment of the homeless population is families with children. They account for _____% of the homeless population.
- A nurse is caring for a patient. Visitors at the bedside include the patient’s life partner, widowed mother, sister, and nephew. The nurse acknowledges that current trends in American families include:
|A.||couples having many children.|
|B.||more singles choosing to live alone.|
|C.||a very different look than 15 years ago.|
|D.||a mother, father, and more than one child.|
- A husband and wife are having a loud discussion regarding acceptable health care practices. The nurse uses therapeutic communication to deal with this situation. The nurse understands that effective communication within the family promotes:
|A.||increased financial opportunities for the family.|
|B.||socialization among individual family members.|
|C.||role development of each individual family member.|
|D.||problem solving and emotional support of the family members.|
- A nurse is attempting to complete the nursing admission data on a patient. To complete the admission and formulate a plan of care, the nurse needs to:
|A.||test the family’s ability to cope.|
|B.||evaluate communication patterns.|
|C.||identify the family’s form and attitudes.|
|D.||gather health data from all family members.|
- A patient comes from a close-knit extended family. If the patient’s family functions as context, the nurse needs to evaluate:
|A.||attainment of patient needs.|
|B.||family attainment of developmental tasks.|
|C.||individual family members’ caring about one another.|
|D.||family satisfaction with its new level of functioning.|
- An older adult patient is returning home after a total knee replacement. The patient lives within an alternative pattern relationship. The patient is unable to perform the postoperative exercises. What is the most appropriate action the nurse should take?
|A.||Referring the patient to an outpatient exercise group|
|B.||Arranging for a private duty nurse to help perform exercises three times a week|
|C.||Informing the patient that if he cannot do the exercises, he will have to go to an extended care facility|
|D.||Investigating whether or not someone else in the home will be able to assist with the knee exercises|
- The family of a patient attends a patient care conference. When planning family goals the nurse should:
|A.||view the family as a system.|
|B.||make the goals as broad as possible.|
|C.||assess the availability of family members.|
|D.||not recognize developmental stages of family members.|
- A nurse is preparing to present a class entitled “Nursing and the Family” to a group of co-workers. The nurse wants to present current concepts related to trends that threaten the family unit, which would include which of the following?
|B.||Alternative relationship patterns|
|C.||Shifting of traditional or generational roles|
|D.||Decreased health insurance or lack of access to health care|
- A married couple takes four children to an immunization clinic. The nurse notes that the children’s permission slips include three children with one last name and one child with a different last name. On questioning the parents the nurse discovers that this family group consists of a ____________________.
Potter: Basic Nursing, 7th Edition
Chapter 24: Stress and Coping
- Kelly is a nursing student who has been assigned to care for a 67-year-old postoperative patient who is very demanding. She was late for clinical rounds because she had to change the tire on her car. Kelly is in the process of preparing pain medication for her patient when her nursing instructor asks her to identify the drug classification of the pain medication she is preparing. Kelly finds the she is very frustrated and becomes tearful. Kelly’s reaction to her instructor is most likely due to what ego-defense mechanism?
- Michael is a 44-year-old nurse who works in a small clinic with two other nurses and a nurse practitioner. Recently Michael has been staying at work longer than he usually does. Michael’s neighbor, a patient at the clinic, asked one of the other nurses at the clinic how Michael was coping since his wife left him. Michael had not shared this information with his co-workers. The nurse is concerned that Michael may be coping with his loss with which of the following?
- Monty is a 4-year-old boy who has been admitted to the hospital with pneumonia. He has been in the hospital for 3 days and has suddenly started to become incontinent of urine. This is most likely a result of what ego-defense mechanism?
- Daniel is a 48-year-old patient who was involved in a motor vehicle accident. He was driving home from a wedding with his family when he was hit by a drunk driver. Daniel’s 23-year-old daughter and his wife were killed in the accident. Daniel is in the trauma unit with internal injuries. He had to have his left leg amputated above the knee. How is the crisis that Daniel is facing best described?
- Sally is a registered nurse who works in a mental health clinic. She is admitting 17-year-old Elliott who has been referred to the clinic by his pediatrician. Elliott has recently been doing poorly in school, his girlfriend broke up with him, and his best friend was killed in a motor vehicle accident. Elliott tells Sally that he is missing classes because he does not have any motivation to get up in the morning. This assessment finding is from what psychological domain?
- Richard is a nursing student who has severe test anxiety. When he receives a test in class, his heart rate increases, he feels more mentally alert and his pupils dilate. According to the general adaptation theory, this is what stage of the body’s reaction to stress?
- The __________ system mediates emotions and is responsible for the mind-body connection.
- Crystal is a new nurse who is looking for a staff nurse position. She had several instances during clinical rotations in nursing school where she was late because she studied until the early hours of the morning. According to her circadian rhythm she would be best suited for which of the following positions?
|A.||Full-time 8-hour day/evening rotation on the orthopedic unit|
|B.||Part-time 12-hour day position in the emergency department|
|C.||Full-time 12-hour night position in surgery|
|D.||Part-time 8-hour day/night position on the pediatric unit|
- Kevin is a student nurse who is talking to a 23-year-old patient who was involved in a motor vehicle accident. The patient asked Kevin why he didn’t feel any pain at the time of the accident. What is the best explanation that Kevin can give the patient?
|A.||“You were probably in shock.”|
|B.||“Endorphins are released during a time of stress, and they act like morphine to reduce pain.”|
|C.||“Hormones are released by your body during a time of stress.”|
|D.||“The stress of the accident caused you to forget the pain that you felt.”|
- Janet is a nurse who has a lot of stress in her life. Which of the following situational factors would be considered work stress?
|A.||Speeding ticket she received on her way to work|
|B.||Death of a friend she used to work with|
|C.||Overdrawn checking account|
- Florence is a student nurse who has been involved in administering flu vaccines. Kevin, one of the children who is scheduled to receive the vaccine, is afraid of needles and is tearful, and his younger brother is trying to calm him down. Florence knows that Kevin has evaluated this event as significant and is experiencing psychological stress due to which of the following?
- Jenny has recently been promoted to a new management position in her hospital. She is concerned about her new responsibilities and has found that she is having difficulty sleeping at night. This is an example of what ego-defense mechanism?
- A patient who was injured in a motor vehicle accident is taken via ambulance to the emergency department. The nurse performing the physical assessment knows that, according to the general adaptation syndrome, the patient should be expected to exhibit:
|A.||an increased appetite.|
|B.||an increased heart rate.|
|D.||a decreased respiratory rate.|
- A patient complains of pain. The nursing order calls for pain medication via injection. The patient is afraid of needles. The nurse can assist the patient through this stressful incident by encouraging the patient to think of a relaxing situation. The nurse’s actions can be identified as:
|D.||progressive muscle relaxation.|
- A patient and family attend a counseling session. The patient has become depressed after a job loss. The nurse leading the counseling session informs the patient and his family that this type of crisis is:
- A patient telephones a crisis intervention hot line. The nurse assigned to this center assesses that the patient is experiencing a crisis. What is the most appropriate action for the nurse to take?
|A.||Recommending ongoing therapy|
|B.||Focusing on the problem at hand|
|C.||Allowing the patient to work through stress|
|D.||Completing an in-depth evaluation of the situation|
- A nurse has been working overtime because of high hospital census and a decreased work force. A danger of work-related burnout is:
|B.||a perception of personal accomplishment.|
|C.||functioning at a more effective level.|
|D.||hurting other’s feelings without concern for their reaction.|
- An older adult patient in a long-term care facility recently suffered a stroke after experiencing a myocardial infarction. The patient is not speaking or eating. The nurse notices a change in vital signs. When a patient is unable to resist the effects of a stressor, the nurse can identify this stage of the general adaptation system as:
|B.||the resistance stage.|
|C.||the exhaustion stage.|
- A busy executive works 80 hours a week. The patient is admitted for angina. The patient is demonstrating physical signs of stress related to the work environment. An appropriate nursing intervention for this patient includes using physiological functions every 2 hours. This type of intervention is best known as:
- Because stress plays a central role in vulnerability to disease, nursing interventions are required. Nurses using Neuman Systems Model can relate this model to the general adaptation syndrome because both ____________________.
Potter: Basic Nursing, 7th Edition
Chapter 25: Loss and Grief
- Harold is a 45-year-old man who recently lost his job as a result of downsizing at his company. Harold was employed at this company since graduating from college and identifies himself by the work that he did. He is currently grieving as a result of which type of loss in his life?
- Kelly is a nursing student who has maintained a 4.0 GPA since she has been in nursing school. The past semester she has started working, is planning a wedding, and has moved into a new home. Kelly has not been able to maintain the 4.0 GPA this semester and as a result, Kelly is feeling like a failure. How is this loss best described?
- Jenny is the young mother of three children. Her oldest child has started school this year, and she cried as she left him at kindergarten on the first day. How is the loss that Jenny is experiencing best described?
- Denise is a recently widowed mother of two. Her late husband was starting his own business, and she was managing the accounting paperwork. The family had no life or health insurance. When her husband suddenly died, Denise was left with a large hospital bill, funeral expenses, unemployment, and no means of support. How are the multiple losses that Denise is experiencing best described?
- Bowlby’s phases of mourning are founded on which of the following human instincts?
- Bernice is a widow who lost her husband 3 years ago. She has recently started dating and is thinking about going back to school to complete a degree she had started when she was younger. Which of Bowlby’s phases of mourning best describes Bernice’s behavior?
|B.||Yearning and searching|
|C.||Disorganization and despair|
- Renee is the mother of a child who drowned in a neighbor’s pool that was not secured. According to Bowlby’s phases of mourning, when would this mother be most likely to file a wrongful death lawsuit against her neighbor?
|B.||Yearning and searching|
|C.||Disorganization and despair|
- A young widower who lost his wife in Afghanistan has worked through the first task of Worden’s mourning theory. He asks you if he will ever feel able to move forward with his life. According to Worden’s theory, what is your best response?
|A.||“You will never love anyone as much as your wife.”|
|B.||“Nobody will ever be able to take your wife’s place.”|
|C.||“It takes time to adjust to this type of loss, typically at least a year.”|
|D.||“Some people are able to move forward faster by suppressing the pain.”|
- Kim is a nursing student who grew up in Korea and has been in the United States for the past 4 years. She is especially sensitive about the differences in how mourning is different between her native culture and that of western society. She should use which model of mourning to help her understand an action-oriented process of grieving?
|A.||Bowlby’s Four Phases|
|B.||Worden’s Four Tasks|
|C.||Rando’s R Process|
|D.||Kübler-Ross’ Five Stages|
- Mrs. Unger, a 76-year-old patient, has been suffering from liver cancer for more than a year. The family has requested hospice services. The family members are taking turns staying with Mrs. Unger. They have been reminiscing with Mrs. Unger about her life and are now saying their good-byes. The type of grief that this family is experiencing is best described as which of the following?
- When a person has difficulty progressing through his or her loss experience, he or she experiences complicated grief. What are the four types of complicated grief?
|A.||Chronic, delayed, exaggerated, and masked|
|B.||Chronic, delayed, exaggerated, and dysfunctional|
|C.||Acute, delayed, exaggerated, and dysfunctional|
|D.||Acute, delayed, exaggerated, and masked|
- Eleanor is a 45-year-old widow who is being seen in a mental health clinic for clinical depression and alcohol dependency. She lost her husband and her son in a boating accident 10 months ago and has become increasingly despondent and withdrawn. She verbalizes that she feels overwhelmed by her loss. Her daughter urged her mother to seek help. Which type of complicated grief best explains Eleanor’s behavior?
- Hannah is a 34-year-old single mother of three who had been involved in a secret relationship with her boss, a married man who was 24 years her senior. When her boss suddenly died as the result of a heart attack, Hannah had difficulty expressing the extent of her loss. The grief that Hannah was experiencing could best be described as which of the following?
- Mary, a student nurse, is caring for a 3-year-old niece whose mother has recently died of cancer. Because of the child’s stage of development, Mary expects that the child will most likely see the loss of her mother as which of the following?
|B.||A threat to her self-concept|
|D.||A challenge to her emerging identity|
- Last year Margaret, a student nurse, became very involved in her church’s youth group when she lost her father to cancer. Currently Margaret is facing another challenge in her life because her dog has become terminally ill and is not expected to live. How will Margaret most likely cope with the death of her beloved pet?
|A.||Dropping out of school|
|B.||Staying busy with her student nurse organization|
|C.||Turning to alcohol|
|D.||Becoming obsessive compulsive about her personal hygiene|
- Robert is a businessman who has been diagnosed with multiple sclerosis. His health care provider has not given him a very positive prognosis because his disease is progressing very quickly. What is the most important thing for Robert to maintain at this point in his illness for his sense of well-being?
- Bruce is a nurse caring for a patient with terminal lung cancer. The patient is in a great deal of pain and is anxious. Bruce contacts the health care provider to request pain medication for the patient and is given an order for morphine, but the family of the patient refuses to let Bruce administer it on religious grounds. This is most likely due to the patient and family being of which of the following faiths?
- Wendy is a nursing student who is admitting Mrs. Williams, a 75-year-old patient into the gastrointestinal laboratory for a routine colonoscopy. During the assessment, Wendy learns that Mrs. Williams lost her husband 4 months ago to stomach cancer and has not been sleeping well. Which of the following is the best question to obtain more data regarding Mrs. Williams’ sleeping pattern?
|A.||“Are you taking medication to help you sleep?”|
|B.||“How long have you had difficulty sleeping?”|
|C.||“What time do you go to bed at night?”|
|D.||“Are you taking a nap in the afternoon?”|
- Denise is attending a grief support group that you are facilitating. She lost her son in Iraq 18 months ago. She confides in you that she went to her son’s grave yesterday and broke down. She told you that she hurt as deeply as the day she found out that he had been killed and feels that she would never get through this feeling of intense grief. On listening to her you discover that yesterday would have been her son’s twenty-first birthday. What is the best response to Denise?
|A.||“It would be best to avoid the cemetery on dates that might trigger this type of reaction.”|
|B.||“What happened to you yesterday is understandable and common in people who have lost loved ones.”|
|C.||“Next time you go to the cemetery you should take someone with you.”|
|D.||“Why don’t you go home and take a bubble bath instead of attending the support group this evening.”|
- Nancy is the charge nurse on the evening shift of a busy medical unit in an acute care hospital. She received a call from a physician office that they are admitting a patient who is dying of lung cancer. Nancy is told that the patient’s family is out of town and isn’t expected to make it to the hospital before the patient expires. What is the best room for Nancy to place this patient?
|A.||A private room near the nurse’s station|
|B.||A semiprivate room halfway down the hall with another terminally-ill patient|
|C.||A private room at the end of the hall|
|D.||A semiprivate room at the end of the hall with a patient who has a lot of family visitors|
- Mildred, a 104-year-old extended care resident, was dying. Her family came to visit, but one of her granddaughters had difficulty accepting her grandmother’s impending death. What is the best thing that the nurse can do to help her feel more comfortable?
|A.||Telling her that once her grandmother passes she will be glad that she came|
|B.||Explaining to her that her grandmother needs her to be there|
|C.||Asking her if she would like to brush her grandmother’s hair|
|D.||Telling her that her grandmother’s time is near|
- After the death of a patient, it is the __________ responsibility to provide postmortem care.
- Which of the following would not be appropriate for a patient undergoing palliative care?
|A.||Insertion of a peripherally inserted central line|
|D.||Knee replacement surgery|
- Mrs. Cherewski is a 78-year-old patient from Poland who has been admitted to the hospital with advanced colon cancer. She is receiving palliative care at this time. Which of the following questions would be best for the nurse to ask to obtain information about cultural factors that influence grieving?
|A.||“How have you coped with other hospitalizations?”|
|B.||“Tell me about the family that is available to help you.”|
|C.||“What do you expect will happen to you?”|
|D.||“What do you believe about death?”|
- A nurse is caring for a patient who has become depressed because her children have gone away to college. The nurse assesses this type of depression as __________ loss.
