Exam 1

15. A nursing student in the final term of nursing school is overheard by a nursing faculty member telling another student that she got to insert a nasogastric tube in the emergency department while she was working as a nursing assistant. What advice is best for the nursing faculty member to give to the nursing student? A. "Just be careful when you are doing new procedures and make sure you are following directions by the nurse." B. "Review your procedures before you go to work, so you will be prepared to do them if you have a chance." C. "The nurse should not have allowed you to insert the nasogastric tube because something bad could have happened." D. "You are not allowed to perform any procedures other than those in your job description even with the nurse's permission."

ANS: D When nursing students work as nursing assistants or nurse's aides when not attending classes, they should not perform tasks that do not appear in a job description for a nurse's aide or assistant. The nursing student should always follow the directions of the nurse, unless doing so violates the institution's guidelines or job description under which the nursing student was hired. The nursing student should be able to safely complete the procedures delegated as a nursing assistant, and reviewing those not done recently is a good idea, but it has nothing to do with the situation. This option does not address the situation that the nursing student acted outside the job description for the nursing assistant position. The focus of the discussion between the nursing faculty member and the nursing student should be on following the job description under which the nursing student is working.

13. A nursing student has been written up several times for being late with providing patient care and for omitting aspects of patient care and not knowing basic procedures that were taught in the skills course one term earlier. The nursing student says, "I don't understand what the big deal is. As my instructor, you are there to protect me and make sure I don't make mistakes." What is the best response from the nursing instructor? A. "You are expected to perform at the level of a professional nurse." B. "You are expected to perform at the level of a nursing student." C. "You are practicing under the license of the nurse assigned to the patient." D. "You are expected to perform at the level of a skilled nursing assistant."

ANS: A Although nursing students are not employees of the health care agency where they are having their clinical experience, they are expected to perform as professional nurses would in providing safe patient care. Different levels of standards do not apply. Nursing students, just as nurses, provide safe, complete patient care, or they don't. No standard is used for nursing students other than that they must meet the standards of a professional nurse. The nursing instructor, not the nurse assigned to the patient, is responsible for the actions of the nursing student

6. The nurse questions a physician's order to administer a placebo to the patient. The nurse's action is based on which ethical principle? A. Autonomy B. Beneficence C. Justice D. Fidelity

ANS: A Autonomy refers to the freedom to make decisions free of external control. In this case, the nurse questions the physician's order for a placebo because it supports the patient's autonomy. Although beneficence, taking a positive action for others, has implications here, it is not the primary operating principle. Justice refers to fairness and is most often used in discussions about access to health care resources. Fidelity refers to the agreement to keep promises.

11. A nurse is teaching a community group of school-aged parents about safety. The most important item to prioritize and explain is how to check the proper fit of A. a bicycle helmet. B. swimming goggles. C. soccer shin guards. D. baseball sliding shorts.

ANS: A Bicycle-related injuries are a major cause of death and disability among children. Proper fit of the helmet helps to decrease head injuries resulting from bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death.

5. A nurse performs cardiopulmonary resuscitation (CPR) on a 92-year-old with brittle bones and breaks a rib during the procedure, which then punctures a lung. The patient recovers completely without any residual problems and sues the nurse for pain and suffering, and for malpractice. What key point will the prosecution attempt to prove? A. The CPR procedure was done incorrectly. B. The patient would have died if nothing was done. C. The patient was resuscitated according to policy. D. Patients with brittle bones might sustain fractures when chest compressions are done.

ANS: A Certain criteria are necessary to establish nursing malpractice. In this situation, although harm was caused, it was not because of failure of the nurse to perform a duty according to standards the way other nurses would have performed in the same situation. The nurse would have had to have done the procedure correctly, or the patient most likely would not have survived without any residual problems such as brain damage. The fact that the patient sustained injury as a result of age and physical status does not mean the nurse breached any duty to the patient.The nurse would need to make sure the defense attorney knew that the cardiopulmonary resuscitation (CPR) was done correctly. Without intervention, the patient most likely would not have survived. The prosecution would try to prove that a breach of duty had occurred, which had caused injury, not that cardiopulmonary resuscitation was done correctly. The defense team, not the prosecution, would explain the correlation between brittle bones and rib fractures during CPR.

2. The nurse is caring for an elderly patient admitted with nausea, vomiting, and diarrhea. Upon completing the health history, which priority concern would require collaboration with social services to address the patient's health care needs? A. The electricity was turned off 2 days ago. B. The water comes from the county water supply. C. A son and family recently moved into the home. D. The home is not furnished with a microwave oven.

ANS: A Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the nausea, vomiting, and diarrhea—potential food poisoning. This discussion about the patient's electrical needs can be referred to social services. The water supply, the increased number of individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient.

9. Which philosophy of healthcare ethics would be particularly useful when making ethical decisions about vulnerable populations? A. Feminist ethics B. Deontology C. Bioethics D. Utilitarianism

ANS: A Feminist ethics particularly focuses on the nature of relationships, especially those where there is a power imbalance or a point of view that is not routinely accepted. Examples of populations that are considered vulnerable include children, pregnant women, incarcerated persons, and minority groups. Deontology refers to making decisions or "right-making characteristics," bioethics focuses on consensus building, and utilitarianism speaks to the greatest good for the greatest number.

15. The nurse is caring for a severely ill patient with AIDS who now requires ventilator support. Which intervention is considered futile? A. Administering the influenza vaccine B. Providing oral care every 5 hours C. Applying fentanyl patches prn for pain D. Supporting the patient's lower extremities with pillows

ANS: A Futile refers to something that is hopeless or serves no useful purpose and in nursing refers to interventions that are unlikely to produce benefit for the patient. Care delivered to a patient at the end of life is focused on pain management and comfort measures. A vaccine is administered to prevent or lessen the likelihood of contracting an infectious disease at some time in the future.

1. Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle is compromised when only one nurse anesthetist is on call? A. Justice B. Nonmaleficence C. Beneficence D. Fidelity

ANS: A Justice refers to fairness and is used frequently in discussion regarding access to health care resources. Here the just distribution of resources, in this case pain management, cannot be justly apportioned. Nonmaleficence means "do no harm," beneficence means "to do good," and fidelity means "to be true to, or honest." Each of these phrinciples is partially expressed in the question; however, justice is most comprised because not all laboring patients have equal access to pain management owing to lack of personnel resource

2. The nurse is caring for a patient who is known as a "frequent flyer," and who has been labeled as "noncompliant" by most of the staff because she does not follow her prescribed regimen for diabetes management. As a prescriber to Orem's theory, the nurse interviews the patient in an attempt to identify the cause of the patient's "noncompliance." This is because Orem's theory? A. Is useful in designing interventions to promote self-care. B. Does not allow for environmental influences on care. C. Allows for development of a plan of care that the patient must follow. D. Is not useful in promoting self-care regimens.

ANS: A Orem's theory explains the factors within a patient's living situation that support or interfere with the patient's self-care ability. This theory has value in helping nursing design interventions with the patient that will help to promote the patient's self-care in managing an illness, such as diabetes or arthritis

12. The nurse is visiting a patient at home after he was discharged from the hospital following a heart attack. She listens to the patient's concerns about being an invalid for the rest of his life because of his bad heart, but he is afraid of having "open heart" surgery. The nurse explains the different surgical procedures that are available to the patient, as well as other options such as cardiac rehabilitation. After several such visits, the patient states that he believes that cardiac rehabilitation therapy would be best for him, and asks the nurse how he can get in. The nurse calls the patient's physician and sets up a referral for cardiac rehabilitation. This action most closely fits which of the following theories? A. Peplau's theory B. Henderson's theory C. Nightingale's theory D. Orem's self-care deficit theory

ANS: A Peplau's theory focuses on the individual, the nurse, and the interactive process or nurse-patient relationship. Goals are to educate the patient and family and to help the patient define the problem and solutions. Henderson's theory focuses on helping the patient with activities that the patient would perform unaided if he or she were able. Nightingale viewed nursing not as limited to the administration of medications and treatments, but rather as oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. The goal of Orem's theory is to help the patient perform self-care.

5. Ethical dilemmas are common occurrences when caring for patients. The nurse understands that dilemmas are a result of A. Presence of conflicting values. B. Hierarchical systems. C. Judgmental perceptions of patients. D. Poor communication with the patient.

