Fundamentals Nursing Active Learning 1st Edition By Yoost Crawford – Test Bank
Chapter 01: Nursing, Theory, and Professional Practice
- A group of students are discussing the impact of non-nursing theories in clinical practice. The students would be correct if they chose which theory to prioritize patient care?
|a.||Erikson’s Psychosocial Theory|
|b.||Paul’s Critical Thinking Theory|
|c.||Maslow’s Hierarchy of Needs|
|d.||Rosenstock’s Health Belief Model|
- A nursing student is preparing study notes from a recent lecture in nursing history. The student would credit Florence Nightingale for which definition of nursing?
|a.||The imbalance between the patient and the environment decreases the capacity for health.|
|b.||The nurse needs to focus on interpersonal processes between nurse and patient.|
|c.||The nurse assists the patient with essential functions toward independence.|
|d.||Human beings are interacting in continuous motion as energy fields.|
- Which nurse established the American Red Cross during the Civil War?
- The nursing instructor is researching the five proficiencies regarded as essential for students and professionals. Which organization, if explored by the instructor, would be found to have added safety as a sixth competency?
|a.||Quality and Safety Education for Nurses (QSEN)|
|b.||Institute of Medicine (IOM)|
|c.||American Association of Colleges of Nursing (AACN)|
|d.||National League for Nursing (NLN)|
- The nurse manager is interviewing graduate nurses to fill existing staffing vacancies. When hiring graduate nurses, the nurse manager realizes that they will probably not be considered “competent” until:
|a.||They graduate and pass NCLEX.|
|b.||They have worked 2 to 3 years.|
|c.||Their last year of nursing school.|
|d.||They are actually hired.|
- The prospective student is considering options for beginning a career in nursing. Which degree would best match the student’s desire to conduct research at the university level?
|a.||Associate Degree in Nursing (ADN)|
|b.||Bachelor of Science in Nursing (BSN)|
|c.||Doctor of Nursing Practice (DNP)|
|d.||Doctor of Philosophy in Nursing (PhD)|
- During a staff meeting, the nurse manager announces that the hospital will be seeking Magnet status. In order to explain the requirements for this award, the nurse manager will contact the:
|a.||American Nurses Association (ANA).|
|b.||American Nurses Credentialing Center (ANCC).|
|c.||National League for Nursing (NLN).|
- The nurse is caring for a patient who refuses two units of packed red blood cells. The nurse notifies the health care provider of the patient’s decision. The nurse is acting in the role of the:
- The nursing student develops a plan of care based on a recently published article describing the effects of bedrest on a patient’s calcium blood levels. In creating the plan of care, the nursing student has the obligation to:
|a.||Critically appraise the evidence and determine validity.|
|b.||Ensure that the plan of care does not alter current practice.|
|c.||Change the process even when there is no problem identified.|
|d.||Maintain the plan of care regardless of initial outcome.|
- The nurse is delegating frequent blood pressure (BP) measurements for a patient admitted with a gunshot wound to a licensed practical nurse (LPN). When delegating, the nurse understands that:
|a.||He/she may assume that the LPN is able to perform this task appropriately.|
|b.||The LPN is ultimately responsible for the patient findings and assessment.|
|c.||The LPN may perform the tasks assigned without further supervision.|
|d.||He/she retains ultimate responsibility for patient care and supervision is needed.|
- The nurse is preparing to discharge a patient admitted with fever of unknown origin. The patient states, “I never got past the fifth grade in school. Don’t read much. Never saw much sense in it. But I do OK. I can read most stuff. But my doctor explains things good, and doesn’t think that my sickness is serious.” The nurse should:
|a.||Provide discharge medication information from a professional source to provide the most information.|
|b.||Expect that the patient may return to the hospital if the discharge process is poorly done.|
|c.||Assume that the physician and the patient have a good rapport and that the physician will clarify everything.|
|d.||Defer offering the patient the opportunity to get the influenza vaccine because of the rapport that he has with his physician.|
- A nurse is caring for a patient who lost a large amount of blood during childbirth. The nurse provides the opportunity for the patient to maintain her activity level while providing adequate periods of rest and encouragement. Which nursing theory would the nurse most likely choose as a framework for addressing the fatigue associated with the low blood count?
|a.||Watson Human Caring Theory|
|b.||Parse’s Theory of Human Becoming|
|c.||Roy’s Adaptation Model|
|d.||Rogers’ Science of Unitary Human Beings|
- Which nursing theorist described the relationship between the nurse and the patient as an interpersonal and therapeutic process?
- A nursing class volunteers to serve hot meals at a local homeless shelter on a Saturday afternoon. This focus on serving the community is called:
- A patient is being discharged from the hospital with wound care dressing changes. The nurse recommends a referral for home health nursing care. The nurse is using which standard of practice?
- The nurse administers a medication to the patient and then realizes that the medication had been discontinued. The error is immediately reported to the physician. The nurse is complying with the standards of professional performance known as:
- A newly licensed registered nurse is curious about the scope of care that she has in caring for patients undergoing conscious sedation. Which would be the best source of information?
|a.||National Student Nurses Association|
|b.||Nurse Practice Act|
|c.||ANA Standards of Professional Performance|
|d.||National League for Nursing|
- The nursing student is writing a paper about the direct patient care role of advanced practice nurses. Which of the following advanced practice roles would the student include in the report?
|b.||Clinical Nurse Leader|
|c.||Clinical Nurse Specialist|
- The nurse is determining the patient care assignments for a nursing unit. Which of the following responsibilities may be delegated to the licensed practical nurse?
|a.||Initiating the nursing care plans|
|b.||Formulating nursing diagnoses|
|c.||Assessing a newly admitted patient|
|d.||Administering oral medications|
- The nursing student is taking a class in Nursing Research. In class she has learned that the most abstract level of knowledge is the:
- Which statement contributes to the understanding that nursing is considered a profession? (Select all that apply.)
|a.||Nursing requires specialized training.|
|b.||Nursing has a specialized body of knowledge.|
|c.||The ANA regulates nursing practice.|
|d.||Nurses make independent decisions within their scope of practice.|
|e.||Once licensure is complete, no further education is required.|
- The Institute of Medicine (IOM) Report identified several goals for nursing in the United States. The IOM suggested that: (Select all that apply.)
|a.||Nurses should practice to the full extent of their education.|
|b.||Nursing education should demonstrate seamless progression.|
|c.||Nurses should continue to be subservient to physicians in the hospital setting.|
|d.||Policy making requires better data collection and information infrastructure.|
|e.||Higher levels of education should not be sought by practicing nurses.|
- The nurse is caring for a patient admitted for the removal of an infected appendix. Which actions by the nurse would indicate an understanding of the 2012 hospital safety goals? (Select all that apply.)
|a.||Places an identification band on the right arm|
|b.||Marks the surgical site with a black-felt pen|
|c.||Checks medications three times before administration.|
|d.||Washes hands between patients and/or when soiled.|
|e.||Removes allergy bands prior to transfer to surgery.|
- The nurse is conducting a health assessment on a patient from a foreign country. Which of the following should be addressed during the interview? (Select all that apply.)
- The nurse documents that patient laboratory results often take 4 hours to populate into the electronic medical record. The lengthy time frame has contributed to delayed antibiotic administration. From this point, what should the nurse do to produce change using the evidence-based process? (Select all that apply.)
|a.||Assess the need for change and identify a problem.|
|b.||Reconstruct the information into an answerable question.|
|c.||Review pertinent journal articles from the literature search.|
|d.||Apply the findings to clinical practice through collaboration.|
Chapter 02: Values, Beliefs, and Caring
- Enduring ideas about what a person considers is desirable or has worth in life is known as a:
|c.||higher order belief|
- A group of students are discussing the history of nursing. A student states, “Yea, nurses used to be called the doctor’s handmaiden.” This type of comment is known as a:
- A values system is a set of somewhat consistent values and measures that are organized hierarchically into a belief system on a continuum of relative importance. A value system is also:
|b.||unique to each individual.|
|c.||a poor basis for making decisions.|
|d.||rigid and uniform within a culture.|
- The nurse is caring for a patient who is under arrest for murder. She is attempting to perform her duties while, at the same time, feeling a sense of repugnance toward the patient. The nurse is undergoing:
- While helping patients with values clarification and care decisions, nurses should:
|a.||convince the patient to do what the nurse believes is best.|
|b.||give advice about what the nurse would do.|
|c.||tell the patient what the right thing to do is.|
|d.||provide information so that the patient can make informed decisions.|
- A patient with terminal cancer says to the nurse, “I just don’t know if I should allow CPR in the event I quit breathing. What do you think?” Which statement by the nurse would be most beneficial to the patient?
|a.||“If it were me, I would want to live no matter what.”|
|b.||“Don’t worry. You have plenty of time to decide that later on.”|
|c.||“It’s totally up to you. Have you discussed this with your family?”|
|d.||“Let’s talk about what CPR means to you.”|
- The nurse is observed sitting at the bedside of a patient discussing the nursing care plan for the shift. Which theory or model most accurately reflects this nurse–patient relationship?
|a.||Swanson’s Theory of Caring|
|b.||Travelbee’s Human-to-Human Relationship Model|
|c.||Watson’s Theory of Caring|
|d.||Leininger Cultural Care Theory|
- The student nurse is planning care for a patient who believes that Western medicine is effective but not always accurate. Nursing theory would best explain the patient’s health practices?
|a.||Nursing: Human Science and Human Care|
|b.||Cultural Care Theory|
|c.||Human-to-Human Relationship Model|
|d.||Five Caring Processes|
- Which nursing theorist describes the nurse–patient relationship as interpersonal with a focus on compassion and empathy?
- The nurse on a busy medical–surgical floor contacts a social worker requesting a home care referral prior to a patient’s discharge. This action is best illustrated by which of Swanson’s Five Caring Processes?
- Which action observed by a nurse manager may be indicative of codependency behavior?
|a.||A staff nurse orders extra desserts for a patient diagnosed with morbid obesity.|
|b.||A medication nurse administers scheduled pain medication to patients as ordered.|
|c.||A respiratory therapist teaches a patient’s wife how to adjust an oxygen mask.|
|d.||A nursing assistant encourages a patient to assist with the morning bath.|
- When developing a nursing practice, it is important for the nurse to:
|a.||be exposed to negative as well as positive role models.|
|b.||avoid negative role models as much as possible.|
|c.||understand that caring and compassion are taught in class.|
|d.||consider another profession if he/she is not naturally compassionate.|
- The nurse is discussing the use of a values clarification tool with a patient. The patient asks, “What is the goal of the values clarification tool?” Which is the best response by the nurse?
|a.||“The tool will help change your value system so that you can make the right decision.”|
|b.||“The tool will dispel your current beliefs and formulate brand new ones.”|
|c.||“The tool will assist you in prioritizing your value preferences and help you make decisions.”|
|d.||“The tool allows you to make decisions without the need of self-awareness.”|
- The nurse is preparing to perform a health history interview with a non-English speaking patient. An interpreter has been assigned to assist in the translation. Which action by the nurse indicates understanding the guidelines for working with an interpreter?
|a.||Use short sentences and allow time for translation.|
|b.||Ask the interpreter to use third person.|
|c.||Look at the interpreter during the interview.|
|d.||Suggest the use of paraphrasing whenever possible.|
- Patients who enter the health care system have two reasonable expectations. The first is not to be harmed, and the second is that the nurses providing care will be both competent and compassionate. Provision of care that is consistent and delivered in a predictable way can make the experience less intimidating for the patient. The nurse provides predictable care by:
|a.||Explaining what is going to take place beforehand.|
|b.||Never making promises to patients.|
|c.||Assuring the patient that his/her requests will get done eventually.|
|d.||Protect the patient from knowing why things are happening.|
- The nurse is planning to change a dressing on an anxious patient. The best approach for the nurse is to:
|a.||ask another staff member to perform the task.|
|b.||tell the patient the dressing change will take 30 minutes.|
|c.||schedule a time in collaboration with the patient.|
|d.||review the physician’s order prior to the procedure.|
- Nurses must collaborate effectively with patients to find treatment methods that are congruent with the patients’ belief systems and that promote healthy outcomes. This approach requires:
|a.||focusing on patient values only and disregard family desires in setting goals.|
|b.||relying more and more on their scientific background.|
|c.||listening carefully to how the patient’s beliefs impact their health beliefs.|
|d.||Understanding that the nurse’s beliefs are the most important.|
- The nurse is caring for a patient scheduled for heart surgery. Which statement made by the patient requires further discussion?
|a.||“My friend died on the operating table several months ago.”|
|b.||“The surgeon has a great reputation in the community.”|
|c.||“I believe that this surgery is going to make me better.”|
|d.||“Yesterday I asked my pastor to visit me after the procedure.”|
- A vital aspect of providing effective and appropriate nursing care is being able to actively listen to a patient. This requires the nurse to:
|a.||pay attention as if in a social conversation with the patient.|
|b.||practice and develop this skill over many years.|
|c.||focus on what the patient is saying.|
|d.||passively listen with the ears.|
- The nurse is caring for a patient with lung disease. The patient tells the nurse that the most important thing to do during the shift is to walk down to the nurses’ station and back without having shortness of breath. The patient’s request is an example of which nursing theory?
|a.||Leininger’s Cultural Care Theory|
|b.||Travelbee’s Human-to-Human Relationship Model|
|c.||Swanson’s Theory of Caring|
|d.||Watson’s Human Science and Human Care Theory|
- In dealing with beliefs and values, the type that is based in the unconscious are:
- A nurse working in a dermatology clinic observes that a patient of Mexican-American descent typically arrives 10 to 15 minutes late to every appointment. Based on an understanding of first-order beliefs, the nurse determines that: (Select all that apply.)
|a.||first-order beliefs serve as the basis of a person’s belief system.|
|b.||first-order beliefs begin to develop in early adolescence.|
|c.||first-order beliefs are completely formed in childhood.|
|d.||people seldom question their first-order beliefs.|
|e.||challenging a patient’s first-order beliefs may cause cognitive upset.|
- The most effective approach for dealing with a values conflict in which substance abuse or an addiction is involved is to begin with an assessment interview, during which the nurse should: (Select all that apply.)
|a.||listen for subtle signs of denial.|
|b.||directly confront the patient about his drug abuse.|
|c.||use a matter-of-fact approach to inform the patient.|
|d.||provide straightforward information.|
|e.||avoid direct confrontation.|
- Caring, according to the American Nurses Association (ANA) Code of Ethics (2001), is having concern or regard for that which affects the welfare of another. As a profession, nursing can trace its earliest beginnings to the types of nurturing activities that demonstrate care, such as: (Select all that apply.)
|b.||advocating for the vulnerable.|
|c.||valuing all individuals.|
|d.||separating healing from spirit.|
|e.||attempting to relieve pain.|
- Touch is the intentional physical contact between two or more people. It occurs so often in patient care situations that it has been deemed to be an essential and universal component of nursing care. Task-oriented touch occurs when the nurse: (Select all that apply.)
|a.||holds the patient’s hand during a painful procedure.|
|b.||gives the patient an injection to treat discomfort.|
|c.||starts an intravenous (IV) line for fluid administration.|
|d.||inserts a nasogastric tube to decompress the patient’s stomach.|
|e.||shakes the patient’s hand in order to establish rapport.|
Chapter 03: Communication
- The nurse is caring for an adult patient with a recent below-the-knee amputation. During shift report, the nurse reports that the patient has urinated in the bed multiple times since the surgery. Which defense mechanism best describes this behavior?
- A female patient is admitted to the emergency department after being raped by a neighbor. The patient refuses to discuss the circumstances surrounding the event with the sexual assault nurse examiner. This patient is most likely using the defense mechanism of:
- A patient calls the nurse to report the smell of cigarette smoke in the bathroom. The event which triggers this communication process is referred to as the:
- The nurse manager sends an e-mail to the nursing staff as a reminder for a scheduled monthly meeting. In doing so, the nurse manager understands that e-mail:
|a.||is usually slower than other methods to disseminate knowledge.|
|b.||has the potential for miscommunication.|
|c.||cannot be used to deliver vital information.|
|d.||is especially effective because of the use of nonverbal cues.|
- The nursing student has been assigned to help feed patients at lunch time. Which of these nursing interventions would be most effective when assisting a blind patient to eat a meal?
|a.||Speak loudly to ensure that the patient understands.|
|b.||Describe the food arrangement using the numbers on a clock.|
|c.||Tell the patient what is on the plate, assuming he has lost the sense of smell.|
|d.||Encourage the patient to eat faster so that the task will be done.|
- The nurse observes a confused patient pacing back and forth in the dining room. The patient yells, “The doctor is going to make us all drink poison!” The most appropriate intervention at this time would be to:
|a.||ask the patient why he would say something like that.|
|b.||change the subject to disrupt the patient’s thought process.|
|c.||tell the patient that he should probably think of something else.|
|d.||quietly ask the patient to explain the statement.|
- A patient with an inoperable brain tumor says to the nurse, “I just want to die now. It’s going to happen soon anyway.” Which of the following would be the most appropriate response?
|a.||“Don’t worry about that right now. It’ll be OK.”|
|b.||“I disagree with what you just said!”|
|c.||“Honey, now don’t you talk like that.”|
|d.||“Tell me why you are saying that.”|
- The nurse is caring for a patient with chronic lung disease. The patient demands a cigarette after eating breakfast. The nurse responds, “If that was me, I wouldn’t be asking for a cigarette. That is what has made you so sick in the first place.” This nontherapeutic communication response is an example of:
|a.||changing the subject.|
|c.||a stereotypical response.|
- What would be an acceptable personal space distance for most English-speaking persons?
- Based on a patient’s perception of professional competence and caring, the nurse should wear:
|a.||large, dangling, hoop earrings|
|b.||bright red, acrylic fingernails|
|c.||a clean, neatly pressed uniform|
|d.||offensive tattoos that cannot be covered|
- The nurse is admitting a patient with a foul smelling leg wound. Which behavior by the nurse indicates an understanding of appropriate body language?
|a.||Using hand gestures to enhance verbal communication|
|b.||Standing at the end of the bed with arms crossed|
|c.||Facial grimacing at the sight of the wound|
|d.||Gentle touching of the patient’s shoulder|
- Several nurses on a medical–surgical unit have been asked by the nurse manager to form a group and gather data regarding patient complaints of late meals. The nurses meet and establish ground rules. This phase of group development is called:
- A nurse has been working with a patient for the entire shift. Which action by the nurse is unacceptable?
|a.||Sharing a personal mobile phone number|
|b.||Touching the patient’s hand during a painful procedure|
|c.||Standing 6 feet away from the patient when conversing|
|d.||Using the SBAR method of hand-off communication|
- During a shift report, a staff member briefly describes the history of a patient admitted with chronic gastrointestinal bleeding. In which SBAR topical area would this information be presented?
- The nurse is performing an abdominal assessment on a postoperative surgical patient. The nurse notes that the dressing needs to be changed twice a day and discusses when the patient would like to have it done. The nurse then plans to change the dressing at that time. In which phase of the nurse–patient helping relationship would this process occur?
- The nurse is collaborating with a patient to determine interventions to ensure compliance with medication administration after his pending discharge. The goals and nursing interventions would be agreed upon in the:
- A patient complains that several staff members entered the room during the morning bath without knocking. Which component of professional nursing communication has been violated in this scenario?
- The nurse is caring for a patient who is unable to take oral medications because of persistent nausea and vomiting. The nurse decides to call the primary care physician and ask for a different medication administration route. This demonstrates the act of:
- The nurse is assisting a co-worker who is preparing to change a deep wound dressing on a patient’s abdomen. Several of the patient’s out-of-town friends are at the bedside watching a football game. Which action is most appropriate for the nurse to consider prior to the dressing change?
|a.||Ask the friends to leave the room.|
|b.||Pull the curtain around the bed.|
|c.||Allow visitors to stay in the room during the procedure.|
|d.||Ask the patient to turn up the volume on the television.|
- The nurse is conducting a presurgical screening interview with a patient at a local surgical center. When performing a health assessment, the primary source of information should be:
|b.||the medical record.|
|c.||a close relative.|
- A mother of a young child kicks a trashcan in anger and says to the nurse, “You just don’t understand! Why can’t the doctor find out what is wrong with my child?” This behavior is most likely an example of:
- The nurse is caring for a patient scheduled for a partial mastectomy resulting from advanced cancer. The patient tells the nurse, “I’m sure when the surgeon operates on me, he will not find any cancer in my breast. It looks just fine.” The patient is using which defense mechanism to cope with the medical diagnosis?
- A helping relationship develops through ongoing, purposeful interaction between a nurse and a patient. Nurse–patient relationships focus on: (Select all that apply.)
|c.||tearing down boundaries.|
|d.||developing a plan of care.|
- The nurse is administering a bath to a hearing-impaired patient. The nurse should: (Select all that apply.)
|a.||speak very loudly into the patient’s right ear.|
|b.||control background noise as much as possible.|
|c.||turn away when responding to a question.|
|d.||adjust the lighting in the room.|
|e.||be wary of consistent affirmative answers.|
- The nursing student is writing a report on the use of nonverbal techniques to encourage therapeutic communication. Which examples should be included in the report? (Select all that apply.)
|a.||Providing a backrub|
|c.||Avoiding distracting body movements|
|d.||Facing the patient|
Chapter 04: Critical Thinking in Nursing
- The patient is complaining of severe incisional pain 2 days after surgery. The patient has Morphine ordered intravenously or by mouth. The nurse chooses to give the medication orally. This is an example of:
- The nurse is reviewing the last 3 days of a patient’s pain history and notes that the pain level has remained constant. The nurse validates the pain level with the patient and decides to contact the physician for further orders. In this scenario the nurse is using the process of:
- The nurse has been hired for her first job and is nervous about making errors in clinical judgment. It is important for the nurse to realize that clinical reasoning and the ability to make decisions in a clinical setting:
|a.||has been instilled in the content covered in nursing school.|
|b.||is solely based in clinical experience.|
|c.||develops over time with increased knowledge and expertise.|
|d.||is an expectation of all nurses regardless of experience.|
- The nurse is taking an advanced cardiac life support (ACLS) recertification class. As part of that class, the nurse, and other nurses in the group, rotates responsibilities during multiple mock code exercises simulating cardiac arrest scenarios. The process of assigning nurses to different responsibilities is known as:
- The nurse is preparing to administer an anticoagulant when the patient says, “Why do I have these bruises on my arms?” The nurse reviews the patient’s blood tests and notes an abnormal bleeding time. Based on the findings, the nurse decides to hold the medication and notifies the health care provider. This action, by the nurse, is an example of:
|b.||reviewing the literature.|
|c.||applying knowledge .|
- The nurse is preparing to restart a patient’s intravenous line and discovers that the patient has no usable veins in either arm. To solve this problem, the nurse should:
|a.||discuss the problem with the nurse in charge.|
|b.||not start the intravenous line.|
|c.||conduct an internet search for infusion journal articles.|
|d.||contact the physician and report the concern.|
- The nurse has finished her shift and is on her way home. During the shift, one of the patients attempted to climb out of bed and fell. On her way home the nurse is thinking about what she could have done differently to prevent the fall. This is an example of using:
|c.||attributes or traits.|
- To develop critical thinking, the nurse needs to develop a critical-thinking character that includes:
|a.||developing honesty and confidence.|
|b.||learning from experiences.|
|d.||growing a “thick skin” to withstand criticism.|
- The nurse is caring for a patient scheduled for a heart catheterization. During shift report, the nurse describes an overheard telephone conversation regarding the patient’s HIV-positive son-in-law. This information should be evaluated for:
- A patient arrives at the urgent care clinic and complains of vague pains in the legs. The nurse asks the patient to describe this pain. This type of question meets the intellectual standard of precision. As with any skill, critical thinking questions:
|a.||are used to avoid repetition in providing care.|
|b.||can be enhanced through practice.|
|c.||should be based in thought and not spontaneity.|
|d.||become dull when used routinely.|
- The nurse is planning care for a group of patients. Which of the following activities may be delegated to unlicensed assistive personnel?
|a.||Analysis of the patient’s physical condition|
|b.||Morning vital signs, height, and weight.|
|c.||Evaluation of whether colostomy drainage is normal|
|d.||Determining patient readiness for postsurgical learning|
- The nurse is caring for a patient who is suspected of having early stages of dementia. The nurse observes mild confusion, short-term memory loss, and restlessness. The nurse conducts a mini-mental status exam. The nurse is using which of the following components of critical thinking?
- The nursing student is admitting a patient with abdominal distention and severe nausea. The physician orders the insertion of a nasogastric tube. The student reviews the procedure, gathers the supplies, and tells the instructor, “I’m ready to begin.” Which of the following critical thinking traits suggest that the student is prepared for the task?
- A patient has been instructed in self-administration of insulin injections. The nurse observes the patient attempting to recap the needle and realizes that further teaching is needed. The nurse is applying which critical-thinking skill of the nursing process?
- The nurse completes the health interview and physical exam on a patient admitted with an infection of the gallbladder. The nurse reviews the medical record and compares the abnormal lab results to the normal standards. Which critical thinking skill is the nurse using in this part of the nursing process?
- A patient, frequently admitted to the hospital for chronic back pain, asks the medication nurse for additional pain medication. The nurse has seen patients like this before, and “knows” that the only reason that these people come to the hospital is to get their pain medication. The nurse is demonstrating:
|d.||an erroneous assumption.|
- The nurse has received advanced orders for a patient that she is expecting to be admitted from the emergency room (ER). The patient’s name is Mr. Herman Goldstein. Trying to get ahead on her task, the nurse changes the patient’s diet from “Regular” to “Kosher.” When the patient reaches the unit, the nurse discovers that the patient is Catholic even though his father is Jewish. The nurse is guilty of giving in to:
|d.||an erroneous assumption.|
- The nursing student is observing a staff nurse demonstrating a subcutaneous injection during a skills competency fair. The student tells the nurse that nursing textbooks indicate that aspirating for blood is not necessary. The nurse replies, “I prefer to check for blood, just in case. This is the way I learned to give shots and it works for me.” The nurse’s response is most likely related to:
|d.||an erroneous assumption.|
- The nurse is preparing to teach Foley insertion techniques to a group of graduate nurses. Which of the following teaching–learning strategies would the nurse find most useful in teaching this skill?
- The nurse is administering medications to a patient with high blood pressure. The patient states, “This pill made me so sick yesterday. Are you sure I have to take it now?” The nurse should:
|a.||give the medication because no one gets sick on this pill.|
|b.||hold the medication and check the order since there may be a lack of information.|
|c.||give the medication since he/she is the nurse and knows what should be done.|
|d.||give the medication since the nurse did not see the doctor come so the order is valid.|
- A patient is admitted to a skilled nursing facility with a closed head injury. The nurse believes that the patient has been pocketing food in his cheeks during the noon meal although she has not found any food pocketed. The nurse refers the patient to the speech therapist for a swallowing evaluation. The nurse is using which critical thinking component in making this decision?
- The nurse observes that a patient who recently had an indwelling urinary catheter removed complains of burning on urination and that the urine is cloudy and foul smelling. On the basis of this assessment, the nurse may reason that the patient has a urinary tract infection (UTI). The nurse comes to this conclusion using:
|c.||intellectual thought processes (thinking).|
- When a patient is initially interviewed and assessed, the nurse must: (Select all that apply.)
|a.||analyze the patient’s psychomotor status.|
|b.||take the patient’s vital signs.|
|c.||weigh the patient using a bed scale.|
|d.||evaluate the patient’s emotional and spiritual needs.|
|e.||ensure the coordination of the patient’s care.|
- Professional nursing requires a commitment to lifelong learning because: (Select all that apply.)
|a.||treatment modalities and technology continue to advance.|
|b.||there are always new things to memorize and store in memory.|
|c.||nurses are expected to update and maintain competency.|
|d.||critical thinking is essential in nursing.|
|e.||nursing school gives the nurse all he/she needs to be competent.|
- The nurse has been practicing for several years and has become the unofficial leader, with newer nurses going to her for advice about patient care. They are amazed at how much the older nurse “thinks like a nurse.” In order to “think like a nurse,” the nurse must: (Select all that apply.)
|a.||be a nurse for several years.|
|b.||be able to apply knowledge in making clinical decisions.|
|c.||actively participate in the process.|
|d.||accept procedures that have been in place for years as right.|
|e.||develop a questioning attitude.|
Chapter 05: Introduction to the Nursing Process
- The nursing process is the foundation of professional nursing practice. As such, the nursing process can be defined as:
|a.||The framework that nurses used to provide care.|
|b.||A complex process during which nurses think about their thinking.|
|c.||The process that allows nurses to collect essential data.|
|d.||Thinking like a nurse in developing plans of care.|
- The term nursing process was first used in 1955. In 1973, the American Nurses Association identified five specific steps of the process. The essential step that was added in 1991 is:
- The nursing process is cyclic rather than linear. Because of the cyclic nature, as an individual patient’s condition changes:
|a.||The nurse’s thought processes do not have to vary.|
|b.||Plans of care are easier to use and do not need modification.|
|c.||The accuracy and effectiveness of thought processes must be considered.|
|d.||Reflective thought is not necessary since issues tend to be repetitive.|
- The charge nurse is discussing a patient’s care plan during a team meeting. The team determines that the patient has not met the goal of “ambulating to the nurse’s station twice a day” and decides to revise the plan. Which of the following characteristics of the nursing process most represents this decision?
- The nurse is caring for a patient who will be discharged home following surgical repair of a broken shoulder. The patient tells the nurse, “I don’t have anyone at home who can help me cook my meals. Is there something you can do?” Demonstrating the adaptability of the nursing process, the nurse should:
|a.||adjust the patient’s care plan so that nursing goals can be met.|
|b.||consult the care provider about extending the patient’s hospitalization.|
|c.||abandon the plan of care as not able to be done.|
|d.||contact the social worker about community services.|
- The community health nurse is applying the nursing process to the care of patients with coronary artery disease. The nurse determines that most of the patients eat high-fat meals from the local fast-food restaurant and plans a nutrition workshop. The nurse is applying the nursing process characteristic of:
- The nursing student is caring for a patient admitted with severe anemia. The patient receives two units of packed red blood cells and tells the student, “I am feeling so much better. I’m not so tired anymore and can bathe myself.” The student reviews the patient goal “report an increase in activity tolerance” and concludes that the patient’s goal has been met and adjusts the patient’s plan of care. This is an example of nursing process:
- The nurse is completing the health history on a patient admitted for cardiac rehabilitation. The health history is conducted in which step of the nursing process?
- The nurse is assisting a patient to bed when the patient says, “My chest hurts and my left arm feels numb. What’s wrong with me?” What is the type and source of data obtained from the patient’s complaint?
|a.||Objective data from a primary source|
|b.||Objective data from a secondary source|
|c.||Subjective data from a primary source|
|d.||Subjective data from a secondary source|
- Which of the following is a correctly written nursing diagnosis appropriate for a patient’s plan of care?
|a.||Ineffective airway clearance related to excessive secretions as evidenced by diminished breath sounds.|
|b.||Imbalanced nutrition: less than body requirements.|
|c.||Impaired physical mobility related to contractures.|
|d.||Risk for suffocation related to smoking in bed as evidenced by absent breath sounds.|
- The nurse is admitting a patient experiencing chest discomfort and shortness of breath. The patient also has a history of stroke. The nurse documents the nursing diagnosis “Risk for stroke related to history of stroke.” The risk factor for this patient is:
|b.||history of stroke.|
|d.||shortness of breath.|
- A patient with a congenital heart defect is admitted for further testing. The nurse observes the patient has increased shortness of breath and is restless. The nurse is demonstrating which phase of the nursing process?
- During a patient’s bath, the nurse observes the patient having a tonic clonic seizure. The nurse immediately turns the patient to a side-lying position. The nurse is demonstrating which phase of the nursing process?
- The nurse is caring for a patient diagnosed with Lyme disease. The patient tells the nurse, “My heart seems to be skipping some beats. My doctor told me to let the nurse know if this happens since it might be a complication of my disease.” The nurse auscultates the heart and confirms the palpitations. Which step of the nursing process does the nurse’s action demonstrate?
- In which step of the nursing process does the nurse prioritize the nursing diagnoses and identify interventions to address the patient goals?
- The nurse writes a short-term goal for a patient scheduled for surgery in the morning. The goal that contains all of the necessary elements is:
|a.||The patient will walk to the bathroom within 48 hours after surgery.|
|b.||The patient will walk to the bathroom without experiencing shortness of breath within 48 hours after surgery.|
|c.||The patient will walk to the bathroom without experiencing shortness of breath.|
|d.||The patient will walk to the bathroom without experiencing shortness of breath after surgery.|
- A new community health nurse observes that a patient has generalized itching and a red rash after touching a latex glove. The nurse asks the manager if there is a document written by the physician for this type of reaction. The nurse is referring to a:
- All nursing interventions that are implemented for patients must be documented or charted. Proper documentation of interventions:
|a.||facilitates communication with all members of the health care team.|
|b.||are only considered “legal” if documented in the paper chart.|
|c.||leads to errors of omission and repetition of care.|
|d.||does not directly measure goal achievement or outcomes.|
- The nurse makes the following entry on the patient’s care plan: “Goal not met. Patient refuses to walk and states, ‘I’m afraid of falling.’” The nurse should:
|a.||ignore the patient’s concern in evaluating goal attainment.|
|b.||document the patient’s unwillingness to continue the plan of care.|
|c.||continue the plan of care as originally agreed upon.|
|d.||modify the care plan in response to the patient’s condition and wishes.|
- The nurse is demonstrating how to correctly perform deep breathing and coughing exercises to a patient scheduled for back surgery. Which step of the nursing process is the nurse addressing?
- The nurse develops a list of nursing diagnoses for a patient receiving intravenous chemotherapy for breast cancer. The patient tells the nurse, “I understand that I will lose most of my hair. Will it grow back?” Which of the following diagnoses will have the highest priority?
|a.||Disturbed body image|
|c.||Risk for bleeding|
|d.||Imbalanced nutrition: less than body requirements|
- The nurse is gathering data on a patient with acute bacterial pneumonia. This is an example of which step of the nursing process?