- For a nurse to be effective in assisting patients with problems associated with loss and grief, a nurse’s most appropriate action should include:
|A.||believing in God and life after death.|
|B.||completing a course in death and dying.|
|C.||sharing personal feelings and being sympathetic.|
|D.||knowing how people normally cope with loss and grief.|
- A middle-age patient with a terminal disease is speaking harshly to the nurse every time the call light is answered. The nurse identifies that this dying patient is experiencing the second stage of Kübler-Ross’s stages of dying. What is the second stage?
- The paramedics brought a college-age person to the emergency department after a motor vehicle accident. After the family arrived, the patient died. To assist the family during this time the nurse should:
|A.||isolate the parents from other relatives in the initial grieving process.|
|B.||include all family members in working through the grieving process.|
|C.||be prepared for a realistic acceptance by some of the family members of this crisis.|
|D.||separate out those family members closest to the deceased and counsel them.|
- A patient suffering from lung cancer experiences nausea and vomiting. When rendering palliative care, what is the best action for the nurse to take?
|B.||Offering high-protein food|
|D.||Increasing patient’s fluid intake of milk and fruit juice|
- A patient’s daughter died in a ski accident after crashing into a tree. The patient stated, “I cannot believe my daughter has died.” According to Worden’s tasks of mourning, the patient is experiencing task:
- After the death of a patient, one of the nurse’s responsibilities is:
|A.||insisting that the family view the body even if they are reluctant.|
|B.||placing the body in a supine position to make it look as natural as possible.|
|C.||removing dentures, jewelry, and other personal items to return to the family.|
|D.||making arrangement with the local mortuary for transportation and arrangements.|
- A first-year nursing student is assigned to care for a dying patient. To best prepare for this assignment, the student should:
|A.||complete a course on death and dying.|
|B.||be able to control his or her own emotions about death.|
|C.||compare this experience to the death of a family member.|
|D.||develop a personal understanding of his or her own feelings about grief and death.|
- A nurse is caring for a patient with a terminal illness. The patient is focusing on relief of pain. The nurse recognizes this as:
- A hospitalized husband and father of two children just learned that his wife was killed in a motor vehicle accident. The method in which this patient manifests loss will be influenced by:
|D.||the stage of human development.|
Potter: Basic Nursing, 7th Edition
Chapter 26: Exercise and Activity
- Kelly is a nursing student who is working on an orthopedic unit. She has to assist a lot of patients who have limited mobility. She knows that she should maintain a position that most favors function, requires the least muscular work to maintain, and places the least strain on muscles, ligaments and bones. What is the term that best describes this?
|C.||Center of gravity|
- Marge is a nursing student who is completing her clinical rotation on a geriatric unit. She cares for patients with fragile skin on this unit and looks for ways to reduce the friction caused when repositioning a patient in bed. Which of the following causes the most friction when repositioning a patient?
|A.||Lifting the patient|
|B.||Using a drawsheet|
|C.||Pushing the patient|
|D.||Using a transfer board|
- Brenda is a nurse who works on the orthopedic unit. She knows that in addition to providing support, bones perform other functions in the body. Besides support, which of the following is the most important bone function during activity and exercise?
- Michael has been diagnosed with a progressive neuromuscular disease. He is curious about what to expect and has numerous questions for both his health care provider and his nurse. He is having difficulty walking and has less awareness of the position of his body. Michael asks the nurse if there is a word to describe this phenomenon. What is the term to best describe this?
- Bernice has a brain tumor and, as a result, has trouble with balance. Bernice’s husband asks the nurse how her tumor could affect her balance. The nurse explains that the tumor is growing in the part of the brain that is responsible for balance, which is which of the following?
- Rachel is a nurse manager who is concerned with the safety of her staff as they transfer patients. She reinforces the principles of appropriate body mechanics, which include all of the following except:
|A.||a wide base of support increases stability.|
|B.||a higher center of gravity increases stability.|
|C.||facing the direction of movement prevents abnormal twisting of the spine.|
|D.||pivoting requires less work than lifting.|
- Doug is a 67-year-old bus driver who recently had a myocardial infarction and underwent a triple bypass surgery. He didn’t suffer any muscle damage to the heart. His nurse wants to discuss an exercise program with Doug. Which of the following statements best indicates that Doug is ready to change his behavior?
|A.||“I used to eat a lot of snacks during the day; I know that wasn’t good for me.”|
|B.||“I am looking forward to returning to work when I am discharged.”|
|C.||“I am so thankful that I didn’t have any lasting effects from my heart attack.”|
|D.||“My wife is looking forward to me coming home.”|
- Esther, a devout Muslim, is a 46-year-old client who is being evaluated for weight-loss surgery. One aspect of the comprehensive bariatric program is that clients begin an exercise program. Esther is self-conscious about her weight and concerned about maintaining her modesty. Which of the following exercise programs would be the best choice for the nurse to suggest to Esther?
|A.||A private trainer at a local fitness center|
|B.||An aerobics class at the local YMCA|
|C.||The evening yoga class at a local country club|
|D.||Walking 30 minutes a day at the mall with a friend|
- Jared is a small business owner and has noted an increase in the rate of back injuries in recent years. When discussing his concern with Becky, an occupational health nurse, he finds that this is a trend throughout the country. Becky shares with him that the most common back injury is caused by a strain to which of the following muscle groups?
- Alton is a 79-year-old patient who experienced a stroke and is immobile. Harriett is a student nurse who is caring for him. She knows that to prevent skin breakdown when Alton is in bed, she must reposition him at least every _____ hour(s).
- Mr. Kelly is a 56-year-old patient with COPD. He does not tolerate a supine position for sleeping. What is the best position for the nurse to suggest for him?
- Mrs. Keller is a 67-year-old patient who is comatose. Richard is the student nurse caring for her. To minimize her risk for aspiration, he knows to avoid placing her in what position?
- Clara is a 19-year-old patient with cerebral palsy who has been admitted to the hospital with pneumonia. Clara has limited voluntary motor control. Rachel, the student nurse caring for Clara, knows that the easiest intervention to maintain joint mobility for her is which of the following exercises?
|A.||Active range-of-motion exercises|
|D.||Passive range-of-motion exercises|
- Mr. Stephens, a 46-year-old patient, has been hospitalized for 5 days after pancreatic surgery. Jillian, the student nurse caring for him, is preparing him to ambulate for the first time. What is the best thing that Jillian can do to prevent Mr. Stephens from suffering orthostatic hypotension when helping him stand up?
|A.||Having him sit up in bed for a few minutes before standing|
|B.||Having him sit up with his legs dangling over the side of his bed for a few minutes before standing|
|C.||Placing him in a high-Fowler’s position for a few minutes before standing|
|D.||Placing him in a low-Fowler’s position for a few minutes before standing|
- Paul is a student nurse assisting Mr. Jenkins with his new walker. Which of the following is appropriate information for Paul to provide to Mr. Jenkins?
|A.||“The top of the walker should line up with the crease on the inside of your elbows.”|
|B.||“You should walk behind the walker to maintain balance.”|
|C.||“You should lean forward over the walker to maintain balance.”|
|D.||“When walking, you should take a step, move the walker forward, and take another step.”|
- Brittney is a student nurse caring for Mrs. Flowers, a 67-year-old patient who recently had a stroke that left her with left-sided weakness. Brittney is providing patient teaching regarding the use of a quad-cane for ambulation. Which of the following statements is correct?
|A.||“You should use the cane on the stronger side of the body.”|
|B.||“Move the stronger leg with the cane.”|
|C.||“When walking, advance the weaker leg past the cane.”|
|D.||“Your body weight should be supported by the cane and stronger leg.”|
- Which of the following statements is appropriate for a nurse to teach a patient regarding the use of crutches?
|A.||“The axillae should support all your body weight.”|
|B.||“Your elbows should be straight when your hands are on the crutch handgrips.”|
|C.||“The distance between the crutch pad and axillae should be three to four finger widths.”|
|D.||“Your elbows should be flexed about 45 degrees when the handgrip position is correct.”|
- A nurse is educating a patient who needs stability about how to use the crutches that have been ordered. The use of the technique the nurse is teaching requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch so that three points of support are on the floor at all times. The term for this gait is the __________ gait.
- Theresa is a nurse caring for five orthopedic patients on her shift. Kate is a nursing assistive personnel who is assisting Theresa. Which of the following tasks is most appropriate for Theresa to delegate to Kate?
|A.||Moving a 45-year-old patient who had a CVA toward the head of the bed|
|B.||Repositioning a confused 87-year-old patient with contractures|
|C.||Providing discharge teaching for a 49-year-old patient who had a stroke|
|D.||Preparing a 77-year-old patient for hip replacement surgery|
- A nurse and another staff member are preparing to reposition a patient in bed. To prevent back strain, these two health care providers must:
|A.||keep their knees stiff to enhance their lifting strength potential.|
|B.||keep the weight of the patient as close to their bodies as possible.|
|C.||loosen their stomach muscles to keep from injuring the pelvic region.|
|D.||twist their upper torsos to enhance the use and strength of their upper extremities.|
- A nurse is caring for a patient who has pneumonia. To facilitate respiration and lung drainage this patient should be placed in what position?
- A patient presents to the emergency department with a fractured leg that requires a full leg cast. The nurse needs to teach the patient to ambulate with crutches using the:
|D.||tripod alternating position.|
- A nurse is caring for a patient with a neuromuscular condition. The nurse needs to assess the patient’s muscle movement and strength. In doing so, the nurse recalls that chemicals that transfer electrical impulses from the nerve across the myoneural junction, such as acetylcholine, are called:
- A nurse is assisting a patient with right-sided hemiplegia to transfer from the bed to a chair. The most appropriate action for the nurse is to:
|A.||support the affected (right) side.|
|B.||grab the patient under the arms while assisting with the transfer.|
|C.||stand on the stronger side of the patient to ensure less strain on the nurse’s back.|
|D.||encourage the patient not to use the hand rests because of their restrictions on movement.|
- A patient with arthritis is complaining of sensitivity and warmth in the elbow and wrist joints. To determine the degree of limitation or injury, the nurse can assess:
|D.||joint range of motion.|
- The nurse delegates the task of ambulating a patient to the assistive personnel. The nurse ascertains that the assistive personnel understands how to intervene when the patient complains of dizziness when the assistive personnel verbalizes:
|A.||“I call for help.”|
|B.||“I gently lower the patient to the floor.”|
|C.||“I support the patient and walk quickly back to the room.”|
|D.||“I lean the patient against the wall and wait until the episode passes.”|
Potter: Basic Nursing, 7th Edition
Chapter 27: Safety
- The Martin family has recently moved into a newly renovated home in the inner city. The house is the dream home that they have been saving for years to purchase. Mrs. Martin has been to the clinic with her 12-year-old daughter. She complains that they have been having headaches and nausea since the first of the year, shortly after moving into the new home. As the nurse gathers information, what other question would be most appropriate to ask Mrs. Martin?
|A.||“When was your last period?”|
|B.||“Have you changed your diet since moving?”|
|C.||“What type of furnace do you have?”|
|D.||“Do you have a history of headaches?”|
- Sally is a registered nurse who works for a home health agency. She has been asked to admit Mr. Kelly, a 72-year-old patient who was released from a rehabilitation hospital following therapy after he fell at home and broke his hip. As Sally surveys the home environment, which of the following situations is most dangerous to Mr. Kelly?
|A.||Bedside lamp with an extension cord|
|B.||Handrail on one side of stairs only|
|C.||Throw rugs in the bedroom|
|D.||No handrail near toilet|
- Of the following, who is most at risk for accidental poisoning?
|A.||Supervised 16-month-old toddler in the kitchen|
|B.||Unsupervised 2-month-old infant left near a closed bottle of prescription medication|
|C.||Unsupervised 4-year-old child playing dress-up with mother’s makeup|
|D.||Supervised 6-year-old child playing with watercolor paints|
- A nursing student is volunteering with a local agency to help prepare his community for a potential bioterrorist attack. On which of the following threats should he focus?
- A student nurse is working on her senior project for school. She is concerned about the safety of patients in the hospital, especially regarding the transmission of pathogens. She knows that the most common means of transmission of pathogens in this environment is caused by which of the following?
|A.||Contaminated blood products|
|C.||Insufficient hand hygiene|
- A registered nurse works in a small rural health clinic. He is explaining to a new mother the need to have her infant immunized. Which of the following is the best explanation for why she should immunize her child?
|A.||“Immunization reduces or prevents the transmission of disease.”|
|B.||“It is against the law not to immunize your child.”|
|C.||“Immunization will keep your child well.”|
|D.||“Your child may get sick from the immunization, but it will keep him from getting the disease.”|
- A student nurse is giving anticipatory guidance to the mother of an 18-month-old child. The student nurse is focusing on providing a safe environment for the child. Which of the following is the best statement regarding childhood safety?
|A.||“Whooping cough is the number one cause of death in children older than 1 year old.”|
|B.||“The majority of deaths in children between the ages of 1 and 3 years old are caused by contagious diseases.”|
|C.||“Injuries to children older than 1 year old cause more death than all diseases combined.”|
|D.||“Measles causes more deaths in children younger than 5 years old than all other diseases combined.”|
- The father of a 13-year-old boy is concerned because his son wants to hang out with friends all the time and has asked his father for permission to get his ear pierced because all his friends have earrings. What is the best response from the nurse?
|A.||“I think you need to seek counseling for your son.”|
|B.||“This is just a phase that will quickly pass.”|
|C.||“Your son needs to find new friends.”|
|D.||“Your son’s behavior is normal; he is trying to assert his independence.”|
- Edith is the mother of a 16-year-old who is being seen in the emergency department for a minor injury when he was involved in a motor vehicle accident. Edith told the nurse assessing her son that during the past 3 months he has been increasingly difficult to get along with and has been spending most of his time in his room. Which of the following topics is most important for the nurse to discuss with Edith?
|A.||Accident prevention measures|
|B.||Enrolling her son in a defensive driving course|
|C.||The possibility of substance abuse|
|D.||The importance of automobile insurance|
- Mrs. Unger is a 36-year-old bank executive who was recently promoted to vice president. She and her husband have two school-age children. Recently Mrs. Unger has been experiencing abdominal pain and diarrhea. She is currently at a clinic where Thomas, a registered nurse, has worked since graduating from nursing school. As Thomas is assessing Mrs. Unger, she tells him that her family will be moving to another state because of her promotion and that her children are upset about leaving their friends. Thomas is planning care for Mrs. Unger and decides that which of the following is a priority for patient teaching?
|A.||Providing growth and development information about the school-age child|
|B.||Recommending a gastroenterologist|
|C.||Discussing potential fluid volume deficit related to diarrhea|
|D.||Discussing how a high level of stress can cause illness|
- Dr. Martin is an 85-year-old retired physician who has recently been prescribed a new medication by his health care provider for a complication related to diabetes. He now takes 13 different mediations daily. A student nurse who is seeing Dr. Martin during her community health clinical rotation prioritizes her assessment. Which of the following is most important to assess?
|A.||Altered mental status|
|B.||Potential for falls|
|D.||Medication side effects|
- A senior nursing student is undergoing her community health clinical rotation. One of the clients who she will see is a 53-year-old grandmother who has recently assumed custody of her daughter’s two young children. Regarding the children’s welfare, which of the following is most important for the nursing student to assess on this visit?