ANS: A Poor communication and the hierarchical systems that exist in health care, such as reporting structures within the hospital or the historically unequal relationship between physicians and nurses, may complicate dilemmas. The primary, underlying reason that ethical dilemmas occur is that there are no clear cut, universally accepted solutions to a problem when participating individuals do not share the same values. Without clarification of values, the nurse may not be able to distinguish fact from opinion or value, and this can lead to judgmental attitudes

4. The nurse researcher is evaluating whether holding pressure at an injection site after injecting the anticoagulant enoxaparin (Lovenox) will reduce bruising at the injection site. This study involves a prescriptive theory because it A. Tests a specific nursing intervention. B. Explains why bruising occurs. C. Is broad in scope and complex. D. Reflects a wide variety of nursing care situations.

ANS: A Prescriptive theories guide nursing research to develop and test specific nursing interventions. Grand theories are broad in scope and complex, and require further specification through research. Descriptive theories do not direct specific nursing activities but help to explain patient assessment. The phenomena within middle-range theories tend to cross different nursing fields and reflect a wide variety of nursing care situations.

19. Equipment-related accidents are risks in the health care agency. The nurse assesses for this risk when using A. Sequential compression devices. B. A measuring device that measures urine. C. Computer-based documentation. D. A manual medication-dispensing device

ANS: A Sequential compression devices are used on a patient's extremities to assist in prevention of deep vein thrombosis and have the potential to malfunction and harm the patient. Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient

14. The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes. Which question would be the most important to ask this group? A. "Are you able to hear the tornado sirens in your area?" B. "Are you able to read your favorite book?" C. "Are you able to remember the name of the person you just met?" D. "Are you able to open a jar of pickles?"

ANS: A The ability to hear safety alerts and seek shelter is imperative to life safety. Although age-related changes may cause a decrease in sight that affects reading, and although difficulties in remembering short-term information and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the priority.

3. The patient has been diagnosed with a respiratory illness and complains of shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual comfort range for most patients? A. 65° F to 75° F B. 60° F to 75° F C. 15° C to 17° C D. 25° C to 28° C

ANS: A The comfort zone for most individuals is the range between 65° F and 75° F (18.3° C to 23.9° C). The other ranges do not reflect the average person's comfort zone.

13. The nurse is caring for a patient who is actively bleeding. The physician orders blood transfusions. The nurse notes in the chart that the patient is a Jehovah's Witness and informs the patient of the physician's order. The patient states that she is a Jehovah's Witness and does not want blood products. The nurse contacts the physician to tell him that blood cannot be given to this patient and requests alternative treatment. In doing so, the nurse is operating within which of the following theories? A. Leininger's cultural care diversity and universality theory B. Roy's adaptation theory C. Watson's philosophy of transpersonal caring D. Orem's self-care deficit theory

ANS: A The goal of Leininger's theory is to provide the patient with culturally specific nursing care that integrates the patient's cultural traditions, values, and beliefs into the plan of care. The goal of Roy's model is to help the person adapt to changes in physiological needs, self-concept, role function, and relations. Watson's theory believes that the purpose of nursing action is to understand the interrelationship between health, illness, and human behavior. The goal of Orem's theory is to help the patient perform self-care.

16. The prospective nursing student is trying to decide on which nursing program to attend. She is examining the nursing philosophies of each program. She believes that the essence of nursing is "Caring." Which of the following theories would most likely meet her needs? A. Benner and Wrubel's theory of nursing B. Roy's adaptation theory C. Orem's self-care deficit theory D. Rogers' theory

ANS: A The primacy of caring is a model proposed by Patricia Benner and Judith Wrubel. Caring is central. Roy's model is to help the person adapt to changes in physiological needs, self-concept, role function, and relations. The goal of Orem's theory is to help the patient perform self-care. Roger's theory considers the individual as an energy field coexisting within the universe.

28. A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? A. Risk for injury: Prevent harm to patient, use restraints if alternatives fail. B. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter. C. Disturbed body image: Encourage patient to express concerns about body. D. Caregiver role strain: Identify resources to assist with care.

ANS: A The priority nursing diagnosis is risk for injury. This patient could cause harm to himself by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include distraction and providing companionship or supervision. Patients may be moved to a location closer to the nurses' station; trained sitters or family members may be involved. Nurses need to ensure that patients are provided adequate food, liquid, toileting, and relief from pain. If these and other alternatives fail, this individual may need restraints; in this case, an order would need to be obtained for the restraint. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints; however, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patient's caregiver is strained.

6. The nurse is preparing a patient for surgery. The nurse explains that the reason for writing in indelible ink on the surgical site the word "correct" is to A. Distinguish the correct surgical site. B. Label the correct patient. C. Comply with the surgeon's preference. D. Adhere to the correct regulatory standard.

ANS: A The purpose of writing on the surgical site as part of the Universal Protocol from the Joint Commission is to distinguish the correct site on the correct patient and match with the correct surgeon for patient safety and prevention of wrong site surgery. All patients who are having an invasive procedure should receive labeling in many different ways, including the record and patient armbands. Writing in indelible ink may comply with the surgeon's preference, but safety is the driving factor. Although labeling of the site helps to meet regulatory standards, this is not the reason to do this activity—the reason is to keep the patient safe.

36. The nurse is instructing the student nurse regarding discharge teaching and medications. Which response by the student would indicate that learning has occurred? A. "I need to be precise when teaching a patient about Zyprexa (olanzapine) and Zyrtec (cetirizine)." B. "The medications can be picked up at the pharmacy on the way out of the hospital." C. "I need to be sure to give the patient leftover medications from the medication drawer." D. "I need to remember to teach the patient to take all medications at the same time of the day."

ANS: A Zyprexa and Zyrtec are sound-alike, look-alike medications. Zyprexa is an antipsychotic and Zyrtec an antihistamine; these agents treat two different conditions. Bringing the differences and similarities in spelling and sound to the attention of the patient is important for patient safety. Medications are not distributed by the hospital, and medications do not need to be administered at the same time each day.

16. The nurse calculates the medication dose for an infant on the pediatric unit and determines that the dose is twice what it should be. The pediatrician is contacted and says to administer the medication as ordered. What is the next action that the nurse should take? (Select all that apply.) A. Notify the nursing supervisor. B. Check the chain of command policy for such situations. C. Give the medication as ordered. D. Give the amount calculated to be correct. E. Contact the pharmacy for clarification.

ANS: A, B Nurses follow health care provider's' orders unless they believe the orders are in error or may harm patients. Therefore, the nurse needs to assess all orders. If an order seems to be erroneous or harmful, further clarification from the health care provider is necessary. If the health care provider confirms an order and the nurse still believe that it is inappropriate, the nurse should inform the supervising nurse or follow the established chain of command. The supervising nurse should be able to help resolve the questionable order, but only the health care provider who wrote the order or a health care provider covering for the one who wrote the order can change the order. Harm to the infant could occur if the medication dosage was too high. The nurse cannot change an order. Giving the amount calculated to be correct would not be what another nurse would do in the same situation. Although the pharmacy is an excellent resource, only the health care provider can change the order.

37. A nurse is caring for an adult patient who has had a minor motor vehicle accident. The health history reveals that the patient is currently in the process of obtaining a divorce. Which of the following actions should the nurse take? (Select all that apply.) A. Agree upon and make time for the patient to talk. B. Use active listening skills and therapeutic touch as appropriate. C. Teach stress reduction strategies. D. Inform patient that stressed individuals are more likely to have accidents. E. Agree to witness telephone conversations with separated husband. F. Refer the patient to the nurse's church marriage counselor.

ANS: A, B, C, D Agreeing and making time for conversation, using active listening skills and therapeutic touch, teaching stress reduction strategies, and informing the patient of the risk to health associated with stress are interventions that are within the nurse's scope of practice. Agreeing to witness a telephone conversation could draw the nurse into divorce proceedings when the focus should be on the patient and his health. Referring the patient to the nurse's church counselor without a specific request from the patient may not take into consideration cultural care and could be considered unprofessional. If the patient requested a marriage counselor, a better solution would be to provide a referral to social services that may include a list of possible counselors from which the patient could choose.

43. The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which of the following should the nurse implement? (Select all that apply.) A. Close all doors. B. Note evacuation routes. C. Note oxygen shut-offs. D. Await direction from the fire department. E. Evacuate everyone from the building. F. Review "Stop, drop, and roll" with the nursing staff

ANS: A, B, C, D Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shut-offs is important in case the direction to evacuate comes from established channels. Evacuation from the building is determined by the established chain of command or the fire department. Evacuation is done only when necessary. Review of "stop, drop, and roll," although important, is not a priority at this time.