- Which of the following statements would be considered objective data? (Select all that apply.)
|a.||“I’m short of breath.”|
|b.||“Blood pressure 90/68, apical pulse 102, skin pale and moist.”|
|c.||“Lung sounds clear bilaterally, diminished in right lower lobe.”|
|d.||“I feel weak all over when I exert myself.”|
|e.||“My pain level is down to 2. It was 8.”|
- The nurse is attempting to develop nursing diagnoses for her patient. The nurse understands that nursing diagnoses: (Select all that apply.)
|a.||identify actual or potential problems as well as responses to a problem.|
|b.||require naming patient problems using nursing diagnostic labels.|
|c.||utilize objective data since subjective data are often inaccurate.|
|d.||includes unvalidated data to determine an accurate and thorough diagnosis.|
|e.||are similar to medical diagnoses since they both are labels for diseases.|
- Establishing short- and long-term goals to address nursing diagnoses involves: (Select all that apply.)
|a.||discussion with the patient.|
|b.||exclusion of family with making patient decisions.|
|c.||collaboration with other members of health care team.|
|d.||making the health care provider as the central figure.|
|e.||coordination of care as collaborative care.|
Chapter 06: Assessment
- The nurse is caring for a patient with pneumonia. The patient is a retired soldier who served in World War II. In light of this, the nurse should:
|a.||shake the patient’s hand and allow the patient time to “warm up.”|
|b.||expect the patient to be optimistic and question everything.|
|c.||allow the patient to multitask and talk in short “sound bites.”|
|d.||understand that the patient is probably technologically literate.|
- The patient interview consists of three phases: orientation (introductory), working, and termination. Each phase contributes to the development of trust and engagement between the nurse and the patient. During the orientation phase of the interview, the nurse should:
|a.||obtain demographic data using open-ended questions.|
|b.||establish the name by which the patient prefers to be addressed.|
|c.||gather general information using closed-ended questions.|
|d.||stand by the bedside to ask the needed questions.|
- A nurse is conducting a health interview on a newly admitted patient. To establish a trusting relationship with the patient, the nurse:
|a.||avoids eye contact to appear less threatening.|
|b.||demonstrates professionalism by not smiling.|
|c.||sits close and leans in slightly toward the patient.|
|d.||speaks in a slow rate of speech and low tone.|
- The nurse is assigned the admission health history and physical for a patient diagnosed with a fever of unknown etiology. The patient tells the nurse, “I just don’t feel good. I’m so hot and I feel sick to my stomach. Can you ask me those questions later?” The best response by the nurse is:
|a.||“It will not take too long. I can hurry.”|
|b.||“We need the information to complete your admission paperwork.”|
|c.||“I will come back in a few minutes and we can start over.”|
|d.||“Let me see if you can have something for the nausea and then talk later.”|
- The nurse is using a stethoscope to assess a patient’s cardiac status. This assessment technique is known as:
- The nurse is performing an assessment of a patient’s right kidney. The nurse bluntly strikes the area of the costovertebral angle while observing the patient’s reaction. The physical assessment technique being used is:
- The nurse is performing a physical exam on a patient diagnosed with liver failure resulting from chronic alcoholism. The nurse notes that the abdomen is swollen and decides to assess for abdominal skin tenderness and temperature. Which of the following techniques would the nurse use to collect this data?
- The triage nurse in a hospital emergency department is determining the order of care for several patients. Which of the following would the nurse consider as having the highest priority?
|a.||A 68-year-old patient suffering from dehydration and disorientation|
|b.||A 14-year-old patient having respiratory distress and increasing anxiety|
|c.||A 46-year-old patient with multiple cuts and abrasions to the upper extremities|
|d.||A 38-year-old patient with a broken right hip and in severe pain|
- The morning nurse is assigned to care for a patient admitted during the night with rectal bleeding. When making rounds, the nurse observes that the patient’s face is ashen in color and the skin is cool and clammy. The nurse auscultates the patient’s heart and lungs. Which category of physical assessment is the basis for the nurse’s response?
- The nurse is performing her initial assessment of the day when she notices that the patient has a facial droop that he did not have yesterday and that was not reported in the hand-off report from the night nurse. The nurse proceeds to assess the neurological status of the patient. This type of assessment is known as:
|a.||an emergency assessment.|
|b.||a focused assessment.|
|c.||a complete physical examination.|
|d.||a comprehensive assessment.|
- The nurse is documenting data collected during a health assessment interview. Which statement indicates subjective data?
|a.||“My last bowel movement was 4 days ago.”|
|b.||Abdomen distended; firm and tender.|
|c.||Dark colored; hard pellet-shaped stool.|
|d.||Color pink. Skin warm and dry. No sign of discomfort.|
- A patient is transported to the emergency room from a local skilled nursing facility and admitted for a bacterial blood infection. The nurse reviews the transferring physician notes, which indicate that the patient has dementia. The nurse contacts the patient’s son for additional health history information. Information provided by the son would be considered:
|a.||primary, objective data.|
|b.||primary, subjective data .|
|c.||secondary, objective data.|
|d.||secondary, subjective data.|
- The nurse is monitoring the blood sugar results of a patient receiving an intravenous nutritional supplement. The patient tells the nurse, “I have never had sugar problems before. My doctor says it is because I am getting this sugar water.” These types of data are considered:
|a.||primary, objective data.|
|b.||primary, subjective data.|
|c.||secondary, objective data.|
|d.||secondary, subjective data.|
- The unlicensed nursing assistive person (UAP) reports to the nurse that a patient is crying during a comedy show on television. The nurse’s best response should be:
|a.||“Maybe the patient doesn’t think the show is funny.”|
|b.||“Don’t worry about it. Her daughter says this is normal.”|
|c.||“I will go visit her right away and see what is going on.”|
|d.||“Just document what you observe in your notes.”|
- A patient with moderate lower back pain tells the nurse, “My urine smells awful and is as dark as my glass of tea.” Which action will assist in validating the patient’s concern?
|a.||Ask the patient to describe the back pain.|
|b.||Review the lab results of the most recent urinalysis.|
|c.||Request the nursing assistant to obtain a set of vital signs.|
|d.||Check the patient’s history for urinary tract infections.|
- The nurse is attempting to get the patient to sign the operative consent. When asked if the health care provider explained the procedure to the patient, the patient replies “Not much.” The nurse should:
|a.||develop a comprehensive teaching plan related to the surgical procedure.|
|b.||ask the patient what information the doctor has explained about the surgery.|
|c.||contact the surgeon and ask for further clarification of information given to patient.|
|d.||focus on postoperative exercises and home-care following surgery.|
- After the patient’s data are collected, validated, and interpreted, the nurse organizes the information in a framework (format) that facilitates access by all members of the health care team. The framework that provides the most holistic view of the patient’s condition is:
|a.||the head-to-toe pattern|
|b.||Marjory Gordon’s Functional Health Patterns.|
|c.||the cephalic-caudal pattern.|
|d.||the body systems model.|
- The wound care nurse is assessing a non-healing leg wound on a patient recently admitted for uncontrolled diabetes. The nurse organizes the data using Gordon’s Functional Health Pattern of:
|a.||nutrition and metabolism.|
|b.||activity and exercise.|
|c.||sleep and rest.|
- During the health history interview, the patient tells the nurse, “Just walking to the mailbox and back makes my calves ache. Is this normal?” Which of the following frameworks would the nurse most likely choose to document this data?
|b.||Gordon’s Functional Health Patterns|
|c.||Body systems model|
- An in-depth health history: (Select all that apply.)
|a.||includes demographic data.|
|b.||lists the patient’s allergies.|
|c.||contains the family history of diseases.|
|d.||explains the patient’s health promotion practices.|
|e.||is completed only once and can be recalled electronically.|
- The nurse is admitting a patient for uncontrolled diabetes mellitus. The nurse suspects that the patient could benefit from diabetic teaching. To corroborate her suspicion, during the patient interview the nurse: (Select all that apply.)
|a.||determines the patient’s cognitive ability and potential language barriers.|
|b.||gathers information about what the patient already knows about diabetes.|
|c.||Attempts to determine the need for referrals and education.|
|d.||Formulates the patient’s plan of care using a standard protocol.|
|e.||Prepares to teach the patient using materials written at a third-grade level.|
- The nurse is preparing to begin a physical examination for a patient with open lesions on the lower extremities. Which should the nurse evaluate during the physical assessment? (Select all that apply.)
|a.||Blood test results|
|c.||Recent vital signs|
|d.||Patient’s health history|
- The charge nurse is planning vital sign assignments for the unlicensed assistive personnel (UAP) on a busy medical–surgical unit. Which patients are appropriate for the UAP to obtain vital signs? (Select all that apply.)
|a.||A 28-year old patient scheduled to be discharged home today|
|b.||A 49-year-old patient with stable chronic lung disease|
|c.||A 78-year-old patient with recent onset of rectal bleeding|
|d.||A 35-year-old patient waiting for transfer to a rehabilitation center|
|e.||A 40-year-old patient being admitted from the emergency department|
- Which of the following examples given indicate objective data? (Select all that apply.)
|a.||Respirations – 24 breaths per minute|
|b.||Platelet count – 350,000 mm3|
|c.||Wound size – 3 cm X 2 cm|
|d.||Temperature – 98.4° F (36.8° C)|
|e.||Complaints of severe abdominal pain.|
- Patient-centered care requires the nurse to: (Select all that apply.)
|a.||understand patient preferences|
|b.||be aware of family values|
|c.||recognize the patient’s expectations|
|d.||base conclusions on the nurse’s personal experiences|
|e.||provide care in a standardized manner|
Chapter 07: Nursing Diagnosis
- The nurse completes a health and physical assessment on a patient admitted with a fractured pelvis. Which of the following tasks should the nurse do next?
|a.||Analyze and cluster the assessment information.|
|b.||Formulate a nursing diagnosis addressing actual issues.|
|c.||Determine the need for potential nursing diagnoses.|
|d.||Create health promotion diagnoses for the patient.|
- A group of patients in a community center attend a nursing-led information session on the risks of contracting tuberculosis. After the presentation several patients ask the nurse for additional web-based resources regarding the lung disease. Which type of nursing diagnosis would the nurse choose for the community care plan?
- A nurse completes a care plan for an assigned patient diagnosed with an inflammation of the pericardium. Which diagnosis written on the plan indicates a need for further instruction on using the nursing process?
|c.||Risk for decreased cardiac output|
- North American Nursing Diagnosis Association International (NANDA-I) is an organization focusing on revising nursing diagnosis taxonomy and evaluates nursing research to validate the diagnostic labels. The NANDA-I taxonomy and new nursing diagnoses are published every:
- A patient is receiving an experimental drug for leukemia. The nurse is worried that the drug may cause a reduction in platelets leading to intestinal tract bleeding. Which type of nursing diagnosis should the nurse use to address this concern?
- The nurse is writing the care plan for a patient admitted to the hospital for complications associated with muscular dystrophy. Which nursing diagnoses written on the care plan indicate a need for further instruction in constructing the diagnostic statement?
|a.||Constipation related to immobility as manifested by lower extremity weakness.|
|b.||Activity intolerance related to weakness as evidenced by verbal report of fatigue.|
|c.||Feeding self-care deficit related to fatigue as manifested by inability to swallow food.|
|d.||Ineffective airway clearance related to muscle weakness.|
- Nursing students are analyzing the following nursing diagnostic statement during a study group session. Acute pain related to pressure on lumbar spinal nerves as evidenced by a pain level of 9, patient verbalizations of pain, and grimacing when walking. The students would be correct if they stated that the etiology of the patient’s problem is:
|a.||patient verbalizations of pain.|
|c.||pressure on lumbar spinal nerves.|
|d.||grimacing when walking.|
- The nurse is caring for a patient diagnosed with blood clots in the right lower extremity. The admitting physician orders bed rest. The patient tells the nurse, “I usually exercise three times a week. It helps me go to the bathroom.” The nurse determines that the patient may have difficulty with bowel movements. Which nursing diagnosis statement accurately reflects the nurse’s concern?
|a.||Constipation related to bed rest as manifested by hard, dry stools.|
|b.||Perceived constipation resulting from patient’s expectation manifested by patient statement.|
|c.||Risk for constipation related to immobility as manifested by verbal complaint.|
|d.||Risk for constipation related to insufficient physical activity.|
- The nursing student is reviewing the components of a nursing diagnosis. Which statement made by the student indicates correct understanding of a health-promotion diagnostic statement?
|a.||“The defining characteristics will include the patient’s willingness to get better.”|
|b.||“The risk factors are only psychological in nature, not physical.”|
|c.||“The health-promotion diagnostic statement is composed of three parts.”|
|d.||“An example of a health-promotion label is ineffective community coping.”|
- The nurse is reviewing assessment findings on a patient admitted with an extremely slow heart rate. The patient complains of dizziness, shortness of breath, chest pain, and fainting spells. Vital signs are blood pressure of 98/60 mm Hg and pulse of 52 beats/minute. Oxygen saturation is 88%. Which action should the nurse perform next?
|a.||Exclude all subjective data in favor of objective data.|
|b.||Focus on data gathered during the physical assessment.|
|c.||Evaluate the data looking for patterns and related data.|
|d.||Dismiss family members input as “hearsay.”|
- The nurse is admitting a patient with severe dehydration. Assessment data reveal a decreased blood pressure, an increased pulse rate, and a low circulating blood volume. The student observes that the patient is confused and restless. Which patient information would the nurse consider as a contributing factor when choosing the nursing diagnostic label?
|a.||Blood pressure, pulse rate|
|b.||Blood pressure, pulse rate, blood volume|
|c.||Blood pressure, pulse rate, blood volume, mental status|
|d.||Blood pressure, pulse rate, blood volume, mental status, dehydration|
- The nurse is reviewing data obtained through the health history interview and physical assessment of an assigned patient. Data collected include dry skin, brittle nails, weight gain, thinning hair, constipation, prolonged menstruation, and the patient’s complaints of feeling tired and cold. Which statement represents an appropriate data cluster?
|a.||Prolonged menstruation, constipation|
|b.||Dry skin, brittle nails, weight gain|
|c.||Tired, cold, thinning hair|
|d.||Constipation, weight gain|
- The nurse in an outpatient clinic obtains a blood pressure of 190/88 mm Hg on a patient diagnosed with high blood pressure. The patient tells the nurse, “My blood pressure medicine is really expensive. Do you think I really need it?” The nurse assumes the patient is not taking the medication based on the blood pressure result and the patient’s statement and chooses noncompliance as a diagnostic label. The action by the nurse is an example of:
|a.||clustering unrelated data in the diagnostic statement.|
|b.||selecting erroneous data for use in the diagnostic statement.|
|c.||using medical diagnoses in the diagnostic statement.|
|d.||identifying multiple problems within one diagnostic statement.|
- The nurse is developing a plan of care for a patient with gastritis and an inflammation of the intestines. The patient is complaining of severe abdominal discomfort and nausea. The patient also reports having restless leg syndrome and an inability to urinate. As a problem statement of the nursing diagnosis, the nurse should write:
|a.||Gastritis related to inflammation.|
|b.||Alterations in comfort and ability to void.|
|c.||Abdominal pain and nausea related to inflammation.|
|d.||Alteration in comfort related to restless leg syndrome and inflammation.|
- The nursing student submits a care plan to the nursing instructor for a review prior to implementing the nursing interventions. Which of the following nursing diagnostic statements is written incorrectly?
|a.||Ineffective coping related to inadequate support systems as evidenced by patient’s verbalization, “I don’t have any friends or family in town. I just moved here a week ago.”|
|b.||Activity intolerance related to immobility as manifested by shortness of breath and patient’s verbalization of fatigue.|
|c.||Insomnia and knowledge deficit related to stress as evidenced by patient report of difficulty sleeping and lack of energy.|
|d.||Self-care deficit bathing related to upper extremity weakness as manifested by inability to wash body.|
- When creating a nursing diagnosis, the related factor:
|a.||should be based on the medical diagnosis.|
|b.||in unrelated to the pathophysiology with which the patient is dealing.|
|c.||is the underlying etiology of the patient’s situation.|
|d.||does not reflect the nurse’s understanding of pathophysiology.|
- The nurse is caring for a complex patient needing physical and emotional support. As the primary care giver, the nurse:
|a.||is ultimately responsible for assessment of patient needs and progress.|
|b.||delegates to people who know what they are doing and operate independently.|
|c.||provides total care to the patient after getting direction from other disciplines.|
|d.||understands that the patient is ultimately responsible for failure or success.|
- The nurse has identified several problems for a patient scheduled for a bone marrow transplant. By formulation of nursing diagnoses, the nurse:
|a.||embraces “cook book medicine” and rejects professional autonomy.|
|b.||uses a language that is difficult to interpret by legislators.|
|c.||is able to communicate with other nurses but not other disciplines.|
|d.||facilitates communication of patient needs and promotes accountability.|
- The nurse is developing a plan of care for a patient who has had a stroke. Assessment findings include weakness in right upper and lower extremities, numbness in face, slurred speech, and headache. Which of the following would best represent the etiology of the patient’s gait and balance problems?
|a.||Lack of muscle motor movement|
|b.||Decreased sensation to touch|
|c.||Inability to speak clearly|
|d.||Pain in back of head|
- The nurse is caring for a Vietnamese-American admitted to the intensive care unit as a result of malnutrition. The patient is unable to walk because of his malnutrition, and he has developed a pressure ulcer from lying in bed constantly without changing positions. The family believes that the patient is depressed and that is why he stopped getting up. When planning this patient’s care, the nurse should:
|a.||develop multiple nursing diagnoses.|
|b.||develop only one nursing diagnosis to aid in focusing.|
|c.||focus on the physical issues facing this patient.|
|d.||deal primarily with the patient’s psychological needs.|
- The nurse is creating a care plan for a patient admitted with severe bone pain related to an infected leg wound. Which diagnosis written on the plan indicates an understanding of the components of a nursing diagnosis? (Select all that apply.)
|b.||Risk for impaired walking|
|c.||Ineffective bone tissue perfusion|
- The nurse is caring for a patient admitted to the psychiatric unit as a result of an overdose of cocaine. Which nursing diagnosis indicates an understanding of a nursing diagnostic statement? (Select all that apply.)
|a.||Ineffective breathing pattern related to drug effect on the respiratory center|
|b.||Risk for injury related to hallucinations|
|d.||Chronic confusion related to excessive stimulation of nervous system as evidenced by impaired socialization|
- A patient is admitted to the emergency room after experiencing severe chest pain and difficulty in taking deep breaths. The patient anxiously tells the nurse, “My father died suddenly of a heart attack at the age of 52. I’m so scared.” Which nursing diagnoses are appropriate for this situation? (Select all that apply.)
|c.||Risk for aspiration|
|d.||Risk for infection|
- A group of nursing students is discussing the importance of accurately selecting nursing diagnoses. Which of the following are reasons for choosing the diagnoses carefully? (Select all that apply.)
|b.||Positive patient outcomes|
|c.||Quality patient care|
|d.||Help develop standardized care plans|
|e.||Determine appropriate interventions|
- The nurse has requested an order to place a patient on suicide watch. Which data noted in the health assessment led the nurse to this conclusion? (Select all that apply.)
|a.||Threats of killing oneself|
|c.||History of prior suicide attempt|
|e.||Stable heart rhythm|
Chapter 08: Planning
- The nurse is caring for a patient who has undergone abdominal surgery. The patient stated prior to surgery that “I don’t think I’ll be able to handle this if I get a colostomy. I wouldn’t know how to manage it.” There is no “next of kin” listed in the patient’s record. The patient is complaining of severe surgical pain. The nurse is correct when addressing which nursing diagnosis first?
|b.||Alteration in body image|
|d.||Risk for falls|
- Setting priorities among identified nursing diagnoses is the first step in the planning process. The nurse is responsible for:
|a.||monitoring patient responses.|
|b.||carrying out the physician’s plan of care.|
|c.||providing all interventions.|
|d.||preventing interference from other disciplines.|
- Which assessment made by the nurse should be addressed first?
|a.||Reddened area to coccyx|
|b.||Decreased urinary output|
|c.||Shortness of breath|
|d.||Drainage from surgical incision|
- Which should the nurse address first?
|d.||Absence of pulse|
- The nurse has a thorough understanding of the planning phase of the nursing process when stating:
|a.||“Patients should be included in the planning process.”|
|b.||“Patient families should not interfere in the planning process.”|
|c.||“The planning process should focus on short-term goals only.”|
|d.||“Planning is the first phase of the nursing process.”|
- Goals are broad statements of purpose that describe the aim of nursing care. As such, goals:
|a.||are considered short term if achieved within a month of identification.|
|b.||always have established time parameters, such as “long-term” or “short-term.”|
|c.||are mutually acceptable to the nurse, patient, and family.|
|d.||can be vague to facilitate evaluation of achievement.|
- In developing the nursing care plan, the nurse creates goals:
|a.||with the patient and possibly the family.|
|b.||that the nurse wants the patient to achieve.|
|c.||and actions needed to accomplish the goal.|
|d.||that are aggressive to ensure success.|
- Which statement is correct regarding diversity considerations?
|a.||The male gender may struggle less with health care terminology.|
|b.||High numbers of minority populations do not understand health teachings.|
|c.||Older adults have an easier time understanding health teachings because of life experience.|
|d.||Disabilities have no impact on the development of patient care goals.|
- Which of the following is a correctly written example of a short-term goal?
|a.||By attending the gym, the patient will lose 50 lb in 1 year.|
|b.||In 6 months, patient will be able to ambulate 1 mile without shortness of breath.|
|c.||Patient will be able to change his colostomy bag within 6 weeks of surgery.|
|d.||With diet and exercise, the patient will lose 1 lb this week.|
- Which goal is written correctly for the nursing diagnosis of activity intolerance related to imbalance between oxygen supply and demand?
|a.||Patient will walk 1 mile without shortness of breath.|
|b.||Patient will ambulate 100 feet with no shortness of breath on third day after treatment.|
|c.||Patient will climb stairs without shortness of breath by day 2 of hospital stay|
|d.||Patient will tolerate activity.|
- The nurse recognizes which of the following as a barrier to achieving goals?
|a.||The effects of pain and/or clinical depression|
|b.||Patient involvement in setting patient goals|
|c.||Family involvement in setting patient goals|
|d.||Realistic expectations of the patient’s capabilities.|
- The nurse is caring for a patient who has had abdominal surgery but has developed a slight temperature. A patient-centered goal would be:
|a.||the patient’s temperature will return to normal within 24 hours.|
|b.||the nurse will medicate the patient for surgical pain every 4 hours.|
|c.||skin integrity will be maintained until the patient is ambulatory.|
|d.||the patient will ambulate 10 feet by post-op day 2.|
- An example of a measurable goal would be:
|a.||“The patient will be able to lift 10 lb by the end of week one.”|
|b.||“The patient will be able to lift weights by the end of the week.”|
|c.||“The patient will be able to lift his normal weight amount.”|
|d.||“The patient will be able to life an acceptable amount of weight by week one.”|
- The nurse is formulating the patient’s care plan. In determining when to evaluate the patient’s progress, the nurse is aware that evaluations:
|a.||must be done at the end of every shift.|
|b.||should be done at least every 24 hours.|
|c.||depend on intervention and patient condition.|
|d.||are always done at time of discharge.|
- The nurse knows that standardized care plans may be available and:
|a.||need to be individualized for each patient.|
|b.||are implemented without adjustment.|
|c.||remove the need for nurse involvement.|
|d.||do not require the use of nursing diagnoses.|
- Nursing interventions that originate from the physician or primary care provider orders are:
|d.||Nursing Interventions Classifications|
- Medication administration is what type of nursing intervention?
- Dependent nursing interventions include:
|a.||ordering heel protectors.|
|d.||administer antipyretic medications as appropriate.|
- Physical therapy, home health care, and personal care are examples of:
|b.||dependent nursing interventions.|
|c.||independent nursing interventions.|
- Discharge planning begins:
|a.||the day before discharge.|
|c.||prior to admission.|
|d.||day of discharge.|
- The nurse is accurate when stating that adequate discharge planning:
|a.||“May decrease the incidence of patients required to return to the hospital.”|
|b.||“Increases complications and readmissions in most cases.”|
|c.||“Adapts to the situation as the patient’s conditions changes.”|
|d.||“Should begin as soon as the patient is discharged home.”|
- The significance of developing organized plans of care for patients cannot be stressed enough. In the planning phase, the nurse must take seriously the responsibility of: (Select all that apply.)
|a.||prioritizing patient needs.|
|b.||developing mutually agreed-on goals.|
|c.||determining outcome criteria.|
|e.||implementation of the patient’s plan of care.|
- The nurse is formulating a plan of care for a patient. In this phase of the nursing process, the nurse: (Select all that apply.)
|a.||prioritizes nursing diagnoses.|
|b.||determines short and long-term goals.|
|c.||identifies outcome indicators.|
|d.||lists nursing interventions.|
|e.||gathers assessment data.|
- Patients should be included in the planning process. Involving patients in planning their care helps them to: (Select all that apply.)
|a.||be aware of identified needs.|
|b.||accept that not all goals are measurable.|
|c.||embrace mutually agreed-on goals.|
|d.||feel a sense of empowerment.|
|e.||overcome unrealistic goals.|
- Measurable goals are: (Select all that apply.)
|d.||easy to judge|
Chapter 09: Implementation and Evaluation
- Which of the following is a direct care intervention?
|a.||Administration of an injection|
|b.||Making the change-of-shift report|
|c.||Collaborating with members of the health care team|
|d.||Ensuring availability of needed equipment|
- The nurse manager is creating the patient assignment for today. She has five registered nurses (RNs), two licensed practical nurses (LPNs), and five nurse technicians (NAs) scheduled. When making the assignment, the nurse manager needs to remember that:
|a.||RNs are responsible for all care delegated to unlicensed nursing personnel.|
|b.||delegation is considered direct intervention for patient care.|
|c.||LPNs operate independently and may delegate patient care.|
|d.||nursing practice is clearly delineated and is standard across the country.|
- The nurse is preparing to administer medications to a patient. The patient is complaining of shortness of breath. The nurse should:
|a.||provide the patient with oxygen since it does not require a provider order.|
|b.||complete at least two checks to ensure that the proper medication is given.|
|c.||check the provider orders for all forms of prescription medications.|
|d.||remember that medication administration is an independent nursing action.|
- After the nurse completes a patient’s initial assessment and develops a plan of care:
|a.||continual reassessment of the patient is required.|
|b.||no changes to the care interventions should be allowed.|
|c.||reassessment should be done randomly.|
|d.||the nursing process becomes static to maintain the course of the cure.|
- The male nurse is caring for a female patient who needs a complete bed bath. The patient requests that a female nurse bathe her. The male nurse recognizes this request as an example of:
|a.||gender diversity involving generational norms or cultural considerations.|
|b.||life span diversity.|
- The nurse is providing care for a patient of the Jehovah’s Witness faith. Based on the nurse’s knowledge of the patient’s religious beliefs, the nurse would question which of the following orders?
|a.||Obtain vital signs every shift|
|b.||Regular diet as tolerated|
|c.||Activity as tolerated|
|d.||Infuse 1 unit packed red blood cells|
- The nurse is caring for a patient with blindness. When reviewing the care plan, the nurse notes which of the following goals need to be modified?
|a.||The patient will report any drainage from the wound with a foul odor to the primary care provider after discharge.|
|b.||The patient will agree to report pain promptly while hospitalized.|
|c.||The patient will obtain no injuries while in the hospital.|
|d.||The patient will report any wound drainage with a purulent appearance to the primary care provider after discharge.|
- The registered nurse is providing an independent nursing intervention when:
|a.||administering oral medications.|
|c.||providing emotional support.|
|d.||administering intravenous medication.|
- The nurse recognizes which of the following as appropriate teaching for the patient who is returning from surgery?
|a.||Signs and symptoms of infection|
|b.||Use of patient-controlled analgesia|
|c.||Activity limitations upon discharge|
- The nurse is learning to identify readiness to learn in patients. Which one of the following patients would the nurse identify correctly as ready to learn?
|a.||The patient requesting pain medication for treatment of severe discomfort|
|b.||The patient with nausea and vomiting|
|c.||The patient who learned 30 minutes ago that she has cancer of the pancreas|
|d.||The patient who was recently diagnosed with diabetes mellitus and is scheduled to be discharged in 2 days|
- The nurse is considering asking the patient for permission to involve the patient’s family members in the teaching plan for the patient. Which of the following is the best rationale to support this involvement?
|a.||Involving the family in effective teaching empowers the patient and their support system.|
|b.||Teaching family members decreases the number of questions they may ask.|
|c.||Educated family members choose not to become part of the health care process.|
|d.||The education is interesting although family do not usually care for patients after discharge.|
- Change of shift report, collaboration with other health care members, and ensuring availability of needed equipment are examples of:
- The nurse correctly identifies which one of the following referrals as an inappropriate nursing referral?
|c.||Adaptive care services|
- In implementing research-based interventions, the nurse realizes that:
|a.||implementation of evidence-based care is unique to the nursing profession.|
|b.||evidence-based practice is based entirely in nursing research.|
|c.||evidence-based care is focused on practices and not outcomes.|
|d.||nurses must read recent literature and remain current in practice|
- The nurse has many roles. One is to support and work on behalf of patients for whom he/she has concern. This role is known as:
|b.||primary care provider.|
- Which of the following cannot be delegated?
|a.||Obtaining vital signs|
|b.||Assessment of lung sounds|
|c.||Bathing a patient|
|d.||Ambulating a patient|
- The five rights of delegation include:
|a.||right task, right circumstance, right person, right direction, and right supervision|
|b.||right medication, right route, right time, right patient, and right dose|
|c.||right task, right route, right patient, right direction, and right medication|
|d.||right role, right job, right task, right need, and right dose|
- Repositioning a patient, providing hygiene, and active listening are examples of:
|b.||independent nursing interventions.|
- The patient has an order for morphine sulfate 2 mg intravenously prn (as needed) every 2 hours. When the nurse administers this medication, she is providing:
|a.||an independent nursing intervention.|
|b.||a dependent nursing intervention.|
|d.||an indirect care procedure.|
- Documentation is a vital nursing role since the patient’s health record:
|a.||should be completed accurately and in a timely manner.|
|b.||should not be computerized (EHR) because of disclosure risks.|
|c.||is not a legal document although they can be helpful in lawsuits.|
|d.||cannot be used in determining billing and reimbursement issues.|
- The final phase of the nursing process is evaluation, which focuses on:
|a.||recording the care that was implemented.|
|b.||medical and nursing goals for the welfare of the patient.|
|c.||long-term goals only.|
|d.||the patient responses to interventions and outcomes.|
- During the evaluation phase of the nursing process, the nurse realizes that the patient’s short-term goals have not been met. The nurse should:
|a.||revise or adapt the plan of care.|
|b.||assume that the patient did not want to achieve his goals.|
|c.||understand that a plan of care is almost never changed.|
|d.||reassess plans of care only after major patient–nurse interactions.|
- The nursing process is an attempt to meet patient needs. As such, it:
|a.||is linear in nature.|
|b.||is dynamic and cyclic.|
|c.||requires care plans to be re-evaluated occasionally.|
|d.||does not allow care plans to be modified.|
- Of the following interventions, which are prevention oriented? (Select all that apply.)
|b.||Cleansing an incision|
|c.||Cardiac education related to risk factor modification|
|d.||Placing infants prone when they sleep|
|e.||Teaching patients to ask their physicians to wash their hands|
- Of the following skills, which is considered an invasive procedure? (Select all that apply.)
|a.||Administering oral medications|
|b.||Starting an intravenous (IV) line|
|c.||Repositioning the patient.|
|d.||Inserting a urinary catheter.|
Chapter 10: Documentation, Electronic Health Records, and Reporting
- Accurate documentation by the nurse is necessary since proper documentation:
|a.||is needed for proper reimbursement.|
|b.||must be electronically generated.|
|c.||does not involve e-mails or faxes.|
|d.||is only legal if written by hand.|
- Which of the following is true regarding nursing documentation?
|a.||Standards for documentation are established by a national commission.|
|b.||Medical records should be accessible to everyone.|
|c.||Documentation should not include the patient’s diagnosis.|
|d.||High-quality nursing documentation reflects the nursing process.|
- The medical record:
|a.||serves as a major communication tool but is not a legal document.|
|b.||cannot be used to assess quality of care issues.|
|c.||is not used to determine reimbursement claims.|
|d.||can be used as a tool for biomedical research and provide education.|
- Paper records are being replaced by other forms of record keeping because:
|a.||paper is fragile and susceptible to damage.|
|b.||paper records are always available to multiple people at a time.|
|c.||paper records can be stored without difficulty and are easily retrievable.|
|d.||paper records are permanent and last indefinitely.|
- The nurse is charting in the paper medical record. She should:
|a.||print his/her name since signatures are often not readable.|
|b.||not document her credentials since everyone knows that she is a nurse.|
|c.||skip a line, leaving a blank space, between entries so that it looks neater.|
|d.||use black ink unless the facility allows a different color.|
- The nurse is admitting a patient who has had several previous admissions. In order to obtain a knowledge base about the patient’s medical history, the nurse may use the:
|a.||electronic medical record (EMR).|
|b.||the computerized provider order entry (CPOE).|
|c.||electronic health record (EHR).|
|d.||American Recovery and Reinvestment Act.|
- The use of electronic health records:
|a.||improves patient health status.|
|b.||requires a keyboard to enter data.|
|c.||has not been shown to reduce medication errors.|
|d.||requires increased storage space.|
- The nurse is caring for patients on unit that uses electronic health records (EHRs). In order to protect personal health information, the nurse should:
|a.||allow only nurses that she knows and trusts to use her verification code.|
|b.||not worry about mistakes since the information cannot be tracked.|
|c.||never share her password with anyone.|
|d.||be aware that the EHR is sophisticated and immune to failure.|
- Nursing documentation is an important part of effective communication among nurses and with other health care providers. As such, the nurse:
|b.||documents how he/she feels about the care being provided.|
|c.||documents in a “block” fashion once per shift.|
|d.||double documents as often as possible in order to not miss anything.|
- Nursing documentation is guided by:
|a.||the Nursing process|
|b.||the North American Nursing Diagnosis Association (NANDA) diagnoses.|
|c.||Nursing Interventions Classification.|
|d.||Nursing Outcomes Classification|
- PIE, APIE, SOAP, and SOAPIE are:
|b.||examples of problem-oriented charting.|
|d.||forms of “charting by exception.”|
- A type of charting that records only abnormal or significant data is:
|d.||charting by exception.|
- The nurse is preparing to administer medications to the patient. Prior to doing so, she/he compares the provider orders with the:
- The nurse is caring for a patient for the first time and needs background information such as history, medications taken at home, etc. The best central location to obtain this information is the:
- The nurse is charting using paper nursing notes. The nurse is aware that:
|a.||attorneys are not allowed access to medical records during litigation.|
|b.||when mistakes are made in documentation, the nurse should scribble out the entry.|
|c.||only one nurse should document on a sheet so that it can be removed in case of error.|
|d.||the medical record is the most reliable source of information in any legal action.|
- The nurse is charting using electronic documentation. With electronic documentation:
|a.||errors can be corrected and totally removed from the record in the screen view.|
|b.||log-on access to the electronic record identifies the person charting.|
|c.||each entry requires the nurse to sign her/his name and credentials.|
|d.||documenting significant changes in the electronic record ends the nurse’s responsibility.|
- How should the nurse correct an error in charting?
|a.||remove the sheet with the error and replace it with a new sheet with the correct entry.|
|b.||scribble out the error and rewrite the entry correctly.|
|c.||draw a single line through the error, and then write “error” above or after the entry|
|d.||leave the entry as is and tell the charge nurse.|
- If a verbal or phone order is necessary in an emergency, the order:
|a.||must be taken by an RN or LPN.|
|b.||must be repeated verbatim to confirm accuracy.|
|c.||documented as a written order.|
|d.||does not need further verification by the provider.|
- The process of making a change-of-shift report (handoff):
|a.||is an uncommon occurrence of little importance.|
|b.||occurs only at change of shift and only to oncoming nurses.|
|c.||can lead to patient death if done incorrectly.|
|d.||does not allow for collaboration or problem solving.|
- The patient has fallen when trying to climb out of bed. The nurse:
|a.||needs to complete an incident report as a risk management document.|
|b.||completes an incident report since it is a permanent part of the medical record.|
|c.||must document that an incident report was completed in the medical record.|
|d.||should say nothing about the incident in the medical record.|
- Expected nursing documentation includes: (Select all that apply.)
|b.||the care plan.|
|c.||critique of the physician’s care.|
|e.||patient responses to care.|
- Nurses must be aware of the danger of using abbreviations that may be misunderstood and compromise patient safety. The Joint Commission has compiled a list of do-not-use abbreviations, acronyms, and symbols to avoid the possibility of errors that may be life threatening. Of the following, which are acceptable? (Select all that apply.)