|A.||The patient’s financial ability to care for two young children|
|B.||The patient’s knowledge of safety precautions for young children|
|C.||The patient’s emotional stability|
|D.||The patient’s feelings regarding taking on this responsibility|
- A 66-year-old patient in an acute care hospital who underwent surgery for an abdominal aneurysm developed a urinary tract infection 3 days after placement of a Foley catheter. The nurse believes that this is a reportable incident, and which of the following will happen as a result?
|A.||Medicare will be denied to the patient.|
|B.||The hospital may lose all Medicare funding.|
|C.||Nothing; it is not a reportable incident.|
|D.||Medicare will not reimburse the hospital for her care.|
- A student nurse is concerned because a patient is weak after abdominal surgery. Which of the following should she do to ensure that one of the eight preventable conditions identified by the Center for Medicare and Medicaid does not occur?
|A.||Use the “rights” of medication administration.|
|B.||Provide frequent opportunities to use the bathroom.|
|C.||Complete thorough documentation.|
|D.||Complete discharge teaching as quickly as possible.|
- A 5-year-old child was admitted to the pediatric unit of the hospital with a high fever of unknown origin. Because of his illness, his nurse is concerned about a patient-inherent accident. Which of the following is the best way to prevent this from happening?
|A.||Keep all electric receptacles covered in the patient’s room.|
|B.||Clean up patient spills as they occur.|
|C.||Pad all bed side rails.|
|D.||Do not allow the child in the playroom.|
- Stanley is a nurse who works in busy outpatient surgery center. He works in the patient admissions area and starts multiple IVs each day. One of the surgeons who works at the center orders a different type of IV fluid than the rest of the surgeons. What should Stanley be most concerned about in this situation?
|B.||Potential patient fluid overload|
|D.||Potential electrolyte imbalance|
- A student nurse is working for the medical unit of her local hospital. One of the IV pumps on the unit has been malfunctioning and was placed outside a patient room until it could be repaired. To prevent an equipment-related accident from occurring, which of the following should be done?
|A.||Tag the pump and remove it from the area.|
|B.||Initiate a work order on the pump.|
|C.||Clean the pump and put it in the equipment closet.|
|D.||Call the pump manufacturer.|
- Aaron is a registered nurse who works on the surgical unit of a large urban hospital. He is responsible for the care of six postoperative patients on his shift. Kaleigh is a nursing assistive personnel who is working with Aaron. One of the patients that Aaron is responsible for, Mr. Johnson, is a 56-year-old patient who underwent surgery for a bowel obstruction yesterday. Mr. Johnson is confused this shift and has tried to climb out of bed on his own several times. Aaron is considering options to prevent Mr. Johnson from harming himself. Assuming it is within his organization’s policy, which of the following is most appropriate for Aaron to delegate to Kaleigh?
|A.||Assessing Mr. Johnson for appropriateness of restraints|
|B.||Calling the physician for an order for a restraint alternative|
|C.||Discussing the need for restraints with Mr. Johnson|
- A student nurse has been asked by the registered nurse with whom she is working to apply wrist restraints to a patient who is confused and is trying to remove her endotracheal tube. The student nurse knows that it is important to tie the restraints to which part of the bed?
|B.||Part that moves up and down with the patient|
- A nursing student is in her senior year of nursing school. She is caring for three patients for a busy surgical unit. One of the patients is confused and has been restrained to prevent him from injuring himself. Which of the following is a priority as she plans her care for the shift?
|A.||Calling the physician for an order for a chemical restraint|
|B.||Requesting restraint alternatives from the physician for her patient who is restrained|
|C.||Removing the restraints on the patient at least every 2 hours|
|D.||Checking on the restrained patient last because he cannot get out of bed|
- A nurse for a busy medical unit mistakenly administers a wrong medication to a patient. After assessing this error, the nurse classifies the error as a(n):
|D.||accident related to time management.|
- A newly admitted older adult patient was found wandering in the hallways in the past two nights. What is the most appropriate nursing intervention to prevent a fall by this patient?
|A.||Reassigning the patient to a room closer to the nursing station|
|B.||Using an electronic monitor that sounds an alarm when the patient reaches a near-vertical position|
|C.||Having the night shift raise two or four side rails|
|D.||Placing a loose vest type of restraint on the patient during the nighttime hours of sleep|
- A 3-year-old child is ready to be discharged home to a young single parent. When conducting a home safety assessment with the child’s mother, the most important safety issue for the nurse to identify includes information about the:
|A.||stability of the neighborhood.|
|B.||reasons for outbursts in behavior.|
|C.||storage of cleaning supplies in the house.|
|D.||child’s use of safety equipment when riding or skating.|
- A pediatric nurse is caring for the fourth of five children in one family. The nurse identifies that the parents need additional safety teaching when the mother mentions that:
|A.||a 2-year-old can safely sit in the front seat of a car.|
|B.||teenagers need to practice safe sex.|
|C.||children need to wear a helmet and safety pads when in-line skating.|
|D.||children need to learn to swim even if parents do not have a swimming pool.|
- A fire erupts after a patient drops a cigarette in a hospital waste receptacle in the bathroom. The nurse’s first response is to:
|A.||report the fire.|
|B.||attempt to extinguish the fire.|
|C.||assist the patient to a safe area.|
|D.||close the door to contain the fire.|
- A physician or health care provider orders that a confused and disoriented patient be placed in a full hand restraint because of excessive scratching of skin. The nurse acknowledges that:
|A.||restraints are used on an as-needed basis.|
|B.||no orders or patient consents are needed.|
|C.||restraints must be removed on a regular basis to allow for skin assessment, toileting, and nutrition.|
|D.||an order for restraints may be used indefinitely until the patient no longer needs to be restrained.|
- A patient in the intensive care unit requires mechanical ventilation, a wound V.A.C. system, patient-controlled analgesia, and an intravenous infusion device. Safety precautions a nurse must use in the health care setting include:
|A.||using two-pronged plugs.|
|B.||never operating equipment without previous instruction.|
|C.||always unplugging equipment when moving the patient.|
|D.||never using equipment without having another nurse assist.|
- A nurse is giving injections at an immunization clinic. A patient asks why immunizations are necessary. The nurse informs the patient that after getting an immunization, resistance to an infectious disease is:
- A 72-year-old patient has just undergone an abdominal aortic aneurysm repair. The patient is pulling at the Foley catheter, nasogastric tube, central line, and abdominal dressing. After applying an extremity restraint the nurse needs to assess which of the following? Select all that apply.
|B.||Physician’s or health care provider’s orders|
|C.||Complaints made by the patient|
|D.||Skin and neurovascular status|
- A group of teenagers is attending a preparation class for baby-sitters. The nurse knows that a participant understands safety issues when the participant states which of the following? Select all that apply.
|A.||“Fire is a cause of unintentional death.”|
|B.||“Bacterial food contamination cannot be controlled.”|
|C.||“There should be a working smoke detector in the house.”|
|D.||“Temperature changes in the home do not affect the child’s safety.”|
Potter: Basic Nursing, 7th Edition
Chapter 28: Hygiene
- Brenda is a student nurse who is working on a long-term rehabilitation unit. She is providing care for Mrs. Reynolds, a 46-year-old woman who was the victim of a violent crime and suffered a head injury. Mrs. Reynolds has an endotracheal tube which is secured with tape. The tape is crusted with dried secretions. Brenda is has been asked to provide personal hygiene for Mrs. Reynolds and needs to replace the tape. What is the best way for Brenda to remove the tape?
|A.||Soak it with warm moist washcloths.|
|B.||Pull it gently away from the skin.|
|C.||Saturate it with denatured alcohol.|
|D.||Soak it with adhesive remover.|
- Margaret is a student nurse caring for Mr. Harrison, a 56-year-old patient with acquired immunodeficiency syndrome (AIDS). Margaret is providing oral care for Mr. Harrison and notes that his gums are reddened and bleed easily. She knows that this is a sign of what condition?
- Amber is a nursing student who works for a medical unit in the hospital. One of her job duties as a student nurse is to bathe patients. One of the patients she is responsible for, Mrs. Jones, is a 79-year-old patient with diabetes with fragile skin. Which of the following will most likely not cause Mrs. Jones to experience impaired skin integrity?
|B.||Inadequate fluid and nutrition|
|C.||Turning and repositioning|
|D.||Use of superfatted soap|
- Meredith is a 45-year-old woman with diabetes who has been hospitalized with diabetic ketoacidosis. Jasmine is a nursing student caring for Meredith. Which of the following is most important for Jasmine to assess as she bathes Meredith?
|B.||Condition of teeth|
|C.||Sensation to the foot|
|D.||Skin folds for dirt|
- Michele is a nursing student who is working on a postsurgical unit. She will be assisting patients with personal hygiene and plans to provide a back rub to each of her patients because research demonstrates that it enhances patient comfort and relaxation. On which of the following patients is effleurage contraindicated?
|A.||56-year-old patient with colon resection|
|B.||45-year-old patient with cardiac bypass|
|C.||67-year-old patient with appendectomy|
|D.||24-year-old patient with abdominal hysterectomy|
- Janice is a nurse who works for a pediatric clinic. She is preparing a 13-year-old patient with strep throat for the health care provider. Which of the following is the most important patient teaching information to prevent re-infection?
|A.||“Replace your toothbrush.”|
|B.||“Floss thoroughly after each meal.”|
|C.||“Change your bed sheets.”|
|D.||“Gargle with antiseptic mouthwash.”|
- Micah is a nursing assistive personnel who has been delegated the task of making Mrs. Keller’s bed. Micah has not cared for Mrs. Keller in the past and is not sure how much linen is needed for a complete bed change. She miscalculated the amount of linen needed and took more than needed. What is the best thing for her to do with the unused linen?
|A.||Replace it in the linen closet.|
|B.||Leave it in the room on the bedside table.|
|C.||Use it in another patient’s room.|
|D.||Place it in a laundry bag to be laundered.|
- Jamie is a student nurse who is bathing Mrs. Schmitt, a 47-year-old patient with right lower lobe pneumonia. Jamie is concerned with maintaining Mrs. Schmitt’s dignity, warmth and safety. Which of the following is most important for Jamie to do when bathing her patient to maintain Mrs. Schmitt’s safety?
|A.||Use superfatted soap.|
|B.||Wash from cleanest to less clean.|
|C.||Use gloves when washing her patient’s face.|
|D.||Keep the bed in high position during the bath.|
- Yolanda is a student nurse who is caring for four patients in her senior clinical rotation. She is preparing to bathe her patients and plans to shampoo their hair. On which of her patients will she need a health care provider’s order to shampoo the hair?
|A.||56-year-old man with diabetic ketoacidosis|
|B.||45-year-old woman with a neck injury|
|C.||34-year-old man with facial laceration|
|D.||67-year-old woman with cardiac bypass surgery|
- Thomas is a nursing student caring for Mrs. Jennings, a 64-year-old patient who is hospitalized after knee replacement surgery. As Thomas prepares Mrs. Jennings’ personal care items for her, she shares that she has a lot of plaque formation between professional teeth cleanings. Thomas knows that which of the following foods will help reduce plaque formation?
|A.||Green leafy vegetables|
|B.||Whole grain breads|
- The physician or health care provider orders meticulous foot care on a patient with diabetes. The best rationale for the nurse to assess the patient for complications is:
|A.||poor hygienic practices in patients with diabetes.|
|B.||vascular changes, which reduces circulation.|
|C.||the aging process, which causes skin breakdown and ulceration.|
|D.||limited joint range of motion, which makes caring for feet difficult.|
- An unconscious patient requires mouth care every 2 hours. Before attempting mouth care, the nurse should first:
|A.||assess the patient for a gag reflex.|
|B.||position the patient in a prone position.|
|C.||have an operational suction machine nearby.|
|D.||retract the upper and lower teeth with a padded tongue blade.|
- A patient requires toenail care. While the nurse performs nail care, the patient is instructed to always:
|A.||use a file to trim the nails straight across.|
|B.||apply a hot water bottle to the feet before foot care to soften the tissues.|
|C.||apply over-the-counter preparations to any foot fungus or disease.|
|D.||apply moist wet-to-dry dressing on any cuts and cover with socks.|
- An adolescent visits the health clinic for advice regarding acne. The nurse tells this patient that to deal with the increased oil production he should:
|A.||use an over-the-counter preparation.|
|B.||use shaving cream before shaving facial hair.|
|C.||wash his face and hair daily with soap and hot water.|
|D.||use a moisturizer with a sunscreen every morning.|
- Older adult patients produce less sebum and perspire less than younger patients. Therefore when providing personal hygiene the nurse should:
|A.||use hot water and regular soap.|
|B.||use plain water and a soft towel.|
|C.||provide a total bed bath every day.|
|D.||use warm water and a mild cleansing agent.|
- A nurse is floated to another unit. One male patient is non–English speaking and unable to answer questions. When preparing to bathe this patient the nurse needs to remember:
|A.||to use soap and water on all types of skin.|
|B.||that cultural heritage influences hygiene practices.|
|C.||to shave facial hair to make the patient more presentable.|
|D.||that all patients need to be bathed daily to decrease health care-associated infection rate.|
- A bedridden patient with long hair may experience problems with matting. The most appropriate nursing action includes:
|A.||cutting the matted hair away.|
|B.||braiding the hair to reduce the tangles.|
|C.||using a thick, commercial product to grease the hair.|
|D.||keeping the hair dry by applying powder every morning.|
- A newly admitted patient wears contact lenses. An assistive personnel asks the nurse if contact lenses need special attention and why. The nurse informs the assistive personnel that nonextended-wear contacts left in the eyes for an extended period of time can cause ____________________.
Potter: Basic Nursing, 7th Edition
Chapter 29: Oxygenation
- Becky is a nursing student who is completing her clinical rotation on a pulmonary unit. She is documenting her patient assessment. Which of the following best describes the movement of air in and out of the lungs?
- Joan is a nursing student who has been studying the cardiopulmonary system. She has been explaining to a patient with chronic obstructive lung disease about how the gasses in the lungs move between the airspaces and the bloodstream. This is best described as which of the following?
- The exchange of oxygen and carbon dioxide during cellular metabolism is best described as:
- When giving CPR, Amelia is artificially causing the heart to pump blood into and out of the lungs to the body’s organs. This movement of oxygenated blood is best described as which of the following?
- Ginny is a student nurse caring for Harry, a 49-year-old patient, who is experiencing shortness of breath. About which of the following laboratory tests should Ginny be most concerned?
|B.||White blood cell count|
- Karen is a nurse caring for a 67-year-old patient with chronic obstructive pulmonary disease (COPD). As Karen begins her head to toe assessment of the patient, she finds that his pulse oximetry reading is 89% on room air. What is Karen’s first priority?
|A.||Administering oxygen immediately|
|B.||Calling the physician for an order for oxygen|
|C.||Assisting the patient into a recumbent position|
|D.||Determining the patient’s normal pulse oximetry reading|
- Wesley is a 36-year-old patient with meningitis. He has a fever of 102.3° F. Wesley’s wife is concerned because he is “breathing fast.” Upon assessing Wesley, the nurse notes a respiratory rate of 20. What is the best explanation for the rapid respiratory rate that the nurse can give Wesley’s wife?
|A.||“He is most likely anxious because he is in the hospital.”|
|B.||“His fever has increased his metabolic rate and is causing him to breathe faster.”|
|C.||“He is hyperventilating because he needs more oxygen.”|
|D.||“He has an acid-base imbalance, which is causing him to hyperventilate.”|
- What is the best indicator the nurse can use to determine a patient’s blood flow adequacy?