40. The nurse suspects the possibility of a bioterrorist attack. Which of the following factors is most likely related to this possibility? (Select all that apply.) A. A rapid increase in patients presenting with fever or respiratory or gastrointestinal symptoms B. Lower rates of symptoms among patients who spend time primarily indoors C. Large number of rapidly fatal cases of patients with presenting symptoms D. Shortage of personal protective equipment available from central supply E. An increase in the number of staff calling in sick for their assigned shift F. Patients with symptoms all coming from one location in the area

ANS: A, B, C, F A rapid increase in patients presenting with a specific symptom, lower rates of symptoms among individuals indoors, and large numbers of fatalities with these symptoms all coming from one location are triggers that lead the nurse to suspect a bioterrorist attack. A shortage of personal protective equipment and an increase in the number of staff calling in sick can occur and does occur at times in the hospital setting and may have nothing to do with bioterrorism.

42. The home health nurse is caring for a patient in the home who is using an electrical infusion device. While visiting the patient, the nurse smells smoke and notices an electrical fire started by this device. The nurse uses the fire extinguisher and fights the fire when (Select all that apply.) A. All occupants have left the home. B. Fire department has been called. C. Fire is confined to one room. D. An exit route is available. E. The correct extinguisher is available. F. The nurse thinks she can use the fire extinguisher.

ANS: A, B, D, E In a home setting, if the nurse is present during a fire, she first should remove all occupants and then should call the fire department by dialing 911. If the fire is small—not confined to just one room (this could be too large for the fire extinguisher), if the correct extinguisher is available, and if the nurse knows (not thinks) that she can use it, the nurse may attempt to extinguish the fire. Utilize PASS (Pull the pin, Aim low, Squeeze the handles, Sweep area from side to side) to activate the extinguisher.

11. A patient with sepsis as a result of long-term leukemia dies 25 hours after admission to the hospital. A full code was conducted without success. The patient had a urinary catheter, an intravenous line, an oxygen cannula, and a nasogastric tube. What question is priority for the nurse to ask the family before beginning postmortem care? A. "Do you want to assist in bathing your loved one?" B. "Is an autopsy going to be done?" C. "To which funeral home do you want your loved one transported?" D. "Do you want me to remove the lines and tubes before you see your loved one?"

ANS: B An autopsy or postmortem examination may be requested by the patient or the patient's family, as part of an institutional policy, or if required by law. Because the patient's death occurred as a result of long-term illness, not under suspicious circumstances, and more than 24 hours after admission to the hospital, whether to conduct a postmortem examination would be decided by the family, and consent would have to be obtained from the family. The nurse needs to know the policy to follow regarding removal of lines when an autopsy is to be done. Asking about bathing the deceased patient is a valid question but is not priority, because the nurse needs to know the protocol to follow if an autopsy is to be done. Finding out which funeral home the deceased patient is to be transported to is valid but is not priority, because other actions must be taken before the deceased patient is transported from the hospital. Removal of lines and tubes is not a decision made by the family if an autopsy is to be done. The nurse must first check the protocol to be followed.

3. A 17-year-old patient, dying of heart failure, wants to have his organs removed for transplantation after his death. What action by the nurse is correct? A. Prepare the organ donation form for the patient to sign while he is still oriented. B. Instruct the patient to talk with his parents about his desire to donate his organs. C. Notify the physician about the patient's desire to donate his organs. D. Contact the United Network for Organ Sharing after talking with the patient

ANS: B An individual over age 18 may sign the form allowing organ donation upon death. In this situation, the parents would need to sign the form because the teenager is under age 18. The nurse cannot allow the patient to sign the organ donation document because he is younger than age 18. The physician will be notified about the patient's wishes after the parents agree to donate the organs. The nurse caring for the patient does not contact the United Network for Organ Sharing. A transplant coordinator will be the liaison for this organization.

16. During a severe respiratory epidemic, the local health care organizations decide to give health care providers priority access to ventilators over other members of the community who also need that resource. Which philosophy would give the strongest support for this decision? A. Feminist ethics B. Utilitarianism C. Deontology D. Ethics of care

ANS: B Focusing on the greatest good for the most people, the organizations decide to ensure that as many health care workers as possible will survive to care for other members of the community.

9. Many aspects of nursing theory are based on developmental theories because human growth and development is believed to be A. Erratic and difficult to predict. B. An orderly predictive process. C. An orderly process until adulthood. D. Unpredictable during childhood.

ANS: B Human growth and development is an orderly predictive process that begins with conception and continues through death. It is not erratic or difficult to predict. It does not stop at adulthood and is not unpredictable during childhood.

4. A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 100/56, apical pulse 56, respiratory rate 12. Which of the vital signs should be addressed immediately? A. Respiratory rate B. Temperature C. Apical pulse D. Blood pressure

ANS: B Hypothermia is defined as a core body temperature of 95° F or below. Homeless individuals are more at risk for hypothermia owing to exposure to the elements.

12. Conjoined twins are in the neonatal department of the community hospital until transfer to the closest medical center. A photographer from the local newspaper gets off the elevator on the neonatal floor and wants to take pictures of the infants. What initial action should the nurse take? A. Escort the cameraman to the neonatal unit while a few pictures are taken quietly. B. Tell the cameraman where the hospital's public relations department is located. C. Ask the cameraman to wait while permission is obtained from the physician. D. Ask the cameraman how the pictures are to be used in the local newspaper.

ANS: B In some cases, information about a scientific discovery or a major medical breakthrough or anunusual situation is newsworthy. In this case, anyone seeking information needs to contact the hospital's public relations department to ensure that invasion of privacy does not occur. It is not the nurse's responsibility to decide independently the legality of disclosing information. The nurse does not have the right to allow the cameraman access to the neonatal unit. This would constitute invasion of privacy. The physician has no responsibility regarding this situation and cannot allow the cameraman on the unit. It is not the nurse's responsibility to find out how the pictures are to be used. This is a task for the public relations department

33. The nurse has been called to a hospital room where a patient is using a hair dryer from home. The patient has received an electrical shock from the dryer. The patient is unconscious and is not breathing. What is the best next step? A. Ask the family to leave the room. B. Check for a pulse. C. Begin compressions. D. Defibrillate the patient.

ANS: B In this scenario, the patient is in a hospital setting, and it has been determined that the patient is not conscious and is not breathing. The next step is to check the pulse. An electrical shock can interfere with the heart's normal electrical impulses and can cause arrhythmias. Checking the pulse helps to determine the need for cardiopulmonary resuscitation (CPR) and defibrillation.

25. The patient presents to the clinic with a family member. The family member states that the patient has been wandering around the house and mumbling. What is the first assessment the nurse should do? A. Ask the patient why she has been wandering around the house. B. Introduce self and ask the patient her name. C. Take the patient's blood pressure, pulse, temperature, and respiratory rate. D. Immediately do a complete head-to-toe neurologic assessment.

ANS: B Introduce self and engage the patient by asking her name to assess orientation; ask the patient why she is visiting the clinic today. Continue the assessment with vital signs and a complete workup, including a neurologic assessment.

32. An elderly patient presents to the hospital with a history of falls, confusion, and stroke. The nurse determines that the patient is at high risk for falls. Which of the following interventions is most appropriate for the nurse to take? A. Place the patient in restraints. B. Lock beds and wheelchairs when transferring. C. Place a bath mat outside the tub. D. Silence fall alert alarm upon request of family

ANS: B Locking the bed and wheelchairs when transferring will help to prevent these pieces of equipment from moving during transfer and will assist in the prevention of falls. Patients are not automatically placed in restraints. The restraint process consists of many steps, including thorough assessment and exhausting of alternatives. All mats and rugs should be secured to help prevent falls. Silencing alarms upon the request of family is not appropriate and could contribute to an unsafe environment.

14. A nurse works full-time on the oncology unit at the hospital and works part-time on weekends giving immunizations at the local pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient's arm and is now being sued. How will the hospital's malpractice insurance provide coverage for this nurse? A. It will provide coverage as long as the nurse followed all procedures, protocols, and policies correctly. B. The hospital's malpractice insurance covers this nurse only during the time the nurse is working at the hospital. C. As long as the nurse has never been sued before this incident, the hospital's malpractice insurance will cover the nurse. D. The hospital's malpractice insurance will provide approximately 50% of the coverage the nurse will need.

ANS: B Malpractice insurance provided by the employing institution covers nurses only while they are working within the scope of their employment at that institution. It is always wise to find out if malpractice insurance is provided by a secondary place of employment, in this case, the pharmacy, or the nurse should carry an individual malpractice policy to cover situations such as this.