- Standardized nursing terminologies such as the North American Nursing Diagnosis Association–International (NANDA-I) nursing diagnoses, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) may be used in the documentation process. Use of standardized language: (Select all that apply.)
|b.||improves communication among nurses while excluding non-nurses.|
|c.||increases the visibility of nursing interventions.|
|d.||enhances data collection.|
|e.||supports adherence to care standards.|
- The nurse is charting using the DAR charting system. This form of charting requires documentation about: (Select all that apply.)
|a.||the patient problems.|
|c.||any actions initiated.|
|e.||the patient’s response to interventions.|
- The Health Insurance Portability and Accountability Act (HIPAA) mandates that health information can be shared: (Select all that apply.)
|a.||In order to provide treatment for the patient.|
|b.||To determine billing and payment issues.|
|c.||To enhance health care operations related to the patient.|
|d.||In public areas such as the cafeteria or elevator.|
|e.||Over the telephone with any family member|
Chapter 11: Ethical and Legal Considerations
- Nurses are consistently considered to be honest and ethical professionals by most respondents in an annual Gallup poll. This is because professional nurses understand that ethics are:
|a.||internal values developed outside the influence of societal norms.|
|b.||influenced by family, friends, and socioeconomics, among other variables.|
|c.||societal in nature and do not involve personal influences.|
|d.||totally independent from a person’s character.|
- The nurse is providing patient care and pays special attention to meeting the needs of the patient while maintaining the patient’s right to privacy, confidentiality, autonomy, and dignity. This nurse is applying what ethical theory?
- The nurse is caring for a patient recently diagnosed with cancer that is being asked to participate in a new chemotherapy trial. How would the nurse respond if working under the ethical principle of utilitarianism?
|a.||“The patient should be allowed to decide.”|
|b.||“As your nurse, I’ll support your right to refuse.”|
|c.||“You should do this because many could benefit from it.”|
|d.||“If this is against your beliefs, you should not do it.”|
- The nurse realizes that a medication error has been made. The nurse then reports the error and takes responsibility to ensure patient safety despite personal consequences. This nurse has exhibited:
- The nurse is providing care for a patient who has had a stroke recently and has multiple self-care deficits. The nurse is coordinating care with in-home agencies and arranging for the delivery of needed equipment. What ethical concept is being applied?
- A nurse has been asked to care for a patient who is an inmate from a nearby prison. During shift report, the nurse asks, “Why was the man convicted and imprisoned?” Another nurse responds that this is not important since nurses are required to provide compassionate care for all people in all circumstances. The responding nurse has displayed what concept?
- The nurse is providing care to a patient experiencing pain. The nurse assesses the pain and promptly administers the ordered analgesics as promised to the patient. This nurse has applied:
- “First, do no harm” defines what ethical principle?
- The nurse is caring for a patient whose family does not want the patient to be told about the new diagnosis of cancer because of the poor prognosis. Keeping this secret from the patient is in direct conflict with the ethical concepts of:
|a.||autonomy and veracity.|
|b.||veracity and advocacy.|
|c.||justice and nonmaleficence.|
|d.||confidentiality and justice.|
- The Code of Ethics for Nurses is:
|a.||like the Constitution and not revisable.|
|b.||a succinct statement of ethical obligations.|
|c.||required by entry level nurses only.|
|d.||a negotiable document dependent on individual conscience.|
- Which of the following statements indicates an appropriate understanding by the student nurse (SN)?
|a.||“I will be held to the same ethical standards as professional nurses.”|
|b.||“I will not be held ethically accountable until I graduate.”|
|c.||“My nurse educators are responsible for my ethical standards.”|
|d.||“Ethics are not important as a student.”|
- The nurse is caring for a patient who has been belligerent and is in four-point “leather” restraints. The patient is verbally abusive and still tries to kick and punch staff even though he is restrained. The nurse should:
|a.||ignore the patient’s needs until he “calms down.”|
|b.||strike the patient if necessary to protect herself/himself.|
|c.||continue to attempt to meet the patient’s needs.|
|d.||threaten the patient with retaliation if he doesn’t stop.|
- Which one of the following actions by the nursing student would be considered uncivil?
|a.||Prompt arrival to class|
|b.||Texting during class|
|d.||Active participation in class|
- The nurse is providing end-of-life care. It is essential for the nurse to:
|a.||tell the patient what he might like to hear to relieve anxiety.|
|b.||begin making health care decisions for the patient.|
|c.||provide the patient with the nurse’s personal opinions.|
|d.||offer unconditional support for the patient and family.|
- The nurse frequently cares for patients who are nearing the end of life. A strategy that is designed to prolong the time of death rather than restoring life is:
|a.||establishing a do-not-resuscitate (DNR) order.|
|b.||adherence to living will requests.|
|c.||removal of extraordinary measures already in place.|
|d.||continuance of futile care.|
- In the nursing profession, ethical issues:
|a.||are rare occurrences, but take a great deal of time to resolve.|
|b.||have required The Joint Commission to mandate ethics committees.|
|c.||most frequently lead to legal intervention in patient care matters.|
|d.||lead to ethics committees made up entirely by nurses.|
- Each state has a nurse practice act that establishes the standards of care required for legal nursing practice. In order to protect herself/himself from litigation, the nurse should understand that:
|a.||laws create liability issues for nurses.|
|b.||licensure laws are devised to protect the nurse.|
|c.||the nurse is not responsible for other disciplines’ mistakes.|
|d.||keeping current with changing laws can protect the nurse.|
- Practicing nursing without a license is a:
- Starting an intravenous (IV) infusion line on a patient against his will may be classified as:
- The nurse is caring for a patient who has had many admissions and readmissions. The nurse believes that the patient keeps coming to the hospital because the patient “wants his drugs,” and is “non-compliant” at home with his diabetic therapy. To reduce the risk of slander against this patient, the nurse should:
|a.||write observations and opinions in the medical record only.|
|b.||never share observations.|
|c.||make judgmental statements only when necessary.|
|d.||Avoid stating judgmental statements.|
- The nurse is providing care for a patient who demands discharge from the hospital against the physician’s orders. In order to remove liability from the institution and the physician, the nurse has the patient review and sign the:
|a.||Against Medical Advice form.|
|b.||Code of Academic and Clinical Conduct.|
|c.||Nursing Code of Ethics.|
|d.||Informed consent form.|
- The nurse has been involved sexually with a patient. This is considered an act of:
- State legislatures give authority to administrative bodies, such as state boards of nursing, to:
|a.||create statutory laws.|
|b.||establish regulatory laws.|
|c.||try case law cases.|
|d.||create laws based on social mores.|
- Which of the following nurses has committed a serious documentation error?
|a.||Susan documents all medications for her patients prior to administration.|
|b.||Jim documents medication administration as the medications are given.|
|c.||Jane documents assessments as they are completed.|
|d.||Jon documents meal intake as he picks up meal trays.|
- Who is ultimately responsible for explaining the content of the informed consent?
|a.||The registered nurse|
|b.||The hospital social worker|
|c.||Educated family members|
|d.||The provider of the procedure|
- Which law protects health care professionals from charges of negligence when providing emergency care at the scene of an accident?
|a.||Good Samaritan Act|
- In addition to maintaining current professional practice knowledge, competent practice skills, and professional relationships with patients and their families, nurses should: (Select all that apply.)
|b.||follow legal guidelines for sharing information.|
|c.||block document once per shift.|
|d.||change nursing procedures according to latest journal articles.|
|e.||meet licensure and continuing education requirements.|
- Which statements are correct regarding informed consent and someone who requires an interpreter? (Select all that apply.)
|a.||A professional interpreter is needed.|
|b.||A family member may interpret when convenient.|
|c.||Detailed medical information remains a priority.|
|d.||Professional interpreters are not effective in providing medical information.|
|e.||If necessary, family members can make decisions regarding informed consent.|
- Health care providers are required to supply patients with written information regarding their rights to make medical decisions and implement advance directives, which consist of three documents. Which of the following are considered “advanced directives”? (Select all that apply.)
|b.||Durable power of attorney|
|c.||Health care proxy|
|d.||Patient’s Bill of Rights|
|e.||The Uniform Anatomical Gift Act|
Chapter 12: Leadership and Management
- The terms leadership and management are often used interchangeably. Although these concepts are related, they are different in definition and in practice. Leadership behaviors and management skills complement each other. However,
|a.||managers focus on relationships.|
|b.||a manager may not possess leadership traits.|
|c.||leadership focuses on coordinating and directing others.|
|d.||a manager is a visionary who sets the direction for a group.|
- The nurse correctly defines leadership when stating:
|a.||“Leadership is coordinating others toward a common goal.”|
|b.||“Leadership is the ability to influence others.”|
|c.||“Leadership focuses on the task at hand.”|
|d.||“Leadership is based in formal authority.”|
- The nurse is acting as a leader in the role of charge nurse and notes that the unlicensed assistive personnel (UAP) on the floor are stressed related to their increased workload. The nurse changes the original planned approach based on the presenting situation. What theory of leadership is being implemented?
- The unit charge nurse uses reward and punishment to gain the cooperation of the nurses assigned to the unit. What type of leader is this charge nurse?
- The nurse manager of a unit is sharing the most recent results of a patient satisfaction survey to motivate staff. This nurse manager is a _________________leader.
- The nurse manager is considered a “great communicator.” She can be found on the unit talking with staff, keeping them informed and asking their opinions. She believes that her nurses are motivated by internal means and that they want to participate in making decisions about the unit although the final decision always rests with her. This nurse manager is what type of leader?
- Upon entering a patient’s room, the nurse notes that the patient is unresponsive. The nurse takes control and begins to direct other members of the health care team during this crisis. This style of leadership is:
- A patient is found unresponsive and pulseless. The nurse begins cardiopulmonary resuscitation (CPR) and calls for help. When help arrives, the nurse should take on the role of:
- The nurse has made patient care assignments and expects all team members to set their own goals for the day and manage their time to meet their goals. The nurse is implementing what style of leadership?
- The nurse manager of the emergency room believes that efficiency is the expected standard for her department. She also believes that efficiency lies in following established rules, policies, and guidelines. The only way to change procedures is to changes rules, policies, and guidelines. In order to run the emergency room with this philosophy, the nurse manager must take on the role of:
- The manager of the intensive care unit is accepting an award for excellence and efficiency in the provision of patient care. The manager accepts the award for the unit and cites the contributions of her staff since, without their expertise and dedication, the award may not have been achieved. The manager is demonstrating the quality of:
- The nurse leader is conducting a staff meeting. During the meeting, staff members have verbalized dissatisfaction with the staffing pattern created by the nurse leader. The nurse listens intently as the staff come up with other options. The nurse leader is demonstrating:
- The nurse is acting in the planning function as a manager. Which of the following stages should be completed first?
|a.||Set the plan|
|b.||Assess the situation and future trends|
|c.||Convert plan into action statement|
|d.||Set the goals|
- According to Fayol, controlling is a function of management. Controlling compares to what phase of the nursing process?
- Hiscock and Shuldham state that, in order to deliver quality care, it is important for nurse leaders to be focused on the:
- Communication skills are most essential for the nurse:
|a.||when they become nurse managers.|
|b.||except when delegation is required.|
|c.||to decrease nurse–family interaction.|
|d.||to obtain information from patients.|
- For patient care to be completed in a safe and timely manner, it is sometimes necessary for the nurse to delegate tasks to other health care providers. The ANA describes delegation as:
|a.||a transfer of authority to a less-qualified individual.|
|b.||the nurse transferring accountability to the delegate.|
|c.||the transfer of tasks by the nurse while retaining accountability.|
|d.||transferring responsibility for assessments and planning.|
- Which of the following was delegated inappropriately?
|a.||Personal hygiene by the UAP|
|b.||Assistance with eating breakfast by the UAP|
|c.||Assistance with toileting by the UAP|
|d.||Interpretation of abnormal vital signs by the UAP|
- Which of the following has been done improperly?
|a.||The UAP re-delegates vital signs to the student nurse.|
|b.||The RN delegates assistance with bathing to the student nurse.|
|c.||The RN delegates monitoring of intake and output to the UAP.|
|d.||The RN delegates assistance with mobility to the UAP.|
- The leadership theory that assumes that leaders are born with certain leadership skill that few people possess is known as:
- A nurse does not have to be a manager to be a leader. Even at the bedside, nurses use leadership skills, although possibly in different ways than a nurse manager. The nurse who plans, organizes, delivers, and evaluates nursing care for patients is functioning as a:
|a.||patient care provider.|
|d.||clinical nurse leader.|
- An effective manager must: (Select all that apply.)
|a.||understand the concepts of budgeting.|
|b.||run a unit efficiently without regard to cost.|
|c.||be able to staff the unit effectively.|
|d.||be adept at information management.|
|e.||achieve desired outcomes in any way possible.|
- When delegating to other health care providers, the nurse understands that the task: (Select all that apply.)
|a.||must be within the scope of the person to whom it is being delegated.|
|b.||is one that can be delegated to other health care providers.|
|c.||can be delegated whenever assessments are required.|
|d.||may be re-delegated by the person to whom it was first delegated.|
|e.||may require the nurse to procure resources to complete the task.|
- The nurse has a question regarding scope of practice and delegation. Where should the nurse seek clarification? (Select all that apply.)
|a.||The state’s Nurse Practice Act|
|b.||Theory X management|
|c.||Nurse’s Code of Ethics|
|d.||The NCSBN website|
|e.||NCSBN journal articles|
- Mintzberg described management in terms of behaviors. Mintzberg’s decisional roles include: (Select all that apply.)
Chapter 13: Evidence-Based Practice and Nursing Research
- Testing the application of theories in different situations with different populations is considered to be:
- The American Nurses Association (ANA) standards of professional performance require nurses to use research findings in practice. This means that nurses:
|a.||need to regulate their practice according to the latest journal articles.|
|b.||nurses need to use the best available evidence to guide practice decisions.|
|c.||nurses only need to participate in research while in advanced practice.|
|d.||may use evidence-based practice to develop procedures but not policies.|
- The nurse is reviewing a research study that includes data in the form of numbers. This study is likely what type of study?
- In practice, the nurse has identified an observable phenomenon and wants to conduct research to generate a hypothesis through observation of the situation. The best way for the nurse to conduct this type of investigation would be to conduct a:
|a.||correlational research study.|
|b.||experimental research study.|
|c.||descriptive research study.|
|d.||quasi-experimental research study.|
- The nurse is conducting a qualitative research study. Qualitative research:
|a.||is based on a constructivist philosophy.|
|b.||assumes that reality is the same for everyone.|
|c.||is deductive in nature and approach.|
|d.||proceeds from specific facts to generalizations.|
- The nurse is conducting a quantitative research study. Quantitative research:
|a.||assumes that reality is fixed and stable.|
|b.||is based on an inductive approach.|
|c.||seeks to gain knowledge through observation.|
|d.||usually produces data in narrative format.|
- The nurse is preparing to conduct a research study and is interested in exploring the lived experiences of nurses responsible for approaching patients and family members about the donation of organs. This type of research would be considered:
- The nurse has identified a research problem. What is the next step for this student?
|a.||Conduct a literature review.|
|b.||Address ethical procedures.|
- The nurse is conducting a literature review to determine the statistical results of all related studies. This type of review is known as:
|b.||an integrative literature review.|
|c.||a systematic review.|
|d.||grounded theory research.|
- In researching the effectiveness of an antihypertensive medication, the nurse knows that the medication would be the _________________ variable and the person’s blood pressure would be the ____________________ variable.
- While conducting a controlled research study, the nurse wants greater assurance that the result is due to treatment itself and not another factor. For this purpose, the researcher should include:
|a.||a treatment group.|
|b.||an independent variable.|
|c.||a dependent variable.|
|d.||a control group.|
- An institutional review board (IRB) is a review committee established to:
|a.||approve research involving animal subjects.|
|b.||approve research that is not government funded.|
|c.||function differently than scholarly journals do.|
|d.||protect the rights of human research subjects.|
- The nurse is preparing to conduct a study involving the “post-prandial” blood sugars in patients who have received intensive diabetic rehabilitation versus diabetics undergoing “usual care.” In order for the consent to be valid, the nurse would have to:
|a.||change the language of the consent.|
|b.||keep explanations to a minimum to reduce stress.|
|c.||keep potential risks undisclosed.|
|d.||insist that the participant sign the consent right away.|
- The nurse researcher audiotaped interviews with subjects and would like to play these tapes during dissemination. What steps might this require?
|a.||Inform the participants that they cannot hear the tapes beforehand.|
|b.||None, if the tape is of a group, since there is no expectation of anonymity.|
|c.||None, since the tape is a direct “quote” and voice recognition is not controllable.|
|d.||A release will need to be obtained from the subjects.|
- A human subject is defined as a living individual about whom an investigator conducting research obtains:
|a.||data without direct or indirect interaction or intervention.|
|b.||information that is not expected to be made public.|
|c.||no diagnostic information and does not manipulate the subjects environment.|
|d.||information without any communication/contact during the research.|
- The nurse is ready to analyze the data obtained through a qualitative study. What approach to data analysis should the nurse use?
|c.||Coding of themes|
- The nurse correctly devises a dissemination plan at what point during the research process?
|a.||Conclusion of the study|
|b.||After the literature review|
|c.||The beginning of the research process|
|d.||While conducting research|
- When applying research to practice, the nurse finds that:
|a.||it is usually easy to access information at the bedside.|
|b.||research articles are clear in defining nursing practice.|
|c.||bedside care is not directly related to research.|
|d.||nursing research should be used to improve care.|
- The acronym PICO assists in remembering the steps to constructing a good research question. The “O” in the acronym stands for:
- The third phase of evidence-based research involves:
|a.||searching for evidence and evaluating.|
|b.||assessing the problem.|
|c.||developing a question.|
|d.||performing a critical appraisal.|
- If the nurse is trying to determine the best treatment or course of action and wants to incorporate the most reliable evidence into the decision, the nurse will use a filtered resource such as:
- Florence Nightingale is noted to have provided the initial basis for evidence-based practice (EBP). She did this by: (Select all that apply.)
|a.||basing her work in trial and error as well as observation.|
|b.||using statistical data as a basis for improvements.|
|c.||applying statistical methods such as “pie charting” to display results.|
|d.||focusing on bedside care and ignoring nursing education.|
|e.||publishing the first EBP journal.|
- Barriers to the use of evidence-based practice (EBP) include: (Select all that apply.)
|a.||nurses critiquing research.|
|b.||difficulty communicating how to conduct EBP.|
|c.||the copious amount of literature available.|
|d.||the short time between research and practice.|
|e.||the reluctance of organizations to fund research.|
- Nurses use the new information in their practice. In the process of implementing EBP, the nurse: (Select all that apply.)
|a.||develops clinical questions.|
|b.||creates workshops and in-services.|
|c.||seek answers to support the clinical decision.|
|d.||applies finding to patients.|
|e.||publishes a bulletin.|
- A Magnet hospital is characterized by: (Select all that apply.)
|a.||excellent medical outcomes.|
|b.||a high level of nursing job satisfaction.|
|c.||a low number of grievances.|
|d.||nursing care leading excellent patient outcomes.|
|e.||a high nurse turnover rate.|
Chapter 14: Health Literacy and Patient Education
- The unique ability of the patient to understand and integrate health-related knowledge is known as:
|b.||formal patient education.|
|c.||informal patient education.|
- The patient is reportedly well educated and employed as an engineer, but is struggling to comprehend terms found in health-related literature given to explain his disease process. This is evidence of:
|c.||affective domain deficiency.|
|d.||low health literacy.|
- To teach effectively, nurses must recognize that:
|a.||age and socioeconomic status play a large role in understanding.|
|b.||90% of Americans possess rudimentary literary skills.|
|c.||the ability to comprehend is a very new concept in health care.|
|d.||most health care teaching is effective and understood.|
- As the health care community explores the concept of health literacy, many organizations recognize that:
|a.||consumers need to understand has no governmental support.|
|b.||improvements are dependent on developing operational definitions.|
|c.||low literacy and low health literacy are interchangeable terms.|
|d.||interest in effective patient education is unique to the United States.|
- The nurse is preparing to discharge a patient home. In providing instruction about the patients medications, the nurse should state:
|a.||“Before taking Metoprolol, you need to take your BP and rate.”|
|b.||“MS should be taken only when needed for pain.”|
|c.||“Take 1 baby aspirin by mouth every morning.”|
|d.||“Take your water pill bid and you should be fine.”|
- The nurse has established a teaching plan including goals. This type of education is termed:
- The nurse is admitting a patient who has cystic fibrosis. During the admission interview, it is apparent that the patient is well versed in most aspects of his illness. When asked about where he learned so much, the patient responds, “I learned most of it myself. I looked things up on the Internet and read books. You have to know what’s wrong with you to be sure that you’re being treated right.” This is an example of:
- During patient teaching led by the nurse with goals established through cooperation of the nurse and patient, the patient asks questions as needed and the nurse answers. This is known as:
|c.||both formal and informal teaching.|
- The nurse is implementing a patient teaching plan regarding diabetes mellitus. One of the short-term goals of the plan is that the patient will be able to verbalize three symptoms of hypoglycemia. This is an example of:
- The nurse is working with a diabetic patient, and is attempting to teach psychomotor skills. This is occurring when the nurse has the patient:
|a.||verbally describe his feelings about diabetes.|
|b.||answer three of five true-or-false questions about diabetes.|
|c.||identify 3 positive lifestyle changes to manage blood sugar.|
|d.||draw up and self-inject insulin correctly.|
- The nurse is preparing to teach a patient for the first time and needs to evaluate the health literacy of the patient. She uses the VARK assessment to:
|a.||assess the learning styles of the patient.|
|b.||find the one method that the patient uses to learn.|
|c.||be sure that the patient is a unimodal learner.|
|d.||reduce the need for creating a collaborative learning plan.|
- The nurse is preparing to teach a 90-year-old patient. In teaching an elderly patient, the nurse realizes that:
|a.||most elderly patients are highly literate.|
|b.||cognitive abilities always decline with age.|
|c.||sensory alterations often occur with aging.|
|d.||teaching methods are the same as for the middle aged.|
- Which of the following patients would most likely need to have adjustments made to the education plan for discharge because of role function?
|a.||A 67-year-old married female who lives with her retired husband|
|b.||A 32-year-old single mother of a toddler following hysterectomy.|
|c.||A 13-year-old who lives at home with his parents after appendectomy|
|d.||A 50-year-old married mother with 2 child in college and teenager at home|
- The nurse is preparing to provide preoperative teaching to a patient who is deaf. To ensure proper learning, the nurse may:
|a.||use printed materials.|
|b.||provide unamplified recorded materials.|
|c.||use a family member to interpret.|
|d.||place an interpreter behind the patient.|
- The nurse is preparing to teach a 5-year-old child postoperative care that will be anticipated after a tonsillectomy. The nurse should:
|a.||use pictures and simple words to describe care to the patient.|
|b.||teach the parents alone to reduce fear in the patient.|
|c.||exclude the parents to reduce parental anxiety.|
|d.||use clear simple explanations to convey information.|
- The nurse is preparing a teaching plan and is applying evidence-based practice. To promote involvement, the nurse must:
|a.||provide the latest professional literature to the patient.|
|b.||ensure that the patient understands relevant information.|
|c.||use only one teaching method to reduce confusion.|
|d.||not review previously learned information.|
- In determining patient goals, the nurse should:
|a.||allow patients to identify what is most important to them.|
|b.||take the lead and determine what is best for the patient.|
|c.||should focus on health promotion and staying healthy.|
|d.||explain the importance of avoiding complications.|
- Ongoing evaluation of patient education occurs by:
|a.||each member of the health care team who provides teaching.|
|b.||the nurse who evaluates the patient’s physical abilities.|
|c.||the patient stating that he understands the instruction.|
|d.||not allowing review so the focus remains forward.|
- In addressing patient education, the nurse recognizes that patient education is a process involving: (Select all that apply.)
|d.||implementation and evaluation.|
|e.||reliance on evidence-based practice (EBP).|
- According to the Healthy People 2020 initiative, health information and the associated access issues have become more complicated. There are many considerations when determining whether an individual has proficient health literacy. The patient should be able to: (Select all that apply.)
|a.||read and identify credible health information.|
|b.||recognize abnormalities on an x-ray.|
|c.||navigate complex insurance programs.|
|d.||evaluate EKG findings.|
|e.||advocate for appropriate care.|
- In preparing to teach the patient, the nurse must consider: (Select all that apply.)
|e.||readiness to learn.|
- The nurse is to teach an 84-year-old Spanish-speaking patient newly diagnosed with diabetes how to self-administer insulin. The patient has hearing and visual impairments. In order to be effective as a teacher, the nurse should: (Select all that apply.)
|a.||assess reading level and learning style.|
|b.||determine readiness to learn.|
|c.||use family members as interpreters.|
|d.||provide written instruction in English.|
|e.||place the patient in group classes.|
- When teaching children, the nurse should: (Select all that apply.)
|a.||exclude the children from teaching.|
|b.||encourage parents or caregivers to be present.|
|c.||use age-specific strategies.|
|d.||consider the stages of development.|
|e.||remember that parents are not the targets of the teaching.|
- The nurse must provide patient education to a patient who has just been told by the patient that he has stage III lung cancer. The patient is complaining of chest and bone discomfort. Before providing the needed education, the nurse should: (Select all that apply.)
|a.||draw the curtain in the semi-private room.|
|b.||medicate the patient to ease his pain.|
|c.||place the patient in a private room if possible.|
|d.||perhaps wait until later in the day.|
|e.||keep the room dark to provide solitude.|
- On completion of assessment, a nursing diagnosis relevant to the educational needs of the patient or caregiver can be determined. Diagnoses specifically related to patient education include: (Select all that apply.)
|b.||readiness for enhanced knowledge.|
|e.||alteration in elimination.|
Chapter 15: Nursing Informatics
- The integration of nursing, computers, and information science for the management and communication of data, information, knowledge, and wisdom is:
- The hospital has recently implemented computer charting. The computerization of nursing practice:
|a.||enhances and increases the time spent on documentation.|
|b.||makes patient data immediately available to the health care team.|
|c.||makes retrieval of data more difficult but safer.|
|d.||is enhanced by limiting the use of point-of-care technology.|
- Nurses working surrounded by computers and mobile IT must develop skills in the use of all available technology. At the same time, it is important to recognize that:
|a.||the technology in use today will be the same tomorrow.|
|b.||cell phones are not usually allowed in the acute care setting.|
|c.||most forms of mobile technology are in violation of HIPAA guidelines.|
|d.||the technology supports bedside and remote charting.|
- The home health nurse provides care for a patient with congestive heart failure. Daily the patient weighs himself and takes his own temperature, pulse, respirations and blood pressure. That information is sent as electronic data to the patient’s physician and nurse daily to make adjustments to the plan of care as indicated. This is an example of:
|b.||computerized decision support system (DSS).|
|c.||computerized provider order entry (CPOE).|
|d.||point of care technology.|
- Information technology (IT) can be used to increase patient safety. The nurse uses IT in this way by:
|a.||creating redundancy in orders making them safer.|
|b.||removing the need for verification by the nurse.|
|c.||analyzing errors to develop prevention strategies.|
|d.||eliminating the need for bar codes in medication administration.|
- When technology such as a bar-code medication administration (BCMA) system is used as part of the process of medication administration, fewer errors are made. The proper procedure when using the BCMA includes:
|a.||signing into the system using the patient’s ID number.|
|b.||typing in the patient’s name and room number.|
|c.||scanning the patient’s ID, MAR, and medication.|
|d.||discontinuing the medication if the system signals an error.|
- Computerized provider order entry (CPOE) allows orders to be directly communicated to the appropriate department. Other advantages of CPOE include:
|a.||decrease in number of transcribing errors.|
|b.||enhanced provider acceptance because of new technology.|
|c.||decreased work flow issues in general.|
|d.||less dependence on technology and computers.|
- When using electronic medical records (EMR), the nurse knows that the EMR:
|a.||holds the documentation of a single episode of care.|
|b.||is a longitudinal record of care for each patient.|
|c.||is widely used for individual health care encounters.|
|d.||includes progress notes for all disciplines.|
- Computerized provider order entry (CPOE):
|a.||allows orders to be communicated to the appropriate department.|
|b.||creates an intermediary for order transcription.|
|c.||slows documentation and provider communication.|
|d.||may lead to increased ordering and transcription errors.|
- The nurse is providing care to a patient newly diagnosed with multiple sclerosis. The patient expresses the desire to communicate with other people living with the disorder. The nurse appropriately refers the patient to:
|a.||an e-mail list with the patient’s contacts.|
|b.||a social media blog.|
|c.||a listserv concerning multiple sclerosis.|
|d.||Facebook, Twitter, and LinkedIn.|
- The nurse can see data relationships, can make judgments based on trends and patterns in the data, is skilled in information management and the use of computer technology, and is able to suggest areas for IT system improvement. The nurse’s level of informatics competency can be described as:
- The director of nursing on a medical–surgical floor has met education and experience requirements in nursing informatics. The nurse might expect administration to request that he/she pursue:
|c.||certification from ANCC.|
- Patients frequently seek sources for health information online, and nurses, as advocates, need to be prepared to help patients evaluate online sources. To do this, the nurse asks who sponsors the site, is the author listed, and the author’s credentials. The nurse is evaluating what?
- The patient asks the nurse about how to evaluate websites and standards used to evaluate Internet health sites. The nurse appropriately refers the patient to:
|a.||World Health Organization.|
|b.||the U.S. Food and Drug Administration.|
|c.||the Internet Healthcare Coalition.|
|d.||the U.S. Federal Trade Commission.|
- One classification system for nursing informatics competencies uses technical, utility, and leadership categories. Leadership competencies involve:
|a.||maintaining privacy and confidentiality.|
|b.||using computers and other technological equipment.|
|c.||using a variety of software programs.|
|d.||addressing critical thinking applications.|
- The Computer Ethics Institute has developed guidelines for ethics in the development and use of computer technologies. These guidelines are called:
|a.||the Ten Commandments of Computer Ethics.|
|b.||the eHealth Code of Ethics.|
|d.||the Internet Healthcare Coalition.|
- The focus of nursing informatics is:
|a.||direct patient care.|
|b.||increasing documentation time.|
|c.||the introduction of different EHRs.|
|d.||how patient care can be improved.|
- While adopting new technology to enhance patient care and safety, nurses can continue to provide:
|c.||self-management of wellness.|
|d.||education about health care.|
- The use of telemonitoring offers the opportunity to: (Select all that apply.)
|a.||reduce cost of health care.|
|b.||improve patient satisfaction.|
|c.||increase duplicate orders.|
|d.||improve patient outcomes.|
- The Technology Informatics Guiding Education Reform (TIGER) initiative identified a set of skills needed by all nurses practicing in the 21st century. The TIGER Vision Pillars include: (Select all that apply.)
|a.||management and leadership.|
|b.||certification by HIMSS.|
|c.||communication and Collaboration.|
|e.||IT policy and culture.|
- In reviewing a patient’s written chart, the nurse notes the use of the terms “bed sore,” “decubitus ulcer.” And “pressure ulcer.” The nurse knows in order to reach maximum potential in computerized charting and data analysis that a standardized nursing terminology must be utilized. In an attempt to standardize nursing terminology: (Select all that apply.)
|a.||The Nursing Minimum Data Set (NMDS) was the first attempt to do so|
|b.||The focus was to provide a shared understanding of patient problem labels.|
|c.||The NMDS data was completed and is the definitive source of patient labels.|
|d.||The ICNP was developed to provide a standard for international nurses.|
|e.||Standardized terminology can lead to better utilization of resources.|
- The Health Insurance Portability and Accountability Act (HIPAA) of 1996: (Select all that apply.)
|a.||requires the user to have verification codes.|
|b.||ensures access to information without fear of audits.|
|c.||sets the standards on how information is maintained.|
|d.||sets the penalties for any breach in security of health data.|
|e.||has no legal authority relative to security issues.|
Chapter 16: Health and Wellness
- The World Health Organization defines health as
|a.||the absence of disease.|
|b.||the lack of infirmity.|
|d.||being independent of fiscal responsibility.|
- Several models exist that describe the relationship between health and wellness. The model used to understand the interrelationship between elements of basic requirements for survival and the desires that drive personal growth and development and is represented as a pyramid is:
|a.||Maslow’s hierarchy of needs.|
|b.||Health Belief Model.|
|c.||Health Promotion Model.|
|d.||Holistic Health Model.|
- The nurse is developing a plan of care for a patient with a hip fracture. In order to prioritize the patient’s care, the nurse should use:
|a.||the Health Belief Model.|
|b.||Pender’s Health Promotion Model.|
|c.||Maslow’s hierarchy of needs.|
|d.||the Holistic Health Model.|
- The nurse is preparing a patient teaching plan and is seeking a way to determine the patient’s readiness and motivation to act regarding lifestyle changes to best manage diabetes mellitus. Which model would be useful for this nurse?
|a.||Maslow’s hierarchy of needs.|
|b.||Holistic Health Model.|
|c.||Health Promotion Model.|
|d.||Health Belief Model.|
- According to the Health Belief Model, which of the following patients would be most likely to change health behavior?
|a.||The person who perceives that he is at risk for colon cancer|
|b.||The person who recognizes that colon cancer is easily cured|
|c.||The person who believes that behavior can change outcomes|
|d.||The patient who faces multiple social barriers|
- Intentional behaviors to circumvent illness, detect it early, and maintain the best possible level of mental and physiologic function within the boundaries of illness describe:
- The nurse caring for a patient with chronic pain uses guided imagery, therapeutic touch, and relaxation techniques as interventions for pain. The nurse is using what type of approach?
|c.||Risk factor reduction|
- An overweight, sedentary middle-aged smoker with a family history of cardiac disease has noticed a steady rise in resting blood pressure over a 3- to 4-year period. The patient is concerned about his slightly elevated blood pressure and begins walking 20 to 30 minutes in the evenings with his wife and reduces his pack-a-day cigarette habit to ten cigarettes a day. This person has taken the first steps in:
|a.||risk factor reduction.|
- The nursing goal for all individuals and their families seeking preventive care is to have individuals and families:
|a.||take responsibility for their health and wellness.|
|b.||abandon the use of electronic educational media.|
|c.||make lifestyle changes after diseases occur.|
|d.||use temporary changes until the danger has passed.|
- The use of seatbelts and airbags in automobiles is an example of:
|c.||holistic care model.|
- A 40-year-old patient presents to her provider for a yearly physical. The provider notes a family history of breast cancer in the patient’s mother. The provider schedules the patient for a mammogram. The nurse recognizes this as what level of prevention?
- The patient asks the nurse to explain collaborative health care partnerships. The nurse gives a correct description when stating that collaborative care:
|a.||does not require participation of the patient.|
|b.||is individual and cannot be mandated or legislated.|
|c.||education needs are delegated to assistive personnel.|
|d.||is designed to provide care to the patient as a whole.|
- A patient is diagnosed with pneumonia after an abrupt onset of fever, cough, and malaise. The patient is started on antibiotic therapy and is expected to improve in 2 to 3 weeks. The nurse correctly identifies this illness as:
- When caring for patients with chronic illness, the nurse needs to:
|a.||help the patient face the reality that he will not get better.|
|b.||emphasize to the patient that the illness is not his fault.|
|c.||emphasize improving quality of life through preventive behaviors.|
|d.||acknowledge the limitations placed on the patient by his suffering.|
- A patient presents to the clinic for illness, and the sick role is legitimized by the provider. The nurse recognizes this as what stage of illness according to Suchman’s Model?