- Nancy is a student nurse working on a cardiac unit. Randy, a 54-year-old patient who was admitted with bradycardia, tells her that he is confused about what the doctor told him regarding the electrical system in his heart. What is Nancy’s best response?
|A.||“The sinoatrial node is the ‘pacemaker’ of your heart.”|
|B.||“Myocardial contractility determines your heart rate.”|
|C.||“The atrioventricular node is the ‘pacemaker’ of your heart.”|
|D.||“The ventricular Purkinje network determines your heart rate.”|
- Oscar is a 67-year-old patient who experienced a myocardial infarction. He asks the nurse why his chest hurt when he had his heart attack. What is the best response from the nurse?
|A.||“One of your heart valves wasn’t working properly and caused an obstructed blood flow.”|
|B.||“One of your coronary arteries was blocked, and your heart muscle wasn’t able to get enough blood.”|
|C.||“Your heart muscle was deprived of oxygen, which caused chest pain.”|
|D.||“The heart muscle is sensitive to changes in electrical conduction.”|
- Mary is a 35-year-old patient who recently returned to the surgical unit after surgery to remove an abdominal tumor. As the nurse performs a postsurgical assessment, she discovers that Mary’s blood pressure is 90/54, heart rate is 94, and respiratory rate is 22. Mary’s nurse should be most concerned with which of the following?
|B.||Left-sided heart failure|
|C.||Right-sided heart failure|
- Jane and Jerry are the parents of Herman, a premature infant who was delivered at 31-weeks’ gestation. Yolanda, the nursery nurse, continues to provide patient teaching to Jane and Jerry as Herman is expected to be discharged from the hospital within the next few days. Which of the following is most important to stress to the parents in terms of Herman’s respiratory health?
|A.||“You will need to limit Herman’s exposure to crowds of people.”|
|B.||“You need to make sure that his car seat is facing backwards in the backseat of your car.”|
|C.||“You will need to make a follow-up appointment with the health care provider for Herman to be seen next week.”|
|D.||“You must sterilize all his bottles for the first 6 months.”|
- Esther is the mother of a 3-month-old infant who is being seen for a well-child check at the pediatric clinic. The nurse is spending some time with her with anticipatory guidance about the infant’s growth and development. One of the topics that the nurse has chosen to address in this session is the risk for airway obstruction. What is the main reason that the nurse has chosen this topic?
|A.||Infants can have severe allergic reactions to food as it is introduced.|
|B.||Infants are prone to lower airway infections that can become obstructive.|
|C.||Infants have a tendency to place foreign objects in their mouths.|
|D.||Infants can have airway obstruction from excessive drooling associated with teething.|
- Maggie is 7 months pregnant with her first child. She is 37 years old and waited to start a family until she felt established in her career. She is visiting the health care provider for her scheduled prenatal check up and tells the nurse that she is short of breath and fatigued. What is the best response from the nurse?
|A.||“You should have let us know immediately instead of waiting until your appointment.”|
|B.||“I’ll make a note of it on your chart.”|
|C.||“That is normal; your uterus is pushing on your diaphragm, making it more difficult to breathe.”|
|D.||“The health care provider should have warned you about this on your last visit.”|
- Mrs. Stone is an 87-year-old patient who is at the clinic for her annual check-up. She tells the nurse that she noticed her blood pressure is higher than it was when she was younger. She asks the nurse why this would happen. What is the nurse’s best response?
|A.||“It’s probably due to your age.”|
|B.||“I think you need to discuss this with your health care provider.”|
|C.||“As we age, our blood vessels become less elastic, which causes higher blood pressure.”|
|D.||“I don’t think it’s anything to worry about.”|
- Barbara is a healthy 33-year-old mother of three active boys. She asks Janie, a student nurse, how she can increase her energy level. What is Janie’s best response?
|A.||“You should see your health care provider.”|
|B.||“Daily exercise has been shown to increase a person’s energy level.”|
|C.||“Energy drinks are a good alternative when you can’t exercise.”|
|D.||“Increasing your protein intake will increase your energy level.”|
- Sarah is a student nurse doing her clinical rotation on a medical unit. She is caring for Mr. Harris, a 73-year-old patient with chronic obstructive pulmonary disease (COPD). Mrs. Harris tells Sarah that she doesn’t understand why Mr. Harris is losing weight because he eats the same amount of food that she does, and she is very physically active. What is Sarah’s best response to this statement?
|A.||“Maybe Mr. Harris has a higher metabolic rate than you.”|
|B.||“It doesn’t seem fair that some people can lose weight so easily.”|
|C.||“COPD burns a lot of calories because it takes a lot of energy to breathe.”|
|D.||“You need to discuss this with the health care provider.”|
- Mark is a 22-year-old college student who smokes. Mark attends one of his classes with Chad, a nursing student. One day on the way to class, Mark asked Chad if smoking really is related to lung cancer. Chad told Mark that the risk for lung cancer for smokers than for nonsmokers is _____ times greater.
- Frank is a nursing student who is working on a surgical unit. He is caring for a patient who has recently undergone surgery to remove stomach cancer. In addition to the physiological stress this patient has undergone, he has also had to deal with the psychological stress of finding out that the cancer has metastasized to his liver. Frank would expect to see what physiological change in response to stress?
|A.||Decreased heart rate|
|B.||Increased depth of respiration|
|C.||Decreased respiratory rate|
|D.||Decreased cardiac output|
- Margaret is a 47-year-old woman with diabetes who called the clinic complaining of epigastric pain and shortness of breath. Debbie, the nurse, answered Margaret’s call. What is her best response to Margaret?
|A.||“We don’t have an opening until next week.”|
|B.||“Does the pain get worse with activity?”|
|C.||“Have you taken any antacids yet?”|
|D.||“Hang up and call 9-1-1.”|
- Brandy is a 57-year-old patient with COPD. She has been admitted to the pulmonary unit of the hospital with right lower lobe pneumonia. Diane is the nurse caring for Brandy and notes that she has a respiration of 18 with retractions. Brandy complains of dyspnea. Diane knows that this is a clinical sign of which of the following?
- Bernice is a 34-year-old nurse who works for a home health agency. She had her annual TB test administered 56 hours ago. The injection site is very red and flat. The certified nurse who is reading Bernice’s test should do which of the following?
|A.||Advise Bernice not to return to work.|
|B.||Request a chest x-ray.|
|C.||Document the results as a negative reaction.|
|D.||Measure the area in millimeters and document the reaction.|
- Joan is formulating a nursing care plan for a patient with chronic obstructive pulmonary disease (COPD). The care plan is directed toward meeting the potential oxygenation needs of her patient. Which of the following examples would be the best way for Joan to write a goal for her care plan?
|A.||“The patient will have less pain.”|
|B.||“The patient will be able to breathe better.”|
|C.||“The patient’s pulse oximetry reading will remain greater than 90%.”|
|D.||“The patient’s lab results will be normal.”|
- Blair is a nurse who works for a pulmonary unit. Together she and Sheila, a nursing assistive personnel (NAP), are caring for six patients on her shift. Sheila is relatively new, but has been checked on basic competencies. Which of the following tasks would be most appropriate for Blair to delegate to Sheila?
|A.||Taking vital signs on a 56-year-old man with dyspnea|
|B.||Suctioning a patient with hemoptysis|
|C.||Encouraging a postoperative patient to use the incentive spirometer|
|D.||Performing chest percussion on a patient with atelectasis|
- Ellen is a student nurse caring for a patient with a chest tube. Ellen has been asked to ambulate the patient. Which of the following is the most appropriate action in regards to caring for a patient with a chest tube?
|A.||Clamping the chest tube prior to ambulating|
|B.||Keeping the drainage device above the chest tube insertion site|
|C.||Draining all fluid from the drainage device before ambulating|
|D.||Maintaining drainage device below the patient’s chest|
- A new graduate is being oriented to work for an intensive care unit. The hemodynamic data indicate that the patient has a decreased preload. The nurse demonstrates that she understands the concept of preload when she states that preload is interpreted as:
|A.||a decreased left ventricular output.|
|B.||the amount of ventricular filling at rest.|
|C.||a decrease in the length of time for cardiac conduction.|
|D.||decreased resistance to the cardiac ejection volume.|
- A patient with pulmonary congestion needs to cough to clear secretions. The nurse instructs the patient to inhale and perform a series of coughs during exhalation. The nurse identifies this type of cough as:
- The nurse is evaluating a post-thoracotomy patient who has a chest tube. To properly maintain chest tube function the nurse’s best action is to:
|A.||strip the tube every hour to maintain drainage.|
|B.||place the device below the patient’s chest.|
|C.||double clamp the tubes except during assessments.|
|D.||remove the tubing from the drainage device to check for proper suctioning.|
- A patient presents with an acute myocardial infarction that results in right ventricular damage. The nurse needs to assess the patient for complications, which include:
|A.||decreased cardiac output.|
|B.||jugular neck vein distention.|
|C.||increased myocardial perfusion.|
|D.||hyperventilation related to pain.|
- A patient complains of chest pain. The nurse is attempting to assess the pain to differentiate the pain as cardiac, respiratory, or gastrointestinal. The nurse can properly identify the pain as cardiac in origin when the nurse states that cardiac pain:
|A.||does not occur with respiratory variations.|
|B.||is peripheral and may radiate to the scapular areas.|
|C.||is aggravated by inspiratory movements.|
|D.||is nonradiating and occurs during inspiration.|
- A patient with a tracheostomy is experiencing thick and tenacious secretions. To maintain this patient’s airway, what is the most appropriate action for the nurse?
- On entering the room, a nurse finds the patient sitting upright in bed with his upper torso resting on the over-bed table. The nurse assesses that this patient is experiencing respiratory distress. Contributing factors may include which of the following? Select all that apply.
|C.||Decreased metabolic rate|
- An older adult patient frequents the health care clinic complaining of various cardiopulmonary symptoms. The nurse can assist this patient by suggesting this patient do which of the following? Select all that apply.
|B.||Decreasing exercise regimen|
|C.||Adding high-cholesterol items to diet|
|D.||Going on a weight reduction program|
- An adult has just collapsed at the grocery store. After completing the “ABCs” this person is found to be pulseless and requires CPR. When resuscitating this person, which of the following actions are required? Select all that apply.
|B.||Using an AED|
|D.||Performing 15 compressions and two breaths for two-rescuer CPR|
- The assistive personnel reports that an older patient is complaining of shortness of breath and palpitations. The nurse connects the patient to an electrocardiogram monitor and analyzes the rhythm with normal P wave and normal QRS and T waves. The rate is 116 beats per minute and regular. The nurse identifies this rhythm as ____________________.
Potter: Basic Nursing, 7th Edition
Chapter 30: Sleep
- Alex is a college student who is working in northern Alaska during the summer. He has noticed that he has had difficulty sleeping since he moved north. He discusses this with his aunt, who is a nurse. She suspects that his sleep disturbance is most likely due to the:
|A.||stress of his new job|
|B.||increased daylight hours in Northern Alaska.|
|C.||physical demands of his new job.|
|D.||change in diet that he has experienced.|
- Mary is a student nurse who works in a pediatric clinic. One of the patients in the clinic is a 16-year-old boy whose mother is concerned about his lack of sleep. She states that he “goes to school, works at a part-time job until 10 PM, and then stays up doing homework until after midnight. I am worried that he is not getting enough sleep.” What is Mary’s best response to the patient and his mother?
|A.||“I don’t get enough sleep either; I spend most of my time studying.”|
|B.||“You need to discuss this with the health care provider.”|
|C.||“Sleep deprivation can cause you to get sick.”|
|D.||“High school is a tough time in life, but I’m sure your son will be fine.”|
- Judy is a nursing student caring for Jackie, an 18-year-old college student who is hospitalized with a ruptured appendix. Jackie states that she never dreams any more. Judy tells Jackie that everyone dreams, but most people forget about them upon awakening. She tells Jackie that the best way to remember her dreams is to:
|A.||eat spicy food before going to sleep.|
|B.||avoid caffeine in the afternoon.|
|C.||consciously think about her dreams upon awakening.|
|D.||sleep at least 8 hours before awakening.|
- Jenny is a new mother and has brought in Nicholas, her week-old infant, to the health care provider for his one-week well baby check. She is breast-feeding and has only been sleeping a couple of hours at a time during the night between feedings. She asks the nurse, “When can I expect Nicholas to sleep through the night?” What is the nurse’s best response?
|A.||“Some children don’t sleep through the night until they are 2 years old.”|
|B.||“Most children begin to sleep through the night around 3 months.”|
|C.||“As long as you are breast-feeding he will be awake to nurse every 3 to 4 hours.”|
|D.||“Are you feeling tired?”|
- Randy is a single parent of 6-year-old Brianna. She is being seen at the clinic for a well-child check-up. Randy tells the nurse that Brianna needs her sleep, but she is having difficulty getting to sleep at night. He asks the nurse if she has any suggestions. What is the nurse’s best response?
|A.||“You should play an active game with her like basketball to wear her out.”|
|B.||“It would be a good idea to save homework until right before bedtime.”|
|C.||“Quiet activities like reading sometimes help to settle down children her age.”|
|D.||“You could try to delay dinner time until later to help make her sleepy.”|
- George is a 67-year-old farmer who is at the clinic because he has been sleepy during the day. He recently fell asleep while driving his tractor and drove it into a ditch; luckily he wasn’t injured. Mary, the nurse at the clinic, knows that as people age, they report more problems with sleep. What is the percentage of people over the age of 65 who report sleeping difficulties?
- Bernice is a 73-year-old grandmother. She complains to her daughter Kate, who is a nurse, about waking up early and not being able to return to sleep. On investigation, Kate finds that her mother does not go to bed until after the evening news. Kate suspects that her mother isn’t getting enough sleep due to “phase advance.” What is the best advice Kate can give her mother to ensure that she gets enough sleep at night?
|A.||Take an afternoon nap.|
|B.||Go to bed earlier.|
|C.||Go to bed later.|
|D.||Take a sleeping aid.|
- Samantha is a nurse manager for a busy medical unit in an acute care hospital. She noticed that in the past few weeks that there has been a trend of complaints regarding the restful environment of her unit in the patient satisfaction reports. She discusses this issue with her staff, and they decide that the best thing to do is which of the following?
|A.||Keeping all patient doors shut|
|B.||Clustering nursing activities at night|
|C.||Turning off all alarms after 2200|
|D.||Strictly enforcing the visitation policy|
- Malcolm is a 57-year-old farmer who has recently begun having difficulty falling asleep. His nurse asks him about recent changes in his lifestyle. Which of the following lifestyle changes is probably not responsible for the change in his sleeping pattern?
|A.||Change in mealtime|
|B.||Recent weight loss|
|C.||Change in bowel habits|
- Priscilla is a 63-year-old patient who is suffering from a sleep disorder. When visiting the clinic, a nurse takes Pricilla’s sleep history and notes that she has a deviated septum. The nurse knows that this structural abnormality predisposes Priscilla to which of the following?
|C.||Obstructive sleep apnea|
- Jane’s health care provider has diagnosed her as having a parasomnia. She asks the nurse to explain to her what that means. What is the best explanation?
|A.||A person is unable to breathe and sleep at the same time|
|B.||A sleep disorder that produces abnormal sleep movements|
|C.||A rare dysfunction of the mechanism that regulates sleep and wake states|
|D.||A sudden muscle weakness during intense emotions|
- Which of the following data is most important to assess if a patient is receiving sufficient sleep?
|A.||Number of hours of sleep each night|
|C.||Whether the patient feels rested|
|D.||Number of times the patient awakens during sleep|
- Becky is a student nurse who is admitting Mrs. Beasley to the surgical unit of the hospital for a bilateral oophorectomy. Which of the following statements from Mrs. Beasley requires additional follow-up by Becky?
|A.||“I understand that all patients get a sleeping pill at night.”|
|B.||“I sleep better with my door closed at night.”|
|C.||“I usually go to bed after the late evening news.”|
|D.||“I like a glass of milk before going to bed.”|
- Ralph is a student nurse who is admitting Mr. Thomas to the hospital. Mr. Thomas has told Ralph that he has a sleep problem. For Ralph to better understand the problem, he asks additional questions. Which of the following questions will help Ralph understand the severity of Mr. Thomas’s sleep problem?
|A.||“How long does it take you to fall asleep?”|
|B.||“Tell me why you think you have a sleep problem.”|
|C.||“Have you been told that you snore loudly?”|
|D.||“When did you notice the problem?”|
- John is a 66-year-old man who recently came to the clinic because he is having difficulty sleeping. Kevin, the nurse at the clinic, asked John and his partner to keep a sleep-wake diary. For how long will John and his partner will need to keep the diary?