11. As the initial model for nursing, Nightingale's "descriptive theory" encouraged nurses to A. Know all about the disease processes affecting their patient. B. Think about their patients and patients' environment. C. Combine nursing knowledge with medicine. D. Focus on medication administration and treatments

ANS: B Nightingale's "descriptive theory" provides nurses with a way to think about patients and their environment. Nightingale's concept of the environment was the focus of nursing care, and her suggestion that nurses need not know all about the disease process represents early attempts to differentiate between nursing and medicine. Nightingale did not view nursing as limited to the administration of medications and treatments.

2. The patient tells the nurse that she is afraid to speak up regarding her desire to end care for fear of upsetting her husband and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? A. Responsibility B. Advocacy C. Confidentiality D. Accountability

ANS: B Nurses advocate for patients when they support the patient's cause. A nurse's ability to adequate advocate for a patient is based on the unique relationship that develops and the opportunity to better understand the patient's point of view. Responsibility refers to respectingone's professional obligations and following through on promises. Confidentiality deals with privacy issues, and accountability refers to owning one's actions

7. A pediatric oncology nurse floats to an orthopedic trauma unit. What actions should the nurse manager of the orthopedic unit take to enable safe care to be given by this nurse? A. Provide a complete orientation to the functioning of the entire unit. B. Determine patient acuity and care the nurse can safely provide. C. Allow the nurse to choose which meal time she would like. D. Assign nursing assistive personnel to assist her with care.

ANS: B Nurses who float need to inform the supervisor of any lack of experience in caring for the type of patients on the nursing unit. They also need to request and receive an orientation to the unit.Supervisors are liable if they give a staff nurse an assignment that he or she cannot safely handle. Before accepting employment, learn the policies of the institution regarding floating, and have an understanding as to what is expected. A basic orientation is needed, whereas a complete orientation of the functioning of the entire unit would take a period of time that would exceed what the nurse has to spend on orientation. Allowing the nurse to choose which meal time she would like is a nice gesture of thanks for the nurse, but it does not enable safe care.Having nursing assistive personnel may help the nurse complete basic tasks such as hygiene and turning, but it does not enable safe nursing care that she is ultimately responsible for.

7. The nurse is caring for a patient diagnosed with essential hypertension. The physician orders blood pressure medication that the nurse administers. The nurse then monitors the patient's blood pressure for several days to help determine the effectiveness of the administration. In doing so, the nurse evaluates which of the following system components? A. Input B. Output C. Feedback D. Content

ANS: B Output is the end product of a system and, in the case of the nursing process, it is defined as whether the patient's health status improves or remains stable as a result of nursing care. Input consists of the data that come from a patient's assessment. Feedback serves to inform a system about how it functions. Content is the product and information obtained from the system.

3. The type of theory that is used to develop and test specific nursing interventions is known as _____ theory. A. Grand B. Prescriptive C. Descriptive D. Middle-range

ANS: B Prescriptive theories are action oriented and test the validity and predictability of a nursing intervention. These theories guide nursing research to develop and test specific nursing interventions. Grand theories are broad in scope and complex, and require further specification through research. Descriptive theories do not direct specific nursing activities buthelp to explain patient assessment. The phenomena within middle-range theories tend to cross different nursing fields and reflect a wide variety of nursing care situations.

21. A patient with an intravenous infusion requests a new gown after bathing. Which of the following actions is most appropriate? A. Disconnect the intravenous tubing, thread the end through the sleeve of the old gown and through the sleeve of the new gown, and reconnect. B. Thread the intravenous bag and tubing through the sleeve of the old gown and through the sleeve of the new gown without disconnecting. C. Inform the patient that a new gown is not an option while receiving an intravenous infusion in the hospital. D. Call the charge nurse for assistance because linen use is monitored and this is not a common procedure.

ANS: B Procedure-related accidents such as contamination of sterile items can occur in the health care setting. Keeping the intravenous tubing intact without breaks in the system is imperative to decrease the risk of infection while changing a patient's gown and satisfying the patient's request.

13. Which issue has increased the attention paid to quality of life concerns in recent history? A. Health care disparities B. National movement regarding disabled persons C. Aging of the population D. Health care financial reform

ANS: B Quality of life (QOL) is often at the center of ethical dilemmas, including futile care and DNRdiscussions, and has been reshaped in the United States. The national effort to better respect the abilities of the disabled has forced Americans to reconsider the definition of QOL. Health care disparities, an aging population, and health care reform are components impacted by personal definitions of quality but are not the underlying reason why QOL discussions have arisen in the United States

35. The nurse has placed a patient on high-risk alert for falls. Which of the following observations by the nurse would indicate that the patient has an understanding of this alert? A. The patient removes the high alert armband to bathe. B. The patient wears the red nonslip footwear. C. The call light is kept on the bedside table. D. The patient insists on taking a "water" pill on home schedule in the evening.

ANS: B Red nonslip footwear helps to grip the floor and decreases the chance of falling. The communication armband should stay in place and should not be removed, so that all members of the interdisciplinary team have the information about the high risk for falls. Call lights should be kept within reach of the patient. Taking diuretics early in the day assists with decreasing the number of bathroom trips at night—the time when falls are most frequent

11. The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? A. Advocacy B. Responsibility C. Confidentiality D. Accountability

ANS: B Responsibility refers to one's willingness to respect and adhere to one's professional obligations. One of the obligations nursing has is to protect patients and communities, including other nurses. If narcotics are missing, this may indicate that patients have not received medications ordered for their care, or it may suggest that a health care professional may be working under the influence. Accountability refers to the ability to answer for one's actions. Advocacy refers to the support of a particular cause. The concept of confidentiality is very important in health care and involves protecting patients' personal health information

15. The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint? A. The patient refuses to call for help to go to the bathroom. B. The patient continues to remove the nasogastric tube. C. The patient gets confused regarding the time at night. D. The patient does not sleep and continues to ask for items.

ANS: B Restraints are utilized only when alternatives have been exhausted, the patient continues a behavior that can be harmful to himself or others, and the restraint is clinically justified. In this circumstance, continuing to remove a needed nasogastric tube would meet these criteria. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

1. A newly hired experienced nurse is preparing to change a patient's abdominal dressing and hasn't done it before at this hospital. Which action by the nurse is best? A. Ask another nurse to do it so the correct method can be viewed. B. Check the policy and procedure manual for the agency's method. C. Change the dressing using the method taught in nursing school. D. Ask the patient how the dressing change has been recently done.

ANS: B The Joint Commission requires accredited hospitals to have written nursing policies and procedures. These internal standards of care are specific and need to be accessible on all nursing units. For example, a policy/procedure outlining the steps to follow when changing a dressing or administering medication provides specific information about how nurses are to perform. The nurse being observed may not be doing the procedure according to the agency's policy or procedure. The procedure taught in nursing school may not be consistent with the policy or procedure for this agency. The patient is not responsible for maintaining the standards of practice. Patient input is important, but it's not what directs nursing practice.

15. The patient is newly diagnosed with diabetes and will be discharged in the next day or so. The nurse is teaching the patient how to draw up and self-administer his insulin. Which nursing theory is the nurse utilizing? A. Watson's philosophy of transpersonal caring B. Orem's self-care deficit theory C. Rogers' theory D. Henderson's theory

ANS: B The goal of Orem's theory is to help the patient perform self-care. In Watson's theory, the nurse is concerned with promoting and restoring health and preventing illness. Rogers' theory considers the individual as an energy field coexisting within the universe. Henderson defines nursing as "assisting the individual, sick or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death, and that the individual would perform unaided if he or she had the necessary strength, will, or knowledge."

9. A nurse notices that his neighbor's preschool children are often playing on the sidewalk and in the street unsupervised and repeatedly takes them back to their home and talks with the parent available, but the situation continues. What immediate action by the nurse is mandated by law? A. Talk with both parents about safety needs of their children. B. Contact the appropriate community child protection agency. C. Tell the parents that the authorities will be contacted shortly. D. Take pictures of the children to support the overt child abuse.

ANS: B The nurse has a duty to report this situation to protect the children. Any health care professional who does not report suspected child abuse or neglect may be liable for civil or criminal legal action. The person making the report has legal immunity if the report is made ingood faith. Talking with the parents is not mandated by law. There is no obligation to tell the parents that they will be reported to authorities. There is no obligation for the nurse to take pictures of the children

29. The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which of the following nursing diagnoses will the nurse add to the patient's plan of care? A. Risk for poisoning B. Deficient knowledge C. Risk for imbalanced body temperature D. Risk for suffocation

ANS: B The patient needs to understand the purpose of the compression devices and that proper application is needed for them to be effective. The patient has a knowledge need and requires instruction regarding the device and its purpose and procedure. The nurse will intervene by teaching the patient about the sequential compression device and instructing the patient to call for assistance when getting up to go to the bathroom in the future, so that the nurse may assist with removal and proper reapplication. No data support a risk for poisoning, imbalanced body temperature, or suffocation.