- When considering factors influencing health and the impact of illness, specifically age, the nurse would correctly identify which patient as having the greatest risk?
|a.||A 47-year-old man|
|b.||A 23-year-old woman|
|c.||a 10-year-old girl|
|d.||an 85-year-old woman|
- The nurse is discussing immunizations for infants and children with new parents. The nurse should focus on:
|a.||providing scientific evidence to parents.|
|b.||stressing that non-immunization is a crime.|
|c.||acknowledging that immunizations are not needed.|
|d.||informing the parents that they have no choice.|
- The genetic vulnerability of an organism, or risk of disease expression based on genotype, is
|a.||involuntarily passed from biologic parents to offspring.|
|b.||totally unrelated to environmental factors.|
|c.||non-responsive to alteration by way of lifestyle modification.|
|d.||not a factor in mental illness because it is behavioral.|
- The patient is asking about using the Internet for resources regarding lifestyle behaviors and benefits of modification. The nurse’s should tell the patient that:
|a.||information on lifestyle behaviors is not available on the Internet.|
|b.||the patient should use websites that are easy to understand.|
|c.||,most websites are designed for health care providers only.|
|d.||only negative outcomes are evaluated on the Internet.|
- The nurse is assessing a patient’s environment and its impact on outdoor activity and notes that the child rarely plays outside. Which is true regarding the indoor environment?
|a.||Indoor environments protect the patient from toxics chemicals.|
|b.||Indoor activity is sometimes a result of unsafe outdoor conditions.|
|c.||Indoor activity decreases the risk of respiratory illness.|
|d.||Indoor lifestyles reduce the risk for sedentary behaviors.|
- The nurse correctly recognizes which one of the following illnesses to trigger the broadest range of emotional and behavioral responses?
- Self-concept refers to the way in which individuals perceive unchanging aspects of themselves, such as social character, cognitive abilities, physical appearance, and body image. As such, self-concept:
|a.||if negative, will allow the patient to compensate for weaknesses.|
|b.||if positive, will cause the patient to see challenges as devastating.|
|c.||is a concept that is derived from the patient internally.|
|d.||depends on relationships with family and friends.|
- The nurse is reviewing recommendations for screenings. Recommendations state that: (Select all that apply.)
|a.||women ages 21 to 29 should have a Pap test every 3 years.|
|b.||self-breast exams should be addressed with male and female patients.|
|c.||adolescent males should perform monthly self-testicular exams.|
|d.||women ages 30 to 65 should receive Pap tests every 10 years.|
|e.||after a total hysterectomy, Pap testing should be more frequent.|
- Exercise is essential for the prevention of illness and promotion of wellness. Regular physical exercise: (Select all that apply.)
|a.||enhances the immune system.|
|b.||decreases bone density.|
|c.||limits joint mobility.|
|d.||improves mental health.|
|e.||helps to prevent diabetes.|
- The economic stability of individuals or families can determine whether they are willing to seek preventive care or screening examinations. Which statements about screening examinations are true? (Select all that apply.)
|a.||Free or low-cost screening ensures patient screening.|
|b.||People may not screen due to fear of testing positive.|
|c.||Early screening ensures minimal treatment costs|
|d.||Employment stability is enhanced by early screening.|
|e.||Treatment of disorders often means lost wages.|
Chapter 17: Human Development: Conception through Adolescence
- The nurse is asked by the parent of a pediatric patient to explain the difference between growth and development. Which response by the nurse is best?
|a.||“Growth is physical while development relates to physical, emotional, and cognitive function.”|
|b.||“There really is no difference between the two since they occur simultaneously.”|
|c.||“Development refers to musculoskeletal and nervous system abilities and growth is a change in height and weight.”|
|d.||“Both refer to an increase in abilities and functions of the child that occur sequentially over time.”|
- The pediatric nurse is treating a patient who has questions about safer sexual practices. The patient states, “I think I should wait until marriage to be sexually active because I’m not sure sex is OK outside of marriage.” The nurse understands the student is acting with which component of Freud’s theory?
- The nurse is collecting a history from the parents of a 4-year-old female at a well-child visit. The parents express concern that they often find their daughter performing what appears to be masturbation. The nurse offers reassurance by explaining which stage of development according to Freud?
- A nurse is providing anticipatory guidance to a new mother about the Erikson stage of trust versus mistrust. What education should the nurse provide to the mother to help her child successfully master this stage?
|a.||Consistently provide your child with food and attention.|
|b.||Ensure someone is able to feed your child on a schedule.|
|c.||Allow unrestricted crawling and exploring as the child develops.|
|d.||Provide firm guidelines for behavior and activities.|
- The nurse is caring for a patient that is actively trying to conceive a child but continues to drink alcohol. The patient states that she’ll stop drinking once she is pregnant. What is the most appropriate response by the nurse?
|a.||“Abstaining is best since most fetal development occurs before you realize you are pregnant.”|
|b.||“Small amounts of alcohol are safe at any time during pregnancy.”|
|c.||“Things will be okay if you quit drinking alcohol once you know you are pregnant.”|
|d.||“Alcohol use should be avoided early in pregnancy but is acceptable past week 20.”|
- The perinatal clinic nurse is going to teach a woman from a culture unfamiliar to the nurse about child-rearing practices. What action by the nurse is best before planning the education?
|a.||Ensure the availability of written material to give the woman|
|b.||Assess what practices are important to her cultural group|
|c.||Determine if the woman is the primary family decision maker|
|d.||Refer the woman to a prenatal educational class|
- A home health care nurse is making a well-baby visit to the home of a new mother who has an infant. What assessment finding leads the nurse to provide further anticipatory guidance and teaching to the mother?
|a.||Mother states she does not breastfeed but uses a recommended formula.|
|b.||Crib has colorful blankets and pillows for the baby to cuddle.|
|c.||A mobile is hanging well above the crib playing soft music.|
|d.||Several rattles and plush toys are available in different textures.|
- To help a hospitalized infant master the tasks in Erikson’s stage of Trust versus Mistrust, which action by the nurse is best?
|a.||Provide calming music during quiet time so the infant can sleep|
|b.||Give the family food vouchers for the hospital cafeteria|
|c.||Arrange to have a cot or small bed placed in the infant’s room|
|d.||Do not allow unlicensed assistive personnel to care for the infant|
- The home health care nurse is visiting a family with a 3-year-old to observe a meal. The parent gives the child a plate with cup of pureed meat. What action by the nurse is best?
|a.||Document how well the child eats the serving of meat.|
|b.||Inquire if the child still drinks from a bottle between meals.|
|c.||Ask the parents what they serve the child for snacks.|
|d.||Provide teaching on the appropriate serving size for this child.|
- A preschool-aged child got into the cookie jar and ate several cookies before dinner. When confronted by the parent, the child responds, “My pet horse ate them.” What does the nurse teach the parents about this response?
|a.||It is normal for children to have imaginary friends at this age.|
|b.||This vivid imagination will lead the child to misbehave later on.|
|c.||Lying is disobedient and should be punished consistently.|
|d.||The child is obviously afraid of the parents’ response.|
- A toddler has been hospitalized. The parents become upset when the toddler starts wetting his bed, saying that he has been potty trained for some time now. What response by the nurse is best?
|a.||“Don’t worry, this behavior will stop when he gets home.”|
|b.||“Maybe he has a urinary tract infection; I’ll get a urine sample.”|
|c.||“I can call the Child Life Specialist for diversionary activities.”|
|d.||“It is common for kids in the hospital to regress to earlier behaviors.”|
- The nurse is conducting a home visit on a newborn. What observation would require the nurse to provide further education?
|a.||The caregiver warms the bottle and tests heat on the inside of the wrist.|
|b.||The parents state the infant is sleeping with them until they buy a crib.|
|c.||One parent states that when the child gets frustrating, the other parent takes over.|
|d.||Caregivers consistently wash their hands before holding the baby.|
- The parents of a 4-year-old express concern that the child is wearing the same size clothing as she did last year. What action by the nurse is most appropriate?
|a.||Weigh and measure the child and compare with last visit.|
|b.||Reassure parents that their child is growing normally.|
|c.||Assess the child’s eating and activity patterns.|
|d.||Encourage the parents to provide the child a multivitamin.|
- A nurse is conducting a preschool screening in the community. Which child would the nurse refer for further assessment?
|a.||A 4-year-old who throws a ball over-handed but better under-handed.|
|b.||A 4-year-old who can skip across the room after being shown how.|
|c.||A 5-year-old who is able to ride a bicycle with training wheels.|
|d.||A 5-year-old who is unable to ride a tricycle without falling.|
- A father expresses frustration that his school-aged child is suddenly “sick all the time.” What action by the nurse is best?
|a.||Encourage the father to give the child a multivitamin each day.|
|b.||Explain that illness is frequent in this age group because of exposure to others.|
|c.||Encourage the father to discuss testing the child’s immunity with the provider.|
|d.||Make sure the parents are washing their hands frequently in the home.|
- A school-aged child is scheduled for a minor procedure and is very nervous. What response by the nurse is best?
|a.||Reassure the child the procedure is too minor to worry about.|
|b.||Read the child a pamphlet about what to expect during the procedure.|
|c.||Tell the child you will have the provider “put her to sleep” during the procedure.|
|d.||Explain the procedure and what to expect in simple terms.|
- A nurse is assessing an adolescent female who began menstruating 2 years ago. She has grown 1/2 inch in the last 2 years but has not gained any weight. What action by the nurse is most appropriate?
|a.||Ask the teen to provide a 24-hour diet recall.|
|b.||Talk to the teen about healthy dietary practices.|
|c.||Reassure the teen she will have a growth spurt soon.|
|d.||Collaborate with the provider for endocrine testing.|
- A parent is concerned that her 16-year-old is spending most of his time away from the family in his room and does not want to be involved in family activities he used to enjoy. What action by the nurse is best?
|a.||Reassure the parent the teen is exerting independence.|
|b.||Ask the parent about the teen’s friends and activities.|
|c.||Assess the teen for depression and possible suicide risk.|
|d.||Refer the family to the community depression support group.|
- A nurse assesses a 4-month-old infant and notes the baby does not follow a moving object with her eyes. What action by the nurse is best?
|a.||Document the findings and continue the assessment.|
|b.||Refer the child and parent to a pediatric neurologist.|
|c.||Assess the child for other age-appropriate behaviors.|
|d.||Assess the child for signs of child abuse or neglect.|
- A home health care nurse notes a parent becoming irritated when his toddler repeatedly throws his rattle from the high chair to the floor. What action by the nurse is most appropriate?
|a.||Teach the parent about age-appropriate discipline.|
|b.||Educate the parent on age-appropriate behaviors.|
|c.||Tell the parent to stop giving the rattle back to the child.|
|d.||Assess the child for signs of abuse or neglect.|
- The nurse is teaching parents about actions to assist in developing a critical skill in the concrete operations phase of Piaget’s developmental theory. What activities does the nurse suggest the parents participate with their child in? (Select all that apply.)
|a.||Separating a collection of toy horses into functions each type performs.|
|b.||Exploring a space and astronomy museum and planetarium together.|
|c.||Making a scrapbook of leaves sorted by color or type of tree.|
|d.||Having the child explore how common objects can be used for different purposes.|
|e.||Asking the child to describe an event from several different points of view.|
- A nurse is assessing a 12-month-old at a well-baby visit. For what developmental milestones does the nurse assess this child? (Select all that apply.)
|a.||Sitting up by himself or herself|
|b.||Transferring objects from one hand to the other|
|c.||Able to roll around on the floor|
|d.||Using fingers as a pincer to grasp objects|
|e.||Trying to imitate words he hears others say|
- A nurse is planning a community education event for parents on the topic of school-aged children and the risks of too much social media time. What topics should the nurse plan to include? (Select all that apply.)
|b.||Decreased physical activity|
|c.||Decreased understanding of spatial relationships|
|d.||Weight loss and malnutrition|
- A high-school nurse is planning an educational presentation for juniors. What activities are most appropriate for the nurse plan to include? (Select all that apply.)
|a.||Video showing the aftermath of a drunk driving car crash|
|b.||Confidential depression and suicide risk assessment|
|c.||Same-age speaker sharing her story about the impact of HIV disease|
|d.||Charts and graphs showing the physical changes of puberty|
|e.||Bicycle helmet fitting station to see if child has outgrown the helmet|
- A pregnant woman in her second trimester is scheduled for quad testing. What conditions does the nurse explain are screened for in this assessment? (Select all that apply.)
|a.||Blood clotting abnormalities|
|b.||Neural tube defects|
Chapter 18: Human Development Young Adult to Older Adult
- The nurse working in long-term care knows that there are multiple theories regarding aging. The one the nurse most identifies with proposes that the body’s cells are leading to damaged organs and organ systems. This description is congruent with which theory?
|a.||Cross-linking theory of aging|
|c.||Gould’s theory on adult development|
|d.||Senescence theory of aging|
- A nurse is obtaining a history from a 37-year-old patient. What statement by the patient indicates that he has met the age-appropriate developmental task according to Gould?
|a.||Patient describes moving out of his parents’ house into an apartment.|
|b.||Patient reminisces about past life events and accomplishments.|
|c.||Patient questions his life choices such as profession and decision not to marry.|
|d.||Patient expresses satisfaction in having his own family and successful career.|
- The nurse plans to develop a comprehensive screening tool to use with young adults, assessing their lifestyles and healthy living habits. What barrier must the nurse plan to overcome in order to make this screening successful?
|a.||Young adults may not see a health provider regularly.|
|b.||Young adults are so diversified that a screening tool may not be appropriate.|
|c.||Young adults have too many risky lifestyle behaviors to make education relevant.|
|d.||Young adults are too busy with their lives to see a health care provider regularly.|
- A nurse who uses Havighurst’s theory of development is assessing a young adult. What question does the nurse ask to provide the most relevant information about this person’s successful negotiation of this developmental stage?
|a.||“Do you find yourself doing familiar tasks in new ways to accomplish them?”|
|b.||“Please count backwards from 100 by 7s, such as 100, 93, and so on.”|
|c.||“What occupation have you chosen for your life’s work?”|
|d.||“Do you still have a good relationship with your parents and siblings?”|
- A nurse reads on a patient’s chart that she has sarcopenia. What assessment does the nurse perform to confirm this?
|a.||Mini-mental state exam|
|b.||Tests of muscle strength|
|c.||Gait and balance|
|d.||Vision and hearing|
- A nurse is assessing a middle-aged adult for cognitive skills. The patient has difficulty with seriation tests. What action by the nurse is most appropriate?
|a.||Document the findings and continue the assessment.|
|b.||Perform another test for fluid intelligence.|
|c.||Consult with the provider about dementia screening.|
|d.||Ask the patient about family medical history.|
- A nurse working with a middle-aged adult is concerned that the adult is not meeting developmental tasks associated with Erikson’s theory. What question by the nurse is most appropriate?
|a.||Are there community organizations you would like to volunteer with?|
|b.||Do your children come to see you on a regular basis?|
|c.||Do you get at least 30 minutes of exercise most days of the week?|
|d.||How do you feel about reading for a leisure time activity?|
- A nurse is planning a community event in which participants will be assessed for their risk of having a stroke. Which site does the nurse choose to access the highest-risk population?
|a.||Community elder center|
|c.||Synagogue in a rural area|
|d.||Asian-American grocery store|
- An adult caregiver for an older adult reports the adult is doing well other than sleeping more frequently and for longer periods. What response by the nurse is best?
|a.||Assess the older adult for exercise habits.|
|b.||Perform a screening for depression.|
|c.||Reassure the caregiver that this is normal.|
|d.||Ask the older adult to provide a sleep diary.|
- A community nurse is working with a family that consists of a middle-aged adult, an older parent with dementia, and two school-aged children. Which assessment by the nurse is most important for this family?
|b.||Child care arrangements|
|c.||Functional ability of the older adult|
|d.||Knowledge of health screening needs|
- A young nursing student is assessing an older patient. The nurse questions whether or not to take a sexual history. What response by the faculty is best?
|a.||Since procreation is not an issue, you do not need to discuss this.|
|b.||Only discuss this topic if you are comfortable in doing so.|
|c.||Ask the patient if he or she wants to talk about sexuality.|
|d.||Sexuality is a basic human need and needs to be assessed.|
- The nurse working with older adults encourages them to stay healthy. What instruction by the nurse takes priority?
|a.||Eat at least seven servings of produce a day.|
|b.||Get at least 8 hours of sleep a night.|
|c.||Get some exercise at least most days of the week.|
|d.||Stay away from people who are ill.|
- The nurse is performing wellness checks at a community center for older adults. Which person would the nurse evaluate as having the highest risk of stroke?
|a.||White, 55 years of age, BP 148/92 mm Hg|
|b.||African-American, 70 years of age, BP 150/100 mm Hg|
|c.||Asian-American, 40 years of age, BP 146/78 mm Hg|
|d.||White, 74 years of age, BP 150/82 mm Hg|
- The nurse working with an adult population knows that many age-related declines in function begin occurring at what age?
- A young adult asks the nurse why she should participate in health screening and educational events. What response by the nurse is best?
|a.||“Your choices now affect your future health.”|
|b.||“It’s free and full of good information.”|
|c.||“Wouldn’t you want to know if you had a problem?”|
|d.||“You can change bad habits now if you know about them.”|
- A young adult tells the nurse he has quit smoking cigarettes and now “vapes” (uses electronic cigarettes [e-cigarettes]). What response by the nurse is best?
|a.||“Excellent! That is so much better for you than tobacco.”|
|b.||“The health consequences of e-cigarettes are not known.”|
|c.||“Using e-cigarettes actually is much worse for your health.”|
|d.||“Tobacco or e-cigarettes…doesn’t matter. You need to quit.”|
- A nurse notes an older adult puts excessive amounts of salt on her food. What intervention by the nurse is best?
|a.||Teach the adult how salt intake relates to hypertension.|
|b.||Ask the older adult why she puts so much salt on food.|
|c.||Encourage the older adult to use less salt on her food.|
|d.||Explore other herbs and flavor enhancers with the adult.|
- A nurse in the family practice clinic is assessing an older adult who has dementia. The adult daughter/caregiver expresses concern that the parent should no longer be left alone while the daughter is at work. What response by the nurse is best?
|a.||Refer the family to a social worker.|
|b.||Encourage the daughter to look into nursing homes|
|c.||Tell the daughter there are medications for dementia.|
|d.||Help the daughter explore adult day care options.|
- An adult child brings his father to the emergency department and describes the sudden onset of a panic attack and aggressiveness. After ruling out an infectious process, what action by the nurse is best?
|a.||Assess the patient for mental illness.|
|b.||Perform a mini-mental state exam on the patient.|
|c.||Ask about risk factors for delirium.|
|d.||Assess the patient for illicit drug use.|
- The nurse knows that which attributes are characteristics of the young adult age group? (Select all that apply.)
|a.||The number of high school graduates going to college is decreasing.|
|b.||More than 88% of people aged 25 to 34 have completed high school.|
|c.||More males aged 20 to 24 were married than females in the same age group.|
|d.||A significant percentage of those aged 25 to 34 has advanced degrees.|
|e.||Adult roles for the young adult are more diverse than for other age groups.|
- The nurse is planning an educational workshop on health risks for the young adult. What topics does the nurse plan to include as priorities? (Select all that apply.)
|a.||Sexually transmitted diseases|
|c.||Responsible alcohol use|
|d.||Intimate partner and sexual violence|
- The nurse working in a family practice clinic has very limited time to assess patients for health concerns. When working with middle-aged patients, which problems does the nurse assess for as the priorities? (Select all that apply.)
|c.||Sexually transmitted diseases|
- The nurse tells the student that which disorders are related to the presence of free radicals? (Select all that apply.)
- The student of adult development learns that cognitive abilities improve during the young adult stage because of the influence of which experiences? (Select all that apply.)
|a.||Physical growth of the brain|
|d.||Overall life experiences|
|e.||Specific profession chosen|
- The nurse is assessing hospitalized older adults for risk factors that could lead to delirium. For which patients does the nurse plan extra care to prevent delirium? (Select all that apply.)
|b.||On multiple pain medications|
|d.||Two days post operative|
Chapter 19: Vital Signs
- A nurse notes a patient has abnormal vital signs. What action by the nurse is best?
|a.||Document the findings.|
|b.||Notify the provider.|
|c.||Compare with prior readings.|
|d.||Retake the vital signs.|
- A patient returned from a procedure and has vital sign measurements ordered every hour. The patient’s blood pressure has dropped from 132/82 mm Hg an hour ago to 90/66 mm Hg. What action by the nurse is most appropriate?
|a.||Take the vital signs again in another hour.|
|b.||Document the findings in the patient’s chart.|
|c.||Have another nurse recheck the vital signs.|
|d.||Plan to take the vital signs more often.|
- A nurse is told in the hand-off report that a patient is afebrile. What assessment finding correlates with this statement?
|a.||Blood pressure 152/98 mm Hg|
|b.||Temperature 98.4° F (36.8° C)|
|c.||Pulse 82 beats/min|
|d.||Respirations 16 breaths/min|
- A nurse is caring for a patient who has a high temperature. The nurse plans to help the patient regain a normal temperature through conduction. What technique does the nurse use?
|a.||Placing a cooling fan in the patient’s room|
|b.||Putting ice packs in the patient’s axillae|
|c.||Spraying the patient with a fine mist of water|
|d.||Turning the temperature down in the room|
- A nurse is going to take a patient’s oral temperature. The patient has been drinking coffee. What action by the nurse is best?
|a.||Have the patient drink room temperature water.|
|b.||Return in 30 minutes to take the patient’s temperature.|
|c.||Take the patient’s temperature rectally instead.|
|d.||Document that temperature is unable to be obtained.|
- A nurse observes a student taking an adult patient’s tympanic temperature. What action by the student requires the nurse to intervene?
|a.||Student washes hands prior to patient contact|
|b.||Student pulls the pinna of the patient’s ear down and back|
|c.||Student explains the procedure to the patient|
|d.||Student pulls the pinna of the patient’s ear up and back|
- A nurse assesses a patient’s radial pulse rate to be 110 beats/min and regular. What action by the nurse is best?
|a.||Assess the patient for causes of tachycardia.|
|b.||Take an apical heart rate and compare the two.|
|c.||Document the findings in the patient’s chart.|
|d.||Notify the patient’s health care provider.|
- The student nurse is assessing a patient’s pulses. What action by the student requires the nurse to intervene?
|a.||Assessing apical pulse between the fifth and sixth intercostal spaces|
|b.||Assessing the doralis pedis pulse by palpating behind the patient’s knee|
|c.||Assessing the radial pulse on the patient’s wrist|
|d.||Assessing the brachial pulse on the patient’s inner elbow|
- The nurse assesses a patient’s pulse and finds it hard to obliterate with palpation. What action by the nurse is best?
|a.||Assess the patient for fluid volume overload.|
|b.||Assess the patient for fluid volume deficit.|
|c.||Assess the patient’s apical heart rate.|
|d.||Assess the patient’s pulse deficit.|
- The nursing faculty member is observing a student taking a patient’s carotid pulse. What action by the student requires intervention by the faculty member?
|a.||Counts pulse for 30 seconds and multiplies by two.|
|b.||Performs hand hygiene prior to patient contact.|
|c.||Compares pulses in both carotid arteries at the same time.|
|d.||Assesses pulse on one side then assesses the other side.|
- A nurse is caring for a patient who has orthopnea. What action by the nurse is most appropriate?
|a.||Encourage deep breathing and coughing.|
|b.||Medicate the patient for pain as needed.|
|c.||Keep the head of the bed elevated.|
|d.||Monitor the length of time the patient doesn’t breathe.|
- The nurse has applied a pulse oximeter to the finger of a patient who is hypothermic. The pulse oximeter does not provide a good reading. What action by the nurse is best?
|a.||Move the oximeter probe to another finger.|
|b.||Assess the fingers for good circulation.|
|c.||Document that the reading cannot be obtained.|
|d.||Remove any fingernail polish present on the fingernail.|
- A patient’s blood pressure is 142/76 mm Hg. What does the nurse chart as the pulse pressure?
- A nurse performs orthostatic blood pressure readings on a patient with the following results: lying 148/76 mm Hg, standing 110/60 mm Hg. What action by the nurse is best?
|a.||Instruct the patient not to get up without help.|
|b.||Document the findings and continue to monitor.|
|c.||Reassure the patient that these findings are normal.|
|d.||Reassess the blood pressures in 1 hour.|
- The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate?
|a.||Place a sign above the bed: “No blood pressures on the right arm.”|
|b.||Place a sign above the bed: “No continuous blood pressures on the right arm.”|
|c.||Place a sign above the bed: “Blood pressures in legs only.”|
|d.||No specific action is needed for this situation.|
- A nurse works on a postoperative care unit and sees many patients who have orthopedic surgery. One patient complains of significantly more pain than the other postoperative patients usually do. What action by the nurse is best?
|a.||Explain to the patient that so much pain is not reasonable.|
|b.||Ask the patient to rate and describe the pain.|
|c.||Give the patient pain medications as prescribed.|
|d.||Call the provider and request an extra dose of pain medication.|
- The nurse receives a handoff report on four patients. Which patient should the nurse assess first?
|a.||Pain rating 4/10 after pain medication|
|b.||Blood pressure 102/62 mm Hg|
|c.||Pulse 42 beats/min|
|d.||Respiratory rate 18 breaths/min|
- A nursing student is caring for a patient with metabolic acidosis. The student asks the registered nurse why the patient’s respiratory rate is so high. What response by the nurse is best?
|a.||“The patient’s metabolic rate is increased from being ill.”|
|b.||“The lungs are trying to rid the body of extra carbon dioxide.”|
|c.||“The patient is trying to reduce his temperature through panting.”|
|d.||“Patients who are acutely ill often have abnormal vital signs.”|
- The nursing student learns that the purpose of measuring vital signs includes which rationale? (Select all that apply.)
|a.||Monitor body systems functioning.|
|b.||Identify early signs of problems.|
|c.||Evaluate effectiveness of interventions.|
|d.||Determine if a cure has been obtained.|
|e.||Provide a baseline to compare against.|
- The nurse is delegating taking vital signs to an unlicensed assistive personnel (UAP). What instructions does the nurse provide the UAP? (Select all that apply.)
|a.||“Let me know if Mr. Smith’s blood pressure is low.”|
|b.||“Take Mrs. Jones’ blood pressure every 15 minutes.”|
|c.||“Call me if Ms. Walsh’s systolic blood pressure drops to under 100 mm Hg.”|
|d.||“Do you want me to demonstrate using the electronic blood pressure cuff?”|
|e.||“I’ll take Mr. Derby’s blood pressure since he is not stable.”|
- The nurse understands that which factors can increase blood pressure? (Select all that apply.)
|b.||Decreased fluid volume|
|d.||Recent food intake|
- The nurse assessing respirations understands that problems in what organs can directly affect the process of respiration? (Select all that apply.)
- A nurse is teaching a patient and the patient’s family about self-care measures for hypertension. Which topics does the nurse include? (Select all that apply.)
|a.||Increase exercise on most days|
|b.||Maintain a normal body weight|
|c.||Abstain from any alcohol|
|d.||Reduce dietary sodium to 2.4 g/day|
|e.||Follow the DASH diet|
- Which parameters does the nurse include when assessing pain? (Select all that apply.)
- A nurse is caring for an unconscious patient. What objective assessments does the nurse use to help evaluate pain in this patient? (Select all that apply.)
Chapter 20: Health History and Physical Assessment
- A nurse is conducting a physical assessment in a clinic with a partly undressed patient. What action by the nurse is most appropriate?
|a.||Offer the patient a small pillow for under his/her head.|
|b.||Provide a method for ensuring the patient stays warm.|
|c.||Raise the head of the bed to about 30 degrees.|
|d.||Ensure there is enough lighting for an adequate examination.|
- A patient wishes to review his medical record. What response by the nurse is best?
|a.||“I’m sorry, we don’t allow you to look at your chart.”|
|b.||“Let me check to see if we can allow you to do that.”|
|c.||“Yes, I can sit with you while you look at it so you can ask questions.”|
|d.||“Yes, all patients can review their charts at any time they wish.”|
- A clinic nurse is examining an older, confused patient on an examination table and realizes a piece of needed equipment was left outside in the hall. What action by the nurse is best?
|a.||Tell the patient to lie still and go get the equipment.|
|b.||Call for another staff member to bring the equipment.|
|c.||Have the patient get into a chair and get the equipment.|
|d.||Finish the rest of the exam, get the equipment, and use it.|
- A student nurse is preparing to auscultate a patient’s lungs. What action by the student leads the instructor to intervene?
|a.||Student asks to turn the television volume down.|
|b.||Student warms the bell of the stethoscope before use.|
|c.||Student uses the stethoscope bell to listen to bowel sounds.|
|d.||Student places the stethoscope diaphragm on the patient’s skin.|
- The nurse is assessing a patient’s alcohol intake. What question is most appropriate?
|a.||“Do you drink alcohol at all?”|
|b.||“You don’t drink much do you?”|
|c.||“When was your last drink?”|
|d.||“How much alcohol do you drink daily?”|
- The nurse is planning to educate four patients on preventing skin cancer and early warning signs. Which patient is the priority for this education?
|a.||Adolescent who uses a tanning bed|
|b.||Middle-aged adult who walks for fitness|
|c.||Older woman who sits in the sun for 10 minutes daily|
|d.||Person who works indoors under fluorescent lights|
- A nurse has assessed a patient’s capillary refill, which was 5 seconds. What action by the nurse is most appropriate?
|a.||Document the findings and continue the examination.|
|b.||Ask the patient about the use of artificial nails.|
|c.||Ask the patient about his/her occupation.|
|d.||Assess the patient for signs of hypoxia.|
- The student nurse asks if it matters whether a healthy eye or a diseased eye should be examined first. What response by the faculty is best?
|a.||Diseased eye first because it is the priority|
|b.||Healthy eye first to prevent spread of disease|
|c.||It does not matter as long as both eyes are examined|
|d.||Start with the eye the patient wants you to start with|
- A nurse observes a patient sitting up in bed, leaning forward with the arms braced against the over-the-bed table. What action by the nurse is best?
|a.||Assess the patient for a barrel-chest appearance.|
|b.||Palpate the patient’s abdomen for tenderness.|
|c.||Inspect the patient’s spine for deformities.|
|d.||Ask the patient if he/she is experiencing dizziness.|
- The nurse is assessing a patient whose chart indicates a Grade 3 heart murmur. What action is best in order to hear the murmur?
|a.||Ensure that the room is extremely quiet.|
|b.||Use a specialized stethoscope with amplification.|
|c.||Auscultate the patient’s chest with a stethoscope.|
|d.||Place the stethoscope diaphragm on the patient’s back.|
- A nurse has conducted an Allen’s test on a patient and the result was 8 seconds. What action by the nurse is best?
|a.||Document the findings and continue the assessment.|
|b.||Notify the health care provider immediately.|
|c.||Elevate the patient’s arm above the level of the heart.|
|d.||Assess the patient for other signs of circulatory problems.|
- A hospitalized patient complains of bilateral leg pain and asks the nurse to massage her legs. One calf is noticeably larger than the other and is warm and slightly reddened. What action by the nurse is best?
|a.||Only massage the leg with normal assessment findings.|
|b.||Massage the front of both legs gently, and avoid the posterior surfaces.|
|c.||Perform a Homan’s test to both legs prior to massaging either of them.|
|d.||Educate the patient on why a massage would be contraindicated.|
- A nurse is told in handoff report that a patient opens eye spontaneously, is confused but able to answer questions, and demonstrates purposeful movement to painful stimuli. What does the nurse calculate the patient’s Glasgow Coma Scale to be?
- A nurse is assessing a patient’s abdomen and hears bowel sounds every 20 to 25 seconds. What action by the nurse is best?
|a.||Avoid palpating this patient’s abdomen.|
|b.||Document the findings in the patient’s chart.|
|c.||Have another nurse verify the findings.|
|d.||Ask the patient when the last food intake was.|
- A nurse is assisting a patient who is having an examination of the female genitalia. What action by the nurse is best?
|a.||Get the provider; assist patient into lithotomy position.|
|b.||Assist the patient into lithotomy position; get the provider.|
|c.||Get the provider; assist patient into Sims position.|
|d.||Assist the patient into Sims position; get the provider.|
- A nurse assesses a patient’s lungs and notes the presence of low-pitched snoring sounds that clear with coughing. What action by the nurse is best?
|a.||Prepare to treat the patient for asthma.|
|b.||Prepare to treat the patient for pneumonia.|
|c.||Teach the parent how to prevent croup.|
|d.||Assess the patient for heart failure.|
- The nurse is assessing a patient’s cranial nerve III. What technique is best?
|a.||Have patient identify a common scent with closed eyes.|
|b.||Shine a light into the patient’s eyes to assess pupil response.|
|c.||Have the patient read a newspaper or use the Snellen chart.|
|d.||Assess if patient can hear both spoken and whispered words.|
- A nurse is assessing a patient’s cranial nerves and notes an abnormal response to testing cranial nerve VI. What action by the nurse is best?
|a.||Ask the patient about recent facial trauma.|
|b.||Inform the provider immediately.|
|c.||Document findings in the patient’s chart.|
|d.||Have the patient frown and lift the eyebrows.|
- The nurse reads in a chart that a patient has a paronychia. What assessment technique is most appropriate?
|a.||Auscultate the patient’s bowel sounds.|
|b.||Test the cranial nerves for sensory function.|
|c.||Inspect the patient’s nails and surrounding skin.|
|d.||Inspect the skin using the ABCDE mnemonic.|
- A new nurse is conducting a patient interview. What behaviors observed by the experienced nurse require education on this process? (Select all that apply.)
|a.||Typing intently on a keyboard when asking questions.|
|b.||Allowing family to accompany the patient as requested.|
|c.||Using gestures and eye contact to demonstrate interest.|
|d.||Closing the door to the room to ensure privacy.|
|e.||Providing non-verbal cues to negative thoughts.|
- A nurse is conducting a physical examination using palpation. Which assessments might the nurse note? (Select all that apply.)
|a.||Rebound tenderness: tenderness long after palpation|
|b.||Crepitation: crackling or rubbing|
|c.||Guarding: holding the nurse’s hands away from the body|
|d.||Turgor: tension caused by fluid content|
|e.||Consistency: organ location and size|
- A nurse conducting the general survey of a patient includes which items? (Select all that apply.)
|a.||Hygiene and grooming|
|b.||Affect and mood|
|c.||Sex and gender orientation|
|d.||Sexual preferences and practices|
- The nurse examining a patient’s skin correlates which conditions with which underlying pathology? (Select all that apply.)
|a.||Albinism: Full-thickness burns|
|b.||Peripheral cyanosis: poor circulation|
|c.||Purpura: clotting disorders|
|d.||Jaundice: liver disease|
|e.||Vitiligo: skin infestation|
- A nurse is educating women on breast cancer risk reduction. What topics does the nurse include in the presentation? (Select all that apply.)
|d.||Breast self exams|
- A nurse has finished examining a patient. What actions does the nurse take next? (Select all that apply.)
|a.||Document all findings.|
|b.||Provide privacy for dressing.|
|c.||Provide any hygiene material needed.|
|d.||Tells the patient he/she can leave.|
|e.||Cleans the room after the patient leaves.|
Chapter 21: Ethnicity and Cultural Assessment
- A faculty member is contrasting culture and ethnicity to students. Which statement is most accurate?
|a.||Culture is biologically determined; ethnicity is chosen.|
|b.||Culture is socially transmitted; ethnicity is identification with a group.|
|c.||Culture is a chosen identity whereas ethnicity is biologically based.|
|d.||Culture and ethnicity are similar constructs used interchangeably.|
- A nursing student wants to observe enculturation practices of an ethnic minority community. What action by the student is best?
|a.||Attend a community dance.|
|b.||Learn to cook an ethnic meal.|
|c.||Visit the group’s worship service.|
|d.||Observe a grandmother teaching a child.|
- The student learns that which item is the most important symbolic aspect of culture?