- Randy is a 45-year-old obese patient who has been scheduled for cardiac bypass surgery. Rachel is a student nurse who is preparing him for surgery. One of the questions that she asks him is, “Do you have a history of sleep apnea?” This is important to know before surgery because patients with sleep apnea:
|A.||are prone to snore after surgery and require a private room.|
|B.||who receive general anesthesia have a greater risk for airway obstruction.|
|C.||generally need additional pain medication.|
|D.||usually require sleep aids to provide more restful sleep.|
- Brenda is a student nurse who is caring for an elderly patient with a sleeping disorder. She is formulating a care plan for this patient and has determined that the goal will be that “the patient establishes a healthy sleep pattern.” Which of the following is the best example of a measurable outcome to meet her goal?
|A.||The patient will fall asleep more easily.|
|B.||The patient will sleep longer throughout the night.|
|C.||The patient will have less than two awakenings throughout the night.|
|D.||The patient will wake up more refreshed in the morning.|
- Jerry is a home health nurse who is assessing Mr. Williams’ home to promote a safe sleeping environment. Which of the following is an unsafe situation in Mr. Williams’ home?
|A.||A small night light in Mr. Williams’ bedroom|
|B.||All clutter removed between the bed and the bathroom|
|C.||Side rails on the bed used to keep Mr. Williams from getting out of bed on his own|
|D.||Small call bell at the bedside for Mr. Williams to alert family members|
- Mr. Bean is a 76-year-old patient who has been hospitalized with pneumonia. He has had some difficulty sleeping since his hospitalization. He would like to avoid taking medication to help him sleep since he has had problems with sleeping pills in the past. Which of the following is the least likely measure to promote sleep?
|A.||Encouraging Mr. Bean to void before bedtime|
|B.||Asking Mr. Bean’s wife to give him a backrub|
|C.||Giving Mr. Bean an extra blanket|
|D.||Providing a warm cup of hot cocoa before bedtime|
- During night shift rounds, the assistive personnel discovers that a patient has a lack of airflow lasting 1 to 2 minutes several times during the shift. The nurse informs the assistive personnel that this condition is known as:
- An older adult widow tells the nurse that he is having problems sleeping at night. He misses his wife. The nurse recognizes this may be one reason for this patient’s problem sleeping. The nurse also recognizes that older patients:
|A.||are difficult to assess.|
|B.||take less time to fall asleep.|
|C.||have a reduced ability to sleep deeply.|
|D.||require more sleep than middle-age adults.|
- A 2-year-old child in the pediatric unit resists going to sleep. To promote sleep the best action for the nurse to take includes:
|A.||eliminating a daytime nap.|
|B.||offering the child a favorite bedtime snack.|
|C.||maintaining the child’s home bedtime routine.|
|D.||allowing the child to sleep longer in the morning.|
- A patient’s vital signs are significantly lower than normal while sleeping. The nurse understands this to be a normal finding when the patient is in what stage of the sleep cycle?
- The nurse encourages a postoperative patient to get adequate amounts of sleep after discharge from the health care facility. When the patient asks why, the nurse responds that sleep:
|A.||restores biological processes.|
|B.||stimulates appetite on waking.|
|C.||produces a mental and physiological calm.|
|D.||produces dreams that stimulate cerebral blood flow.|
- A patient asks the nurse to explain how sleep occurs. The nurse explains to the patient that the physiology of sleep is a complex process. However, in simple terms:
|A.||the circadian sleep rhythm controls sleep.|
|B.||sleep occurs when a person’s basal metabolic rate falls.|
|C.||the control and mechanism of sleep are controlled by lower brain functions.|
|D.||two interrelated, complex mechanisms of the higher brain control wake and sleep cycles.|
- Hospitalized patients often have problems sleeping. A nurse can help promote sleep in a patient by:
|A.||reducing or eliminating the patient’s pain.|
|B.||offering a large meal 1 hour before bedtime.|
|C.||adjusting the room environment to 86° F.|
|D.||disconnecting the patient from all machines from 9 PM until the next morning.|
- A patient arrives at the ambulatory clinic for a normal assessment. The nurse inquires about the patient’s sleep pattern. The patient has a history of sleep pattern disturbances. The nurse evaluates that the patient is sleeping better when the patient states:
|A.||“I don’t take melatonin as frequently.”|
|B.||“I increased my alcohol consumption before bedtime.”|
|C.||“I increased my use of over-the-counter substances.”|
|D.||“I take more daytime power naps.”|
- A student nurse confides to the lead nurse that she is having difficulty sleeping. To help resolve the problem the nurse suggests that the student nurse:
|A.||take an afternoon nap.|
|B.||change her bedtime preparation routines.|
|C.||review activities done before bedtime.|
|D.||go to bed earlier and wake up earlier.|
- A nursing student asks a nurse to differentiate the concepts of rest and sleep. The nurse ascertains that the student understands these concepts when the student states that sleep is ____________________.
- A nurse is caring for a patient who suffers from a sleep pattern disturbance. To promote adequate sleep, what are the most appropriate nursing interventions? Select all that apply.
|A.||Dimming lights in the patient’s room|
|B.||Synchronizing the medication, treatment, and vital signs schedule|
|C.||Encouraging the patient to exercise immediately before going to bed|
|D.||Discussing with the patient the benefits of beginning a long-term nighttime medication regimen|
- A nurse has been temporarily assigned to the night shift. A change in this circadian rhythm may cause which of the following? Select all that apply.
|D.||Increased periods of sleep|
|E.||Variation in body temperature|
- Becky is a student nurse who is working in a health care clinic. She is preparing Mrs. Jennings for her annual check-up with the health care provider. Becky asks Mrs. Jennings if she has any difficulty sleeping, to which Mrs. Jennings replies, “Since my husband passed away last month, I have not been sleeping well at all.” What is the most appropriate intervention for Becky to make? Select all that apply.
|A.||Suggesting that Mrs. Jennings ask the health care provider for a sleeping aid|
|B.||Contacting a pastoral care professional|
|C.||Consulting with a psychiatric clinical nurse specialist|
|D.||Consulting with a clinical psychologist|
Potter: Basic Nursing, 7th Edition
Chapter 31: Pain Management
- Kelly is a 17-year-old paraplegic patient who lost the use of his legs as a result of a spinal cord injury that he suffered when he was involved in a four-wheeler accident. Which of the following is one of the most important topics for patient teaching to prevent him from further injury?
|A.||Reminding him that he can be injured and not feel pain below his waist|
|B.||Suggesting that his parents purchase a motorized wheelchair to prevent arm muscle strain|
|C.||Providing precautions against taking too much pain medication|
|D.||Reminding him to drink plenty of fluids to maintain hydration|
- Nellie is a student nurse who is working for a diabetes unit. Her nurse manager has prepared a very thorough orientation for her, which includes check-offs for taking vital signs. Nellie’s nurse manager has told her that their hospital has adopted the Joint Commission’s pain standard and that they will be assessing five vital signs. Nellie knows that the fifth vital sign is:
|A.||arterial blood gasses.|
- Kevin is a registered nurse who works for the emergency department. He sees a lot of patients who seek services due to pain. One of the things that Kevin learned in nursing school and has been validated in his practice is that pain is:
|A.||caused by a single physiological sensation.|
|B.||due to a specific stimulus.|
|D.||universally the same for everyone.|
- Rhonda has been a registered nurse for more than 20 years. She has had a lot of experience caring for postsurgical patients. When Theresa, a student nurse, asked Rhonda why many of the seasoned nurses working on the surgical unit don’t give their patients the full amount of pain medication ordered by the surgeon, Rhonda replied that the literature shows that many nurses don’t give the full amount of pain medication because they:
|A.||do not believe that the patient is experiencing that much pain.|
|B.||do not want to contribute to pain medication addiction.|
|C.||believe that limiting the amount of pain medication lowers costs.|
|D.||are concerned about drug interactions with pain medication and other postsurgical medications.|
- When a person touches a hot stove, the resulting cellular damage causes a reaction that converts the stimuli into a pain impulse. What is the term for this conversion?
- When a person cuts a finger, nerve impulses travel to the spinal cord along afferent peripheral nerve fibers. What is this process?
- Pain impulses are sent to the brain where the central nervous extracts information regarding location, duration and quality of the pain impulse. What is this process?
- When a person accidentally touches a hot pan, their protective reflex causes them to immediately withdraw their hand from the hot pan. This protective reflex is known as:
- Henry is a 56-year-old patient who has undergone triple cardiac bypass surgery. His incisions are healing well, but he is complaining of pain at the incision sites on his legs. The nurse knows that this is which of the following?
|B.||Chronic noncancer pain|
|C.||Chronic pain exacerbation|
- Janie is a student nurse who is caring for Mrs. Kinney, a 67-year-old patient with rheumatoid arthritis. Mrs. Kinney states that she has pain, is having difficulty sleeping, and has lost weight over the past 2 months. What is the most important question for Janie to ask Mrs. Kinney?
|A.||“Have you started a new diet?”|
|B.||“Have you ever thought of suicide?”|
|C.||“What are you taking for your pain?”|
|D.||“Do you take naps during the day?”|
- Ellen is a 47-year-old nurse who has been suffering from rheumatoid arthritis (RA). She has been seeing a rheumatologist for the management of her disease. She also uses herbal remedies and seeks acupuncture for pain relief. She reads the latest research regarding RA. This coping style is best described as a(n) ______ loci of control.
- Hank is a student nurse who is assessing the pain of Thomas, a 15-year-old patient with cancer. Hank asks Thomas about precipitating factors, quality, relieving factors, where the pain is, the severity of pain, and the effect of the pain on Thomas. What is the other indicator that Hank should make part of his pain assessment?
|A.||Medications Thomas is taking for pain|
|B.||Timing of the pain|
|C.||Side effects of Thomas’s chemotherapy|
|D.||Thomas’s ability to take oral pain medication|
- A patient has a morphine sulfate epidural catheter in place for postoperative pain control. When the nurse enters the room, the patient complains of pain. The nurse’s first response is to:
|A.||stop the infusion.|
|B.||call the physician or health care provider immediately.|
|C.||ask the patient to describe the pain.|
|D.||speak to the patient in a calming tone to reduce anxiety.|
- A patient in sickle cell crisis states that the pain is lessened when watching television. The patient’s physiological response is best attributed to:
|A.||the perception of pain.|
|C.||a negative protective reflex response.|
|D.||the application of the gate control theory.|
- According to established standards, nurses must frequently assess patients experiencing pain. The most appropriate action for the nurse to take when assessing a patient’s pain is to:
|A.||ask what precipitates pain.|
|B.||question the patient about the location of the pain.|
|C.||offer the patient a pain scale to objectify the patient’s response.|
|D.||use open-ended questions to find out about the patient’s sensations.|
- A young adult has just undergone surgery for repair of a torn left knee anterior cruciate ligament (ACL). When informing the patient of several pain relief interventions, the nurse most appropriately urges the patient to select:
|D.||patient-controlled analgesia pain management.|
- A smiling and cooperative patient complains of severe pain. Nurses caring for patients who report pain need to recognize and avoid common misconceptions and myths about pain. To properly care for patients in pain, nurses need to remember which of the following?
|A.||Chronic pain is psychological in nature.|
|B.||Patients are the best authority of their pain experience.|
|C.||Regular use of narcotic analgesics leads to drug addiction.|
|D.||The amount of tissue damage is reflected in the severity of the pain perceived.|
- A nurse explains the sensation of a needle stick to a patient who needs to have blood drawn. What is this behavioral response to pain?
- A mother suffering from new-onset back pain makes a first-time visit to the pain clinic. The patient informs the nurse that “all of those medications make me feel drugged.” The nurse tells the patient that she may benefit from:
|B.||hiring home care.|
|D.||alternating opioid and nonopioid medications.|
- A terminally ill patient with cancer is experiencing increased pain. Nursing implications used to care for this patient include:
|A.||giving medications as needed.|
|B.||using the World Health Organization three-step approach.|
|C.||using a holistic approach to pain management.|
|D.||holding regular doses to prevent life-threatening side effects.|
- A patient is using patient-controlled analgesia to control postoperative pain. The nurse can evaluate the effectiveness of the medication when the patient’s:
|A.||vital signs have returned to normal baseline.|
|B.||family members indicate the pain has subsided.|
|C.||baseline pain compares with ongoing assessments.|
|D.||body language is incongruent with the report of pain relief.|
- A patient presents to the emergency department with a large leg laceration received in a bicycle accident. The nurse knows that the physician or health care provider chose a local anesthetic because of which of the following? Select all that apply.
|A.||The patient appears very apprehensive.|
|B.||A local anesthetic has very few side effects.|
|C.||The potential for hemorrhage precludes the use of IV anesthesia.|
|D.||The local anesthetic produces temporary loss of sensation by inhibiting nerve conduction.|
Potter: Basic Nursing, 7th Edition
Chapter 32: Nutrition
- Melvin is a 68-year-old man who has high cholesterol. He asks the nurse if he needs to limit all fat in his diet in order to lower his cholesterol. What is the nurse’s best response?
|A.||“You should limit the amount of monounsaturated fats.”|
|B.||“You should limit the amount of unsaturated fatty acids.”|
|C.||“You should limit the amount of saturated fats.”|
|D.||“Your cholesterol shouldn’t be influenced by your diet.”|
- Mary is a nurse caring for five patients on the oncology unit where she works. She is prioritizing her care for the day. One of her concerns is that her patients receive the nutrition that is needed to promote metabolism for energy. Which of the following patients should Mary be most concerned about?
|A.||50-year-old woman with pancreatic cancer|
|B.||38-year-old man with liver cancer|
|C.||67-year-old man with prostate cancer|
|D.||83-year-old woman with colon cancer|
- Emma is a 14-year-old patient with cancer who is concerned about her diet. She asks Rachel, the student nurse, about taking vitamins to supplement her diet. Emma states that she has been reading and doesn’t think her diet alone is providing the UL of vitamins that she needs. What is the best response from Rachel?
|A.||“You should try to get your vitamins from food, rather than a supplement.”|
|B.||“‘UL’ stands for the tolerable upper intake level; you should be trying to achieve the ‘RDA.’”|
|C.||“You should compare your diet to the UL for children, not the UL for adults.”|
|D.||“Vitamins aren’t important as long as you are getting enough calories.”|
- William is a student nurse who is doing his community health rotation. One of his clients is a pregnant teen. William has been teaching his client about infant nutrition. Which of the following statements indicates to William that his client needs additional teaching?
|A.||“Breast milk is all my baby will need for the first 6 months.”|
|B.||“Breast milk should be the major source of nutrition for the first year.”|
|C.||“My baby won’t need as many calories per kilogram as I will.”|
|D.||“Breast-feeding my baby will decrease his chances for food allergies.”|
- Timothy is a nurse who works on a medical unit in the hospital. He admits four patients on his shift. After his nursing assessment, which of his patients should Timothy refer for a nutritional consultation?