10. A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that he should not touch these lines, but the patient continues. What is the best action by the nurse at this time? A. Apply restraints loosely on the patient's dominant wrist. B.Try other approaches to prevent the patient from touching these care items. C. Notify the health care provider that restraints are needed immediately to maintain the patient's safety. D. Allow the patient to pull out lines to prove that the patient needs to be restrained.

ANS: B The risks associated with the use of restraints are serious. A restraint-free environment is the first goal of care for all patients. Many alternatives to the use of restraints are available, and the nurse should try all of them before notifying the patient's health care provider. The situation states that the patient is touching the items, not trying to pull them out. At this time, the patient's well-being is not at risk. The nurse will have to check on the patient frequently and then will determine if the health care provider needs to be informed of the situation. Restraints can be used (1) only to ensure the physical safety of the resident or other residents, (2) when less restrictive interventions are not successful, and (3) only on the written order of ahealth care provider. The health care provider needs to know the situation but also needs to know that all approaches possible have been used before writing an order for restraints. Allowing the patient to pull out any of these items could cause harm to the patient

20. A patient's condition is slowly deteriorating. What actions should the nurse take to provide thebest care possible? (Select all that apply.) A. Allow the nursing student to receive verbal orders from the physician in the room while the nurse is in the medication area down the hall. B. Document the patient's status changes in the medical record in a timely manner. C. Document that the health care provider has been notified of the specific patient status, including date and time that messages were left. D. Check the chart for frequent orders. D. Omit charting what the health provider's response is to notification of the patient'sstatus change

ANS: B, C Clear, concise, and timely communication is essential whenever charting in the patient's medical record occurs. Nursing students are not permitted to receive verbal orders. Documentation regarding communication with the health care provider must contain what wascommunicated by the nurse and the health care provider, orders if given, date, time, and identification of who is documenting the situation

41. The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. The nurse diagnoses risk for injury with a goal of keeping the patient safe in the event of a seizure. Which interventions should the nurse utilize for this patient? (Select all that apply.) A. Teach the family how to insert an oral airway during the seizure. B. Assess the home for items that could harm the patient during a seizure. C. Provide information on how to obtain a Medical Alert bracelet. D. Teach the patient to communicate to the caregiver plans for bathing. E. Discuss with family steps to take if the seizure does not discontinue. F. Demonstrate how to restrain the patient in the event of a seizure.

ANS: B, C, D, E Assessment of the home for safety, providing information on Medical Alert bracelets, teaching the patient to communicate before bathing, and discussing steps to take with status epilepticus are important interventions for the patient who is having seizures. Inserting an airway may harm the patient by forcing the object into the mouth or by biting down on a hard object. Never restrain a patient who is having a seizure, but protect the patient from hitting his body on objects around him to prevent traumatic injury

44. The nurse is caring for a patient in restraints. Which of the following pieces of information about restraints requires nursing documentation in the medical record? (Select all that apply.) A. The patient states that her gown is soiled and needs changing. B. Attempts to distract the patient with television are unsuccessful. C. The patient has been placed in bilateral wrist restraints at 0815. D. One family member has gone to lunch. E. Bilateral radial pulses present, 2+, hands warm to touch F. Released from restraints, active range-of-motion exercises complete

ANS: B, C, E, F Attempts at alternatives are documented in the medical record, as are type of restraint and time restrained. Assessments related to oxygenation, orientation, skin integrity, circulation, and position are documented, along with release from restraints and patient response. Comments about hygiene or the activities of one family member are not necessarily required in nursing documentation of restraints.

39. Which of the following concepts are important to utilize when evaluating orders for restraints (Select all that apply.) A. Behaviors that necessitate the use of restraint are part of the nursing plan of care. B. A physician's order is required for restraint and includes a face-to-face evaluation. C. The physician's preference for the format of the order can override agency policy. D. Orders are time limited. Restraints are not ordered prn (as needed). E. It should be specified that restraints are to be removed periodically. F. Restraint orders are time dated and signed by the physician

ANS: B, D, E, F Physicians are responsible for writing restraint orders and conducting face-to-face evaluations, as well as for putting time limits, specifying when to remove, and time dating and signing orders. Behaviors that necessitate the use of restraint not only are part of the nursing documentation but are to be included as part of the order for restraint. The physician's formatting is not a consideration for evaluating restraint orders. Formatting of restraint orders typically follows state rules and regulations, as well as regulatory agency standards.

18. The nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. The patient has not been identified, and no family members have been found. The nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. The nurse determines that this is an ethical dilemma not resolved by scientific data. Place the steps the nurse will use to resolve this ethical dilemma in the correct order. A. The nurse identifies possible solutions or actions to resolve the dilemma. B. The nurse reviews the medical record, including entries by all healthcare disciplines, to gather information relevant to this patient's situation. C. Health care providers use negotiation to redefine the patient's plan of care. D. The nurse evaluates the plan and revises it with input from other health care providers as necessary. E. The nurse arranges a meeting with health care team members to clarify opinions, values, and facts. F. The nurse states the problem.

ANS: B, E, F, A, C, D Using the steps of processing an ethical dilemma, once the nurse identifies that an ethical dilemma exists, the nurse then gathers information relevant to the case; clarifies values and distinguishes between fact, opinion, and values; and verbalizes the problem. Then the nurse identifies possible solutions or actions, works with the health care team to negotiate a plan, and evaluates the plan over time.

4. An obstetrical nurse comes across an automobile accident. The patient seems to have a crushed upper airway, and while waiting for emergency medical services to arrive, the nurse makes a cut in the trachea and inserts a straw from her purse to provide an airway. The patient survives and has a permanent problem with his vocal cords, making it difficult to talk. Which statement is true regarding the nurse's performance? A. The nurse acted appropriately and saved the patient's life. B. The nurse acted within the guidelines of the Good Samaritan Law. C. The nurse took actions beyond those that are standard and appropriate. D. The nurse should have just stayed with the patient and waited for help

ANS: C An obstetric nurse would not have been trained in performing a tracheostomy or a cricotomy, and doing so would be beyond what she has been trained or educated to do. The nurse did not do what another nurse would have done in the same situation. The nurse is not protected by the Good Samaritan Law because she acted outside of her scope of practice and training. The nurse should have acted within what she was trained and educated to do in this circumstance, not just stay with the patient.

6. A recent immigrant who does not speak English is alert and requires hospitalization. What is the initial action that the nurse must take to enable informed consent to be obtained? A. Ask a family member to translate what the nurse is saying. B. Notify the health care provider that the patient doesn't speak English. C. Request an official interpreter to explain the terms of consent. D. Use hand gestures and medical equipment while explaining in English.

ANS: C An official interpreter must be present to explain the terms of consent if a patient speaks only a foreign language. A family member or acquaintance who speaks a patient's language should not interpret health information. Family members can tell those caring for the patient what the patient is saying, but privacy regarding the patient's condition, assessment, etc., must be protected. There is no way that the nurse can know that the family member is translating exactly what the nurse is saying. Privacy must be ensured and accurate information must be provided to the patient. After consent is obtained for treatment, the health care provider would be notified because little can be done without consent. The health care provider needs to have the translator available during the history and physical, as well as at other times, but the first step is to get a translator to obtain informed consent because this is not an emergency situation. Using hand gestures and medical equipment is inappropriate when communicating with a patient who does not understand the language spoken. Certain hand gestures may be acceptable in one culture and not appropriate in another. The medical equipment may be unknown and frightening to the patient, and the patient still doesn't understand what is being said.

23. During the admission assessment, the nurse assesses the patient for fall risk. Which of the following has the greatest potential to increase the patient's risk for falls? A. The patient is 59 years of age. B. The patient walks 2 miles a day. C. The patient takes Benadryl (diphenhydramine) for allergies. D. The patient recently became widowed

ANS: C Benadryl (diphenhydramine) has the potential to cause drowsiness and dizziness as a side effect, thereby increasing the risk for falls. Over 60 is the age typically found on fall assessments that increase the risk for falls. Walking has many benefits, including increasing strength, which would be beneficial in decreasing risk.