- A charge nurse works on an inpatient unit in a diverse city. Knowing some generalizations about different ethnic groups, which action is best?
|a.||Assign a female nurse to a female Muslim patient.|
|b.||Allow the family to stay when the Russian patient is told he has cancer.|
|c.||Start a meeting with a Hispanic family promptly on time.|
|d.||Have the Amish patient watch patient education podcasts.|
- A nurse has been told he has many obvious stereotypes about a specific cultural group. What action by the nurse is best?
|a.||Ask to not care for members of this cultural group.|
|b.||Ask to take care of as many members of this group as possible.|
|c.||Begin to educate himself on aspects of this cultural group.|
|d.||Vow to not allow his stereotypes to show when providing care.|
- A nurse is caring for a homeless patient and tells the manager, “I will make sure he doesn’t steal food from our nourishment center.” What action by the manager is best?
|a.||Tell the nurse she is right to monitor the patient’s activity.|
|b.||Inform the nurse that not all homeless people will steal.|
|c.||Educate the nurse that hunger might make the patient steal.|
|d.||Remind the nurse to initiate a social work consultation.|
- The new nurse tells the preceptor that since she is not prejudiced against ethnic minorities, they will not be discriminated against while in the hospital. What statement by the preceptor is most appropriate?
|a.||Discrimination can occur at the societal level.|
|b.||The hospital needs more nurses like her.|
|c.||Prejudice and discrimination are not the same thing.|
|d.||There is always some discrimination against minorities.|
- What does the nursing student learn about race?
|a.||It is biologically based.|
|b.||It is a social construct.|
|c.||It is chosen by the person.|
|d.||It helps establish superiority.|
- The nurse is caring for a patient from a culture that is unfamiliar. The patient nodded her head “yes” when asked if she will take her prescriptions as ordered, but the nurse discovers the patient does not take the medication, but uses herbs for treatment. What action by the nurse is best?
|a.||Warn the patient of the consequences on non-compliance.|
|b.||Tell the patient how the medication will help the condition.|
|c.||Ask the patient why herbal preparations are preferred.|
|d.||Ask the patient to explain the meaning of the herbal products.|
- A nurse is caring for a refugee patient who wants the community shaman to perform a healing ritual at the bedside. What action by the nurse is best?
|a.||Work with the patient to allow the shaman to perform the ritual.|
|b.||Investigate whether the ritual will harm the patient.|
|c.||Check to see if the ritual breaks laws or policies.|
|d.||Offer to call the hospital chaplain instead.|
- A new graduate nurse tells the manager that she does not believe she needs more in-service training on culturally congruent care because she already recognizes that there are significant differences among cultures to take into account when providing care. What response by the manager is best?
|a.||“You have done a great job becoming culturally competent.”|
|b.||“Providing culturally congruent care takes ongoing work and effort.”|
|c.||“That is a great start, but be sure to sign up for the in-service.”|
|d.||“Cultural sensitivity and cultural competence are not the same.”|
- A nurse is working with a patient who has limited English proficiency. What action by the nurse is best?
|a.||Use a qualified interpreter.|
|b.||Ask family members to translate.|
|c.||Use drawings and pictures.|
|d.||Speak in simple sentences.|
- The nurse is working with a patient from an unfamiliar culture. After assessing the patient and the patient’s cultural beliefs related to health care, what action by the nurse is best?
|a.||Create a nursing plan of care for the patient.|
|b.||Recheck cultural beliefs with the patient.|
|c.||Use a standard plan of care for consistency.|
|d.||Have an interpreter validate the information.|
- A patient from an unfamiliar culture appears disinterested when the physician is telling her about options for treatment of a new diagnosis. After the physician leaves, the nurse attempts to talk to the patient and notices the same behavior. What action by the nurse is best?
|a.||Give the patient the information in writing to read later.|
|b.||Ask the patient about the meaning of the patient’s behavior.|
|c.||Investigate nonverbal communication patterns of this group.|
|d.||Leave the patient alone to come to terms with the diagnosis.|
- A patient in the emergency department needs an emergency operation. The patient refuses to consent and wants the nurse to call a respected elder in the community for consent. What action by the nurse is best?
|a.||Explain that this violates privacy laws.|
|b.||Call the elder to get consent for the operation.|
|c.||Tell the woman she has the right to consent.|
|d.||Arrange for admission without the operation.|
- A patient refuses to take his blood pressure medication because “I feel totally fine and don’t need it.” What action by the nurse is best?
|a.||Assess the patient’s time orientation.|
|b.||Document the patient’s non-compliance.|
|c.||Educate the patient about the medication.|
|d.||Warn the patient about possible complications.|
- The nurse is caring for a patient from a different cultural background. What action by the nurse best demonstrates cultural maintenance?
|a.||Assist the patient with a healing ritual.|
|b.||Teach the patient a heart healthy diet.|
|c.||Instruct the patient on monitoring blood glucose.|
|d.||Discuss what self-care activities the patient is willing to do.|
- A student nurse is caring for a patient who is a refugee. The patient will take his own blood glucose readings and will self-administer a set dose of insulin but will not follow a sliding scale regimen in which the patient has to choose what dose of insulin to give. What action by the student nurse is best?
|a.||Ask the provider to prescribe only a set insulin regimen.|
|b.||Instruct the patient on the benefits of sliding scale insulin.|
|c.||Teach the patient that strict carbohydrate limits are needed.|
|d.||Ask the patient to explain the meaning of making this decision.|
- A home health care nurse is visiting the home of a patient whose culture is totally unfamiliar to the nurse. What action by the nurse is best?
|a.||Perform nursing care with a high degree of professionalism.|
|b.||Watch family interaction patterns closely and try to copy them.|
|c.||Tell the family you need to learn about their culture.|
|d.||Apologize after performing tasks that make the patient uncomfortable.|
- The nurse is caring for a patient from a different culture. After assessing the patient and formulating the care plan, what action by the nurse is best?
|a.||Review the care plan for acceptance by the patient.|
|b.||Delegate appropriate tasks to unlicensed assistive personnel.|
|c.||Go over the care plan with the charge nurse.|
|d.||Begin implementing the planned interventions.|
- A patient has hypertension and is on a very-low-sodium diet. However, the patient is going to celebrate an important religious holiday soon that includes many food items high in sodium. What action by the nurse is best?
|a.||Tell the patient you are so sorry she can’t have any of these foods.|
|b.||Consult with the prescriber about increasing the blood pressure medications.|
|c.||Collaborate with the patient and dietitian to include some of these foods.|
|d.||Tell the patient eating these foods once won’t hurt her condition.|
- The student studying culture learns that which are characteristics of all cultures? (Select all that apply.)
- The nurse understands that which are important in the process of developing a cultural identity? (Select all that apply.)
- The nursing student learns that which are correct regarding acculturation and assimilation? (Select all that apply.)
|a.||Assimilation is forced entry into a different culture.|
|b.||Acculturation depends on first-hand contact between groups.|
|c.||Acculturation results in changes to the minority culture only.|
|d.||Assimilation can occur at the group or individual level.|
|e.||Assimilation causes a minority group member to blend into the majority group.|
- The nurse is using Giger and Davidhizar’s Transcultural Assessment Model to gain information about a patient from an unfamiliar culture. What questions does the nurse ask that are relevant to this mode? (Select all that apply.)
|a.||“Who would you like present to help answer questions?”|
|b.||“What do you believe caused your current illness?”|
|c.||“How important is planning for the future to you?”|
|d.||“Why don’t you want to shake my hand?”|
|e.||“What activities would you do to control your health?”|
Chapter 22: Spiritual Health
- The student nurse asks why he needs to assess a patient’s spirituality when he can call the chaplain. What response by the nurse is best?
|a.||“This way you learn what is involved in a spiritual assessment.”|
|b.||“Students need to perform all aspects of patient care.”|
|c.||“Regulatory organizations list this as a required BSN competence.”|
|d.||“All patients should have a spirituality assessment.”|
- The nurse is caring for four patients. Which one should the nurse assess for spirituality needs as a priority?
|a.||New mother, older child at home|
|b.||Faces terminal diagnosis|
|c.||Needs to change medications|
|d.||Pleasant but quiet|
- A patient has the nursing diagnosis Spiritual Distress. What assessment by the patient best indicates that an important goal has been met?
|a.||Observed praying quietly|
|b.||Indecisive about treatment|
|c.||Asks nurse if God exists|
|d.||Executes living will|
- The nurse concerned about a patient’s spiritual needs can best address this by which action?
|a.||Leaving a note on the chart for other professional|
|b.||Calling the chaplain to come see the patient|
|c.||Collaborating during interdisciplinary rounds|
|d.||Informing the provider of the patient’s needs|
- A patient is concerned that she will not be able to maintain her dietary restrictions while in the hospital. What nursing diagnosis is most appropriate for this patient?
- A patient is considering a life-saving procedure that is not accepted by his faith community. What nursing diagnosis is a priority as the nurse plans care?
- A patient asks the nurse to pray with him. The nurse is an atheist and uncomfortable with this request. What action by the nurse is best?
|a.||Deny the request because of atheistic beliefs.|
|b.||Offer to call the chaplain instead.|
|c.||Agree to sit with the patient while he prays.|
|d.||Ask the patient if he will meditate instead.|
- A nurse is concerned about not consistently meeting the spiritual needs of patients. What action by the nurse is best?
|a.||Care for own spiritual needs|
|b.||Begin a meditation practice|
|c.||Consult the chaplain|
|d.||Read books on the subject|
- The student nurse asks why spirituality is important in health care. What response by the registered nurse is best?
|a.||“All people have a spiritual aspect to their beings.”|
|b.||“Spirituality affects behavior, which also affects health.”|
|c.||“Knowledge of it is needed to understand a patient holistically.”|
|d.||“People who are less spiritual have worse outcomes.”|
- A patient who claims to be very involved in church is near death. What action by the nurse is best?
|a.||Get permission to contact the religious leader.|
|b.||Allow the family to stay at the patient’s bedside.|
|c.||Call the hospital chaplain to come to the bedside.|
|d.||Ask if the patient and family want to pray.|
- A patient, who is an adherent Muslim, is in a burn unit with severe burns. The patient has high caloric requirements but is refusing to eat during Ramadan. What action by the nurse is best?
|a.||Insert a feeding tube and provide enteral feedings.|
|b.||Ask the provider about Total Peripheral Nutrition.|
|c.||Call the patient’s religious leader for advice.|
|d.||Tell the patient he has to eat to get better.|
- A patient in the hospital is an adherent Muslim. Which of the five pillars of Islam can the nurse assist the patient in meeting?
|a.||Praying five times a day|
- A nurse works in a pediatric oncology unit and is feeling depressed and discouraged. What initial action by the nurse is best?
|a.||Apply for a job transfer to another unit.|
|b.||Consult with the hospital chaplain.|
|c.||Make an appointment with Employee Assistance.|
|d.||Ask other nurses how they deal with the stress.|
- A patient died suddenly in the emergency department. Which action by the nurse best provides the family connection with others?
|a.||Offering the family written information on grief support groups.|
|b.||Asking the family if there is someone the nurse can call for them.|
|c.||Having the hospital social worker or chaplain sit with the family.|
|d.||Offering to stay with the family during this difficult time.|
- The charge nurse overhears a new nurse telling a patient that he should no longer follow his vegetarian diet because his protein needs are so high and because “God made animals for us to eat.” What action by the charge nurse is best?
|a.||No action is necessary for the charge nurse to take.|
|b.||Reinforce the nurse’s teaching on proper diet.|
|c.||Offer to call the dietitian to work with the patient.|
|d.||Privately speak to the nurse about this conversation.|
- A home health care nurse has been working with a patient who has the nursing diagnosis Spiritual Distress. After a few weeks of implementing the care plan, what method is best for the nurse to determine if goals have been met?
|a.||Ask the patient to what extent he/she feels goals have been met.|
|b.||Ask the patient to rate the distress on a scale of 1-10.|
|c.||Assess for objective data to support goal attainment.|
|d.||Determine if the patient thinks the interventions are helpful.|
- A patient is scheduled to have an MRI and has a metal religious icon pinned to his gown, which can’t go in the scanner. What action by the nurse is best?
|a.||Take the icon off the patient’s gown until she returns.|
|b.||Give the icon to the patient’s family for safekeeping.|
|c.||Pin the icon to the patient’s pillow so it can go to radiology.|
|d.||Explain the restriction and ask the patient’s preference.|
- The nursing student learns which facts about religion and spirituality? (Select all that apply.)
|a.||Spirituality focuses on the meaning of life to people.|
|b.||Religion and spirituality are mutually exclusive.|
|c.||Religion implies an organized way of worship.|
|d.||Religion provides the structure by which to understand spirituality.|
|e.||Spirituality is an individual practice that does not include others.|
- The student nurse learns that spirituality consists of practices that lead to connection to which items? (Select all that apply.)
- The nurse who is aware of spirituality practices of major religions knows that which religions view health and illness as a process of balance or imbalance? (Select all that apply.)
- Which actions by a nurse constitute spiritual care? (Select all that apply.)
|a.||Baptizing a critically ill child per the parent’s request.|
|b.||Leaving the room, giving the patient and family privacy for prayer.|
|c.||Considering developmental stage when planning care.|
|d.||Notifying the hospital chaplain of a patient’s request.|
|e.||Praying with patients and families when requested.|
- The student using the FICA Spiritual Health Assessment will consider which factors? (Select all that apply.)
|a.||Faith and belief|
|c.||Importance of faith|
|d.||Faith community involvement|
|e.||Address spirituality in care|
- The nurse assessing a patient using the SPIRIT framework would ask which questions? (Select all that apply.)
|a.||“Do you follow a particular religion?”|
|b.||“How involved in your church are you?”|
|c.||“Are there any practices I can help you with?”|
|d.||“How will your religion affect your care?”|
|e.||“What gives you hope in bad situations?”|
- When does the nurse assess patients’ spirituality? (Select all that apply.)
|d.||When the chaplain makes rounds|
|e.||When facing treatment decisions|
- The nurse who incorporates the HOPE framework assesses a Native-American patient for which of the following? (Select all that apply.)
|a.||Desire for shaman to be present|
|b.||Personal use of herbs and prayers|
|c.||Desire to create a living will|
|d.||Power of storytelling for healing|
|e.||Involvement in church activities|
Chapter 23: Public Health, Community Base, and Home Health Care
- The student learns that which is the best definition of a public health nurse?
|a.||Works with the public|
|b.||Works in public areas|
|c.||Works with the greater community|
|d.||Works with public funding|
- A nurse is discharging a patient and is planning on what material to give the patient to take home. What action by the nurse is best?
|a.||Assess the patient’s ability to read and understand.|
|b.||Determine if the patient wants to take written material home.|
|c.||Give the patient the same material as other patients get.|
|d.||Ask the patient if he/she has a need for written material.|
- A nurse is planning primary prevention activities. Which activity would the nurse include in this plan?
|a.||Safer sex education for teens|
|d.||Annual physical exams|
- A nurse wants to volunteer for a community group providing secondary prevention. What activity would the nurse attend?
|a.||Stroke rehabilitation support group|
|b.||Blood pressure screening at the mall|
|c.||Bicycle safety class at the elementary school|
|d.||Drop by nutrition station at the grocery store|
- A nurse is orienting to a new job in a home health care agency and is told that most of her patients need tertiary prevention. What activity does the nurse plan to include in the daily routine?
|a.||Household safety checks|
|d.||Monthly blood pressure assessments|
- A nurse is interested in epidemiology. What work activity would best fit this role?
|a.||Studying census data to determine common causes of death|
|b.||Researching population variables that contribute to disease|
|c.||Developing sanitary measures to prevent foodborne illness|
|d.||Designing research to determine the connection between pollution and cancer|
- The student studying community health nursing learns that vulnerable populations can be best assisted by which activity?
|a.||Researching their genetic risk for health problems|
|b.||Working with the community to decrease health risks|
|c.||Studying vital statistics to determine their causes of death|
|d.||Making sure the population maintains immunizations|
- A nurse is completing an OASIS assessment on a patient. What data would be most important for the nurse to assess?
|a.||Presence of grocery stores nearby|
|b.||Safety concerns within the home|
|c.||Number and kind of pets|
|d.||Proximity to a health care facility|
- A community was devastated by a tornado several months ago. What nursing diagnosis would be most appropriate for the nurse to consider?
|b.||Deficient community resources|
|c.||Ineffective community coping|
|d.||Deficient community health|
- When planning interventions for a community, what action by the nurse is best?
|a.||Involve community leaders in planning.|
|b.||Create a plan of action addressing priorities.|
|c.||Determine what resources are available.|
|d.||Attempt to find funding for the plan.|
- A nurse has referred a patient to a community agency. When talking to the patient later, he states that he did not find the agency helpful. What action by the nurse is best?
|a.||Determine what the patient would find helpful.|
|b.||Review the agency’s mission and scope.|
|c.||Make another appointment with the agency.|
|d.||Warn the patient that non-adherence affects payment.|
- A nurse has assessed a community and has found many areas in which health can be improved. As a result, the nurse has multiple ideas for programming. What action by the nurse is best?
|a.||Determine what the community thinks is most important|
|b.||Use vital statistics to determine which is most important|
|c.||See what other communities are focusing programming on|
|d.||Choose the easiest problem to address first|
- A home health care nurse is working with the family of a patient who has Alzheimer disease and requires 24-hour care. What assessment by the nurse indicates the family is meeting an important goal for caregiver role strain?
|a.||Family eats dinner together every night.|
|b.||Family uses respite care one night a week.|
|c.||Family investigates research trials for patient.|
|d.||Family verbalizes exhaustion from caregiving.|
- The nurse has implemented a community-wide immunization program for seasonal influenza. Once the program has ended, what action by the nurse is best?
|a.||Begin planning for next year’s program.|
|b.||Send mail surveys to participants.|
|c.||Determine financial gains or losses.|
|d.||Evaluate the program and outcomes.|
- A nurse is wondering if home health care nursing is a good fit. What characteristic or ability does the experienced home health care nurse suggest is most important?
- A nurse is a case manager for a home health care agency. The nurse often orders supplies for patients seen by the agency. What action by the nurse is best?
|a.||Negotiate for cheaper prices from suppliers.|
|b.||Investigate what each patient’s insurance will cover.|
|c.||Refer the patient to the closest supply source.|
|d.||Use the same supplier for all patients’ needs.|
- The public health nurse volunteers for a missionary group caring for Ebola patients in Africa. The nurse is reviewing the data using analytic epidemiology methods. What information does the nurse collect as the priority?
|a.||Cultural norms in burial practices|
|b.||Genetic variables in disease acquisition|
|c.||Statistics related to incidence and prevalence|
|d.||Autopsy data on direct cause of death|
- The student nurse learns the ANA’s Scope and Standards of Practice for public health nursing include which of the following? (Select all that apply.)
|d.||Responsible resource use|
- A nurse is assessing social determinants of health. Which does the nurse include in the assessment? (Select all that apply.)
|d.||Roles for women|
- A nurse is studying intrinsic factors that influence the development of asthma in a community. What factors does the nurse assess? (Select all that apply.)
|c.||Pollution in the area|
- The nurse is conducting a windshield survey. What items does the nurse assess? (Select all that apply.)
|a.||Types of housing available|
|c.||Cars seen in parking lots|
|d.||Health care facilities|
|e.||Places of worship|
- The community health nurse knows that which are standards of professional performance for home care nurses? (Select all that apply.)
- A nurse wants to create a community action plan for health problems related to air pollution from a nearby factory. Which stakeholders does the nurse consult as the priority? (Select all that apply.)
|d.||Local health care providers|
- The nurse explains to the patient that which services will be covered under Medicare? (Select all that apply.)
- The home health care nurse educates patients on which goals of hospice care? (Select all that apply.)
|b.||Support the patient and family|
|c.||Provide grief support|
|d.||Keep patients out of the hospital|
|e.||Lower medical expenses|
Chapter 24: Human Sexuality
- A parent confides to the nurse that the parent’s 3-year-old son seems to be touching his genitals frequently. What response by the nurse is best?
|a.||“This is normal behavior at his age.”|
|b.||“Why do you think he is doing that?”|
|c.||“Does he complain of burning with urination?”|
|d.||“I’d ignore that behavior; it’s attention-seeking.”|
- The nurse learns that spermatozoa are produced in which sexual organ?
- The nursing student learns that the function of the hypothalamus is to do which of the following?
|a.||Cause lactation to begin|
|c.||Release follicle-stimulating hormone|
|d.||Release gonadotropin-releasing hormone|
- A patient states, “I just don’t conform to my gender role.” What does the nurse understand about this statement?
|a.||The patient is a homosexual.|
|b.||The patient’s behaviors are abnormal.|
|c.||The patient’s actions differ from what is expected.|
|d.||The patient is having a gender crisis.|
- A patient asks the nurse to recommend a non-prescription contraceptive. What options does the nurse discuss?
- A patient has been diagnosed with a sexually transmitted disease (STD) and the patient’s partner is angry, saying, “She must have cheated on me.” What response by the nurse is most appropriate?
|a.||“This infection may have been present for a long time.”|
|b.||“You need to be tested for this disease too.”|
|c.||“Yes, you’re right; if you don’t have the STD, she cheated.”|
|d.||“Now, now, getting angry will not help anything.”|
- A nurse is working with a patient using the PLISSIT model. In the LI phase, what is an appropriate activity?
|a.||Educate the patient on water-based lubricants.|
|b.||Ask the patient for permission to discuss sexuality.|
|c.||Instruct the patient on positions acceptable after knee replacement.|
|d.||Refer the patient and partner to a licensed therapist.|
- A nurse in the emergency department wants to screen a patient for domestic violence, but the woman’s partner won’t leave. What action by the nurse is best?
|a.||Ask the questions anyway.|
|b.||Tell the partner to leave.|
|c.||Go with the patient to the bathroom.|
|d.||Skip the abuse assessment.|
- A woman complains that her partner threatens her and berates her in front of the children. She denies being in an abusive relationship or being the victim of physical violence. What action by the nurse is best?
|a.||Tell the woman to leave the abusive partner.|
|b.||Educate the woman on forms of domestic abuse.|
|c.||Help the woman work on a physical safety plan.|
|d.||Insist the woman take written information.|
- The nurse is working with a patient who has a sexual dysfunction. What statement by the patient indicates progress toward an important goal?
|a.||“I am beginning to enjoy sex more these days.”|
|b.||“I’m glad my partner is understanding of the lack of sex.”|
|c.||“I wish I didn’t need these pills but I know they are important.”|
|d.||“I hope one day to have a sexual partner again.”|
- A nurse is working with a patient after the patient had a heart attack and is using the PLISSIT model to address sexuality needs. For the SS phase, what action by the nurse is best?
|a.||Ask the patient if he wants to discuss sexuality.|
|b.||Teach the patient positions that require less stress.|
|c.||Offer the patient a referral to a sex therapist.|
|d.||Direct the patient to speak with the doctor about sex.|
- A nurse wishes to incorporate an assessment of patient sexuality into all patient encounters but is concerned about appearing inappropriate. What action by the nurse is best?
|a.||State, “I always ask my patients permission to discuss sexuality. Is this alright?”|
|b.||Wait for the patient to bring the subject of sexuality up to the nurse.|
|c.||Give the patient written material on sexuality, then ask if he/she has questions.|
|d.||Tell patients that if they have any sexual concerns, you would be happy to discuss them.|
- An emergency department (ED) manager wants to improve care for victims of sexual assault. What action by the manager is best?
|a.||Designate a private area of the ED for examinations.|
|b.||Establish a SART team for the department.|
|c.||Ask nurses to volunteer to be advocates for these patients.|
|d.||Have victims examined immediately, rather than waiting their turn.|
- A nurse is caring for a victim of domestic violence. What charting by the nurse is most appropriate?
|a.||Patient allegedly beat up by her boyfriend.|
|b.||Patient has several bruises on the legs.|
|c.||Patient states, “My boyfriend hit me with a hammer.”|
|d.||Patient claims she was assaulted last night.|
- A patient is recovering from colostomy surgery and states, “I guess I’ll never be able to have sex again…who would want me?” What nursing diagnosis is most important for this patient?
|b.||Ineffective sexuality pattern|
- A male patient takes a medication known to cause erectile dysfunction. What action by the nurse is best?
|a.||State, “If this medication has bad side effects, talk to your doctor.”|
|b.||Ask, “Are you having any sexual problems in your life right now?”|
|c.||Give the patient written information on the side effects of the drug.|
|d.||State, “Many men have erectile dysfunction on this drug.”|
- A school nurse is planning a sex education activity. What information from research does the nurse apply to this education?
|a.||Sex education should wait until high school.|
|b.||Parents desire multiple educational strategies.|
|c.||Abstinence is the only birth control method that should be taught.|
|d.||No need to change the current method of education.|
- A nurse is teaching patients about their medications and implications for sexuality. Which combinations are correct? (Select all that apply.)
|a.||Antipsychotics: Erectile dysfunction|
|b.||Phenytoin: Decreased desire|
|c.||Antihistamines: Increased vaginal lubrication|
|d.||SSRIs: Prolonged orgasm|
|e.||Marijuana: Chronic use—reduced inhibitions|
- A nurse is planning sexuality education programs. Which topics are important to each age group? (Select all that apply.)
|c.||Young adults: conception|
|d.||Middle adulthood: sexual dysfunction|
|e.||Old age: decreased sexuality|
- The student learns that which are cycles in the female sexual response cycle? (Select all that apply.)
- A nurse is uncomfortable with a patient’s comments, which are sexual in nature. Which actions by the nurse are most appropriate? (Select all that apply.)
|a.||Tell the patient to stop making sexual comments.|
|b.||Try joking with the patient to establish rapport.|
|c.||Tell the patient you are leaving and will return in a few minutes.|
|d.||Inform the patient he/she can be sued for this behavior.|
|e.||Explain to the patient how you feel about the comments.|
- The nurse has assessed a patient and determined that the patient has a sexual issue that needs to be addressed. What actions by the nurse are most appropriate? (Select all that apply.)
|a.||Use information from multiple sources to help plan care.|
|b.||Collaborate with other health professionals to develop the plan.|
|c.||Involve the patient and significant other in the process.|
|d.||Use standard care plans to limit patient embarrassment.|
|e.||Examine one’s own biases before implementing the plan.|
- A nurse is planning an educational event of safer sex. What topics does the nurse include? (Select all that apply.)
|a.||Proper use of condoms|
|b.||Avoidance of risky behaviors|
|c.||Need for routine examinations|
|d.||Avoidance of homosexual activity|
|e.||Symptoms of common STDs|
- A nurse understands that which characteristics of family dynamics impact a patient’s sexuality? (Select all that apply.)
- The nurse is assessing factors that affect sexual function in patients with chronic diseases. What topics does the nurse include in the assessment? (Select all that apply.)
Chapter 25: Safety
- The increase focus in nursing on patient safety has resulted in a project funded by the Robert Wood Johnson Foundation called:
- Individual factors affecting safety include those that are related to the functioning of body systems and those that are directly associated with a person’s particular lifestyle. Changes in which body system affect overall mobility increasing the propensity of falling?
- The nurse is visiting a patient with cardiac disease who has been experiencing increased episodes of shortness of breath when she tries to exercise. The nurse is concerned that her decrease in activity may lead to:
|b.||increase risk of heart disease.|
|c.||loss of short-term memory.|
|d.||worsening shortness of breath.|
- Conversations about safe sexual practices, including the consequences of unprotected sex such as pregnancy and sexually transmitted infections, are important to begin in what patient population?
- The nurse manager is developing a training guide. Which is the best organization to help her develop guidelines she can use to help her to prevent exposure to hazardous situations and decrease the risk of injury in the work place?
- The nurse is educating parents about firearm safety. Which of the following statements indicates a need for further education?
|a.||“I should make sure I obtain the proper permits.”|
|b.||“It is okay to store firearms with ammunition loaded.”|
|c.||“I should store all firearms without ammunition.”|
|d.||“I should make sure all firearms have trigger locks in place.”|
- The nurse recognizes that a patient is using a portable generator in the house as a power source. What source of poisoning does the nurse appropriately identify?
- The nurse is educating the patient about the proper disposal of medications in the home. Which statement by the patient indicates she has a good understanding of the information?
|a.||“Remove the label from the bottle and throw in the trash.”|
|b.||“Flush the medication.”|
|c.||“Mix the medications with kitty litter and place the mixture in a jar and put the jar in the trash.”|
|d.||“Dissolve the medication in water and pour down the drain.”|
- The nurse knows that which of the following patients has a teaching need based on statements by the patient or the patient’s parents?
|a.||“My 6-month-old daughter only sleeps with me when she’s ill.”|
|b.||“I do not put pillows in the bed with my 3-month-old son.”|
|c.||“I do not feed popcorn to my 2-year-old.”|
|d.||“I have discussed the risks of the ‘choking game’ with my 16-year-old.”|
- The nurse is working with a student nurse to teach her about restraint use in patients. Which statement by the student nurse indicates a learning need regarding restraints?
|a.||“Having all four side rails up on the bed is considered a restraint.”|
|b.||“The use of restraints has been shown to decrease fall-related injuries.”|
|c.||“Death has been associated with the use of restraints.”|
|d.||“Medications administered to control behavior are considered a chemical restraint.”|
- The nurse displays an understanding of high-risk populations for MRSA when identifying which group as the lowest risk?
|b.||College dorm residents|
|d.||Food service workers|
- The nurse knows that which of the following is not used to assess fall risk?
|a.||Glasgow Falls Scale|
|b.||Johns Hopkins Hospital Fall Assessment Tool|
|c.||Morse Fall Scale|
|d.||Hendrich II Fall Risk Model|
- The patient has a nursing diagnosis of risk for falls. Which goal is most important?
|a.||Patient will ambulate twice a day.|
|b.||Patient will have no symptoms of infection.|
|c.||Patient will perform activities of daily living.|
|d.||Patient will have no injuries during hospital stay.|
- Which collaborative team member would be most effective in assisting the nurse to identify medication alternatives that are less likely to cause drowsiness and dizziness to reduce the risk of falls in the elderly patient?
|a.||Nursing house manager|
- The nurse is concerned about helping the patient find resources to obtain assistive equipment to be used in the home. Which team member should the nurse contact first?
- Which statement by the patient indicates a teaching need regarding safety in the home?
|a.||“I will put a night light in every room.”|
|b.||“I will not use an extension cord to plug in multiple items.”|
|c.||“I will wash my throw rugs in the bathroom regularly.”|
|d.||“I will keep all cleaning supplies out of reach of children.”|
- The ER nurse is triaging a patient with suspected poisoning. Who should the nurse anticipate contacting first?
|c.||Poison Control Center|
- Many health care facilities use the fire emergency response defined by the acronym:
- The nurse is ambulating her patient back from the bath when the patient begins to have a seizure. Which of the following actions should the nurse do first?
|a.||Lower the patient to the floor if standing.|
|b.||Move sharp or hard objects away from the patient.|
|c.||Turn the patient to his/her side to prevent aspiration.|
|d.||Attempt to place a tongue blade to prevent choking.|
- The nurse is caring for a confused, combative patient. Which action would be considered last by the nurse to control behavior of the client?
|a.||Orient the patient frequently.|
|c.||Move the patient to a room close to the nurse’s station.|
|d.||Encourage the family to spend time with the patient.|
- The nurse knows that which of the following is an appropriate way to tie restraints?
|a.||Knot tied to the bed frame|
|b.||Quick-release knot tied to the side rail|
|c.||Bow tied to the bed frame|
|d.||Quick-release knot tied to the bed frame|
- Which statement by the nurse correctly identifies the UAP role in patient restraint use?
|a.||“The UAP can perform initial assessment.”|
|b.||“The UAP can apply a restraint.”|
|c.||“The UAP can assist with applying and monitoring of a physical restraint.”|
|d.||“The UAP can contact the physician and request an order for restraints.”|
- The nurse is explaining the National Patient Safety Goals (NPSG) to the student nurse. Which of the following answers indicates that the student has a good understanding of these goals? (Select all that apply.)
|a.||The NPSG’s focus on treating all infections quickly|
|b.||The NPGS’s focus on improving staff communication|
|c.||The NPGS’s focus on using medications safely|
|d.||The NPGS’s focus on identifying patients correctly|
- The nurse is providing education to a cardiac patient who has multiple life stressors that are impacting the patient’s health. Which of the following statements by the patient indicate he has a good understanding of actions he can take to reduce his stressors? (Select all that apply.)
|a.||“I should change my job.”|
|b.||“I should plan some downtime.”|
|c.||“I should meet with a financial counselor.”|
|d.||“I should talk with my family about my situation.”|
|e.||“I should make my family go to counseling with me.”|
- The nurse is providing some education to a community group on environmental safety. Which of the following safety measures are effective in improving their environmental safety? (Select all that apply.)
|a.||Use of night lights throughout the home|
|b.||Illumination of stairwells and pathways|
|c.||Installation of motion-activated lighting on the exterior of the home|
|d.||Application of wax to all floor to increase shine|
Chapter 26: Asepsis and Infection Control
- The second line of defense that leads to local capillary dilation and leukocyte infiltration is known as:
- The antigen-antibody reaction is an example of what type of immunity?
- The nurse administers an immunization consisting of antibodies against hepatitis B. The nurse knows this is a form of what type of immunity?
|a.||Naturally acquired passive|
|b.||Naturally acquired active|
|c.||Artificially acquired passive|
- A disease-causing organism is known as:
- The nurse is explaining to the patient why she is receiving antibiotics. Her answer would be correct if she stated antibiotics are effective against which microorganism?
- The nurse anticipates correctly that what type of medication would be ordered to treat athlete’s foot?
- The nurse’s stethoscope most correctly represents which possible link in the chain of infection?
|b.||Portal of exit|
|c.||Portal of entry|
|d.||Mode of transmission|
- The nurse is teaching a group of patient about diseases such as Rocky Mountain Spotted Fever that are transmitted by ticks. The nurse’s explanation would be correct if she states that the tick functions as:
- The nurse correctly identifies that the most effective method to prevent hospital-acquired infections is:
|a.||use of sterile technique.|
- The nurse correctly identifies which patient as having the greatest risk for infection?
|a.||An 80-year-old male with an enlarged prostate|
|b.||A 24-year-old female long-distance runner|
|c.||A 50-year-old obese male|
|d.||A 40-year-old sexually active female|
- The nurse understands that which set of vitals most likely indicates infection?
|a.||98.6, 75, 18, 120/80|
|b.||99, 80, 19, 110/70|
|c.||100.5, 96, 22, 150/100|
|d.||98.9, 65, 18, 98/62|
- The nurse notes that a patient’s albumin is low and is concerned about the patient’s ability to fight infection related to antibodies being made from what?
- A patient admitted after abdominal surgery has a nursing diagnosis of risk for infection. Which is the most appropriate goal?
|a.||Patient will ambulate length of hallway this shift.|
|b.||Patient will consume 20% of meals by the end of the week.|
|c.||Patient’s incision will be without signs or symptoms of infection at discharge.|
|d.||Patient will verbalize need to stop antibiotics medication when symptom free.|
- The nurse is caring for a patient who is comatose. Her intervention is appropriate when she performs oral care:
|c.||every 4 hours.|
- The nurse knows that which of the following skills does not require the use of sterile technique?
|a.||NG tube insertion|
|d.||PICC line insertion|
- For which situation is it inappropriate to use alcohol-based hand sanitizer?
|a.||Patient with pneumonia|
|b.||Patient with C. difficile|
|d.||Patient with HIV|
- The nurse is preparing to perform suctioning on a new tracheostomy with the potential for forceful expulsion of secretions. What PPE should be worn?
|a.||Gloves and eyewear|
|b.||Gloves, gown, and mask|
|c.||Eyewear and gown|
|d.||Eyewear, mask, gown, gloves|
- The patient has hepatitis A. Which isolation precaution is correctly implemented?