|A.||24-year-old patient with dry skin|
|B.||45-year-old patient who has lost 34 pounds over the last year with a weight-loss diet|
|C.||33-year-old patient with dehydration|
|D.||74-year-old patient with urinary incontinence|
- Kelly is a student nurse who is talking with Esther, her 84-year-old neighbor who has asked her what she can do about her intermittent constipation. Which of the following would be the best thing for Kelly to do?
|A.||Ask Esther if she is getting enough fiber in her diet.|
|B.||Ask Esther if she is drinking enough water.|
|C.||Have Esther keep a record of her food intake for 3 days.|
|D.||Ask Esther if she takes laxatives.|
- Karen is a student nurse working for a cardiac unit. She is caring for Mr. Gary, a 65-year-old patient with heart failure. Mr. Gary is on Lasix and a low-sodium diet. Which of the following is the best way for Karen to determine if Mr. Gary is retaining fluid?
|A.||Calculating Mr. Gary’s BMI|
|B.||Calculating Mr. Gary’s IBW|
|C.||Taking serial measures of weight during his hospitalization|
|D.||Measuring all fluid intake|
- Mrs. Parker has been hospitalized after a stroke. Her daughter is helping her to eat her meals because the stroke has left her with dysphagia and right side paralysis. Wendy, the student nurse caring for Mrs. Parker, is concerned about aspiration and discusses this potential complication with Mrs. Parker’s daughter. Wendy knows additional teaching is necessary when Mrs. Parker’s daughter states:
|A.||“I will know when Mom is aspirating her food because she will cough.”|
|B.||“Mom’s gag reflex is not as strong as it once was.”|
|C.||“I need to watch for pocketing food as I feed Mom.”|
|D.||“It takes much longer to feed Mom than it did before the stroke.”|
- Mrs. Williams is a 34-year-old mother who recently delivered her third child. She tells the nurse that her New Year’s resolution is to lose the 15 pounds that she gained with this pregnancy over the next month. Which of the following is the best statement that the nurse can make to help Mrs. Williams achieve her weight loss goal?
|A.||“I don’t think you need to lose the weight; you look fine as you are.”|
|B.||“The weight will come off by itself because you are breast-feeding.”|
|C.||“It took you nine months to gain the weight; give yourself a realistic timeframe to lose it.”|
|D.||“It is easier to lose weight if you have a realistic goal.”|
- Katie wants to lose the 17 pounds that she has gained since entering nursing school. She knows that the most successful long-term weight loss programs:
|A.||are those that get the weight off quickly.|
|B.||include awareness of portion sizes.|
|C.||focus on reducing bad carbohydrates.|
|D.||use purchased premeasured food.|
- Harry is a 45-year-old patient with head trauma who is scheduled for a gastrostomy tube to be inserted. His wife asks the nurse why they can’t just feed him through the IV. What is the nurse’s best response?
|A.||“The gastrostomy tube will allow us to give him oral medications as well as his feedings.”|
|B.||“Research has shown that it is safer for patients and will maintain the function of his gut.”|
|C.||“It will be less expensive in the long run to feed him through a gastrostomy tube than an IV.”|
|D.||“The procedure is uncomplicated, and he will be more content being fed through his stomach.”|
- A patient is receiving enteral tube feedings. When introducing a feeding to this patient, the first thing the nurse needs to do is:
|A.||place the patient in a prone position.|
|B.||irrigate the tube with normal saline.|
|C.||check to see that the tube is in the proper position.|
|D.||introduce a small amount of fluid into the tube before the tube feeding.|
- A new mother is breast-feeding her infant. The nurse asks the mother if she is getting the correct amounts of dietary reference intakes. The nurse knows the mother understands dietary guidelines when she states:
|A.||“I am not concerned about dietary guidelines or a strict diet.”|
|B.||“I am taking the vitamin doses according to the television advertisements.”|
|C.||“I am only taking one multiple vitamin a day and eating whatever I want.”|
|D.||“I am eating the correct amount of food according to the recommended dietary allowances and intakes.”|
- A patient presents to an ambulatory care clinic complaining of a lack of energy and tiredness. One of several assessments the nurse wants to make is a diet history. To perform a home diet history the nurse instructs the patient to keep a journal of:
|A.||all food for the last 5 days.|
|B.||only solid food for 3 days.|
|C.||all food for 3 days, including weekends.|
|D.||only solid food for 3 days, including weekends.|
- A nurse is caring for a patient who is receiving feedings through a gastrostomy tube. The patient experiences abdominal cramping and nausea. The nurse’s best action is to:
|A.||warm the formula.|
|B.||readjust the tube.|
|C.||decrease the administration rate.|
|D.||increase the concentration of the formula.|
- A patient needs diet counseling after a myocardial infarction. To reduce this patient’s cholesterol level, the patient should eat foods that are high in:
|B.||saturated fatty acids.|
|D.||polyunsaturated fatty acids.|
- An older adult patient lives in a third-story apartment. The patient is on a limited income and does not drive. The patient complains of weight loss. During the assessment the nurse knows that when a person’s energy needs exceed nutritional intake the patient:
|C.||suffers from anabolism.|
- A patient is receiving parenteral nutrition (PN). While maintaining PN the nurse’s best action is to:
|A.||begin the infusion at 150 mL/h.|
|B.||maintain a consistent infusion rate.|
|C.||change the infusion tubing on a weekly basis.|
|D.||monitor the laboratory values on a weekly basis.|
- A college student visits the student health center. The student is struggling with finances and proper nutrition. The student has become a vegan. The nurse assesses that the student is deficient in protein intake. The nurse informs the student that an inexpensive source of protein is:
|A.||peas and beans.|
|B.||potatoes and rice.|
|C.||rice and macaroni.|
|D.||apples and oranges.|
- A patient is having a problem with wound healing. The nurse assesses the patient’s tray and finds that only 25% of all meals are eaten. The nurse helps the patient to understand that protein intake is important for what reason? Select all that apply.
|A.||It is essential for body tissue growth.|
|B.||It is essential for tissue maintenance.|
|C.||Essential amino acids can only be obtained from dietary sources.|
|D.||It is essential for repair.|
- A school nurse is presenting a class on nutritional needs to a group of 16-year-old adolescents. When discussing a balanced diet and the reasons for adequate food intake, the nurse explains to this age group the food guide pyramid has what goals? Select all that apply.
|A.||To balance energy expenditure and caloric intake to increase weight gain|
|B.||To promote weight loss and/or maintain weight|
|C.||To decrease the intake of vitamins and minerals|
|D.||To lower chronic disease risks by lowering the intake of fats|
Potter: Basic Nursing, 7th Edition
Chapter 33: Urinary Elimination
- Mrs. Woods is an 80-year-old active widow in very good health. She has made an appointment with her health care provider due to a recent bout with urinary incontinence (UI). Mrs. Woods tells Cheryl, the nurse preparing her, that she has recently become incontinent of urine and thinks it is due to her age. What is he best response from Cheryl?
|A.||“Most older people are incontinent.”|
|B.||“It’s too bad that as we age our bodies start failing us.”|
|C.||“It is a myth that incontinence is part of the aging process.”|
|D.||“At least you made it to 80 before experiencing incontinence.”|
- Ira is a nurse who is discussing catheter care with Mike, a nursing assistive personnel. Ira tells Mike that catheter care is very important in the prevention of urinary tract infections (UTI). Ira cites research that states the percentage of health care–acquired infections associated with indwelling urinary catheters is which of the following?
- Mrs. Thornton is a 56-year-old patient who has recently become postmenopausal. She told the nurse that ever since she had gone through menopause she noticed that she was getting more urinary tract infections. What is the best response from the nurse?
|A.||“As we go through menopause, the lining of the urethra becomes more susceptible to infections.”|
|B.||“Why don’t you ask your health care provider for some antibiotics to keep on hand.”|
|C.||“That must be frustrating.”|
|D.||“I’m not looking forward to going through menopause.”|
- Beth Ann is the mother of 3-year-old Haley. She has taken her to the clinic for her annual well-child checkup. Beth Ann tells Rodney, the nurse, that Haley will tell her when she has to go to the bathroom, but refuses to go on the toilet. What is Rodney’s best response?
|A.||“She might be frightened of falling in the toilet.”|
|B.||“You might try putting her in ‘time-out’ when she refuses to sit on the toilet.”|
|C.||“Sometimes children her age see urine and feces as part of themselves.”|
|D.||“She is too young to worry about potty-training.”|
- Laura is a student nurse who is working on a rehabilitation unit in the hospital. She is caring for Mrs. Cruse, a 77-year-old patient who had undergone knee replacement surgery. Since Mrs. Cruse had surgery, she has had several instances of urinary incontinence. The nurse caring for Mrs. Cruse has told Laura that she will be calling the health care provider for an order to anchor a Foley catheter. What is Laura’s best response to this suggestion?
|A.||“Would it be better to request a straight catheter instead?”|
|B.||“I think it would be better to put a disposable undergarment on her.”|
|C.||“Could we try a toileting schedule before you request the Foley?”|
|D.||“I think that is a good idea; it will prevent skin breakdown.”|
- Rodney is a nurse who works for a medical unit in the hospital. He is admitting Harry, a 76-year-old patient from a nursing home. Harry’s health care provider has admitted him with a UTI. During his assessment, Rodney notes that Harry complains of right flank pain. To assess for tenderness, Rodney should gently:
|A.||auscultate the costovertebral angle.|
|B.||palpate the tenth intercostal space.|
|C.||percuss the costovertebral angle.|
|D.||touch the area above the ischial spine.|
- Peter is a student nurse who is caring for Mr. Grey, a patient who has been admitted to the medical unit of the hospital with a fever and malaise. The health care provider has ordered a urinalysis on Mr. Grey. To collect the urine specimen, Peter should:
|A.||obtain the specimen from a straight catheter.|
|B.||use sterile gloves to cleanse the penis and collect the specimen in a sterile cup.|
|C.||ask Mr. Grey to void into a cup.|
|D.||instruct Mr. Grey to cleanse his penis, begin his stream, and then void into a sterile cup.|
- Lisa is a patient who was admitted to the hospital with oliguria. Her health care provider ordered a 24-hour urine specimen to test her renal function. Scott, her nurse, will begin collecting the specimen and asks Lisa to notify him when she needs to void. The 24-hour collection period will begin:
|A.||after the first voided specimen is discarded.|
|C.||after the second voided specimen is collected.|
|D.||at the beginning of Scott’s shift.|
- Wesley is a 34-year-old welder who has been admitted to the hospital with severe flank pain. His health care provider suspects that he has kidney stones. Which of the following tests would the nurse expect the health care provider to request to visualize renal calculi?
- Mary Ellen is a 57-year-old patient who has been incontinent of urine for the past 2 months. Her health care provider has scheduled for her to have a test to check for stress urinary incontinence. For which of the following tests should the nurse prepare Mary Ellen?
- Theresa is a nurse who is caring for a 45-year-old patient who has a tumor in his bladder. His health care provider has told him that he will be having a procedure done to identify the tumor tissue. Which of the following tests is done to collect tissue specimens?
- A patient has just been diagnosed with diabetes mellitus. The patient voices concerns about possible kidney disease in the future. The patient asks the nurse, “Where is urine formed in the kidney?” The nurse’s response is that urine is formed in the:
- A nurse suspects that a patient may be experiencing urinary retention. When assessing this patient, the nurse’s first suspicion is when the patient has:
|A.||spasms and difficulty urinating.|
|B.||pain in the suprapubic region.|
|C.||large amounts of voided cloudy urine.|
|D.||small amounts of urine voided 2 to 3 times per hour.|
- A patient with congestive heart failure is taking a diuretic. The patient asks why she has to urinate so often. The nurse’s best response is that the medication:
|A.||increases urinary output.|
|B.||causes the bladder to relax.|
|C.||relaxes inhibition to void.|
|D.||strengthens the pelvic floor muscles.|
- A patient is taking warfarin (Coumadin), which is making his urine orange. The patient wants to know what normal urine should look like. The nurse informs the patient that normal urine is:
|A.||red to pink.|
|B.||amber to orange.|
|C.||yellow to dark yellow.|
|D.||pale straw to amber in color.|
- A female adolescent who suffers from frequent UTI visits the student health clinic. The student wants to know what she can do to stop these occurrences. What is the nurse’s most appropriate response?
|A.||“Drink at least 2 L of fluid daily.”|
|B.||“Wait to void until the bladder is full.”|
|C.||“Cleanse the perineal area from anus to meatus.”|
|D.||“Take an over-the-counter urinary tract cleanser.”|
- One day after surgery a 4-year-old patient is having difficulty urinating. The nurse realizes that children often are unable to void:
|A.||in a urinal.|
|B.||lying in bed.|
|C.||in bathrooms other than their own.|
|D.||in the presence of persons other than their parents.|
- A patient is scheduled for an intravenous pyelogram (IVP). For this diagnostic examination the nurse needs to:
|A.||make no special preparations before the examination.|
|B.||push oral fluids before the examination.|
|C.||have the patient fast after the procedure.|
|D.||assess the patient for an allergy to iodine before the examination.|
- A patient with a Foley catheter needs a urine sample for culture and sensitivity. Because this requires a sterile sample, what is the most appropriate action for the nurse to take?
|A.||Disconnecting the drainage tube from the catheter|
|B.||Opening the drainage bag and withdrawing urine|
|C.||Withdrawing urine from the closed system drainage bag|
|D.||Inserting a sterile blunt cannula in the catheter port to withdraw urine|
- Patients with urinary incontinence are unable to empty their bladder, which presents a major challenge in nursing. A nurse can assist a patient with voiding using Credé’s method, which includes which of the following? Select all that apply.
|A.||Compressing downward with both hands|
|B.||Pressing above the symphysis pubis|
|C.||Pressing below the umbilicus|
|D.||Contracting the abdominal wall|
- A patient needs to have a Foley catheter inserted. To correctly perform this procedure, the nurse will do the following in what order? Prioritize in order of occurrence. (Separate letters by a comma and space as follows: A, B, C, D.)
|A.||Test the balloon.|
|B.||Open the catheterization kit.|
|C.||Wash the perineal area with soap and water.|
|D.||Position the patient.|
Potter: Basic Nursing, 7th Edition
Chapter 34: Bowel Elimination
- Mrs. Smith is a 67-year-old patient who has been admitted to the hospital with dehydration. Rachael, the student nurse caring for Mrs. Smith, explains to her that diarrhea is the result of abnormally fast peristalsis in what organ?
- Kelly is a student nurse who is caring for Mrs. Mermann, a 33-year-old who is in labor with her first child. Mrs. Mermann has complained to Kelly about the hemorrhoids that she has experienced during the last month of her pregnancy. She asks Kelly what she can do to prevent future problems with hemorrhoids. What is Kelly’s best response?
|A.||“Hemorrhoids are caused by straining.”|
|B.||“You need to soften your stools by drinking plenty of fluids.”|
|C.||“You should eat less carbohydrates.”|
|D.||“There is nothing that you can do to prevent hemorrhoids.”|
- William is a nurse caring for several patients on the surgical unit of the hospital. He knows that constipation can be a significant health hazard and encourages his postoperative patients to drink fluids. Which of the following patients that he is caring for are most at risk from complications of constipation?
|A.||35-year-old man with back surgery|
|B.||47-year-old woman with abdominal hysterectomy|
|C.||29-year-old women with carpal tunnel surgery|
|D.||77-year-old man with hip surgery|
- Mrs. Julian will be undergoing abdominal surgery, which will most likely result in an ostomy. She asks the nurse what the consistency of the stool from her ostomy will be. What is the best answer?
|A.||“Your stools won’t change from what they currently are.”|
|B.||“The consistency will be very soft.”|
|C.||“The consistency will be liquid.”|
|D.||“It depends on the location of the intestine where the ostomy is.”|
- Mrs. White was involved in a motor vehicle accident and underwent a loop colostomy. She asks the nurse about the colostomy and asks what is draining out of each side. What is the nurse’s best response?
|A.||“There is stool draining out of both sides.”|
|B.||“Stool is draining out the right side and mucus is draining out the left side.”|
|C.||“There is mucus and stool draining from both sides.”|
|D.||“Stool is draining out the left side and mucus is draining out the right side.”|
- Mrs. Chavez is a 45-year-old Catholic Hispanic American patient who was admitted to the hospital with pneumonia. On admission, Mrs. Chavez didn’t indicate that she had any food preferences or food allergies. Her nurse notes that she has requested that her family bring in her meals. The nurse suspects it is most likely related to which of the following?
|B.||Hispanic cultural traditions|
- Mrs. Greene is a 67-year-old widow who lives at home by herself. Lisa is a nursing student who visits Mrs. Greene every week as part of her community health rotation. Mrs. Greene is concerned about constipation. What is the best way for Lisa to approach Mrs. Greene’s concern?
|A.||“Tell me why you think you are constipated.”|
|B.||“Are your stools hard?”|
|C.||“How frequently are you having a bowel movement?”|
|D.||“What color is your stool?”|
- Mr. Barnes is a 56-year-old patient who was admitted with diabetic ketoacidosis to the medical unit of the hospital where Maggie works as a registered nurse. As she reviews his labs, which of the following would she expect to be elevated?