17. Determinations regarding quality of life are A. Based on a person's ability to act according to ethical principles. B. Based on a patient's self-determination. C. Value judgments that can vary from person to person. D. Consistent and stable over the course of one's lifetime

ANS: C Determinations regarding quality of life are value judgments. This means that they are judgments based on what individuals believe is desirable. Beliefs about what people find desirable vary from person to person

14. The patient is terminally ill and is under hospice care. The nurse cares for the patient by bathing, shaving, and repositioning him. The family believes that the end is very near and would like a Catholic priest called to provide the patient with the Sacrament of the Sick. The nurse places a call to the Catholic Church the patient attended and arranges for the priest's visit. Under which of the following theories does the nurse's care fall? A. Roy's adaptation theory B. Watson's philosophy of transpersonal caring C. Henderson's theory D. Orem's self-care deficit theory

ANS: C Henderson defines nursing as "assisting the individual, sick or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death, and that the individual would perform unaided if he or she had the necessary strength, will, or knowledge." Roy's model is to help the person adapt to changes in physiological needs, self-concept, role function, and relations. Watson's theory believes that the purpose of nursing action is to understand the interrelationship between health, illness, and human behavior. The goal of Orem's theory is to help the patient perform self-care.

26. The emergency department has been notified of a potential bioterrorist attack. The nurse assigned to the department realizes that the most important task for safety in this situation is to A. Carry out the role and responsibilities of the nurse quickly and efficiently. B. Cluster all patients with the same symptoms to a specific part of the department. C. Determine the biologic agent and manage all patients using Standard Precautions. D. Prepare for post-traumatic stress associated with this bioterrorist attack

ANS: C It is essential to determine the agent and manage all patients who are symptomatic with the suspected or confirmed bioterrorism-related illness using Standard Precautions. For certain diseases, additional precautions may be necessary. Clustering patients may be helpful with staffing and, depending on the illness, may decrease the spread. All nurses every day should carry out their roles quickly and efficiently. Psychosocial concerns are important but are not the first priority at this moment.

10. The nurse is making rounds and finds her older adult patient sobbing and obviously upset. She states that her doctor told her that she has cancer, and she does not want to die. "What's the matter?" she says. "I might as well die. I'm going to anyway. I guess that shows how useless I really am. Nobody wants an old lady around." The nurse notices that the patient's respirations have increased, and the tip of her nose and ear lobes are becoming cyanotic. The nurse assesses the patient and finds that the patient's pulse rate is over 150 beats per minute. According to Maslow's hierarchy of needs, the nurse should first A. Call the physician to request a psychiatric consult. B. Reassure the patient that she has value as a human being. C. Place the patient on oxygen and try to calm her. D. Call the patient's family to help her realize that she is wanted

ANS: C Maslow's hierarchy is useful in setting patient priorities. Basic physiological and safety needs are usually the first priority. These include physiological needs such as air, water, and food. Cyanosis and fast heart rate are indicators of physiological stress and must be dealt with first, or the patient may not survive. The second level includes psychological security. A psychiatric consult would come after physiological stabilization. The third level includes love and belonging needs that would also need to be addressed, and the family may be helpful in dealing with this, once the patient is stabilized. The fourth level involves self-esteem, which would also need to be addressed.

8. The nurse preceptor recognizes the new nurse's ability to determine patient safety risks when which behavior is observed? A. Checking patient identification once every shift B. Multitasking by gathering two patients' medications C. Disposing of used needles in a red needle container D. Raising all four side rails per family request

ANS: C Needles, syringes, and other single-use injection devices should be used once and disposed of in safety red needle containers that will be disposed of properly. Patient identification should be checked multiple times a day, including before each medication, treatment, procedure, blood administration, and transfer, and at the beginning of each shift. Gathering more than one patient's medication increases the likelihood of error. Raising all four side rails is considered a restraint and requires special orders, assessment, and monitoring of the patient

12. A young woman who is pregnant with a fetus exposed to multiple teratogens consents to have her fetus undergo serial PUBS (percutaneous umbilical blood sampling) to examine how exposure affects the fetus over time. Although these tests will not improve the fetus' outcomes and will expose it to some risks, the information gathered may help infants in the future. Which ethical principle is at greatest risk? A. Autonomy B. Fidelity C. Nonmaleficence D. Beneficence

ANS: C Nonmaleficence is the ethical principle that focuses on avoidance of harm or hurt. The nurse must balance risks and benefits of care. Repeated PUBS may place the mother and fetus at risk for infection and increased pain, and may place the mother at risk for increased emotional health stress. Fidelity refers to the agreement to keep promises. Autonomy refers to freedom from external control, and beneficence refers to taking positive actions to help others.

30. The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury with a goal for the patient to be safe. Which of the following actions should the nurse take first? A. Activate the alarm. B. Extinguish the fire. C. Remove the patient. D. Confine the fire.

ANS: C Nurses use the mnemonic RACE to set priorities in case of fire. All of these interventions are necessary, but this patient is in immediate danger with the fire being over his head and should be rescued and removed from the situation.

5. The student nurse is learning nursing theories but fails to see how they relate to the nursing process. The professional nurse realizes that nursing theory A. Has a minor role in professional nursing. B. Requires the nursing process to develop knowledge. C. Can direct how a nurse uses the nursing process. D. Is specific to certain patients only.

ANS: C Nursing theory can direct how a nurse uses the nursing process. Integration of theory into practice serves as the basis for professional nursing. The nursing process provides a systematic process for the delivery of care, not the knowledge component of the discipline. Useful theories are adaptable to different patients and to all care settings.

16. The nurse is discussing with a patient's physician the need for restraint. The nurse indicates that alternatives have been utilized. What behaviors would indicate that the alternatives are working? A. The patient continues to get up from the chair at the nurses' station. B. The patient apologizes for being "such a bother." C. The patient folds three washcloths over and over. D. The sitter leaves the patient alone to go to lunch.

ANS: C Offering diversionary activities such as something to hold is a way to keep the hands busy and provides an alternative to restraints. Assigning a room near the nurses' station or a chair at the desk can be an alternative for continuous monitoring. Getting up constantly can be cause for concern. Apologizing is not an alternative to restraints. Having a sitter sit with the patient to keep him occupied can be an alternative to restraints, but the sitter needs to be continuous.

12. The nurse is presenting an educational session on safety for parents of adolescents. The nurse should include which of the following teaching points? A. Adolescents need unsupervised time with friends two to three times a week. B. Parents and friends should teach adolescents how to drive. C. Adolescents need information about the effects of beer on the liver. D. Adolescents need to be reminded to use seatbelts on long trips

ANS: C Providing information about drugs and alcohol is important because adolescents may choose to participate in risk-taking behaviors. Adolescents need to socialize but need supervision. Parents can encourage and support learning processes associated with driving, but organized classes can help to decrease motor vehicle accidents. Seatbelts should be used all the time.

18. The nurse knows that four categories of risk have been identified in the health care environment. Which of the following provides the best examples of those risks? A. Tile floors, cold food, scratchy linen, and noisy alarms B. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach C. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly D. Dirty floors, hallways blocked, medication room locked, and alarms set

ANS: C The four categories are falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-inherent issues in the hospital setting but are more of patient satisfaction or infection control issues or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues, and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are patient satisfaction issues and examples of following a procedure correctly.

3. The patient's son requests to view the documentation in his mother's medical record. What is the nurse's best response to this request? A."I'll be happy to get that for you." B. "You will have to talk to the physician about that." C."You will need your mother's permission." D."You are not allowed to see it.

ANS: C The nurse understands that sharing health information is governed by HIPAA legislation, which defines rights and privileges of patients for protection of privacy. Private health information cannot be shared without the patient's specific permission. The other three responses either are outright false and/or use poor communication techniques.

34. A nurse is in the hallway assisting a patient to ambulate and hears an alarm sound. What is the best next step for the nurse to take? A. Seek out the source of the alarm. B. Wait to see if the alarm discontinues. C. Ask another nurse to check on the alarm. D. Continue ambulating the patient

ANS: C The nurse who heard the alarm has a duty to address it even though she is busy with another patient. Ask someone to check on the alarm. The nurse cannot leave the patient in the hallway to look for the source of the alarm and cause a potentially unsafe situation for this patient, but a patient on the unit may have an urgent need. Someone needs to seek out the source of the alarm and address it. Never ignore an alarm. Alarms are in place to maximize the safety of the patient. Waiting to see if an alarm stops may cause a delay in a possible emergency situation

9. The nurse is completing discharge education for the patient regarding home medications. Which patient behavior is an indication that the patient understands the directions regarding the antibiotic medication? A. The patient nods throughout the educational session. B. The patient reads the medication prescription out loud. C. The patient states, "I will finish the antibiotic in ten days." D. The patient asks where to get the prescription filled.

ANS: C The patient stating the time frame for when the medication will be complete is the best answer. Nodding, reading the prescription out loud, or knowing where to get the prescription filled does not indicate understanding regarding directions for taking the antibiotic.