- The patient has pertussis. What isolation precaution is correctly implemented?
- The nurse recognizes the correct order to remove PPE as:
|a.||gloves, eyewear, gown, mask.|
|b.||mask, eyewear, gown, gloves.|
|c.||gown, mask, eyewear, gloves.|
|d.||gloves, gown, mask, eyewear.|
- The nurse has placed her sterile gloved hands below her waist. Her hands are now considered:
|d.||free of disease-causing organisms.|
- The nurse is planning care for an elderly patient. The nurse recognizes the patient is at risk for respiratory infections based on which factors? (Select all that apply.)
|a.||Decreased cough reflex|
|b.||Decreased lung elasticity|
|c.||Increased activity of the cilia|
|d.||Abnormal swallowing reflex|
|e.||Increased sputum production|
- The nurse is providing education to a patient who is being discharged home on antibiotic therapy. Which of the following statement(s) by the patient indicates further education is needed? (Select all that apply.)
|a.||“I should take antibiotics every time I am sick.”|
|b.||“I should take all antibiotics as prescribed.”|
|c.||“I should save all unused antibiotics.”|
|d.||“I should stop taking antibiotics when I feel better.”|
- Which statement regarding handwashing indicates a need for further education? (Select all that apply.)
|a.||Wash hands first, then wrists.|
|b.||Rinse from fingertips to wrists.|
|c.||Dry using a scrubbing motion.|
|d.||Turn off faucet with clean, dry paper towel.|
- The nurse knows that standard precautions are indicated for: (Select all that apply.)
|b.||patients with HIV.|
|c.||patients with MRSA.|
|d.||patients with tuberculosis.|
- The patient is on protective precautions. Which is true regarding these precautions? (Select all that apply.)
|a.||A positive-pressure room with a HEPA filtration system is required.|
|b.||Special respirator masks should be available and one size fits all.|
|c.||No live plants are allowed in the room.|
|d.||The patient may eat any foods desired.|
Chapter 27: Hygiene and Personal Care
- The nurse knows that which of the following statements is true regarding the importance of hygiene?
|a.||The nurse has the opportunity to assess the respiratory, gastrointestinal, and genitourinary systems during the bath.|
|b.||UAPs perform hygiene because there is no benefit of nurses doing it.|
|c.||The mucous membranes of the lips, nostrils, anus, vagina, and urethra are not a part of the integumentary system when providing hygiene.|
|d.||The main purpose of bathing is to decrease odor.|
- Excessively dry skin can lead to cracks and openings in the integumentary system. Based on this, what is the most applicable nursing diagnosis for a patient with excessively dry skin?
|a.||Imbalanced Nutrition: Less than body requirements|
|b.||Deficient fluid volume|
|c.||Risk for infection|
- The nurse correctly identifies which patient as having the highest risk for injury related to temperature of water when bathing?
|a.||Patient with asthma|
|b.||Patient with attention deficit hyperactivity disorder|
|c.||Patient with a stroke|
|d.||Patient with diabetes|
- Which tool is used to determine risk for impaired skin integrity?
- The patient expresses a desire to learn methods to be independent regarding self-care. Based on this, the most appropriate nursing diagnosis would be:
|a.||ineffective health maintenance.|
|b.||readiness for enhanced self-care.|
|c.||hygiene self-care deficit.|
|d.||disturbed body image.|
- The nurse is providing care to a post-stroke patient on the rehabilitation floor with a nursing diagnosis of hygiene self-care deficit. Which goal is most appropriate on day one?
|a.||Patient will ambulate independently twice a day.|
|b.||Patient will perform all of own ADLs.|
|c.||Patient will consume 75% of all meals.|
|d.||Patient will begin to perform 50% of own ADLs.|
- The nurse is preparing to give a patient a complete bed bath. What area of the body should be bathed first?
- The UAP asks why the arms are washed from distal to proximal. Which response by the nurse is appropriate?
|a.||To promote circulation|
|b.||To maintain asepsis|
|c.||To maintain comfort|
|d.||To maintain tradition|
- The nurse has assisted the patient to wash his hands, face, axillae, and perineal area. What type of bath should the nurse chart?
|b.||Complete bed bath|
|c.||Partial bed bath|
- The nurse is performing perineal care for the uncircumcised patient. Which of the following is true?
|a.||The foreskin should not be moved.|
|b.||The foreskin should be retracted, pulling it away from the body.|
|c.||The foreskin should be left retracted and allowed to return to position naturally after care.|
|d.||The foreskin should be retracted and returned to position by the nurse after cleaning, rinsing, and drying.|
- Which member of the collaborative team is most appropriate to cut the toenails of a diabetic patient?
- The nurse knows that routine hygienic care does not include:
|a.||massage with lotion.|
|b.||oral care with a toothbrush.|
|c.||shaving with a disposable razor.|
|d.||ear hygiene with cotton-tipped applicators.|
- The nurse is caring for a patient with swallowing concerns and decreased level of consciousness. The nurse knows to put the patient in what position for oral care?
- Regarding denture care, what action by the nurse is inappropriate?
|a.||Carrying the dentures to the sink wrapped in a paper towel.|
|b.||Placing a towel in the sink and brushing the dentures over the towel.|
|c.||Brushing the dentures as the nurse would the teeth of a conscious patient.|
|d.||Applying adhesive, then inserting upper and then lower dentures.|
- What statement is true regarding oral care of patients on anticoagulants?
|a.||Use an electric toothbrush daily.|
|b.||Avoid oral care.|
|c.||Use mouthwash only.|
|d.||Use a soft-bristled toothbrush.|
- The nurse is assisting a patient to insert contacts and a contact is dropped. What action should occur next?
|a.||Moisten the finger with lens solution and gently touch it to pick it up.|
|b.||Moisten the contact lens with tap water and pick it up.|
|c.||Pick it up and insert the contact lens.|
|d.||Discard the contact lens.|
- Which statement by the patient indicates a teaching need?
|a.||“I use bobby pins to remove excessive ear wax.”|
|b.||“I use soap and a warm cloth to clean the outside of my ear.”|
|c.||“My doctor sometimes gives me oil drops for my ears.”|
|d.||“I never use Q-Tips.”|
- The nurse is asked to shave a patient that is taking Coumadin. What is the most appropriate action?
|a.||Refuse to shave the patient because he is on an anticoagulant.|
|b.||Shave as usual with a safety razor.|
|c.||Offer to wax rather than shave the patient.|
|d.||Use an electric razor.|
- The nurse and UAP are making an occupied bed together. Which action by the nurse is incorrect?
|a.||The nurse asks and assists the patient to turn toward the UAP and loosens the fitted sheet and rolls it in toward the patient.|
|b.||The nurse rolls dirty linens to the side then places the linens on the floor while finishing.|
|c.||The nurse tucks the clean bottom sheet under the cleaner underside of the dirty linens.|
|d.||The nurse wears gloves to remove dirty linens.|
- The nurse knows that which areas are at increased risk of excoriation? (Select all that apply.)
|a.||Exposed areas such as the face|
|b.||Areas exposed to stool|
|c.||Skin on skin areas|
|d.||Area under pendulous breasts|
- The nurse is demonstrating cultural sensitivity in performing perineal care when he/she does the following: (Select all that apply.)
|a.||The male nurse delegates perineal care of a female patient to the female UAP.|
|b.||The male nurse asks a female patient if she would prefer a female to perform care.|
|c.||The nurse approaches the care in a sensitive, professional manner.|
|d.||The nurse assesses cultural preferences of the patient prior to care.|
- The nurse is assisting her patients with hygiene care. She knows that this includes the following: (Select all that apply.)
- The nurse is bathing a patient and notes reddened skin above the coccyx. Which action by the nurse is appropriate? (Select all that apply.)
|a.||Apply a barrier cream and massage the area.|
|b.||Document and describe the area and report to the physician.|
|c.||Wash and dry the area and position patient without pressure on coccyx.|
|d.||Report the area to the charge nurse.|
- Regarding perineal care, which nursing action is appropriate? (Select all that apply.)
|a.||The nurse applies gloves prior to performing perineal care|
|b.||The nurse ignores the erection of a male patient during perineal care|
|c.||The nurse documents the perineal care.|
|d.||The nurse only completes perineal care with daily bathing|
- The nurse should avoid soaking the feet of which patient population? (Select all that apply.)
|a.||Patients with peripheral vascular disease|
|b.||Patients with a stroke|
|c.||Patients with diabetes|
|d.||Patients with arthritis|
- The nurse notes that a trauma patient has multiple tangles in the hair. Which of the following actions taken by the nurse is appropriate? (Select all that apply.)
|a.||Work the tangles to the ends of the hair, then trim with scissors.|
|b.||Apply warm water and conditioner.|
|c.||Apply detangler as available.|
|d.||Use a comb or fingers to work through tangles.|
Chapter 28: Activity, Immobility, and Safe Movement
- The nurse knows rheumatoid arthritis affects the musculoskeletal system by causing:
- The nurse is implementing generalized falls precautions for his patients who are at risk for falls. Which intervention indicates a lack of understanding of these precautions?
|a.||The bed is placed in the low position.|
|b.||The patient is wearing socks.|
|c.||The patient’s cell phone is by the bedside.|
|d.||The patient’s call light is within reach.|
- The nurse is educating the family of a patient on falls risk precautions. Which of the following statements by the family indicates a need for further education?
|a.||“I should keep the wheelchair locked unless using it to move Mom.”|
|b.||“I should always leave the bathroom light on.”|
|c.||“I should use nonskid socks, not shoes.”|
|d.||“I should keep her cell phone close to her bed.”|
- The nurse is performing passive range-of-motion exercises on his patient when the patient begins to complain of pain. What is the first thing the nurse should do?
|a.||Notify the health care provider.|
|b.||Hyperextend the joint.|
|c.||Stop the range of motion.|
|d.||Switch to active range of motion.|
- An appropriate goal for the patient who is postoperative day one from a hip fracture with the nursing diagnosis Impaired physical mobility is:
|a.||the patient will interact with others.|
|b.||the patient will ambulate to the bathroom with assistance.|
|c.||the patient will have no skin breakdown.|
|d.||the patient will have a physical therapy consult.|
- An appropriate goal for the patient who is postoperative day one from abdominal surgery and on bed rest with the nursing diagnosis Impaired skin integrity is:
|a.||the patient will ambulate twice a day.|
|b.||the patient will eat 50% of meals.|
|c.||the patient will have no further skin breakdown.|
|d.||the patient will interact with others.|
- The nurse is providing education to the patient about isometric exercises. Which statement by the patient indicates a good understanding?
|a.||“An example of this type of exercise is walking.”|
|b.||“An example of this type of exercise is running.”|
|c.||“An example of this type of exercise is Kegels.”|
|d.||“An example of this type of exercise is weight lifting.”|
- The nurse is preparing to assist her patient to walk to the bathroom after medicating her with a narcotic for pain management. Of what possible adverse effect should the nurse be immediately aware?
- The nurse correctly selects which intervention to avoid causing shear or friction when moving a patient in bed?
|a.||Using an airflow bed|
|b.||Using a slide board|
|c.||Using a trochanter roll|
|d.||Using a gel mattress|
- The nurse knows active assistive range of motion is:
|a.||when the patient is able to independently move all joints.|
|b.||when the patient is able to partially move all joints.|
|c.||when the caregiver must move the patient’s joints.|
|d.||when the patient is performing isotonic exercises.|
- The nurse appropriately delegates care to the UAP when she:
|a.||instructs the UAP to assess the patient’s skin during a bath.|
|b.||instructs the UAP to reposition the patient using the trapeze.|
|c.||instructs the UAP to assess the patient’s ability to perform range-of-motion exercises.|
|d.||instructs the UAP to notify the health care provider of any changes.|
- The nurse knows that manual lifting should only be done in the following situations:
|a.||Patients who are less than 150 lb|
|d.||Patients who are less than 200 lb|
- The nurse is preparing to reposition the patient in bed. What is the first step in this process?
|a.||Position the patient’s arms across his/her chest.|
|b.||Lower the side rails.|
|c.||Grasp the draw sheet.|
|d.||Raise the bed to a working height.|
- The nurse has delegated to the UAP to assist a patient with ambulating in the hallway with a cane. Which statement by the UAP indicates a need for further education?
|a.||“I should report any complaints of soreness to the nurse.”|
|b.||“I should watch for indications that the patient has difficulties using the cane.”|
|c.||“I should let the nurse or PT know if the cane doesn’t seem to fit correctly.”|
|d.||“I should teach the patient how to walk with the cane.”|
- The nurse correctly teaches the patient to rise from a chair using crutches when the following interventions are used:
|a.||Patient starts from the back of the chair.|
|b.||The weak leg is closest to the chair.|
|c.||The hand on the strong side holds the handbar of the crutch.|
|d.||The strong leg is closest to the chair.|
- The nurse is teaching a patient about ways to decrease her risk of bone fractures. The following statements by the patient indicate a good understanding. (Select all that apply.)
|a.||“I should do weight-bearing exercises.”|
|b.||“I should get adequate intake of calcium and vitamin D.”|
|c.||“I should exercise regularly.”|
|d.||“I need to do yoga exercises.”|
- The nurse knows that a patient with a compromised cardiopulmonary system has a diminished capacity for exercise because of the following: (Select all that apply.)
|a.||Decreased tissue perfusion|
|b.||Loss of sensation|
|d.||Diminished respiratory capacity|
- The nurse is educating the patient about the effects of immobility on the body. The following statements by the patient indicate a need for further education: (Select all that apply.)
|a.||“I can become very weak.”|
|b.||“I will gain weight.”|
|c.||“I will lose muscle tone.”|
|d.||“I can get bed sores.”|
- The nurse knows the following items should be included in the documentation of the patient on falls precautions: (Select all that apply.)
|a.||History of any falls|
|b.||Falls risk assessment scores|
|c.||Patient and family education|
|d.||Use of assist devices|
|e.||Any fall or reported fall|
- The nurse knows the following indicates orthostatic hypotension: (Select all that apply.)
|a.||A decrease in systolic blood pressure by 30 mm Hg|
|b.||A decrease in diastolic blood pressure by 10 mm Hg|
|c.||An increase in heart rate by 30 beats/min|
|d.||An increase in systolic blood pressure by 20 mm Hg|
- The nurse appropriately delegates care of her patient to the properly trained UAP when she: (Select all that apply.)
|a.||assigns the UAP to reposition the patient.|
|b.||assigns the UAP to complete the MORSE falls risk scale.|
|c.||assigns the UAP to provide range-of-motion exercises.|
|d.||assigns the UAP to ambulate the patient in the hallway.|
- The nurse is correctly demonstrating the use of a transfer belt when engaging in the following: (Select all that apply.)
|a.||The belt is placed around the patient’s hips.|
|b.||The belt is secure, leaving only enough room for the nurse to grasp the belt.|
|c.||The nurse stands on the weaker side.|
|d.||The nurse holds the belt on the side of the patient.|
- The nurse is correctly assisting the patient in using a cane when the patient demonstrates the following: (Select all that apply.)
|a.||The top of the cane is level with the patient’s bent elbow.|
|b.||The patient holds the cane on his/her weaker side.|
|c.||The patient moves the cane forward first.|
|d.||The patient’s arm is comfortably bent when walking.|
- The nurse is providing discharge education for her patient who is going home with a walker. Which statement by the patient indicates a good level of understanding of safety in the home? (Select all that apply.)
|a.||“I need to remove the throw rugs.”|
|b.||“I should make sure I only take a bath.”|
|c.||“I cannot use the stairs.”|
|d.||“I need to place a nonskid mat in front of the kitchen sink.”|
- The nurse knows the knee-high SCD sleeves are correctly placed on the patient when the following conditions are met: (Select all that apply.)
|a.||Both sleeves are connected to the SCD device.|
|b.||Two fingers fit inside when the SCDs are inflated.|
|c.||There are no kinks in the tubing.|
|d.||The ankle pressure is 55 to 65 mm Hg.|
|e.||The cooling control is on.|
Chapter 29: Skin Integrity and Wound Care
- The nurse knows the following wound would be classified as a closed wound:
|a.||A large bruise on the side of the face|
|b.||A surgical incision that is sutured closed|
|c.||A puncture wound that is healing|
|d.||An abrasion on the leg|
- The nurse is educating the patient about the signs and symptoms of a wound infection. Which statement indicates a need for further education?
|a.||“The wound will be red.”|
|b.||“The wound will have pus.”|
|c.||“The wound will be warm.”|
|d.||“The wound will need to be treated.”|
- The nurse knows the following types of wounds heal by tertiary intention:
|a.||An acute wound in which the patient has sutures placed when it happened|
|b.||A pressure ulcer that was treated with dressing changes and healed|
|c.||An acute wound in which surgical glue was used to close the wound|
|d.||A wound that was left open initially and closed later with sutures|
- The nurse is caring for a patient who is postoperative day one from an abdominal surgery. The patient complains of a “popping sensation” and a wetness in her dressing. The nurse immediately suspects:
|a.||a wound infection.|
|b.||the stitches came loose.|
- The nurse is caring for a postoperative patient who has had abdominal surgery and whose wound has completely eviscerated when she walks into the room. In addition to notifying the physician, what should the nurse do?
|a.||Cover the wound with a sterile gauze pad.|
|b.||Cover the wound with a transparent dressing.|
|c.||Put pressure on the wound with a sterile gauze pad.|
|d.||Cover the wound with gauze soaked with normal saline.|
- The nurse knows the most appropriate goal for a patient with a stage III pressure ulcer who has a nursing diagnosis of Impaired skin integrity is:
|a.||the wound will be completely healed in 72 hours.|
|b.||the wound will show signs of healing within 2 weeks.|
|c.||the patient will develop no new pressure ulcers.|
|d.||the patient will ambulate twice a day.|
- The nurse is delegating care of a patient with a chronic nonsterile wound to a UAP. The delegation is inappropriate if:
|a.||the nurse asks the UAP to assess the wound.|
|b.||the nurse asks the UAP to report increased wound drainage.|
|c.||the nurse asks the UAP to observe changes in dietary intake.|
|d.||the nurse asks the UAP to change the dressing.|
- The nurse is repositioning her patient in the side-lying position. To avoid putting the patient at risk for pressure ulcers, the HOB should be placed at:
- The nurse knows that mechanical debridement involves all of the following except:
|a.||wet to dry dressings.|
|c.||damp to dry dressing.|
- The nurse is explaining to the student nurse the purpose of occlusive dressings. Which statement by the student nurse indicates a lack of understanding?
|a.||“Occlusive dressings are used for autolytic debridement.”|
|b.||“Hydrocolloids are a type of occlusive dressing.”|
|c.||“Occlusive dressings can be used on infected wounds.”|
|d.||“Occlusive dressings support the most comfortable form of debridement.”|
- The nurse knows that a hydrocolloid dressing is appropriate for the following type of wound:
|a.||A wound with a large amount of drainage|
|b.||A wound that is tunneling|
|c.||A postsurgical incision with staples|
|d.||A wound with a moderate amount of drainage|
- The nurse is caring for a patient with a Penrose drain. She knows the patient will require the following care:
|a.||The drain must be compressed after emptying to work properly.|
|b.||The drain must be connected to suction if ordered.|
|c.||The drain is not sutured in place so care is taken to not dislodge it.|
|d.||The suction pulls drainage away from the wound as it re-expands.|
- The nurse is educating the patient about the use of heat/cold therapy at home. The following statement by the patient indicates the need for further education?
|a.||“I should fill my ice bag 2/3 full of ice.”|
|b.||“I should use distilled water in my Aqua-K pad.”|
|c.||“I can warm up my hot pack in the microwave.”|
|d.||“I should check the order for how long to leave the compress on.”|
- The nurse knows to irrigate a deep wound with:
|a.||A 5-mL syringe.|
|b.||A 10-mL syringe.|
|c.||A 3-mL syringe.|
|d.||A 30-mL syringe.|
- The nurse understands the rationale for drying a wound after irrigation is:
|a.||to ensure the new dressing adheres to the wound.|
|b.||to ensure the new dressing remains occlusive.|
|c.||to prevent skin breakdown from moisture.|
|d.||to prevent infection from irrigate solution.|
- The nurse is performing a wet/damp to dry dressing change when the patient begins to complain of severe pain. What should the nurse do first?
|a.||Notify the physician.|
|b.||Notify the wound care nurse.|
|c.||Stop the procedure.|
|d.||Give the patient pain medication.|
- The nurse knows an appropriate goal for a patient with a stage III pressure ulcer with the nursing diagnosis Impaired physical mobility is:
|a.||the patient will remain free of wound infections during the hospitalization.|
|b.||the patient will report pain management strategies and reduce pain to a tolerable level.|
|c.||the patient will turn self in bed using over trapeze every two hours using assistance when needed.|
|d.||the patient will consume adequate nutrition to meet nutritional requirements within 1 week.|
- The nurse knows a stage III pressure ulcer is:
|a.||a pressure ulcer that involves exposure of bone and connective tissue.|
|b.||a pressure ulcer that does not extend through the fascia.|
|c.||a pressure ulcer that does not include tunneling.|
|d.||a partial-thick wound that involves the epidermis.|
- The nurse knows the layer that delivers the blood supply to the dermis, provides insulation, and has a cushioning effect is:
- The nurse knows that the following factors contribute to the development of wounds and lead to delays in wound healing: (Select all that apply.)
|a.||A patient who has diabetes|
|b.||A patient with COPD on long-term steroid therapy|
|c.||A patient with on bed rest who is repositioned|
|d.||A patient who is obese and sweats excessively|
- The nurse knows that the cause of pressure ulcers includes the following factors: (Select all that apply.)
|a.||Intensity of the pressure|
|b.||Duration of the pressure|
|c.||The tissue’s ability to tolerate the pressure|
|d.||The person’s age|
- The nurse is performing a focused wound assessment on a patient. The following should be included in the documentation: (Select all that apply.)
|a.||Location and size|
|b.||Characteristics of the wound bed|
|c.||Patient’s response to wound treatment|
|d.||Patient’s pain level|
|e.||Presence of drainage|
- The nurse is using the Braden scale to assess the patient’s risk for a pressure ulcer. Which risk categories are associated with the Braden scale? (Select all that apply.)
|b.||Friction and shear|
- The nurse is caring for a postoperative orthopedic patient who has two Hemovac drains in place. Which interventions should the nurse perform? (Select all that apply.)
|a.||Measure the amount of drainage in the device prior to emptying.|
|b.||Label each drain and record them separately.|
|c.||Recompress the device after emptying.|
|d.||Secure the device to the patient’s gown above the level of the wound.|
|e.||Check for kinks in the tubing.|
- The nurse knows that cold therapy is contraindicated in the following conditions: (Select all that apply.)
Chapter 30: Nutrition
- The nurse is providing education to patient about the difference between simple and complex carbohydrates. Which statement by the patient indicates a need for further education?
|a.||“Simple carbohydrates give me quick energy.”|
|b.||“Complex carbohydrates come from fruit.”|
|c.||“Complex carbohydrates take longer to break down.”|
|d.||“Simple carbohydrates come from milk products.”|
- The nurse knows that patients should consume the following amounts of fiber every day:
- The nurse is providing education to an older adult around diet to support the challenges related to aging. Which statement indicates a need for further education?
|a.||“I should choose foods that are nutrient dense.”|
|b.||“High-fiber foods minimize the risk of constipation.”|
|c.||“I should eat more calories to avoid malnutrition.”|
|d.||“I can add spices to enhance the taste of food.”|
- The nurse is caring for an adolescent patient with anorexia nervosa. She knows the best treatment option is:
|a.||hospitalization with skill nursing care.|
|b.||compulsory tube feedings.|
|c.||individually determined by a collaborative team.|
- The nurse is measuring his patient’s height. Which of the following steps of the procedure indicates a need for further education on this skill?
|a.||He instructs the patient to remove his shoes.|
|b.||He measures from the top of the patient’s head to the bottom of the patient’s foot arch.|
|c.||He positions the head against the headboard or measuring device.|
|d.||He makes sure the patient is standing erect.|
- The nurse is performing an oral examination on a patient and notices a beefy-red tongue. She knows this is a characteristic finding in:
- The nurse is concerned about aspiration precautions when feeding her patient who has recently suffered a stroke. Which of the following procedures that the nurse performs would demonstrate a need for further education?
|a.||The nurse uses thickened liquids.|
|b.||The nurse puts the bed at 30 degrees.|
|c.||The nurse encourages slow eating.|
|d.||The nurse has the patient alternate between food and sips of fluid.|
- The nurse knows an appropriate outcome statement for the nursing diagnosis Impaired swallowing is:
|a.||the patient will consume 50% of his meal.|
|b.||the patient will gain 2 lb a week.|
|c.||the patient will show any signs of aspiration during meals.|
|d.||the patient will demonstrate using an assistive device to feed himself.|
- The nurse is explaining to the UAP that the patient is on a full-liquid diet. Which statement by the UAP indicates a need for reorientation?
|a.||“I can give the patient orange juice.”|
|b.||“I can give the patient yogurt.”|
|c.||“I can give the patient oatmeal.”|
|d.||“I can give the patient milk.”|
- The nurse is educating her patient about who has just been placed on a renal diet. Which statement by the patient indicates a need for further education?
|a.||“I need to eat a low-sodium diet.”|
|b.||“I can have limited amounts of meat.”|
|c.||“I can drink unlimited cola if it is diet.”|
|d.||“I should avoid or limit bananas.”|
- The nurse knows that initial verification of a nasogastric placement is important. Which method is considered the only reliable method to determine enteral tube placement?
|a.||Auscultation of air bolus|
|b.||Measurement of pH of the aspirate|
|d.||Aspirate contents to visually inspect appearance|
- The nurse is attempting to open an occluded PEG tube. Which of the following interventions requires re-education?
|a.||Flush the tube with a small amount of air|
|b.||Flush the tube using a 50- to 60-mL syringe and 20 to 30 mL of warm water.|
|c.||Reinsert the stylet to break up the clot.|
|d.||Flush the tube with a carbonated beverage.|
- The nurse is caring for a patient who is receiving total parenteral nutrition (TPN). The nurse knows she should change the tubing every:
- The nurse is preparing to insert a nasogastric (NG) tube in her patient. Which of the following steps in the process indicates a need for further education?
|a.||The nurse lubricates 4 inches of the tube prior to insertion.|
|b.||The nurse marks the length of the tube with a marker for insertion.|
|c.||The nurse measures the length of tube needed using the nose-earlobe-xiphoid process.|
|d.||The nurse applies clean gloves for the procedure.|
- The nurse has received an order from the health care provider to discontinue the nasogastric tube. Which of the following actions by the nurse indicates a need for further education?
|a.||The nurse clears the tube with air prior to discontinuing.|
|b.||The nurse stops the tube feeding.|
|c.||The nurse instructs the patient to cough while pulling out the tube.|
|d.||The nurse clamps the tube while pulling it out.|
- Based on research on aging, the nurse knows that improper nutrition may result in the onset of which specific diseases? (Select all that apply.)
|a.||Type 2 diabetes|
- The nurse is helping a patient understand the difference between macronutrients and vitamins and minerals. She is correct when she lists the following items as macronutrients: (Select all that apply.)
- The nurse is providing dietary education to her patient to help him include more complex carbohydrates in his diet. Which of the following would be beneficial to include? (Select all that apply.)
- The nurse is educating a patient about including more omega-3 fatty acids in her diet. Which of the following food sources should be included? (Select all that apply.)
- The nurse is planning dietary education for her patient. What food labeling consideration should she be aware of when planning her education? (Select all that apply.)
|a.||Ask patients if they read food labels.|
|b.||Assess their level of understanding of food labels.|
|c.||Encourage them to read the food labels.|
|d.||Explain to them all food labels are different.|
- The nurse knows that a deficiency in vitamin C can result in the following conditions: (Select all that apply.)
- The nurse is preparing some educational materials for her patient about the impact of obesity and a high body mass index (BMI). She knows that as BMI increases, so does the risk of these conditions: (Select all that apply.)
|a.||Increase in blood pressure|
|b.||Increase in HDL|
|c.||Increase in total cholesterol|
|d.||Development of atherosclerosis|
- The nurse is completing a nutrition assessment on a patient. What are some important considerations? (Select all that apply.)
|a.||The nurse should include the patient’s cultural influences in her assessment.|
|b.||The food diary accuracy is the same for a 24-hour recall or 3- to 5-day food journal.|
|c.||The nurse should be nonjudgmental in her review.|
|d.||A consult with a registered dietician may be indicated.|
- The nurse is educating her patient about the risk of heart disease from metabolic syndrome. She knows metabolic syndrome is a cluster of the following symptoms: (Select all that apply.)
|a.||Elevated blood glucose|
|b.||High waist circumference|
|c.||History of smoking|
|e.||Elevation serum cholesterol|
- The nurse is completing her documentation after feeding a patient with aspiration precautions. Which of the following items should she document? (Select all that apply.)
|a.||Episodes of coughing or gagging|
|b.||Hesitation or fear of eating|
|d.||Aspiration protocol used|
- The nurse is caring for a patient receiving enteral feedings. She appropriately delegates the following to the UAP: (Select all that apply.)
|a.||Verify tube placement|
|b.||Perform oral care|
|c.||Administer tube feeding|
|d.||Obtain vital signs and report results|
Chapter 31: Cognitive and Sensory Alterations
- A nurse is caring for a patient with a stroke that has impacted her ability to see. Which area of the brain was likely impacted by the stroke that is responsible for visual function?
- The family of a patient who was in a motor vehicle accident tells you he “just isn’t the same person before the crash.” You know this is likely because of the injury to what area of his brain?
- The nurse is educating the family of a patient in the intensive care unit about the patient’s cognitive status, including her current problem of delirium. Which statement by the family indicates a need for further education?
|a.||“The delirium can be caused by sensory overload.”|
|b.||“The delirium is reversible.”|
|c.||“The delirium is a mood disorder.”|
|d.||“The delirium is a state of confusion.”|
- The nurse is caring for a patient with depression. Which statement by the patient indicates a need for further education?
|a.||“Depression can be caused by chemical changes in the brain.”|
|b.||“Depression is always treated with medication.”|
|c.||“Depression is a mood disorder.”|
|d.||“Depression can have a rapid onset.”|
- The nurse is caring for a patient who is complaining of tingling in her hands and fingers. The nurse knows this is a sign of what electrolyte imbalance?