- Mr. Hawes is a 56-year-old patient who was admitted to the hospital with abdominal pain. Tony is the nurse caring for Mr. Hawes, and he has an order from the health care provider for a stool specimen for occult blood. Tony notices that the stool specimen that Mr. Hawes produces is black. Tony knows that this is a sign of melena and indicates that Mr. Hawes has lost at least how much blood?
- Desiree is a student nurse who works in a local health care clinic that is doing colon cancer screenings. They are testing stool specimens for microscopic amounts of blood. This fecal occult blood test is also known as a(n) __________ test.
- Mrs. Grant is a patient with colon cancer who recently underwent surgery to remove a portion of her colon. She has a colonostomy and needs patient teaching regarding diet. Which of the following is a food that she needs to avoid to prevent blockages?
- Mrs. Griese is concerned about the intermittent constipation that she has and is confused about all the laxatives that are available. Francine is a student nurse who is teaching Mrs. Griese about various cathartics that are available over the counter. One of the laxatives that Mrs. Griese has used in the past is mineral oil. Francine tells her that this type of laxative is known as a(n):
- A patient is immobilized after surgery. The nurse observes a continual oozing of stool from the patient’s rectum. The nurse recognizes that this condition most likely represents:
|D.||the Valsalva maneuver.|
- A patient with an ileostomy is losing weight. The patient asks the nurse why. The nurse’s best response is to tell the patient that most enzymes and nutrients are absorbed in the:
- To maintain normal elimination patterns in a hospitalized patient, the nurse should encourage the patient to take time to defecate 1 hour after meals because:
|A.||the presence of food stimulates peristalsis.|
|B.||mass colonic peristalsis occurs at this time.|
|C.||irregularity helps to develop a habitual pattern.|
|D.||neglecting the urge to defecate can cause diarrhea.|
- A physician or health care provider orders a patient to have a fecal occult blood test. To receive a correct result, the nurse instructs the patient to:
|A.||submit only one sample for analysis.|
|B.||take extra amounts of iron supplements.|
|C.||drink at least 1 L of fluid before the examination.|
|D.||refrain from ingesting foods and medications that can cause a false-positive result.|
- A nurse is taking a history on a newly admitted patient. The patient states that he recently had a change in diet and medication. When asked about bowel elimination the patient reports that stools are dry and hard to pass. The nurse realizes that this bowel pattern is best identified as:
- A patient in balanced suspension traction can have the head of the bed raised only 30 degrees. To promote normal elimination, patients need to assume a sitting position to:
|A.||stimulate the peristaltic movement.|
|B.||contract the thigh muscles used to defecate.|
|C.||strengthen the internal and external sphincters.|
|D.||exert intra-abdominal pressure, which aids in defecation.|
- A nurse has delegated the administration of a tap water enema to the assistive personnel. The assistive personnel demonstrates understanding of the procedure when she states which of the following? Select all that apply.
|A.||“I will lower the enema when the patient complains of cramping.”|
|B.||“I will speed the enema administration when the patient complains of cramping.”|
|C.||“I will withdraw the tube when the patient complains of cramping.”|
|D.||“I will clamp the tubing when the patient complains of cramping.”|
- An enterostomal nurse is teaching a patient how to pouch a colostomy. The nurse demonstrates in what order? Rank from step A to step D. (Separate letters by a comma and space as follows: A, B, C, D.)
|A.||Cleanse peristomal skin with warm water.|
|D.||Perform hand hygiene.|
Potter: Basic Nursing, 7th Edition
Chapter 35: Immobility
- Mr. Elliott is a 76-year-old patient who was admitted to the hospital after falling in the nursing home. He had broken his right femur and is awaiting surgery. His health care provider told him that his activity would be limited to bed rest. He asks the nurse what this means. What is the best explanation?
|A.||“You are to be immobile.”|
|B.||“You cannot move.”|
|C.||“Your activity is restricted.”|
|D.||“You have to remain in bed.”|
- Mr. Gregory was involved in a motor vehicle accident. He has a fractured right hip and is on bed rest in Buck’s traction. Which of the following systems is least likely to be impaired as a result of his immobility?
- Morgan is a student nurse who is caring for a 24-year-old patient who is immobile with a back injury. On auscultation, Morgan heard rhonchi in his lower lobes. Morgan is most concerned that the patient may have developed which of the following?
|A.||A collapsed lung|
- Michael is a 23-year-old patient who was involved in a motorcycle accident. He was in the intensive care unit of the hospital for 2 months and was just discharged to a rehabilitation hospital. He tells his nurse that he doesn’t understand why he is so weak. What is the best response from the nurse?
|A.||“When you are in bed for a long time, your body begins to break down its own protein.”|
|B.||“When you don’t use it, you lose it.”|
|C.||“You haven’t eaten much for the past couple of months.”|
|D.||“Your body has spent energy trying to heal itself.”|
- Patients on prolonged bed rest are at risk for a deep vein thrombosis. Which of the following factors is not included in Virchow’s triad?
|A.||Loss of integrity of the vessel wall|
|B.||Abnormalities of blood flow|
|C.||Alterations in blood constituents|
|D.||Increased muscle atrophy|
- Mildred is a 92-year-old nursing home resident. She fell 2 weeks ago and has been on bed rest. She has become increasingly fatigued when her caregivers bathe her. Mildred’s family is concerned about her declining condition. The best explanation that the nurse can give the family is that Mildred’s fatigue is caused by which of the following?
|A.||Decreased muscle endurance caused by immobility|
|B.||Her advanced age|
|C.||That she is not eating as much|
|D.||Increased oxygen demands of the healing process|
- Which of the following patients is at greatest risk for developing a pressure ulcer?
|A.||26-year-old man paraplegic with pneumonia|
|B.||64-year-old woman in Buck’s traction|
|C.||14-year-old boy on a ventilator|
|D.||56-year-old woman with breast cancer|
- Which of the following patients is most at risk for developing a urinary tract infection?
|A.||12-year-old comatose boy on a ventilator|
|B.||48-year-old woman after abdominal surgery|
|C.||67-year-old man with Alzheimer disease|
|D.||58-year-old man postcardiac catheterization|
- Kevin is a nurse working with Debbie, a new nursing assistive personnel. Kevin is explaining to Debbie about the importance of repositioning immobile patients to prevent pressure ulcers. At a minimum, patients should be repositioned every:
- Which of the following patients is most likely to have developmental effects due to prolonged immobility?
|A.||18-month-old patient in Buck’s traction for a fractured femur|
|B.||7-year-old patient with third degree burns to lower extremities|
|C.||16-year-old patient with chest trauma on a ventilator|
|D.||53-year-old patient with bilateral fractured ankles|
- Which of the following major musculoskeletal changes would you not expect to see during an assessment of an immobilized patient?
|A.||Loss of muscle tone|
|B.||Decreased muscle strength|
|D.||Increased muscle mass|
- Gina is a nursing student who works for a postsurgical unit of the hospital. She wants to do everything possible to prevent her patients from developing a thrombus. Which of the following is the best thing she can do to prevent thrombus formation in postsurgical patients?
|A.||Maintaining light pressure on the posterior knee when positioning patients|
|B.||Putting pillows under the knees of patients when positioning them in bed|
|C.||Massaging patient’s legs after a bath|
|D.||Avoiding putting patients in tight clothing that constricts the waist|
- A nurse is caring for an immobile patient. The most appropriate nursing intervention to implement is:
|A.||turning the patient every 4 hours.|
|B.||applying an abdominal binder while the patient is lying in bed.|
|C.||encouraging the use of incentive spirometry hourly.|
|D.||maintaining the patient’s maximum fluid intake of 1000 mL daily.|
- A nurse notes a cardiovascular change on an immobilized postoperative patient. One such change the nurse could have noticed is consistent with:
|D.||increased coagulation of blood.|
- A nurse is caring for a patient in Buck’s traction for a compound comminuted fracture of the femur. An appropriate action the nurse must take in order to help preserve skin integrity is to:
|A.||provide meticulous skin care.|
|B.||use analgesia to prevent excessive movement.|
|C.||limit range of joint motion so the traction apparatus is not disturbed.|
|D.||limit the amount of protein intake so renal function can be preserved.|
- Keeping a patient immobilized creates benefits for the patient. Nurses implement therapeutic immobilization as a means to:
|A.||limit the movement of the body.|
|B.||restrain a unstable patient in bed.|
|C.||increase active range of joint motion.|
|D.||strengthen joints and muscles in preparation for ambulation.|
- Immobilized patients are affected by changes in their metabolic rate. Therefore nurses need to monitor:
|A.||increased serum glucose levels.|
|B.||decreased serum calcium levels.|
|C.||positive nitrogen balance.|
|D.||increases in serum potassium levels.|
- The length of immobilization can adversely affect a patient. When assessing patients, nurses need to assess muscle mass for:
|B.||increases in strength.|
|C.||decreases in strength.|
|D.||increases in lean muscle.|
- A patient is recovering from an abdominal aortic bypass graft. To reduce the effects of orthostatic hypotension, the most appropriate action for the nurse to encourage is:
|A.||slowly sitting up in a chair.|
|B.||performing isometric exercises.|
|C.||decreasing the number of ankle pumps.|
|D.||participating in chest physiotherapy.|
- A nurse has finished preoperative teaching for a surgical patient. The nurse evaluates the patient’s understanding of the use of elastic stockings when the patient states:
|A.||“I remove them at night.”|
|B.||“I can roll them no lower than my calf.”|
|C.||“I wear them no longer than 4 hours at a time.”|
|D.||“I can have them removed for 30 minutes every 8 hours.”|
- When completing the assessment of an immobilized patient, the most likely place for the nurse to assess edema includes which of the following? Select all that apply.
- Immobilized patients often become depressed. A nurse can best combat this effect of immobilization by doing which of the following? Select all that apply.
|A.||Limiting visitors so the patient is not bothered|
|B.||Involving the patient in planning time for care and activities|
|C.||Placing the patient in a private room to reduce the interruptions by a roommate|
|D.||Encouraging the patient to comb hair, wear make-up, and/or use cologne if appropriate|
Potter: Basic Nursing, 7th Edition
Chapter 36: Skin Integrity and Wound Care
- Mrs. Jenkins is a 78-year-old patient who was admitted to the hospital for a bowel obstruction. She is immobile and the nurse has noticed that she has a reddened area on her right heel. When the nurse presses on the area it does not turn lighter in color. She knows that the skin injury is reversible if the pressure is relieved and she uses measures to protect the tissue. How should the nurse document the tissue condition?
- Jeannie is a nurse who works in a nursing home. One of the patients, 83-year-old Mrs. Stoll, is bedridden. Jeannie needs to pull her up in bed and instructs Fiona, the student nurse who is with her, that they need to make sure that they use the draw sheet to pull her up to avoid which of the following factors that would contribute to pressure ulcer formation?
- Mrs. Griffin is a frail, elderly patient who has been admitted to the hospital for pneumonia. Which of the following factors is puts her at an increased risk for a pressure ulcer?
|A.||She has had a diet low in protein.|
|B.||She has been on a low sodium diet.|
|C.||She has an IV of lactated Ringers running at 120 mL/hr.|
|D.||She is being repositioned every 2 hours.|
- Dottie is a 67-year-old patient who was admitted to the hospital when a community health nurse discovered that her family was having difficulty caring for her at home. She has a pressure ulcer on her sacrum. The wound is open with exposed bone. The nurse admitting her should document this as what stage of a pressure ulcer?
- Frank is a 4-year-old paraplegic patient with cerebral palsy who was admitted to the hospital with complications from the H1N1 virus. The nurse who was admitting him noted that he had an area of redness on his right malleolus that was nonblanchable. The nurse correctly identified this area as what stage of a pressure ulcer?
- Mrs. Bryant is a 78-year-old patient with diabetes who recently moved into an assisted living apartment because she needs assistance with bathing and housework. When the assistive nursing personnel bathed her for the first time, she noticed that there was a large blister on her right heel. She asked Mrs. Bryant about it, and she denied knowledge of having injured herself. It was reported to the nurse who correctly documented it as what stage of a pressure ulcer?
- Chris is a 38-year-old paraplegic patient who had a traumatic brain injury while serving in Afghanistan. He has been a patient in a long-term rehabilitation hospital and was recently admitted to an acute-care hospital with failure-to-thrive. On admission, he was found to have a wound on his right scapula. The nurse noted full-thickness tissue loss with tunneling, but did not note any bone, tendon or muscle. This was correctly identified as what stage of a pressure ulcer?
- Yolanda is a nursing student caring for Mrs. Gentry, a 77-year-old patient who has been hospitalized after a cerebrovascular accident. While bathing Mrs. Gentry, she noted a reddened area over her coccyx. What is the best thing for Yolanda to do?
|A.||Tell the health care provider about the area.|
|B.||Massage over the skin to restore circulation.|
|C.||Rub the area with a moisturizer.|
|D.||Reposition Mrs. Gentry more frequently.|
- Mrs. Hortin is a 104-year-old patient who resides in a nursing home. Recently Mrs. Hortin was ill with a respiratory infection. During her illness, she became incontinent of both urine and stool. The nursing staff used a special cleanser on her perineum, put a moisture barrier on the exposed area, and placed absorbent briefs on her to prevent her skin from becoming soft because of the moisture. What was the staff trying to prevent?
- Gina is a nurse who works for a trauma unit in the hospital. She is caring for a patient with a necrotic wound on his hip. Which of the following dressings would be the best choice to use on this type of wound to help with debridement?
- A nurse is working in a long-term care facility. The nurse knows that immobilized patients are at risk for pressure ulcer development primarily as a result of:
|D.||protein buildup in tissues.|
- On assessment a nurse notes that a patient’s skin is reddened with a small abrasion. The nurse most correctly will classify this ulcer formation as what stage?