2. A new nurse notes that the health care unit keeps a listing of patient names in a closed book behind the front desk of the nursing station so patients can be located easily. What action is most appropriate for the nurse to take? A. Move the book to the upper ledge of the nursing station for easier access. B.Talk with the nurse manager about the listing being a violation of the Health Insurance Portability and Accountability Act (HIPAA). C. Use the book as needed while keeping it away from individuals not involved in patient care. D. Ask the nurse manager to move the book to a more secluded area.

ANS: C The privacy section of the HIPAA provides standards regarding accountability in the healthcare setting. These rules include patient rights to consent to the use and disclosure of their protected health information, to inspect and copy their medical record, and to amend mistaken or incomplete information. This document limits who is able to access a patient's record. It establishes the basis for privacy and confidentiality about patients in any manner. The book is located where only staff would have access. It is not the responsibility of the new nurse to move items used by others on the patient unit. The listing is protected as long as it is used appropriately as needed to provide care. There is no need to move the book to a more secluded area.

8. The patient is admitted to the ICU to rule out a myocardial infarction (MI). During the admission process, the patient is noted to have a history of methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation until cultures can be obtained and the patient declared noninfectious. During the isolation process, the nurse encourages family visits, realizing that which level of Maslow's hierarchy of needs is at risk? A. First level B. Second level C. Third level D. Fourth level E. Fifth level

ANS: C The third level contains love and belonging needs, including friendship, social relationships, and sexual love. The first level includes physiological needs. The second level includes safety and security needs. The fourth level encompasses esteem and self-esteem needs. The fifth and final level is the need for self-actualization

18. Nursing has its own body of knowledge that is both theoretical and practical. Which of the following is an example of theoretical knowledge? A. Reflection on care experiences B. Synthesis and integration of the art and science of nursing C. Reflection on basic values and principles D. Creating a narrow understanding of nursing practice

ANS: C Theoretical knowledge includes and reflects on the basic values, guiding principles, elements, and phases of nursing. The goals of theoretical knowledge are to stimulate thinking and create a broad understanding of the "science" and practices of the nursing discipline. Practical knowledge is achieved through personal knowing gained through reflection on care experiences, synthesis, and integration of the art and science of nursing.

6. A system is made up of separate components. A closed system A. Interacts with the environment. B. Is exemplified by the human organism. C. Does not interact with the environment. D. Is exemplified by the nursing process.

ANS: C Two types of systems have been identified: open and closed. An open system, such as a human organism or processes like the nursing process, interacts with the environment. A closed system does not interact with the environment.

7. The nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to find resolution in this assignment? A. Call for an ethical committee consult. B. Decline the assignment on religious grounds. C. Scrutinize her own personal values. D. Convince the family to challenge the directive

ANS: C Values develop over time and are influenced by family, schools, religious traditions, and life experiences. The nurse must recognize that no two humans have the same set of experiences, and so differences in values are more likely the norm than the exception. Closer inspection of one's values may be a step in gaining understanding of another person's perspective. Calling for a consult, declining the assignment, and convincing the family to challenge the patient's directive are not ideal resolutions because they do not address the reason for the nurse's discomfort, which is the conflict between the nurse's values and those of the patient.

17. The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous infusion. The nurse begins to develop a plan to care for the patient. Which nursing intervention should take priority? A. Gather restraint supplies. B. Try alternatives to restraint. C. Assess the patient. D. Call the physician for a restraint order

ANS: C When a patient becomes suddenly confused, the priority is to assess the patient, including checking laboratory test and oxygen status and treating and eliminating the cause of the change in mental status. If interventions and alternatives are exhausted, the nurse working with the physician may determine the need for restraints.

5. The nurse is caring for a patient with a urinary catheter. After the nurse empties the collection bag and disposes of the urine, the next step is to A. Use alcohol-based gel on hands. B. Wash hands with soap and water. C. Remove eye protection and dispose of in garbage. D. Remove gloves and dispose of in garbage.

ANS: D After disposing of the urine, the first step in removing personal protective equipment is removing gloves and disposing of them properly. In this scenario, the next step would be to remove eye protection followed by hand hygiene. Wash hands if the hands are visibly soiled; otherwise the use of alcohol-based gel is indicated for routine decontamination of hands.

1. A home health nurse is performing a home assessment for safety. Which of the following comments by the patient would indicate a need for further education? A. "I will schedule an appointment with a chimney inspector next week." B. "Daylight savings is the time to change batteries on the carbon monoxide detector." C. "If I feel dizzy when using the heater, I need to have it inspected." D. "When it is cold outside in the winter, I can warm my car up in the garage."

ANS: D Allowing a car to run in the garage introduces carbon monoxide into the environment and decreases the available oxygen for human consumption. Garages should be opened and not just cracked to allow fresh air into the space and allay this concern. Checking the chimney and heater, changing the batteries on the detector, and following up on symptoms such as dizziness, nausea, and fatigue are all statements that would indicate that the individual has understood the education.

17. The nursing process is A. The generation of nursing knowledge for use in practice. B. A systematic view of a phenomenon specific to inquiry. C. A method used to inform a system about how it functions. D. A systematic process for the delivery of nursing care.

ANS: D Although the nursing process is central to nursing, it is not a theory. It provides a systematic process for the delivery of nursing care. Theory generates nursing knowledge for use in practice. An interdisciplinary theory explains a systematic view of a phenomenon specific to the discipline of inquiry. Feedback serves to inform a system about how it functions.

8. The nurse values autonomy above all other principles. Which patient assignment will the nurse find most difficult to accept? A. Teenager in labor who requests epidural anesthesia B. Middle-aged father of three with an advance directive declining life support C. Elderly patient who requires dialysis D. Family elder who is making the decisions for a 30-year-old female member

ANS: D Autonomy refers to freedom from external control. A person who values autonomy highly may find it difficult to accept situations where the patient is not the primary decision maker regarding his or her care. A teenager requesting an epidural, a father with an advanced directive, and an elderly patient requiring dialysis all describe a patient or family that can make their own decisions and choices regarding care

8. While recovering from a severe illness, a hospitalized patient states that he wants to change his living will, which he signed nine months ago. Which response by the nurse is most appropriate? A. "Check with your admitting health care provider whether a copy is on your chart." B. "Have you talked with your attorney recently about a living will?" C. "Your living will can be changed only once each calendar year." D. "Let me check with someone here in the hospital who can assist you."

ANS: D Each health care facility has personnel who are familiar with the state laws and can assist the patient in revising a living will. They may be in the admissions or risk management department. Checking with the health care provider about the presence of a living will on the chart has nothing to do with the patient's desire to change the living will. The question states that the patient wants to change his living will. Asking whether he has talked to his lawyer recently is a closed-ended question that passes the responsibility to someone else, that is, the attorney, and does not address the patient's current desire to change the living will. It is the nurse's responsibility to find an appropriate person in the facility to assist the patient. A living will can be changed whenever the patient decides to change it, as long as the patient is competent.

10. The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to A. Learning to walk. B. Trying to pull up on furniture. C. Being dropped by a caregiver. D. Growing ability to explore and oral activity.

ANS: D Injury is a leading cause of death in children over age 1, which is closely related to normal growth and development because of the child's increased oral activity and growing ability to explore the environment.

13. The nurse discussed threats to adult safety with a college group. Which of the following statements would indicate understanding of the topic? A. "Our campus is safe; we leave our dorms unlocked all the time." B. "As long as I have only two drinks, I can still be the designated driver." C. "I am young, so I can work nights and go to school with 2 hours' sleep." D. "I guess smoking even at parties is not good for my body."

ANS: D Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning. The average young adult needs 6 1/2 to 8 hours of sleep each night.

22. The nurse is precepting a student nurse and is careful to check with the student all components of the medication process. The nurse explains to the student that most errors occur in A. Ordering and transcribing. B. Dispensing and administering. C. Dispensing and transcribing. D. Ordering and administering

ANS: D Most medication errors occur in the ordering and administering stages of the medication process

20. A patient has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include A. Encouraging visitors in the early evening. B. Placing all four side rails in the "up" position. C. Checking on the patient once a shift. D. Placing a high risk for falls armband on the patient.

ANS: D Placing a high risk for falls armband on the patient encourages communication among the whole interdisciplinary team. Anyone who interacts with the patient should see this armband, understand its meaning, and assist the patient as necessary. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour

31. The nurse is providing information regarding safety and accidental poisoning to a grandmother who will be taking custody of a 1-year-old grandchild. Which of the following comments would indicate that the grandmother needs further instruction? A. "The number for poison control is 800-222-1222." B. "Never induce vomiting if my grandchild drinks bleach." C. "I should call 911 if my grandchild loses consciousness." D. "If my grandchild eats a plant, I should provide syrup of ipecac."