- The nurse is providing discharge instructions to an older adult who is being discharged with orthostatic hypotension. Which of the following responses by the patient indicates a need for further education?
|a.||“I should take my blood pressure once a day at home.”|
|b.||“I should get up quickly to avoid my blood pressure dropping.”|
|c.||“I should drink plenty of water during the day.”|
|d.||“I should get up slowly and carefully.”|
- The nurse is assessing the patient’s ability to hear. Which is the correct procedure for the doing this?
|a.||The nurse whispers to the patient while standing on each side of the patient.|
|b.||The nurse speaks in a normal voice while standing on each side of the patient.|
|c.||The nurse speaks in a normal voice while standing directly in front of the patient.|
|d.||The nurse speaks in a normal voice while standing slightly behind the patient.|
- The nurse notices her 50-year-old patient is holding his lunch menu at arm’s length while trying to read his choices. This is an indication of:
- The nurse is providing discharge education to her patient with diabetes regarding foot care. Which of the following statements by the patient indicates a need for further education?
|a.||“I can go barefoot outside only in the summer.”|
|b.||“I should wear good fitting shoes.”|
|c.||“I cannot soak my feet in a hot tub.”|
|d.||“I can use lotion on my feet.”|
- An appropriate goal for a patient with the diagnosis of acute confusion is:
|a.||the patient will use the call light before getting out of bed within 48 hours.|
|b.||the patient will use a calendar to remember the date within 48 hours.|
|c.||the patient will respond appropriately to questions about place within 48 hours.|
|d.||the patient will remain within the unit while in long-term care.|
- An appropriate goal for a patient with a diagnosis of social isolation is:
|a.||the patient will participate in cognitive exercises.|
|b.||the patient will interact with other residents during activities.|
|c.||the patient will communicate basic needs through use of photos.|
|d.||the patient will remain within the unit while in long-term care.|
- The nurse is educating the family to care for a patient at home with cognitive alterations. Which statement by the family indicates a need for further education?
|a.||“I should keep the home free of scissors.”|
|b.||“I should minimize the number of visitors.”|
|c.||“I should use push-button door locks.”|
|d.||“24-hour supervision may become necessary.”|
- The nurse is delegating care to an unlicensed assistive personnel (UAP) to a patient who has sensory overload. Which statement by the UAP indicates a need for further orientation?
|a.||“I should keep the noise levels low.”|
|b.||“I should schedule all the care together.”|
|c.||“I should keep the room well lit.”|
|d.||“I should allow the family to visit.”|
- The nurse is providing discharge instructions to a patient with visual alterations. Which statement by the patient indicates a need for further education?
|a.||“I should make sure the passageways are wide.”|
|b.||“I should remove all the throw rugs.”|
|c.||“I should keep the lights dim.”|
|d.||“I can use a cane to feel for objects in front of me.”|
- The nurse is completing her assessment of an older adult and notices some cognitive impairment not normally associated with aging. Which of these alterations would prompt further follow-up? (Select all that apply.)
|a.||The patient does not remember where her son lives.|
|b.||The patient is unable to balance her checkbook.|
|c.||The patient got lost in a city she never traveled to before.|
|d.||The patient often has difficulty remembering words.|
|e.||The patient got lost going to her usual grocery store.|
- You are providing education to the family of a patient being discharged with dementia. Which statement by the family indicates a good level of understanding of dementia? (Select all that apply.)
|a.||“The condition is permanent and has an acute onset.”|
|b.||“Alzheimer’s is the most common type of dementia.”|
|c.||“The condition worsens over time.”|
|d.||“I should observe for wandering behavior.”|
|e.||“Agitation can be worse in the evening.”|
- The nurse is caring for a patient who suffered a stroke on the right side of the brain. The nurse is careful to implement what safety measures? (Select all that apply.)
|a.||“Make sure to put a picture board in the room to communicate with the patient.”|
|b.||“Place the call light on the patient’s left side.”|
|c.||“Leave on a light in the bathroom at night for good visibility.”|
|d.||“Place the call light on the patient’s right side.”|
|e.||“Make sure there are no trip hazards in the patient’s room.”|
- The nurse is performing a health history to determine the patient’s cognitive status. Which questions will be best suited to elicit the information needed? (Select all that apply.)
|a.||“Are you able to drive to the store or do errands?”|
|b.||“Do you live with anyone?”|
|c.||“Do you ever feel sad?”|
|d.||“Are you able to smell different foods?”|
|e.||“Have you noticed any difficulty adding up numbers?”|
- The nurse is performing a health history to determine the patient’s sensory status. Which questions will be best suited to elicit the information needed? (Select all that apply.)
|a.||“Do you ever lose your balance?”|
|b.||“Do you wear glasses?”|
|c.||“Do you read the newspaper?”|
|d.||“Can you feel the difference between hot and cold water?”|
|e.||“Do you wear a hearing aid?”|
- The nurse is caring for a diabetic patient who has had a long history of poor glucose control. For what complications is the patient at risk? (Select all that apply.)
|a.||Sudden loss of consciousness|
- The nurse is caring for a patient who is hospitalized with cognitive impairment. The following interventions will assist the patient in orientation: (Select all that apply.)
|a.||Keep a photo of the family in the room.|
|b.||Use a clock on the wall.|
|c.||Make sure the room is kept bright and well lit.|
|d.||Avoid moving the patient from room to room.|
|e.||Have the nurse introduce himself or herself to the patient.|
- The nurse is caring for a patient with expressive aphasia. Which interventions will assist the nurse in communicating with the patient? (Select all that apply.)
|a.||Use simple phrases.|
|c.||Use yes/no questions.|
|d.||Use a picture board.|
|e.||Be patient and unrushed.|
- The nurse is caring for a patient with receptive aphasia. Which interventions will assist the nurse in communicating with the patient? (Select all that apply.)
|a.||Use simple phrases.|
|c.||Stand in front of the patient.|
|d.||Use a picture board.|
|e.||Be patient and unrushed.|
- The nurse is preparing discharge instructions for a patient who has tactile alterations in his legs. Which instructions should be included? (Select all that apply.)
|a.||Verify bath water temperature is approximately 39.5° C.|
|b.||Do not use hot or cold therapy on any extremity.|
|c.||Use sturdy shoes when walking outside or on hard surfaces.|
|d.||Report any changes in skin color on your legs to your health care provider.|
|e.||Set your water heater so that scalding is not possible.|
- The nurse is preparing discharge instructions for a patient who has equilibrium alterations. Which instructions should be included? (Select all that apply.)
|a.||Use grab bars in the tub and/or shower at home.|
|b.||Keep rooms well lit and focus ahead when walking.|
|c.||Change positions quickly to avoid dizziness.|
|d.||Use a cane or walker for stability.|
|e.||Ride in the back seat of the car and look ahead.|
Chapter 32: Stress and Coping
- The nurse knows that one theory explaining the variation in response to stress among individuals is called:
|b.||sense of coherence.|
- The nurse is caring for a patient with a new diagnosis of diabetes type 2. Which of the following statements indicates a negative coping response?
|a.||“I will look up information on the Internet about diabetes.”|
|b.||“I will join a support group.”|
|c.||“I will only focus on learning to manage my medication first.”|
|d.||“I will make changes slowly so I can adapt to each change.”|
- The nurse is caring for a patient who is undergoing a major cardiac procedure. The patient tells you her heart is racing and she feels nauseated. You know this is part of hormone response known as:
|a.||sense of coherence.|
|c.||fight or flight.|
- The nurse is measuring her patient’s blood glucose levels after an acute myocardial infarction (MI). She knows the rationale for doing this is:
|a.||damaged muscle tissue releases glucose.|
|b.||corticosteroids increase glucose.|
|c.||myocardial infarctions are often seen in diabetics.|
|d.||all patients should have their blood glucose checked.|
- The nurse is teaching her patient about the difference between mild anxiety and moderate anxiety. Which statement by the patient indicates a need for further education?
|a.||“Mild anxiety can help me remember things.”|
|b.||“Moderate anxiety will narrow my focus.”|
|c.||“Mild anxiety will help me be creative.”|
|d.||“Moderate anxiety will increase my perception.”|
- The nurse is providing discharge instructions for a patient with multiple sclerosis (an autoimmune disease). Which discharge instruction is aimed at preventing a future exacerbation?
|a.||Engage in some form of exercise as tolerated.|
|b.||Avoid highly stressful situations.|
|c.||Check your skin regularly for pressure sores.|
|d.||Eat a diet with lots of fiber.|
- The nurse is assessing level of stress in a patient from another culture. Which question is the most appropriate in helping the nurse understand the impact of the patient’s belief system?
|a.||“Do you engage in prayer to help you during times of stress?”|
|b.||“Do you go to church or other form of organized worship?”|
|c.||“Do you have certain beliefs that are helpful during times of stress?”|
|d.||“Do you want spiritual counseling while you are here?”|
- The nurse is performing a physical assessment of patient who is undergoing a bone marrow biopsy. What finding by the nurse indicates the patient is experiencing stress?
|a.||Blood pressure of 120/84|
|b.||Temperature of 37.5° C|
|c.||Heart rate of 110 beats/min|
|d.||Respiratory rate of 10 breaths/min|
- The nurse is assessing the patient’s use of coping skills in response to stressful situations. Which of the following questions is the most useful?
|a.||“Have you been evaluated for stress?”|
|b.||“Do you have someone you can go to for help when you are stressed?”|
|c.||“How have you managed stressful situations in the past?”|
|d.||“Does stress cause you to experience muscle tension or headaches?”|
- The nurse is caring for a patient on a medical-surgical inpatient unit. The patient tells the nurse he is very sad and is considering suicide. What is the first thing the nurse should do?
|a.||Notify the health care provider.|
|b.||Make a referral to psychiatric services.|
|c.||Implement one-on-one observations.|
|d.||Document in the electronic medical record.|
- The nurse knows an appropriate goal for the nursing diagnosis of Ineffective coping would be:
|a.||The patient will report an ability to remember discharge instructions.|
|b.||The patient’s family will understand how to access respite care services.|
|c.||The patient will discuss possible coping strategies during weekly counseling sessions.|
|d.||The patient will attend an online support group weekly.|
- The nurse knows an appropriate goal for Stress overload is:
|a.||The patient will attend a weekly support group.|
|b.||The patient will discuss possible coping strategies during weekly office visits.|
|c.||The patient will discuss strategies for coping with relationship violence within 24 hours.|
|d.||The patient’s family will use respite care once a week for the next month.|
- The nurse knows that an appropriate goal for Readiness for enhanced coping would be:
|a.||The patient will report an ability to focus on discharge instructions.|
|b.||The patient will attend a coping skills class on a weekly basis.|
|c.||The patient will discuss possible coping strategies during weekly office visits.|
|d.||The patient will discuss strategies for coping with relationship violence within 24 hours.|
- The nurse knows that when coordination between multiple health care disciplines is needed, the following role is used:
- The nurse is providing education to a patient around anger management strategies. Which statement indicates a need for further education by the patient?
|a.||“Exercise can help me deal with the anger.”|
|b.||“I can use humor.”|
|c.||“I can punch things.”|
|d.||“I can take a time out.”|
- The nurse is educating the patient about alternative therapies. Which statement by the patient indicates a need for more information?
|a.||Alternative therapies can include relaxation techniques.|
|b.||Alternative therapies are used in conjunction with medical therapies.|
|c.||Alternative therapies can be used when patients are experiencing stress.|
|d.||Some alternative therapists require certification.|
- The nurse is educating the patient on the use of relaxing therapy. Which statement by the patient indicates a need for further education?
|a.||“I should relax my muscles from head to toe.”|
|b.||“I visual the relaxed muscle.”|
|c.||“I should do this three times a week.”|
|d.||“I focus on muscles that are tense.”|
- The nurse is seeing a patient during a follow-up visit after discharge in which the patient had a nursing diagnosis of Ineffective coping. Which statement by the patient would be a cause for concern?
|a.||“I am sleeping better most nights.”|
|b.||“I feel less anxious.”|
|c.||“I do not need to do the relaxation exercises anymore.”|
|d.||“I am continuing my exercises every day.”|
- The nurse knows that when patients are experiencing stress, the following change can be seen in their signs and symptoms: (Select all that apply.)
|a.||Increase in heart rate|
|b.||Increase in gastric motility|
|d.||Decrease in blood pressure|
|e.||Increase in respiratory rate|
- The nurse knows that the body’s response to the release of hormones in the “fight or flight” response is which of the following? (Select all that apply.)
|a.||Decreased respiratory rate|
|b.||Slowing of the digestive process|
|c.||Glucose being mobilized from the liver|
|e.||Smooth muscles in the bronchi constricting|
- The nurse knows that certain personality factors have been shown to buffer the impact of stress. These factors are: (Select all that apply.)
|b.||sense of coherence.|
- The nurse knows that childhood stress related to the school experience centers on: (Select all that apply.)
- The nurse knows that the coping strategies that are more frequently seen in older adults are: (Select all that apply.)
- The nurse manager of a busy oncology unit is concerned about compassion fatigue among her nursing staff. Which of the following signs and symptoms would alter her to this problem? (Select all that apply.)
|a.||Nurses become very emotionally upset without an apparent cause.|
|b.||Nurses start to avoid caring for certain patients.|
|c.||Nurses start to call in sick more often.|
|d.||Nurses begin working more overtime.|
|e.||Nurses have difficulty showing empathy for patients.|
- The nurse manager of the unit is implementing a program to assist the nursing staff in managing compassion fatigue. Which intervention will be the most successful? (Select all that apply.)
|a.||Support group that nurses can participate in that meets on the unit|
|b.||Exercise completion to encourage nurse to exercise and log their time|
|c.||Organized break times so nurses can get off the unit for breaks and lunches|
|d.||Quiet area on the unit where the nurses can go during break|
|e.||Promotion of work-life balance|
Chapter 33: Sleep
- The nurse knows that with the onset of darkness and in preparation for sleep:
|a.||cortisol levels peak.|
|b.||cortisol levels increase.|
|c.||core body temperature increases.|
|d.||melatonin levels increase.|
- The nurse knows the reticular activating system (RAS):
|a.||records brain waves and other variables.|
|b.||relays motor impulse to the hypothalamus.|
|c.||influences patterns of biological functioning.|
|d.||is affected by the light-dark cycle.|
- The nurse is educating a patient about taking measures to help avoid disruption to the circadian rhythm. The following statement by the patient indicates a need for further education:
|a.||“I know the circadian rhythm influences biological functions.”|
|b.||“I know the circadian rhythm exists only in humans.”|
|c.||“I know the sleep-wake circadian rhythm is impacted by the light-dark cycle.”|
|d.||“The most familiar circadian rhythm is the day-night 24-hour cycle.”|
- The nurse knows that polysomnograpy is:
|a.||the recording of brain waves and other variables.|
|b.||the relay of motor impulse to the hypothalamus.|
|c.||the patterns of biological functioning.|
|d.||the recording of seizure activity in the brain.|
- The nurse knows the usual progression of sleep is:
|a.||NREM 1-4 then REM, then back through NREM 1 and 2.|
|b.||REM then NREM 1-4, then back through NREM 2 and 3.|
|c.||NREM 1-4 then back through NREM 3 and 2 then REM.|
|d.||REM then NREM 1-4 then back through NREM 3.|
- The nurse is providing discharge instructions to the parents of a toddler about sleeping habits. Which of the following statements indicates further education is needed?
|a.||“Sleep needs may change during growth spurts.”|
|b.||“Children sleep 10 hours a day.”|
|c.||“Toddlers will often resist going to bed.”|
|d.||“The bedtime routine can vary.”|
- The nurse knows that cataplexy includes:
|a.||an uncontrolled desire to sleep.|
|b.||falling asleep for several minutes.|
|c.||loss of voluntary muscle tone.|
|d.||a sleep cycle that begins with NREM.|
- The nurse is providing discharge instructions to a patient who has had sleep alterations. The following statements by the patient indicate further education is needed.
|a.||“I should avoid drinking caffeine too close to bedtime.”|
|b.||“I should not eat anything too close to bedtime.”|
|c.||“I should exercise regularly to help with sleeping.”|
|d.||“I can gain weight if I don’t sleep enough.”|
- The nurse is performing an assessment of the patient’s sleep patterns. Which question will elicit the best response?
|a.||“Do you feel rested when you awaken?”|
|b.||“What is your normal eating pattern?”|
|c.||“Do you awaken during the night?”|
|d.||“Do you drink beverages with caffeine?”|
- The nurse knows an appropriate goal for the nursing diagnosis Sleep deprivation is:
|a.||the patient will remain asleep for 6 to 7 hours consistently for 1 week.|
|b.||the patient will fall asleep within 15 minutes of going to bed.|
|c.||the patient will report an ability to concentrate on tasks.|
|d.||the patient will repeat medication instructions on discharge.|
- The nurse knows an appropriate goal for the nursing diagnosis Disturbed sleep pattern during hospitalization is:
|a.||the patient will fall asleep within 15 minutes of going to bed.|
|b.||the patient will report an ability to concentrate on tasks.|
|c.||the patient will repeat medication instructions on discharge.|
|d.||the patient will be able to sleep for at least 2 hours at a time.|
- The nurse knows an appropriate goal for the nursing diagnosis Insomnia is:
|a.||The patient will report an ability to concentrate on tasks.|
|b.||The patient will repeat medication instructions on discharge.|
|c.||The patient will be able to sleep for at least 2 hours at a time.|
|d.||The patient will be able to fall asleep within 15 minutes.|
- The nurse is providing discharge education for a patient with narcolepsy. The following statement by the patient indicates a need for further education:
|a.||“Daytime naps are helpful.”|
|b.||“Taking the medication will cure it.”|
|c.||“High protein meals are helpful.”|
|d.||“I should avoid alcohol.”|
- The nurse is providing discharge education for a patient with restless leg syndrome. The following statement by the patient indicates a need for further education:
|a.||“I should avoid all caffeine.”|
|b.||“I can using leg massage and knee bends.”|
|c.||“Taking magnesium supplements may be helpful.”|
|d.||“Taking a walk regularly may be helpful.”|
- Which of the following is inappropriate to delegate to the unlicensed assistive personnel (UAP)?
|a.||Providing oral care|
|b.||Evaluating sleep patterns|
|c.||Providing bedtime routines|
|d.||Documenting sleep hours|
- The nurse is providing discharge instructions for the patient with sleep pattern disturbances. Which statement by the patient indicates a need for further education?
|a.||“It is a good idea to have a bedtime routine.”|
|b.||“My bedtime routine can include watching TV in bed until I fall asleep”|
|c.||“I should keep my regular sleep pattern on the weekend.”|
|d.||“If I can’t fall asleep, I should get out of bed and do something relaxing.”|
- The nurse knows that during rapid eye movement (REM) sleep, the following occur: (Select all that apply.)
|a.||Memories are stored|
|b.||Increase in cerebral blood flow|
|c.||Slow rhythmic scanning eye movements|
|d.||Release of epinephrine|
|e.||Repair of brain cells|
- The nurse knows that during non-rapid eye movement (NREM) sleep, the following occur: (Select all that apply.)
|a.||Repair of brain cells|
|b.||Slow rhythmic scanning eye movements|
|d.||Cell division in bone marrow|
|e.||Conservation of energy|
- The nurse knows the following changes in sleep patterns occur in the older adult: (Select all that apply.)
|a.||Sleep increases to approximately 8 to 10 hours a night.|
|b.||REM sleep is shorter.|
|c.||Stage 4 NREM is decreased.|
|d.||The use of medication may interfere with sleep.|
|e.||Older adults awaken more at night.|
- The nurse knows the following information about sudden infant death syndrome (SIDS): (Select all that apply.)
|a.||SIDS is the most common cause of death among infants (1-12 months).|
|b.||The etiology remains largely unknown.|
|c.||The most modifiable risk factor is sleeping supine.|
|d.||Risk factors include being exposed to cigarette smoke.|
|e.||It is defined as sudden unexpected death.|
- The nurse knows that dyssomnias are: (Select all that apply.)
|a.||difficultly getting to sleep.|
|b.||stages of sleep.|
|c.||inability staying asleep.|
|d.||being excessively sleepy.|
|e.||falling asleep during the day.|
- The nurse manager is concerned about her staff who are working the night shift. What interventions can she suggest to assist nurses in overcoming shift related sleep disturbances? (Select all that apply.)
|a.||Power nap before leaving for the first night shift.|
|b.||Get a minimum of 4 hours of sleep.|
|c.||Wear dark glasses when driving home from work.|
|d.||Seek exposure to bright light when waking.|
|e.||Maintain a regular sleeping schedule when working and on nights off.|
- The nurse knows the following risk factors are associated with obstructive sleep apnea (OSA): (Select all that apply.)
- The nurse is admitting a patient to the general medical-surgical unit. What should the nurse assess as part of a routine sleep assessment? (Select all that apply.)
|a.||Usual sleeping and waking times|
|c.||Sleeping environment preferences|
|d.||Medications used for sleep|
|e.||Any current life events|
- The nurse knows the following interventions will help improve sleep quality during hospitalization: (Select all that apply.)
|a.||Maintaining sleep routines|
|c.||Providing light snacks|
|d.||Using sleep medications|
|e.||Using relaxation measures|
Chapter 34: Diagnostic Testing
- The nurse is caring for a patient who states that he has been taking his medications and following his diabetic diet carefully. Which test result indicates to the nurse that the patient has not been compliant with the treatment plan?
|a.||Hemoglobin A1C 16%|
|b.||Random blood sugar (RBS) 112 mg/dL|
|c.||Lactate dehydrogenase (LDH) 55 units/L|
|d.||Erythrocyte sedimentation rate (ESR) 14 mm/hr|
- The nurse is caring for an elderly patient with dementia. Which laboratory finding indicates to the nurse that that patient is often forgetting to eat meals?
|a.||Serum bilirubin 0.4 mg/dL|
|b.||PLT (platelet count) 425,000/mm3|
|c.||Serum cholesterol 175 mg/dL|
|d.||Albumin 1.4 g/dL|
- The nurse is caring for a patient who has a deep leg wound that is badly infected. Which laboratory test results will the nurse expect to find in the patient’s chart?
|a.||C-reactive protein (CRP) 6.5 mg/dL|
|b.||Serum creatinine 0.8 mg/dL|
|c.||Serum bilirubin 0.5 mg/dL|
|d.||Prothrombin time (PT) 11.5 sec|
- The nurse is caring for a patient who has a bleeding gastric ulcer. How will the nurse expect the patient’s stool to appear?
|a.||Soft and formed with bright red streaks|
|b.||Watery with particles of undigested food|
|c.||Sticky and black with strong foul odor|
|d.||Hard lumps that are difficult to pass|
- The nurse is caring for a patient who is to have a noncontrast MRI scan performed. Which assessment finding leads the nurse to report that the patient may not be able to have the test?
|a.||The patient has an implanted insulin pump.|
|b.||The patient is breastfeeding her newborn infant.|
|c.||The patient is severely allergic to iodine and latex.|
|d.||The patient has profound hearing loss.|
- The nurse is caring for a patient who has had severe acid reflux. Which test will allow the physician to directly check for damage to the esophagus?
|a.||Upper GI endoscopy|
|b.||MRI scan with contrast|
|d.||Positron emission tomography (PET) scan|
- The nurse is caring for a woman who has a cyst in her breast that was found at her recent mammogram. The physician wants to make sure that the cyst is not malignant. Which test will be used to determine this?
|a.||Needle aspiration with biopsy|
- The nurse is caring for a patient who is scheduled for a needle aspiration and biopsy to rule out cancer. Which nursing diagnosis is appropriate and important for this patient?
|a.||Fear related to potential for cancer diagnosis depending on biopsy results|
|b.||Ineffective health maintenance related to delayed insurance coverage for procedure|
|c.||Powerlessness related to patient must wait approximately 4 to 5 days to learn of test results|
|d.||Ineffective coping related to patient stated she is a little nervous about the test results|
- The nurse is caring for a patient who will be undergoing flexible sigmoidoscopy testing to screen for colon cancer. What goal will the nurse include in the patient’s plan of care?
|a.||Patient will verbalize understanding of pre-procedure preparation to be completed at home the day before the test.|
|b.||Patient will feel comfortable about the upcoming test and have trust in the health care providers.|
|c.||Patient will learn common side effects of the medications used to prepare the GI tract for endoscopy testing.|
|d.||Patient will realize how important regular sigmoidoscopy testing is in the prevention of colon cancer.|
- The nurse is caring for a patient who will be receiving iodine-based contrast medium for a CT scan. Which allergy should be reported to the technician and radiologist before the test is performed?
|a.||Gluten and lactose|
|c.||Peanuts and cashews|
|d.||Shrimp and scallops|
- The nurse is caring for a patient who has just undergone bronchoscopy. The patient states that she is thirsty and requests a drink of water. What is the nurse’s best action?
|a.||Provide ice chips.|
|b.||Check the patient for a gag reflex.|
|c.||Provide a small cup of ice water with a straw.|
|d.||Keep the patient NPO.|
- The nurse is caring for a patient who will be undergoing bone marrow biopsy. Which statement by the patient indicates that additional teaching is needed?
|a.||“I will count the ceiling tiles when the doctor inserts the numbing medicine.”|
|b.||“I will take acetaminophen (Tylenol) later today if the site becomes uncomfortable.”|
|c.||“I will squeeze your hand to help calm my fears about the test.”|
|d.||“I will keep the biopsy site clean and dry for the next 24 hours.”|
- The nurse is caring for a patient who is sedated following a colonoscopy. Which is the priority action of the nurse?
|a.||Provide a quiet, dark environment so that the patient can rest comfortably.|
|b.||Monitor the patient’s pulse oximetry and respirations closely.|
|c.||Inform the patient that the procedure has been completed.|
|d.||Assess the patient’s bowel sounds and passage of flatus.|
- The nurse is caring for a patient who recently had a liver biopsy. To whom must the nurse give the results?
|b.||The patient’s physician|
|c.||The patient’s insurance provider|
|d.||The patient’s spouse|
- The nurse is caring for a patient who is to collect a 24-hour urine specimen. Which statement by the patient indicates that additional teaching is required?
|a.||“I will keep the urine container on ice to keep it chilled until I bring it to the lab.”|
|b.||“I will start the test over if I forget and urinate into the toilet during the testing time.”|
|c.||“I will start the test tomorrow after I urinate first thing in the morning.”|
|d.||“I will drink extra fluids so that the lab will have an extra large specimen to test.”|
- The nurse is caring for a patient whose immune system is destroying red blood cells at a very rapid rate. Which test result will the nurse expect to see in the patient’s chart as a result?
|a.||Bilirubin level 4 mg/dL|
|b.||Platelet count 450,000/mm3|
|c.||Serum uric acid level 1.7 mg/dL|
|d.||Partial thromboplastin time 45 seconds|
- The nurse is caring for a patient with a urinary tract infection. Which test will indicate which antibiotics will be effective to treat the infection?
|a.||Complete blood count (CBC)|
|b.||Culture and sensitivity (C&S)|
|c.||Renal scan and angiography|
|d.||Radioreceptor assay for HCG|
- The nurse is caring for a patient who has just undergone paracentesis. For which complication will the nurse carefully monitor?
|a.||Collapse of the lung with shortness of breath|
|b.||Fecal impaction from retained barium in the colon|
|c.||Cerebrospinal fluid leak resulting in severe headache|
|d.||Perforation of the bowel resulting in abdominal infection|
- The nurse is caring for a patient who is having blood drawn as part of preoperative testing. Which step is the most important to ensure the safety of the patient and the nurse?
|a.||Ensuring that the tourniquet is not left in place for too long|
|b.||Using the smallest possible needle for venipuncture|
|c.||Properly disposing of the needle after the specimen is obtained|
|d.||Making sure that all of the collection tubes are filled completely|
- The nurse is caring for a diabetic patient who will be doing fingerstick blood glucose testing at home. What is the best way for the nurse to ensure that the patient can perform the procedure correctly?
|a.||Quiz the patient on the steps of the procedure.|
|b.||Have the patient perform the procedure in front of the nurse.|
|c.||Ask the patient if he has any questions about the test.|
|d.||Use terminology that the patient can easily understand.|
- The nurse is caring for a patient who is anemic. Which CBC test results demonstrate that the patient’s treatment plan is effective and the anemia is resolving? (Select all that apply.)
|a.||Red blood cell count (RBC) 5.8 million/mm3|
|b.||Hematocrit (HCT) 25%|
|c.||Hemoglobin (HGB) 14 g/dL|
|d.||White blood cell count (WBC) 4500/mm3|
|e.||Platelet count (PLT) 255,000/mm3|
- The nurse is caring for a patient who has been having abdominal pain. The doctor suspects that the patient may have an abdominal aortic aneurysm. Which tests would confirm the doctor’s suspicion? (Select all that apply.)
|a.||Magnetic resonance imaging (MRI) scan|
|b.||Needle aspiration with biopsy|
|d.||Computed tomography (CT) scan|
- The nurse is caring for a patient who is undergoing a liver biopsy. Which interventions will be included in the patient’s care plan for the diagnosis of Risk for infection: r/t invasive diagnostic procedure? (Select all that apply.)
|a.||Monitor for and report redness, warmth, discharge, or fever promptly to the physician.|
|b.||Carefully maintain the sterile field during the biopsy procedure.|
|c.||Teach patient how to care for the biopsy site when procedure is completed.|
|d.||Provide a supportive, caring presence to minimize patient anxiety.|
|e.||Provide information about the pathophysiology and treatment options for liver cancer.|
|f.||Consider using healing touch and other mind-body-spirit interventions.|
- The nurse is caring for a patient who needs to collect a 24-hour urine specimen at home. Which steps of specimen collection may be delegated to the assistant? (Select all that apply.)
|a.||Label the urine container and lab slips with the patient’s name and information.|
|b.||Assess the patient’s ability to collect the specimen as required.|
|c.||Explain the procedure to the patient.|
|d.||Obtain the urine container from the utility room or laboratory.|
|e.||Transport the specimen to the laboratory once it is collected.|
|f.||Ensure that the correct test is ordered and collected.|
- The nurse is caring for a patient who is taking medication that is toxic to the liver. Which laboratory test results will be reviewed by the nurse to ensure that the patient’s liver is tolerating the medication without damage to the organ? (Select all that apply.)
|a.||Alanine aminotransferase (ALT)|
|b.||Alkaline phosphatase (ALP)|
|c.||Blood urea nitrogen (BUN)|
|d.||Anti-nuclear antibody (ANA)|
|e.||Erythrocyte sedimentation rate (ESR)|
|f.||Fibrin degradation products (FDP)|
Chapter 35: Medication Administration
- Which medication has the highest potential for abuse?
|a.||Methylphenidate (Ritalin) – schedule II|
|b.||Alprazolam (Xanax) – schedule IV|
|c.||Acetaminophen & codeine (Tylenol #3) – schedule III|
|d.||Diphenoxylate & atropine (Lomotil) – schedule V|
- The nurse is caring for a patient who will give himself medication injections at home after discharge. How can the nurse best determine that the patient understands the technique and can administer the injections correctly?
|a.||Provide written instructions about how to administer the injections.|
|b.||Watch the patient give himself an injection.|
|c.||Call the patient the next day to ask if he is having difficulty with the injections.|
|d.||Ask the patient if he understands how to administer the injections.|
- The nurse is caring for a patient who is in agonizing pain. All of the following options are listed on the patient’s medication order sheet to relive pain. Which will provide the most rapid pain relief for the patient?
|a.||Morphine 10 mg PO|
|b.||Dilaudid 1 mg IV push|
|c.||Demerol 75 mg IM|
|d.||Duragesic 50 mcg transdermal patch|
- The nurse administers a medication to a patient. Shortly afterward, the patient develops an itchy rash all of his body and reports feeling very unwell. What is the priority action of the nurse?
|a.||Leave the patient to notify the physician and the pharmacist.|
|b.||Determine if the patient is having any difficulty breathing.|
|c.||Document the reaction in the patient’s chart.|
|d.||Obtain an order for hydrocortisone cream to relieve the itching.|
- Which of the following medication orders is to be administered PRN?
|a.||Zolpidem (Ambien) 10 mg PO tonight if the patient cannot sleep|
|b.||Prednisone 10 mg PO today, then taper down 1 mg each day for the next 10 days|
|c.||Humulin R 10 units subcutaneously before each meal and at bedtime|
|d.||Kefzol (Ancef) 1 g IVPB 30 minutes prior to surgery|
- After administering an antibiotic to the patient, the patient complains of feeling very ill. The nurse notes that the patient is scratching and has hives. The patient soon starts having difficulty breathing and his blood pressure drops. What is the nurse’s assessment of the situation?
|a.||The patient is having a mild allergic reaction and an antihistamine will make the patient feel better.|
|b.||The patient is having an anaphylactic reaction and epinephrine should be administered right away.|
|c.||The patient’s infection is worsening and progressing to septic shock so blood cultures should be drawn.|
|d.||The patient has developed toxic shock syndrome and the antibiotic orders must be changed right away.|
- The nurse makes a medication error. Which action will the nurse take first?
|a.||Prepare an incident report so that the facility can determine the cause of the error.|
|b.||Explain to the patient that a medication error has occurred, and notify the nurse manager.|
|c.||Assess the patient for any adverse reactions and notify the prescriber.|
|d.||Document the medication given, how the patient responded, and the corrective actions taken.|
- The nurse prepares to administer the following medication to the patient. Which instruction will the nurse be sure to give before the patient takes the medication?
Extended release tablets, USP
|a.||“Be sure to swallow the pill whole.”|
|b.||“Crush the medication and place the powder in applesauce.”|
|c.||“Place the pill under your tongue.”|
|d.||“Let the pill slowly dissolve in your mouth.”|
- The nurse begins a shift on a busy medical-surgical unit. The nurse will be caring for multiple patients. Which patient will the nurse assess first?
|a.||A patient who would like some acetaminophen (Tylenol) for a mild headache|
|b.||A patient who has a question about her daily medications|
|c.||A patient who needs discharge teaching about an antibiotic|
|d.||A patient who just received nitroglycerin for chest pain|
- The nurse carefully reviews the patient’s medication list. Which observation about the list indicates the highest risk for serious drug-drug interactions?
|a.||The patient has been taking the same medications for a long time.|
|b.||The patient is taking a large number of medications.|
|c.||Most of the drugs on the list are prescribed at high doses.|
|d.||The patient takes oral, injected, and inhaled medications.|
- The nurse is caring for a patient who is taking many prescription medications for various health problems. Which direction from the nurse will help the patient avoid dangerous drug interactions?
|a.||Only take over-the-counter medications.|
|b.||Have all of the prescriptions filled at the same pharmacy.|
|c.||Avoid taking generic preparations of prescribed medications.|
|d.||Only take the medications that the patient feels are necessary.|
- During discharge teaching, the nurse is to give the patient a signed, dated, and timed prescription from the physician for medications to be taken at home. Which prescription drug order needs to be corrected before it is given to the patient?
|a.||Warfarin (Coumadin) 5 mg PO daily before dinner|
|b.||Methotrexate (Trexall) 8 tablets PO once weekly on Saturdays|
|c.||Levothyroxine (Synthroid) 137 mcg PO daily before breakfast|
|d.||Zolpidem (Ambien) 5 mg PO at bedtime as needed for sleep|
- The nurse administers a medication to the patient. Which symptoms indicate that the patient is having an allergic reaction rather than a side effect?
|a.||Hair loss and sweaty skin|
|b.||Nausea and constipation|
|c.||Heartburn and nasty taste in the mouth|
|d.||Itchy rash and difficulty breathing|
- The nurse suspects that the patient is experiencing a drug toxicity rather than a side effect. Which question will the nurse ask to help confirm this suspicion?
|a.||“When did you take your last dose of the medication?”|
|b.||“Have you been taking extra doses of the medication?”|
|c.||“Are you taking any other medications?”|
|d.||“Have you ever taken this medication in the past? ”|
- The nurse is caring for a patient who is receiving vancomycin (Vancocin) to treat a severe infection. The next vancomycin dose is due to be administered at 10:00 A.M. What time will the nurse draw the vancomycin serum trough level?
- When administering phenytoin (Dilantin) through the patient’s IV line, the nurse carefully flushes the IV with normal saline before and afterward to avoid crystal formation of the medication that occurs when it mixes with dextrose in water (D5W) solution. Which type of drug interaction is the nurse being careful to avoid?
- The nurse is noting an order for a medication to be given TID. Which times will the nurse plan to administer the medication to the patient?
|a.||9 A.M., 1 P.M., 5 P.M. and 10 P.M.|
|b.||9 A.M. and 9 P.M.|
|c.||9 A.M., 1 P.M. and 5 P.M.|
|d.||Nightly before the patient goes to sleep|
- The nurse is caring for a patient who was just made NPO. The nurse is to administer carvedilol (Coreg) 25 mg PO to the patient for control of high blood pressure. What is the best action of the nurse?
|a.||Crush the medication and administer it to the patient mixed with applesauce.|
|b.||Administer the medication to the patient with a small sip of water.|
|c.||Contact the patient’s physician to clarify the order.|
|d.||Administer the equivalent medication dose through the patient’s IV.|
- The nurse is to administer 1 mL of prochlorperazine (Compazine) 10 mg IM to an adult patient. Which syringe will the nurse select to administer the medication?
|a.||1 mL tuberculin syringe with 27 gauge, inch needle|
|b.||3 mL syringe with 23 gauge, inch needle|
|c.||1 mL syringe with 27 gauge, inch needle|
|d.||3 mL syringe with 18 gauge, 1 inch needle|
- The nurse is to administer 15 mg of morphine liquid to the patient. How much morphine liquid will the nurse draw up to administer to the patient?
|Morphine sulfate oral solution
100 mg/5 mL
- The nurse is caring for a patient with multiple chronic illnesses who is having difficulty remembering to take all of her many medications at the correct times. Which is the appropriate nursing diagnosis for this patient?
|a.||Activity intolerance related to inability to take medications on time|
|b.||Ineffective therapeutic regimen management related to complexity of medication schedule|
|c.||Risk for aspiration related to need to swallow many pills during day|
|d.||Acute confusion related to inability to figure out medication dose times|
- The nurse is caring for a patient who takes 6 tablets of methotrexate once every week on Fridays. How many mg of methotrexate does the patient take per dose?
Methotrexate tablets, USP
2.5 mg tablets
- The nurse is to administer 45 mg of phenobarbital to the patient. How many tablets will the patient receive?
|Phenobarbital tablets, USP
- The nurse is caring for a patient who is NPO with a new PEG (percutaneous endoscopic gastrostomy) tube. Which of the patient’s medications can the nurse administer through the tube? (Select all that apply.)
|a.||Edluar (zolpidem tartrate) sublingual tablet 5 mg nightly at bedtime|
|b.||Ondansetron (Zofran) oral disintegrating tablet 8 mg q 8 hours PRN nausea|
|c.||Ceclor (cefaclor for oral suspension) 250 mg q 6 hours|
|d.||Oxymorphone hydrochloride extended release (Opana ER) 40 mg q 12 hours|
|e.||Phenytoin (Dilantin) chewable tablet 100 mg q 12 hours|
|f.||Potassium chloride oral solution 20 mEq daily|
- Which medications are to be administered via parenteral routes? (Select all that apply.)
|a.||Bisacodyl (Dulcolax) 10 mg suppository daily PRN constipation|
|b.||Prochlroperazine (Compazine) 10 mg IM q 6 hours PRN nausea|
|c.||Brimonidine (Alphagan) 0.1% solution 2 drops to each eye daily|
|d.||Proventil (Ventolin) inhaler 2 puffs as needed for shortness of breath|
|e.||Fentanyl (Duragesic) 50 mcg transdermal patch apply every 72 hours|
|f.||Insulin lispro (Humalog) insulin 15 units subcutaneously ac meals|
Chapter 36: Pain Management
- The nurse is caring for a patient who is recovering from knee replacement surgery. The patient complains of severe pain in the knee after receiving hydrocodone with acetaminophen (Vicodin) 2 hours previously. What is the nurse’s best action?
|a.||Administer another dose of Vicodin.|
|b.||Apply ice packs to the knee.|
|c.||Apply heat packs to the knee.|
|d.||Perform gentle range of motion.|
- The nurse is checking on the patient after administering pain medication 30 minutes previously. Which assessment finding best indicates to the nurse that the pain medication was effective?
|a.||The patient is sleeping quietly.|
|b.||The patient states that she has no pain.|
|c.||The patient’s respirations are slow and regular.|
|d.||The patient’s blood pressure has returned to baseline.|
- The nurse is caring for a patient who has severe abdominal pain caused by acute cholecystitis. What type of pain is this patient experiencing?