- A patient who has undergone a colectomy is demonstrating wound healing. The nurse correctly identifies the wound phase characterized by strengthened collagen fibers as:
|D.||healing by secondary intention.|
- A surgical wound requires a hydrogel dressing. The primary advantage of hydrogel is that it provides:
|A.||an absorbent to collect wound drainage.|
|B.||a negative pressure to promote healing.|
|C.||protection from the external environment.|
|D.||moisture needed for wound healing.|
- A patient is wearing a breast binder after breast reconstruction surgery. The nurse needs to assess and document the patient’s:
- A patient’s draining wound is pale and watery with a combination of plasma and red cells. The nurse appropriately documents the drainage as:
- A postoperative patient visits the ambulatory care clinic complaining of just “not feeling well.” The patient has an elevated temperature. As the nurse assesses the surgical wound, an indication that the wound has become infected is that the wound:
|A.||culture is negative.|
|B.||has no odor.|
|C.||edges reveal the presence of fluid.|
|D.||shows purulent drainage coming from the incision area.|
- The application of heat can be very therapeutic. Because the application of heat promotes vasodilation, the nurse knows that this type of therapy is best suited for patients who have:
|A.||low back pain.|
|B.||an infected wound.|
|C.||a first-degree burn.|
|D.||a direct trauma to a joint.|
- An older adult patient is experiencing slow wound healing. On assessment the nurse discovers that the patient has poor nutritional intake. When counseling this patient the nurse informs the patient to increase her intake of:
- Assistive personnel ask the nurse the differences between wound healing by primary and secondary intention. The nurse’s best response is that healing by primary intention occurs when the skin edges:
|B.||slightly overlap each other.|
|C.||appear slightly pink to red.|
|D.||migrate across the incision.|
- On admission a patient is noted to have an alteration in skin integrity on the right heel. The nurse uses the Braden Scale. The nurse knows that this scale measures the degree of which of the following? Select all that apply.
|D.||Friction and shear|
- You have just completed a home visit on a 12-year-old quadriplegic girl. The patient was admitted with pressure ulcers to bilateral ankles. You evaluate the pressure ulcers have healed when there is no evidence of which of the following? Select all that apply.
- When a person suffers a traumatic wound in an emergency situation, a nurse should do the following in what order? (Separate letters by a comma and a space as follows: A, B, C, D.)
|A.||Protect the wound from further injury.|
|C.||Cleanse the wound.|
|D.||Assess the wound.|
Potter: Basic Nursing, 7th Edition
Chapter 37: Sensory Alterations
- Kirby is a 63-year-old welder who has gone to the clinic for his annual check-up. He shares with the nurse that he has been having difficulty hearing conversations at the coffee shop in the mornings. After looking in his ears to determine if there is a build-up of cerumen, the nurse tells Kirby that his hearing loss needs to be checked further, but that it may be associated with aging. What is the best term to describe this?
- Mr. Barnes is a 64-year-old house painter who is seeing his health care provider for his annual check-up. When the nurse asks him if he has had any problems, he tells her that he doesn’t think his vision is as good as it used to be. He states that “things look more yellow than they used to.” She knows that this is a visual change in older adults because the:
|C.||pupils take longer to dilate.|
|D.||pupils take longer to constrict.|
- Omar is a 47-year-old divorced man who recently moved back in with his elderly mother after she had been hospitalized several times with gastrointestinal problems. He is concerned because as he was going through her refrigerator, he noticed food that had turned rancid. His mother hadn’t seemed to notice the spoiled food and was going to heat up some rancid soup for lunch. What is the most likely physiologic reason that Omar’s mother does not realize that the food is spoiled?
|A.||She has early Alzheimer disease.|
|B.||She has a diminished sense of smell.|
|C.||She is frugal and does not want to throw things out.|
|D.||She has a limited vision.|
- Roberta has had a MRSA infection in an abdominal surgical wound. Laura is a student nurse who works on the postsurgical unit of the hospital. Roberta is in a private room, is receiving vancomycin for the MRSA, and her pain is well controlled with a morphine patient-controlled analgesia pump. She is also receiving docusate sodium to prevent constipation. She begins complaining of ringing in the ears on Laura’s shift. Which is the most likely cause of her tinnitus?
- Bernice is a 76-year-old retired secretary with diabetes who is seeing her health care provider because she is having visual changes. She explains to the nurse that she is experiencing distortion that makes the edges of objects appear wavy. The nurse knows that this is an early sign of:
|D.||age-related macular degeneration.|
- Jane is a nursing student who has completed transferring Mrs. Ennis, who is blind, to the orthopedic unit after right knee replacement surgery. The best position for Jane to assume when ambulating Mrs. Ennis is standing on her _____ side and walking a half step _____ her.
- Macie is a nursing student who has been concerned about sensory deprivation with patients in the nursing home where she works. Which of the following can be caused by sensory deprivation?
- Ellen is a student nurse who is visiting Sydney, a 16-year-old mother and her newborn as part of her community health clinical rotation. Sydney tells Ellen that she is concerned that her baby could be deaf because her uncle lost his hearing at a young age. The best way for Ellen to assure Sydney that her baby can hear is by telling her that her baby:
|A.||was discharged from the hospital without any known problems.|
|B.||looks completely normal.|
|C.||responds to loud noises.|
|D.||does not have excessive cerumen in his auditory canal.|
- Mrs. Beeson asks Robert, a visiting nurse, why her older adult mother seems to prefer eating ice cream and other sweets to any other foods. What is Robert’s best response?
|A.||“Maybe she has a ‘sweet tooth.’”|
|B.||“Older adults seem to be able to taste sweet foods best.”|
|C.||“I wouldn’t worry about it as long as she is eating something.”|
|D.||“She is probably getting all the nutrients that she needs.”|
- A visually impaired patient has been hospitalized with pyelonephritis. Because this patient will be making frequent visits to the bathroom, a way for the nurse to maintain a safe environment includes:
|A.||supplying a night light to provide better vision.|
|B.||keeping the bed side rails down so the patient will not fall.|
|C.||assisting the patient by standing on his or her dominant side.|
|D.||keeping necessary objects in a bedside drawer to decrease clutter.|
- A nurse is caring for a patient who signs and lip reads. When communicating, the most appropriate nursing action is to:
|A.||rely on family members to interpret.|
|B.||speak louder and more distinctly than normal.|
|C.||sit facing the patient when speaking.|
|D.||repeat the entire conversation if it is not understood the first time.|
- An older adult patient has been admitted to a busy medical unit. To control environmental stimuli a nurse should:
|A.||leave the hospital room lights on.|
|B.||coordinate patient care activities.|
|C.||leave the widow curtains closed at all times.|
|D.||turn up pump and bed alarms so the patient can hear them.|
- An older adult patient visits the clinic for an annual physical. As the nurse reviews the health assessment sheet, the nurse notes that the patient has experienced a distortion or loss of central vision. The nurse can best identify this sensory change as:
|D.||senile macular degeneration.|
- A school nurse performs a routine screening on a newly transferred school-age child. This nurse is especially interested in discovering the child’s medical history regarding middle ear infections. The nurse knows that chronic ear infections are a major contributing factor to:
- An older adult patient residing at an adult assisted living facility complains of hearing and visual disturbances. A nurse must be alert to the effects of sensory deprivation that are associated with:
|C.||improved task completion.|
|D.||increased need for social interaction.|
- A patient with poor vision is ready to be discharged. The nurse is educating the patient and family regarding ways to improve vision. The nurse teaches the patient and family to avoid reading materials with shiny surfaces. The rationale for this intervention is that:
|A.||glare causes headaches.|
|B.||glare will reduce visual acuity.|
|C.||shiny surfaces reflect damaging rays.|
|D.||too much light is damaging to the eyes.|
- A home care nurse visits a new patient. The family asks how the home can be made safer. The nurse’s best advice includes:
|A.||using throw rugs to prevent tripping.|
|B.||installing extra incandescent lighting.|
|C.||painting the floor black and white to add perception.|
|D.||installing handrails painted the same color as the walls.|
- A home care nurse is conducting a home assessment. The nurse is looking for the presence of sensory alterations. Factors to assess include if any changes have occurred in which of the following? Select all that apply.
|C.||Seeing, hearing, touch|
- Mrs. Thomas is a 49-year-old patient who was admitted to the trauma intensive care unit after a motor vehicle accident. The nurse notes that she becomes increasingly agitated when she has visitors for an extended period or after nursing interventions. The nurse identifies this as sensory overload. Which of the following would most likely help Mrs. Thomas? Select all that apply.
|A.||Reducing the number of visitors to her room|
|B.||Performing dressing changes with the bath|
|C.||Providing a dedicated period of rest time each afternoon|
|D.||Requesting that health care providers do rounds when the family is available|
- A patient has been hospitalized for 5 days and has had no visitors. The nurse observes the patient to be bored, restless, and anxious. The nurse identifies this behavior as ___________.
Potter: Basic Nursing, 7th Edition
Chapter 38: Surgical Patient
- Richard is a 57-year-old patient who is being admitted for an appendectomy. He is a 2-pack-a-day smoker and has a history of diabetes. In addition to his other risk factors, he is 20 pounds overweight. Which of the following potential postoperative complications should the nurse be most concerned with?
|B.||Negative nitrogen balance|
- Misty is a nurse who works in surgery. She knows that pulmonary embolisms can be a deadly complication of surgery. Which of the following patients is most likely to develop a pulmonary embolism?
|A.||45-year-old patient after bariatric surgery|
|B.||23-year-old patient with head trauma|
|C.||13-year-old patient after appendectomy|
|D.||57-year-old patient after cholecystectomy|
- Shawna is a 45-year-old woman with cancerous abdominal tumor. She has been on chemotherapy and is having radiotherapy to shrink the tumor. She will be undergoing surgery to remove the tumor. To best facilitate wound healing, when is the best time for her to undergo surgery?
|A.||During the radiotherapy treatments|
|B.||Immediately after the radiotherapy treatments|
|C.||2 to 3 weeks after radiotherapy treatments|
|D.||4 to 6 weeks after radiotherapy treatments|
- Which of the following patients is most at risk for hypovolemic shock after emergency surgery?
|A.||14-year-old adolescent with gastroenteritis|
|B.||59-year-old patient with pneumonia|
|C.||12-year-old patient with H1N1 flu|
|D.||28-year-old patient with renal calculi|
- Clara is a perioperative nurse. She is monitoring the blood glucose level of Harold, a 56-year-old patient without diabetes who is undergoing orthopedic surgery. What is the main rationale for monitoring his blood glucose level during surgery?
|A.||She does not want Harold to develop type 2 diabetes.|
|B.||Research shows a strong relationship between wound infections and hyperglycemia.|
|C.||She knows that normal glucose levels promote good tissue oxygenation.|
|D.||She is monitoring to prevent hypoglycemia.|
- Maria is a perioperative nurse who is admitting a patient for an elective surgery. She asks about a family history of malignant hyperthermia, which is a life-threatening complication. Which of the following is a late sign of malignant hyperthermia?
|A.||High CO2 levels|
- Lisa is a 44-year-old patient with breast cancer who is scheduled to undergo a right-side mastectomy. Ideally, when should preoperative teaching begin?
|A.||As soon as she is diagnosed with breast cancer|
|B.||One week before surgery|
|C.||The day before surgery|
|D.||The day of surgery|
- Harold is the preoperative nurse who is providing patient teaching to James, a 49-year-old patient who is scheduled to undergo a right-side inguinal surgery repair. Harold tells James that the recommendations of the American Society of Anesthesiologists recommend that patients undergoing surgery with a general anesthesia fast from meat and fried foods for _____ hours before surgery?
- A nurse working in an ambulatory care surgery center is preparing to discharge a postoperative patient. The nurse knows that, to be discharged, the ambulatory center surgical patient:
|A.||will remain in phase 1 recovery before discharge.|
|B.||has to meet established discharge criteria before going home.|
|C.||will be able to ambulate as soon as he or she enters the recovery area.|
|D.||has to be superhydrated to promote metabolism of anesthesia agents.|
- The nurse instructs the postoperative patient to perform leg exercises every hour in order to:
|A.||maintain muscle tone.|
|B.||increase venous return.|
|C.||exercise fatigued muscles.|
|D.||assess range of joint motion.|
- A patient with a ruptured abdominal aortic aneurysm needs to have major surgery. The nurse explains to the family that major surgery:
|A.||is an excision or removal of a diseased body part.|
|B.||involves extensive surgery to reconstruct body parts.|
|C.||is not necessary but may prevent additional problems.|
|D.||is a surgical exploration that allows the physician or health care provider to confirm a diagnosis.|
- A patient is awaiting surgery. The nurse’s best rationale for assessing vital signs is to:
|A.||assess the patient’s anxiety level.|
|B.||determine the patient’s basal temperature.|
|C.||establish a baseline for vital signs comparisons.|
|D.||assess for any changes in the blood pressure and pulse.|
- The operating room environment is deliberately kept cool. When the nurse assesses the patient in the post anesthesia care unit, the patient is shivering. The nurse needs to understand that shivering may:
|A.||be a side effect of anesthesia.|
|B.||indicate a problem of the hypothalamus.|
|C.||indicate the beginning of the infectious process.|
|D.||be a normal response to stabilize blood pressure.|
- The assistive personnel asks the nurse to explain what is involved in perioperative nursing. The nurse’s most appropriate response should be that perioperative nursing includes nursing care that is:
|A.||performed in a variety of settings.|
|B.||rendered before, during, and after surgery.|
|C.||given according to the seriousness of the surgery.|
|D.||classified according to the procedure experienced.|
- All patients undergoing surgery need to have preoperative preparation. When physically preparing the patient, the most appropriate action for the nurse to take is:
|A.||leaving all of the patient’s jewelry in place.|
|B.||removing the patient’s makeup and nail polish.|
|C.||providing the patient with sips of water for a dry mouth.|
|D.||removing the patient’s hearing aid before transport to the operating room.|
- Intraoperatively, the circulating nurse observes a member of the surgical team breach aseptic technique. As a result of this incident the patient postoperatively can be at risk for:
|C.||development of infection.|
|D.||alteration in pulmonary hygiene.|
- A patient asks a nurse to explain the differences between general anesthesia and regional anesthesia. What is the correct response?
|A.||“General anesthesia inhibits peripheral nerve conduction.”|
|B.||“Under general anesthesia all sensation and consciousness is lost.”|
|C.||“Under general anesthesia there is a loss of sensation in a specific area of the body.”|
|D.||“General anesthesia is routinely used for procedures that only require a decreased level of consciousness.”|
- The nurse is conducting preoperative teaching with the patient and family. The nurse teaches the patient the proper use of the incentive spirometer. The nurse knows that the patient understands the need for this intervention when the patient states, “I use this device to:
|A.||help my cough reflex.”|
|B.||expand my lungs after surgery.”|
|C.||increase my lung circulation.”|
|D.||drain excess fluid from my lungs.”|
- When is it appropriate to ask a surgeon to clarify information for a patient who is undergoing surgery? Select all that apply.
|A.||Before the informed consent has been signed|
|B.||When a patient is confused about the reason for the procedure|
|C.||When a patient understands the risks involved in a procedure|
|D.||If there is confusion about the procedure after the informed consent is signed|
- Madelyn is a student nurse who is providing preoperative teaching for a patient regarding pain control after surgery. Which of the following statements is/are true regarding the use of postoperative analgesia? Select all that apply.
|A.||“Analgesics will not provide adequate relief if you wait until the pain becomes excruciating before using them.”|
|B.||“Pain control will help you recover from surgery quicker.”|
|C.||“You shouldn’t be concerned about becoming addicted to your pain medications.”|
|D.||“You will remain pain-free as long as you take your pain medications as prescribed.”|
- Malcolm is a student nurse who has been assigned to Mr. LaMar as part of his surgery clinical rotation. Mr. LaMar is a 67-year-old patient who is undergoing thoracic surgery to remove a tumor. As part of the preoperative teaching, Malcolm discusses the importance of coughing. Which of the following statements is true regarding why post-operative coughing is important? Select all that apply.
|A.||“Coughing assists in removing retained mucus in the airways.”|
|B.||“It won’t hurt to cough with adequate pain control.”|
|C.||“You can splint your incision when coughing to minimize pain.”|
|D.||“Deep breathing and coughing will remove anesthesia gases from your lungs.”|