ANS: D Syrup of ipecac to induce vomiting after ingestion of a poison has not been proven effective in preventing poisoning. This medication should not be administered to the child. The poison control number is 800-222-1222. After a caustic substance such as bleach has been drunk, do not induce vomiting. This can cause further burning and injury as the medication is eliminated. Loss of consciousness associated with poisoning requires calling 911.

24. The older patient presents to the emergency department after stepping in front of a car at a crosswalk. After the patient has been triaged, the nurse interviews the patient. Which of the following comments would require follow-up by the nurse? A. "I try to exercise, so I walk that block almost every day." B. "I waited and stepped out when the traffic sign said go." C. "The car was going too fast, the speed limit is 20." D. "I was so surprised; I didn't see or hear the car coming."

ANS: D The patient did not see or hear the car coming. As patients age, sensory impairment can increase the risk for injury. This statement by the patient would require follow-up by the nurse. The patient needs hearing and eye examinations. Exercise is important at every stage of development. The patient seemed to comprehend how to cross an intersection correctly and was able to determine the speed of the car.

27. The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. These data would help to support a nursing diagnosis of A. Risk for poisoning. B. Knowledge deficit. C. Impaired home maintenance. D. Risk for injury.

ANS: D The patient's behaviors support the nursing diagnosis of risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the scenario refers to the patient's home maintenance

14. Which patient is most likely to have difficulty with the ethical concept of autonomy? A. 18-year-old patient in labor B. 35-year-old patient with appendicitis C. 53-year-old patient with pancreatitis D. 78-year-old patient with rheumatoid arthritis

ANS: D The principle of autonomy refers to freedom from external control and includes commitment to include patients in decisions about their care. People from different generations have differing expectations regarding inclusion in their care. Often, patients who are part of the Silent Generation (born 1925-1945) value formality and authority, which may make them less comfortable with making their own healthcare decisions.

1. The nursing instructor is teaching a class on nursing theory. One of the students asks, "Why do we need to know this stuff? It doesn't really affect patients." The instructor's best response would be? A. "You are correct, but we have to learn it anyway." B. "Exposure to theories will help you later in graduate school." C. "Theories help keep the focus of nursing narrow." D."Theories help explain why nurses do what they do.

ANS: D Theories offer well-grounded rationales or reasons for how and why nurses perform specific interventions. Learning about theories is important because these theories help to describe, explain, predict, and/or prescribe nursing care measures. Although nursing theory will help thenurse in graduate school, it is also an important basis for the nurse's approach to daily patient care, and it expands scientific knowledge of the profession

10. A nurse argues that we need to reform our healthcare system because we have a large number of people who are uninsured and end up needing expensive emergent care when low-cost measures could have prevented their illnesses. What ethical framework is she using to make this case? A. Deontology B. Ethics of care C. Feminist ethics D. Utilitarianism

ANS: D Utilitarianism is a system of ethics that believes that value is determined by usefulness. This system of ethics focuses on the outcome of the greatest good for the greatest number of people. Deontology would not look to consequences of actions. The ethics of care would not be helpful because consensus on this issue is not achievable. Relationships, which are an important component of feminist ethics, are not addressed in this case.

4. When people work together to solve ethical dilemmas, individuals must examine their own values. This step is crucial to ensure that A. The group identifies the one correct solution. B. Fact is separated from opinion. C. Judgmental attitudes are not provoked. D. Different perspectives are respected

ANS: D Values are personal beliefs that influence opinions. To be able to negotiate differences in opinions, the nurse must first be clear about personal values, which will influence behaviors, decisions, and actions. Ethical dilemmas are a problem in that no one right solution exists.

19. A patient has just been told that he has approximately six months to live and asks about advance directives. Which statements by the nurse give the patient correct information? (Select all that apply.) A."You have the right to refuse treatment at any time." B."If you want certain procedures or actions taken or not taken, and you might not be able to tell anyone at the time, you need to complete documents ahead of time that give your health care provider this information." C. "You will be resuscitated at any time to allow you the longest length of survival." D. "You might want to think about choosing someone who will make medical decisions for you in the event that you are unable to make your desires known." e."We will get someone who knows the state's guidelines to assist you in setting up your living will." f."If you travel to another state, your living will should cover your wishes."

ANS: A, B, D, E The ethical doctrine of autonomy ensures the patient the right to refuse medical treatment. Living wills are written documents that direct treatment in accordance with a patient's wishes in the event of a terminal illness or condition. With this legal document, the patient is able to declare which medical procedures he or she wants or does not want when terminally ill or in a persistent vegetative state. Each state providing for living wills has its own requirements for executing the health care proxy or durable power of attorney for health care (DPAHC). This is a legal document that designates a person or persons of one's choosing to make healthcare decisions when the patient is no longer able to make decisions on his or her own behalf. This agent makes health care treatment decisions based on the patient's wishes. Cardiopulmonary resuscitation (CPR) is an emergency treatment provided without patient consent. Health care providers perform CPR on an appropriate patient unless a do not resuscitate (DNR) order has been placed in the patient's chart. The statutes assume that all patients will be resuscitated unless a written DNR order is found in the chart. Legally competent adult patients can consent to a DNR order verbally or in writing after receiving appropriate information from the health care provider. Differences among the states have been noted regarding advance directives, so the patient should check state laws to see if a state will honor an advance directive that was originated in another state.

18. The nurse hears a physician say to the charge nurse that he doesn't want that same nurse caring for his patients because she is stupid and won't follow his orders. The physician also writes on his patient's medical records that the same nurse, by name, is not to care for any of his patients because of her incompetence. What component(s) of defamation has the physiciancommitted? (Select all that apply.) A. Slander B. Invasion of privacy C. Libel D. Assault E. Battery

ANS: A, C Slander occurred when the physician spoke falsely about the nurse, and libel occurred when the physician wrote false information in the chart. Both of these situations could cause problems for the nurse's reputation. Invasion of privacy is the release of a patient's medical information to an unauthorized person such as a member of the press, the patient's employer, or the patient's family. Assault is any action that places a person in apprehension of a harmful or offensive contact without consent. No actual contact is necessary. Battery is any intentional touching without consent

38. The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which of the following should the patient avoid? (Select all that apply.) A. Watering outdoor plants with a nozzle and hose B. Purchasing light bulbs with strength greater than 60 watts C. Missing yearly eye examinations D. Using bathtubs without safety strips E. Unsecured rugs throughout the home F. Walking to the mailbox in the summer

ANS: A, C, D, E Unsecured rugs, using a hose to water plants, missing yearly eye examinations, and using tubs without safety strips are all items the patient should avoid to help in the prevention of falls in the home. Exercise is beneficial and increases strength, which helps with the prevention of falls. It is important that the home is well lit, so encourage the purchase of bulbs with strength of 60 watts or higher for the home.

17. A nurse gives an incorrect medication to a patient without doing all of the mandatory checks, but the patient has no ill effects from the medication. What actions should the nurse take after reassessing the patient? (Select all that apply.) A. Notify the health care provider of the situation. B. Document in the patient's medical record that an occurrence report was filed. C. Document in the patient's medical record why the omission occurred. D. Discuss what happened with all of the other nurses and staff on the unit. E. Continue to monitor the patient for any untoward effects from the medication. F. Send an occurrence report to risk management after completing it

ANS: A, E, F Examples of an occurrence include an error in technique or procedure such as failing to properly identify a patient. Institutions generally have specific guidelines to direct health care providers how to complete the occurrence report. The report is confidential and separate from the medical record. The nurse is responsible for providing information in the medical record about the occurrence. It is also best for the nurse to discuss the occurrence with nursing management only. The risk management department of the institution also requires complete documentation. The fact that an occurrence report was completed is not documented in the patient's medical record. No discussion of why the omission in procedure occurred should be documented in the patient's medical record. Errors should be discussed only with those who need to know such as the health care provider, appropriate administrative personnel, and risk management

7. The nurse identifies that a patient has received Mylanta (simethicone) instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. The nurse's next intervention is to A. Do nothing, no harm has occurred. B. Assess and monitor the patient. C. Notify the physician, treat and document. D. Complete an incident report.

ANS: B After providing an incorrect medication, assessing and monitoring the patient to determine the effects of the medication is the first step. Notifying the physician and providing treatment would be the best next step. After the patient has stabilized, completing an incident report would be the last step in the process.