- Which is the best pain medication option for a patient to manage severe long-term cancer pain at home?
|a.||Duragesic 50 mcg transdermal patch q 72 hours|
|b.||Meperidine (Demerol) 50 mg IM q 6 hours|
|c.||Hydromorphone (Dilaudid) 0.2 mg q 10 minutes IV via PCA pump|
|d.||Hydromorphone (Dilaudid) 0.08 mg/hour infusion through epidural catheter|
- The nurse is caring for a patient with severe chronic pain. The nurse applied the first 50 mcg transdermal fentanyl (Duragesic) patch 2 hours ago. The patient states that the pain is presently rated at 9 on a 1-10 scale. What is the nurse’s best action?
|a.||Instruct the patient that the Duragesic patch will start to work soon.|
|b.||Administer a short-acting narcotic medication like morphine liquid (Roxanol).|
|c.||Give the patient a gentle back rub and encourage guided imagery.|
|d.||Apply a second 25-mcg transdermal fentanyl (Duragesic) patch now.|
- The nurse is caring for a patient who has been taking ibuprofen (Advil, Motrin) 800 mg TID for the last several months to relieve arthritis pain in her knees. Which assessment finding must be reported to the physician promptly?
|a.||The patient has abdominal pain and pale skin.|
|b.||The patient has constipation and takes stool softeners daily.|
|c.||The patient enjoys a glass of wine every Friday and Saturday evening.|
|d.||The patient has gained 15 lb in the last 3 months.|
- The nurse is caring for a patient who just underwent laparoscopic appendectomy. The patient tells the nurse that she is experiencing severe postoperative pain between her shoulder blades. Which term best describes the pain that this patient is having?
- The nurse administered 100 mcg sublingual fentanyl spray (Subsys) at 10:00 A.M. to a patient experiencing severe breakthrough pain. At what time will the nurse ask the patient if pain relief was obtained?
- The nurse is caring for a patient who will be using a hydromorphone (Dilaudid) PCA analgesia pump following surgery. Which intervention is the highest priority for the nurse to include in the patient’s care plan for the diagnosis: Readiness for enhanced knowledge r/t appropriate management of PCA pump?
|a.||Assess the patient’s respiratory status every 30 minutes after PCA pump started.|
|b.||Review patient’s medication profile to check for interactions with hydromorphone.|
|c.||Teach the patient how to use PCA pump when awake and aware and pain level is tolerable.|
|d.||Keep naloxone (Narcan) available at the bedside in case of respiratory suppression.|
- The nurse is caring for a 6-month-old infant who has just undergone surgery. The infant‘s facial muscles are tight with a furrowed brow and the infant’s respirations are shallow and irregular. The infant is mildly fussy and softly crying without muscular rigidity in the arms and legs. What score will the nurse give to the infant on the Neonatal Infant Pain Scale?
- The nurse is caring for a patient who is recovering from thoracotomy surgery. The patient’s respirations are regular but very shallow. Which intervention is the highest priority for the nurse to include in the patient’s care plan for the diagnosis: Ineffective breathing pattern r/t fatigue and pain?
|a.||Encourage the patient to use incentive spirometer after administration of pain medication.|
|b.||Ask the patient to describe prior pain experiences and effectiveness of methods used to manage pain.|
|c.||Help the patient to understand that comfort is a priority goal of nursing care in the postoperative period.|
|d.||Assist the patient to minimize the effects of pain on interpersonal relationships with family members.|
- The nurse is caring for a patient with rheumatoid arthritis who is in constant severe pain. Which nursing diagnosis is the highest priority for this patient?
|a.||Impaired walking r/t patient’s need to use a cane or walker with ambulation|
|b.||Readiness for enhanced comfort r/t sedentary lifestyle and poor physical condition|
|c.||Effective therapeutic regimen management r/t mistrust of health care personnel|
|d.||Chronic pain r/t ongoing inflammatory tissue damage and joint destruction|
- The nurse is caring for a cancer patient with ongoing pain from widespread metastasis to her bones. The nurse notes that the patient’s morphine dosage had to be increased to sufficiently manage her discomfort. What is the nurse’s interpretation of this assessment finding?
|a.||The patient became tolerant to the previous morphine dosage.|
|b.||The patient is becoming addicted to her pain medication.|
|c.||The patient has been abusing her prescribed pain medications.|
|d.||The patient is seeking to end her life with an overdose of morphine.|
- Which patient is best suited for PCA analgesia?
|a.||A patient who is confused after a head injury|
|b.||A patient recovering from total hysterectomy surgery|
|c.||A patient who has severe psychogenic pain|
|d.||A patient with arthritis who is unable to push the nurse call button|
- What is the priority nursing assessment for a patient who his receiving postoperative epidural analgesia with hydromorphone (Dilaudid)?
|a.||Respiratory rate, depth, and pattern|
|b.||Skin underneath the epidural dressing|
|c.||Bladder scanning to check for urinary retention|
|d.||Itching on the trunk and/or extremities|
- The nurse is caring for a diabetic patient who has painful neuropathy in her feet. The patient asks why the nurse is administering gabapentin (Neurontin) when she does not have a history of seizure disorder. What is the nurse’s best response?
|a.||“Neurontin will help you sleep at night so you can deal with the pain more effectively.”|
|b.||“Long-term diabetes can put patients at risk for certain type of seizures.”|
|c.||“Neurontin can help relieve your anxiety from being admitted to the hospital.”|
|d.||“Neurontin works on the nervous system to help relieve the burning pain in your feet.”|
- The nurse is caring for a patient who has a PCA pump following total hysterectomy surgery. The nurse sees the visitor push the PCA button while the patient is sleeping quietly. What is the best response of the nurse?
|a.||“Thank you for pushing the button for her to help keep her comfortable after surgery.”|
|b.||“Please do not push the button for the patient—she could receive more medication than she needs.”|
|c.||“You can push the button for her now, but please have her do it herself when she awakens.”|
|d.||“PCA pumps are great because she doesn’t have to wait for me to administer her pain medication.”|
- Which assessment question helps the nurse determine the character of the patient’s pain?
|a.||“What does the pain feel like, i.e. stabbing, burning or throbbing?”|
|b.||“When did the pain first start?”|
|c.||“What interventions make the pain better?”|
|d.||“Is there any pattern to when the pain occurs?”|
- The nurse is caring for a patient who only speaks a foreign language. What is the best method for the nurse to assess the patient’s pain level?
|a.||Perform a pain assessment using a translator.|
|b.||Check the patient’s vital signs and pulse oximetry.|
|c.||Check the patient’s respiratory rate, depth, and rhythm.|
|d.||Look to see if the patient appears to be resting comfortably.|
- The nurse is caring for a trauma patient with the nursing diagnosis of Acute pain r/t fracture and muscle spasms. Which is an appropriate goal for this nursing diagnosis?
|a.||The patient will experience less pain when participating in physical therapy.|
|b.||The patient will describe meditation techniques that can be used to cope with pain.|
|c.||Nursing staff will explain the ordered pain management approach to the patient.|
|d.||The patient will feel less pain each day when range-of-motion therapy is performed.|
- The nurse is caring for a patient who has pain following abdominal surgery. Which of the following are independent nursing interventions that can be used to make the patient more comfortable? (Select all that apply.)
|a.||Encourage the patient to relax and imagine that he is resting on a tropical beach.|
|b.||Provide headphones so that the patient can listen to his favorite music.|
|c.||Increase pain medication dosage if prescribed regimen is ineffective to manage pain.|
|d.||Teach the patient to take pain medication before discomfort becomes severe.|
|e.||Switch the patient from IV to oral pain medication when bowel sounds return.|
|f.||Demonstrate the use of relaxation breathing before painful procedures.|
- The nurse is caring for a patient who has severe burning pain in his right arm caused by a compressed nerve in his neck. Which medications can be used along with a narcotic pain reliever to relieve the patient’s pain until surgery can be performed to release the nerve? (Select all that apply.)
|a.||Diphenhydramine (Benadryl) 50 mg PO daily|
|b.||Amitriptyline (Elavil) 50 mg PO BID|
|c.||Ondansetron (Zofran) 8 mg PO q 4 hours PRN|
|d.||Gabapentin (Neurontin) 400 mg PO BID|
|e.||Senna (Senokot) 8.6 mg PO daily|
|f.||Naloxone (Narcan) 0.4 mg IV now, may repeat in 1 hour PRN|
- The nurse is caring for a patient who just had knee replacement surgery. Which factors will affect how the patient experiences pain after this surgery? (Select all that apply.)
|a.||The patient has had rheumatoid arthritis for the last 16 years.|
|b.||The patient is allergic to aspirin and strawberries.|
|c.||The patient owns a business and is self-insured.|
|d.||The patient has been a vegetarian for the last 8 years.|
|e.||The patient had her other knee replaced 2 years ago.|
|f.||The patient was a marathon runner in high school and college.|
Chapter 37: Perioperative Nursing Care
- The nurse is caring for a patient who is about to have surgery. Which intervention will be included in the patient’s care to meet the goals for Risk for perioperative positioning injury r/t immobilization during surgical procedure?
|a.||Orient the patient to the OR environment and place the call light within reach.|
|b.||Watch for early signs of hypovolemia caused by patient’s NPO status since midnight.|
|c.||Use therapeutic touch and guided imagery to allay patient’s fears of surgery.|
|d.||Pad all bony prominences and avoid hyperextension of extremities.|
- The nurse is caring for a male patient who will soon have open heart surgery. The patient’s chest is covered with thick hair so the surgical technician comes in to shave the patient’s skin near the operative site. Which action by the technician requires intervention by the nurse to correct the technique?
|a.||A straight safety razor and antibiotic foam is used|
|b.||Disposable electric trimmers are used to trim the hair|
|c.||Antibacterial soap is used prior to hair removal|
|d.||Only the hair directly around the surgical site is removed|
- The nurse is caring for a patient who has just been brought to the postoperative unit following major surgery. The patient has many tubes and monitors in place. Which will the nurse assess first?
|a.||The patient’s intravenous lines|
|b.||The patient’s urinary catheter|
|c.||The patient’s nasogastric tube|
|d.||The patient’s endotracheal tube|
- The nurse is caring for a patient who has a family history of reactions to general anesthesia. Which medication will the anesthesiologist have ready as a precautionary measure before the patient’s surgery is started?
|b.||Dantrolene sodium (Dantrium)|
|c.||Activated charcoal with sorbitol|
|d.||Folinic acid (Leucovorin)|
- Which action by the nurse best demonstrates accountability in the operating room?
|a.||Applying warm blankets when the patient reports feeling chilly|
|b.||Holding the patient’s hand to allay anxiety before anesthesia is administered|
|c.||Double-checking that the surgical site is clearly marked and visible after draping|
|d.||Using calming speech with a reassuring tone of voice when speaking with the patient|
- The nurse is caring for a patient who will be having surgery. The patient has just signed the consent form for the operation. What does the patient’s signature indicate?
|a.||The patient agrees with the doctor’s diagnosis.|
|b.||The patient gives permission for the surgery to be performed.|
|c.||The patient has agreed to pay for any costs not covered by insurance.|
|d.||The patient has been told of all the available treatment options.|
- The nurse is caring for a postoperative patient who is very sleepy following general anesthesia and administration of pain medication. The nurse notes that the patient is making snoring sounds and his pulse oximetry has dropped to 88%. What is the best action of the nurse?
|a.||Insert an oral airway and administer oxygen.|
|b.||Call for anesthesia to immediately reintubate the patient.|
|c.||Remove the pillow from behind the patient’s head.|
|d.||Elevate the head of the patient’s bed.|
- The nurse is caring for a postoperative patient on his first day after surgery. The nurse informs the patient that the plan is to sit in the chair and ambulate in the hallway. The patient states that he is in pain and he has no intention of getting out of bed. What is the nurse’s best response?
|a.||“It’s important to move around so you don’t get a blood clot in your leg.”|
|b.||“Your doctor ordered that you are to get out of bed at least twice every day.”|
|c.||“I understand. You can rest in bed until tomorrow when the pain is better.”|
|d.||“I will call the doctor and let him know that you do not want to get up.”|
- The nurse is walking a postoperative patient in the hallway when she notices a large red stain of fresh blood on the patient’s gown over the abdominal incision. The patient states, “I felt something just ripped open.” What is the priority action of the nurse?
|a.||Lift up the patient’s gown and assess the incision.|
|b.||Assist the patient to the floor and call for assistance.|
|c.||Return the patient to bed and irrigate the wound with sterile saline.|
|d.||Check the patient’s vital signs and pulse oximetry.|
- The nurse is caring for a patient with advanced colon cancer. The patient is to have surgery to relieve a bowel obstruction that has been causing unrelenting vomiting and abdominal pain. What type of surgery will this patient undergo?
- After general anesthesia is administered, the patient is carefully placed in the prone position. What is the primary consideration of the nursing staff as the patient is positioned?
|a.||Making sure that the patient’s endotracheal tube does not become kinked|
|b.||Ensuring that the patient’s head is positioned to prevent cervical nerve injury|
|c.||Carefully taping the patient’s eyes shut to avoid corneal abrasions|
|d.||Padding the operating table carefully and keeping linens free of wrinkles|
- The nurse is caring for a preoperative patient who has just received sedation prior to general anesthesia in the OR. What is the priority action of the nurse?
|a.||Check to make sure that the consent form was signed.|
|b.||Turn off the lights and provide a quiet environment.|
|c.||Raise the side rails on the patient’s stretcher.|
|d.||Indicate the surgical site with an indelible marker.|
- The nurse is caring for a postoperative patient who is recovering from abdominal surgery. The nurse notes that the patient’s breath sounds are clear but diminished, shallow, and slightly labored. The patient’s pulse oximetry is 96% on room air. What is the priority action of the nurse?
|a.||Administer a dose of the prescribed pain medication.|
|b.||Administer 2 L of oxygen via nasal cannula.|
|c.||Obtain an order from the physician for a chest x-ray.|
|d.||Ensure that the patient is using the spirometer 10 times every hour.|
- The nurse will be caring for a patient who has just arrived on the medical-surgical unit following surgical repair of his fractured right ankle. Which is the priority action of the nurse when the patient arrives on the unit?
|a.||Instruct the patient how to call for assistance using the call light.|
|b.||Assess the color and warmth of the toes on the patient’s right foot.|
|c.||Determine when the patient’s next pain medication is due.|
|d.||Check pulse oximetry and obtain a full set of vital signs.|
- The nurse is caring for a patient who is recovering from chest surgery. Which action by the patient indicates that additional teaching is needed about how to use the ordered incentive spirometer correctly?
|a.||The patient breathes into the spirometer so that the marker rises slowly.|
|b.||The patient uses the spirometer at least 10 times every hour while awake.|
|c.||The patient seals his lips tightly around the spirometer mouthpiece.|
|d.||The patient rests for 5 to 10 seconds after each time the spirometer is used.|
- The nurse is caring for a patient who is headed to the operating room for abdominal surgery. Which goal is appropriate for the nursing diagnosis risk for Perioperative positioning injury?
|a.||Patient will deny numbness or tingling in extremities after surgical procedure.|
|b.||Patient will maintain urine output of at least 30 mL/hour during and after surgery.|
|c.||Patient will maintain elastic skin turgor as well as moist tongue and mucus membranes.|
|d.||Patient will have no emesis and deny nausea following arousal from general anesthesia.|
- The nurse is caring for a patient who requires emergency surgery for injuries sustained in a motor vehicle accident. The patient was on his way back to work after having lunch with colleagues when the accident happened. What is the highest priority nursing diagnosis for this patient?
|a.||Risk for imbalanced body temperature|
|b.||Risk for aspiration|
|c.||Risk for perioperative positioning injury|
|d.||Risk for delayed surgical recovery|
- The nurse is caring for a postoperative patient who has a history of COPD. What is the priority nursing diagnosis for this patient?
|a.||Ineffective airway clearance|
|b.||Readiness for enhanced knowledge|
|c.||Risk for delayed surgical recovery|
- The nurse is assigned to care for several patients on the surgical unit. Which patient need will the nurse address first?
|a.||A patient who is waiting for discharge teaching before going home|
|b.||A patient who needs to be ambulated for the first time postoperatively|
|c.||A patient who has not voided since the catheter was removed 8 hours ago|
|d.||A patient who requires a daily dressing change to the surgical incision|
- The nurse is obtaining preoperative information for a patient who will be having emergency surgery shortly for a ruptured appendix. Which information is crucial for the nurse to assess? (Select all that apply.)
|a.||All medications that the patient is taking|
|b.||Use of tobacco, alcohol, or recreational drugs|
|c.||Allergies to medications, foods, or other substances|
|d.||Date of last tetanus shot and flu vaccination|
|e.||Insurance coverage and preauthorization requirements|
|f.||Possibility of pregnancy|
- The nurse is working with a nursing assistant to care for several postoperative patients. Which interventions can the nurse delegate to the assistant for completion? (Select all that apply.)
|a.||Assess patients’ comfort levels and need for pain medication.|
|b.||Empty urinary catheter bags and record urine output.|
|c.||Teach patients how to use incentive spirometers hourly.|
|d.||Provide ice chips and juice to patients who are no longer NPO.|
|e.||Monitor incisions for signs of infection.|
|f.||Applying TED hose and assisting with oral care.|
- Which of the following patients would benefit from preoperative teaching about splinting of incisions to minimize discomfort? (Select all that apply.)
|a.||Patient having coronary bypass graft surgery|
|b.||Patient having open breast biopsy|
|c.||Patient having total hip replacement surgery|
|d.||Patient having lumbar spine decompression surgery|
|e.||Patient having surgery to repair retinal detachment|
|f.||Patient having total abdominal hysterectomy|
- The nurse is caring for a patient who is recovering from bowel resection surgery. Which assessment findings indicate to the nurse that the patient no longer needs to remain NPO and may progress to oral intake of food and fluids? (Select all that apply.)
|a.||The patient passed flatus while ambulating this morning.|
|b.||The patient’s abdomen is soft with active bowel sounds x 4 quadrants.|
|c.||The patient denies nausea or vomiting and states that he feels hungry.|
|d.||The patient’s abdominal incision is clean, dry, and intact with staples.|
|e.||The patient ambulated in the hallway with a slow, steady gait.|
|f.||The patient’s urinary catheter is patent with clear, yellow urine.|
- The nurse is caring for a patient who underwent abdominal surgery the previous day. Which assessment findings indicate to the nurse that the patient may be experiencing serious internal bleeding? (Select all that apply.)
|a.||The patient’s urinary output increased to 40 mL/hr.|
|b.||The patient’s pulse has risen from 76 to 112 beats/min.|
|c.||The patient states that his abdominal pain is worse than yesterday.|
|d.||The patient complains of generalized itching.|
|e.||The patient’s hematocrit dropped from 14.6 to 11.0 g/dL|
|f.||The patient has not been able to have a bowel movement since before surgery.|
Chapter 38: Oxygenation and Tissue Perfusion
- The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient?
|c.||Continuous positive airway pressure (CPAP)|
|d.||High-flow nasal cannula|
- The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation?
|a.||Insert an oral airway.|
|b.||Lower the head of the bed.|
|c.||Turn the patient’s head to the side.|
|d.||Monitor the patient’s pulse oximetry.|
- The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient’s pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?
|a.||Administer the ordered intravenous diuretic.|
|b.||Prepare for insertion of a chest tube.|
|c.||Suction secretions from the patient’s respiratory tract.|
|d.||Have the patient use the ordered incentive spirometer.|
- The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several weeks. The physicians predict that the patient will need to remain on a ventilator for at least several more weeks before he will be able to maintain his airway and breathe on his own. What procedure does the nurse anticipate will be planned for the patient to facilitate his recovery?
|a.||Placement of a tracheostomy tube|
|d.||Lung transplantation surgery|
- The nurse is caring for a patient with a chest tube who was transported to radiology for testing. When the patient returns to the nursing unit, the transporter shows the nurse the patient’s chest tube collection device, which was badly damaged after being caught in the elevator door. What is the priority action of the nurse?
|a.||Clamp the chest tube until the collection device is replaced.|
|b.||Cover the insertion site with a new occlusive dressing.|
|c.||Ensure that there is gentle bubbling in the water seal chamber.|
|d.||Check the patient’s lung sounds and pulse oximetry.|
- The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?
|a.||Activity intolerance r/t generalized weakness and hypoxemia|
|b.||Imbalanced nutrition r/t poor appetite and increased metabolic needs|
|c.||Ineffective airway clearance r/t thick secretions in trachea and bronchi|
|d.||Knowledge deficit r/t use of nebulizer and inhaled bronchodilators|
- The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient’s care plan for the diagnosis Impaired gas exchange r/t impaired pulmonary blood flow from embolus?
|a.||The patient will maintain pulse oximetry values of at least 95% on room air.|
|b.||The patient will verbalize understanding of ordered anticoagulants.|
|c.||The patient will report chest pain of no greater than 3 on a 1-10 scale.|
|d.||The patient will ambulate 50 feet in hallway without shortness of breath.|
- The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse?
|a.||Obtain an arterial blood gas to check for carbon dioxide retention.|
|b.||Increase the patient’s oxygen until the pulse oximetry is greater than 98%.|
|c.||Lower the head of the patient’s bed and insert a nasal airway.|
|d.||Administer a mild sedative and reorient the patient as needed.|
- The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation. The patient tells the nurse that he doesn’t want to take any more pills and asks what could happen if he doesn’t fill the prescription. What is the nurse’s best response?
|a.||“You could have a stroke.”|
|b.||“Your kidneys could fail.”|
|c.||“You could develop heart failure.”|
|d.||“You could go into respiratory failure.”|
- The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care?
|a.||The suction is discontinued when the patient is ambulated to the bathroom.|
|b.||The collection device is emptied at the end of the shift and output recorded in the chart.|
|c.||The patient’s bed is placed in the semi-Fowler’s position to facilitate lung reexpansion.|
|d.||The patient is encouraged to use his incentive spirometer at least 10 times every hour.|
- The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg. Which focused assessment question has the highest priority for this patient?
|a.||“Do you have a headache or any dizziness?”|
|b.||“Do you have any chest pain or shortness of breath?”|
|c.||“When did you first notice the swelling and redness in your leg?”|
|d.||“Do you have any cramping or muscle spasms in your leg?”|
- Which of the following patients would benefit from postural drainage?
|a.||A patient with a heart murmur and jugular venous distention|
|b.||A patient with asthma and audible wheezing|
|c.||A patient with right-sided heart failure and pitting edema|
|d.||A patient with chronic bronchitis and congested cough|
- The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which of the following laboratory results will the nurse expect to find in the patient’s chart?
|a.||Glycosylated hemoglobin 12%|
|b.||Platelet count 450,000/mm3|
|d.||Prothrombin time 8.8 seconds|
- The nurse is caring for a patient with high cholesterol who has been prescribed atorvastatin (Lipitor). Which laboratory result indicates that the patient has been taking the medication as ordered and following the physician’s dietary recommendations?
|a.||Serum triglyceride level 325 mg/dL|
|b.||High-density lipoproteins (HDL) 56 mg/dL|
|c.||Low-density lipoproteins (LDL) 155 mg/dL|
|d.||Total cholesterol level 185 mg/dL|
- The nurse is caring for a patient who has just had a massive myocardial infarction. Which is the priority nursing diagnosis for this patient?
|a.||Impaired comfort r/t noisy ICU environment and need for frequent monitoring|
|b.||Interrupted family processes r/t hospitalization of primary wage earner|
|c.||Readiness for enhanced knowledge r/t cardiac rehabilitation options|
|d.||Decreased cardiac output r/t weakened cardiac muscle and irregular heartbeat|
- The nurse is caring for a patient who has presented to the ER with chest pain. Which diagnostic test will best indicate if there is significant blockage of certain important blood vessels that provide oxygen to the heart muscle?
- The nurse hears a loud murmur when listening to the patient’s heart. Which diagnostic test will best display the condition of the valves and structures within the patient’s heart that could be causing the murmur?
- The nurse is caring for a patient who will be returning to the nursing unit following a cardiac catheterization via the right femoral artery. Which assessment is the highest priority for the nurse to perform when the patient arrives on the unit?
|a.||Checking the patient’s right pedal pulse and warmth of the right leg|
|b.||Checking pulse oximetry and listening to the patient’s lung sounds|
|c.||Checking bilateral radial pulses to check for a pulse deficit|
|d.||Estimating the patient’s jugular venous pressure|
- The home care nurse is caring for a patient who has severe COPD and home oxygen therapy. The patient tells the nurse that she feels much better after increasing the oxygen flowmeter from 2 L to 5 L/min. The patient’s pulse oximetry is 98%. What is the priority action of the nurse?
|a.||Reduce the oxygen flow rate until the patient’s pulse oximetry value is 90% to 92%.|
|b.||Inform the patient’s physician and obtain an order for oxygen at 5 L/min.|
|c.||Document the intervention and findings in the patient’s medical record.|
|d.||Listen to the patient’s lung fields and reinforce pursed-lip breathing techniques.|
- The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The nurse notes that the patient’s lung sounds are diminished bilaterally and the patient’s pulse oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will the nurse take to make the patient more comfortable? (Select all that apply.)
|a.||Increase the patient’s oxygen to 4 L/min via nasal cannula.|
|b.||Suction the patient’s airway using sterile technique.|
|c.||Maintain eye contact and provide calm reassurance.|
|d.||Turn the patient onto the side for postural drainage.|
|e.||Administer the ordered nebulized bronchodilator.|
|f.||Elevate the head of the patient’s bed to fully upright.|
- The nurse is performing a respiratory assessment on a patient. Which assessment findings indicate to the nurse that the patient has a history of long-standing chronic respiratory disease? (Select all that apply.)
|a.||All of the patient’s fingernails are noticeably clubbed.|
|b.||The patient needs to sleep on at least four to five pillows at night.|
|c.||The patient’s chest has equal antero-posterior and transverse diameters.|
|d.||The patient’s lower legs have large areas of brownish spotted discoloration.|
|e.||The patient reports puffiness of both feet when standing for long periods.|
|f.||The patient’s forced vital capacity test result is 3.8 L of air.|
- The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? (Select all that apply.)
|a.||The patient is unable to count out loud past 15 after a deep breath.|
|b.||The patient’s nails are noticeably clubbed.|
|c.||The patient’s sputum has turned from yellow to greenish-brown.|
|d.||The patient has stridor with wheezes heard in all lung fields.|
|e.||The patient’s forced vital capacity has increased from 2.8 to 3.4 L.|
|f.||The patient has become confused and mildly disoriented.|
- The nurse is working with a nursing assistant to care for a patient with a new tracheostomy. Which tasks may the nurse delegate to the assistant? (Select all that apply.)
|a.||Obtaining masks, gloves, and suction supplies from the utility room|
|b.||Helping to reassure the patient before, during, and after suctioning|
|c.||Changing the Velcro or twill ties used to secure the tracheostomy|
|d.||Transporting sputum specimens to the lab for culture and sensitivity testing|
|e.||Assessing need for suctioning of the oropharynx or tracheostomy|
|f.||Teaching the patient how to remove and clean the inner cannula|
- The preceptor is working with a new nurse to provide care for a patient with a new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)
|a.||The outer cannula is cleaned with the brush and half-strength H2O2.|
|b.||The new tracheostomy holder is secured before the old soiled one is removed.|
|c.||A Yankauer suction catheter is used to remove secretions from the patient’s mouth.|
|d.||Sterile gloves are applied before the soiled dressing is removed from the tracheostomy.|
|e.||Half-strength H2O2 is used to remove crusted secretions around the tracheostomy site.|
|f.||Pain medication is administered to the patient prior to suctioning.|
- The preceptor is working with a new nurse to suction a patient through his new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)
|a.||The suction is not applied to the catheter until it is being withdrawn.|
|b.||The patient is placed in the supine position prior to suctioning.|
|c.||The suction catheter is twirled side to side as it is being withdrawn.|
|d.||Suction is applied continuously as the catheter is withdrawn.|
|e.||The patient’s oxygen is reapplied between suction attempts.|
|f.||Water-soluble lubricant is applied to the suction catheter before insertion.|
Chapter 39: Fluid, Electrolytes, and Acid-Base Balance
- The nurse will be caring for a patient who is severely malnourished. Laboratory test results show that the patient’s albumin level is critically low. What assessment finding will the nurse expect to note when meeting with the patient?
|a.||The patient has generalized 3+ pitting edema.|
|b.||The patient is confused and disoriented.|
|c.||The patient’s urine is dark and very concentrated.|
|d.||The patient lung sounds are very diminished.|
- The nurse is reviewing the patient’s laboratory results. Which result must be communicated to the physician immediately?
|a.||Serum chloride level 85 mEq/L|
|b.||Serum sodium level 134 mEq/L|
|c.||Serum potassium level 6.8 mEq/L|
|d.||Serum magnesium level 2.3 mEq/L|
- The nurse is caring for a patient who is at risk for fluid overload as a result of a history of congestive heart failure. Which intervention will the nurse teach the patient to perform at home to monitor fluid balance?
|a.||“Check to make sure that your urine is a bright yellow color.”|
|b.||“Weigh yourself every morning before breakfast.”|
|c.||“Count your heart rate every evening before you go to bed.”|
|d.||“Drink plain water rather than soda, coffee, or fruit juice.”|
- The nurse is caring for a patient who is admitted to the hospital with diabetic ketoacidosis. Which assessment finding indicates an attempt made by the patient’s body to correct the pH?
|a.||The patient’s respirations are very deep and rapid.|
|b.||The patient’s urine is dark and concentrated.|
|c.||The patient’s skin is pale, cool, and diaphoretic.|
|d.||The patient is sleepy and difficult to arouse.|
- The nurse is caring for a patient who takes furosemide (Lasix) daily to treat congestive heart failure. The nurse will watch for which electrolyte imbalance that may occur as a result of this therapy?
- The nurse is caring for a patient who was brought to the ER after overdosing on narcotic pain medication. The patient was found unresponsive with no respirations. Arterial blood gases were drawn shortly after the patient’s arrival to the hospital. Which results will the nurse expect to see?
|a.||pH 7.56, PaCO2 32 mm Hg, HCO3 32 mEq/L, PaO2 90 mm Hg|
|b.||pH 7.35, PaCO2 45 mm Hg, HCO3 26 mEq/L, PaO2 70 mm Hg|
|c.||pH 7.45, PaCO2 38 mm Hg, HCO3 28 mEq/L, PaO2 80 mm Hg|
|d.||pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg|
- The nurse is caring for a patient who is admitted to the hospital with dehydration and gastroenteritis. The patient attempted to walk to the bathroom and fainted right after getting out of bed. Which is the most likely cause of the patient’s collapse?
- The nurse is caring for a patient whose ABG results reveal the following: pH 7.56, PaCO2 32 mm Hg, HCO3 42 mEq/L, PaO2 90 mm Hg. Which condition will the nurse expect to see in the patient’s chart as the underlying cause of these results?
|a.||Gastroenteritis with severe nausea, vomiting, and diarrhea|
|b.||Widespread tissue ischemia caused by cardiogenic shock|
|c.||Respiratory failure caused by pneumonia with pleural effusions|
|d.||Hyperventilation after a panic attack|
- The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient has consumed 250 mL with each of her three meals and had another 150 mL with her medications. The patient has received 150 mL of IV fluids during the day. How many mL of fluid may the patient still consume in order to stay within the prescribed fluid restriction?
- The nurse is caring for a patient who has a history of congestive heart failure. The nurse includes the diagnosis fluid volume excess in the patient’s care plan. Which goal statement has the highest priority for the patient and nurse?
|a.||The patient’s lung sounds will remain clear.|
|b.||The patient will have urine output of at least 30 mL/hr.|
|c.||The patient will verbalize understanding of fluid restrictions.|
|d.||The patient’s pitting pedal edema will resolve within 72 hours.|
- The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid overload. Which IV fluid will the nurse expect to administer to this patient in order to correct the patient’s fluid imbalance?
|a.||0.33% normal saline|
|b.||0.45% normal saline|
|c.||0.9% normal saline|
|d.||3% normal saline|
- The nurse is caring for a patient with congestive heart failure who requires intermittent IV bolus doses of furosemide (Lasix) for a few days to correct fluid volume overload. No continuous IV fluids are ordered. Which type of IV will the nurse insert in order to administer the patient’s medication?
|a.||Peripherally inserted central catheter|
|b.||Midline inside-the-needle catheter|
|c.||Central venous catheter|
- The nurse is caring for a patient who has a central venous catheter (CVC). Which nursing intervention is the most important for the nurse to include in the patient’s plan of care?
|a.||Carefully document all assessments of the catheter site.|
|b.||Use strict sterile procedure when performing dressing changes.|
|c.||Label each new dressing with the date, time, and nurse’s initials.|
|d.||Ensure that the CVC is discontinued as soon as possible.|
- The nurse is caring for a patient with a peripheral IV who tells the nurse that the IV site is painful and puffy. What is the nurse’s best action?
|a.||Discontinue the IV and start another line in the other arm.|
|b.||Aspirate to check for blood return and flush the IV with sterile saline.|
|c.||Clean the IV site with chlorhexidine and apply a new sterile dressing.|
|d.||Change the IV tubing and administer prescribed pain medication.|
- The nurse is caring for a patient who is to receive intermittent bolus doses of phenytoin (Dilantin) through the IV line. Which intervention has the highest priority when administering this medication?
|a.||Check for blood return and compatibility prior to administration.|
|b.||Use a new IV tubing set each time the medication is administered.|
|c.||Document the date, time, and nurse’s initials after each dose is administered.|
|d.||Use sterile gloves when drawing up and administering the medication.|
- The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing. What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank?
|a.||Identify the blood group, type, and expiration date with another nurse.|
|b.||Insert an 18- or 20-gauge angiocatheter into the patient’s other arm.|
|c.||Program the IV infusion pump so that the transfusion will complete within 4 hours.|
|d.||Obtain a new microdrip tubing and extension tubing from the clean utility room.|
- The nurse is caring for a patient who is receiving a blood transfusion. One hour into the transfusion, the patient’s blood pressure decreases significantly and the patient complains of a severe headache. What is the priority action of the nurse?
|a.||Check the patient’s temperature and administer acetaminophen (Tylenol) if higher than 101° F.|
|b.||Recheck the patient’s blood pressure in 15 minutes after administering pain medication.|
|c.||Stop the blood transfusion and administer 0.9% normal saline through new IV tubing.|
|d.||Double-check that the transfusion blood type is an exact match to the patient.|
- The nurse is caring for a patient who is very dehydrated. Which goal best indicates that the nursing diagnosis of Deficient fluid volume has been corrected and that the patient’s fluid balance has been restored?
|a.||The patient had 1300 mL of light yellow urine in the last 24 hours.|
|b.||The patient’s lung sounds are clear bilaterally.|
|c.||The patient has no jugular venous distention.|
|d.||The patient verbalizes need for adequate daily fluid intake.|
- The nurse is caring for a patient who is admitted with a serum sodium level of 120 mEq/L. Which is the most important intervention for the nurse to perform?
|a.||Perform regular neurologic checks and institute seizure precautions.|
|b.||Encourage the patient to eat foods that are high in sodium.|
|c.||Administer hypotonic IV solutions as ordered by the physician.|
|d.||Assess for signs and symptoms of digoxin (Lanoxin) toxicity.|
- The nurse is caring for a patient who has a history of congestive heart failure and takes once-daily furosemide (Lasix) in order to prevent fluid overload and pulmonary edema. The patient tells the nurse that she has stopped taking the medication because she has to urinate frequently during the night. What is the nurse’s best response?
|a.||“You should ask your doctor to decrease the dose.”|
|b.||“Take the diuretic early in the morning before breakfast.”|
|c.||“Eat foods high in potassium and limit your salt intake.”|
|d.||“Restrict your fluid intake after dinner and in the evening.”|
- The nurse is caring for