Fundamentals Midterm

A disaster situation occurs and involves an explosion in a hospital laundry. What would this be classified as? a. Active b. External c.Life-threatening d. Internal

d. internal (Internal disaster often threatens the safety of patients and staff.)

A nurse teaching the mother about infant oral hygiene instructs the mother to offer the infant sips of: a. cola. b. milk. c. juice. d. water.

d. water.

What document identifies the roles and responsibilities of the LPN/LVN? a.Nurse practice Act b. NLN Accreditation Standards c. NAPNE Code d. American Nurses' Association Code

A. Nurse practice Act

What is a set of learned values, beliefs, customs, and practices shared by a group? a. Ethnicity b. Culture c. Race d. Religion

b. Culture (Culture is a set of learned values, beliefs, customs, and practices shared by a group.)

What is the final stage of human growth and development? a. Resolution b. Death c. Integrity d. Despair

b. Death

The nurse is preparing the patient for a thoracentesis. What must be completed before the procedure may be performed? a. Interview b. Informed consent c. Surgical checklist d. Physical assessment

b. Informed consent (The doctrine of informed content refers to full disclosure of the facts the patient needs to make an intelligent (informed) decision before any invasive treatment or procedure is performed. A physical assessment, interview, and surgical checklist are not required before this procedure.)

What action exemplifies a nurse practicing medical asepsis in performing daily care? a. Washing hands for 5 minutes between patients b. Keeping bed linens off the floor c. Using disposable sterile gowns d. Lifting a sterile swab from a sterile field

b. Keeping bed linens off the floor

A 53-year-old woman complains of night sweats and mood swings. The nurse recognizes that these symptoms most likely relate to which condition? a. Thyroid problems b. Menopause c. Weight problems d. Dietary problems

b. Menopause

The nurse lowers the bed to place the patient on the bedpan. The angle of the head of the bed should be raised to: a. 45 degrees. b. 90 degrees. c. 30 degrees. d. 20 degrees.

c. 30 degrees.

What is the leading cause of injury and death among infants and young children? a. Adolescent parents b. Drug abuse c. Accidents d. Child abuse

c. Accidents

How can a family best assist a toddler who is attempting to feed himself? a. Encourage large portions for easier handling. b. Feed the child themselves using a fork. c. Offer the child finger foods. d. Encourage the child to use a fork.

c. Offer the child finger foods.

What should a nurse do when encountering a mercury spill? a. Open interior doors b. Vacuum the spill c. Open any outside windows d. Close all outside windows

c. Open any outside windows (Open outside windows, close interior doors. Spill should not be vacuumed.)

The nurse from New York City is caring for a patient from Atlanta, Georgia. What difference between the nurse and patient may cause them to experience difficulty in communicating? a. Race b. Culture c. Subculture d. Ethnic group

c. Subculture ( Subcultures have characteristic patterns that distinguish them from the rest of the culture. )

A nurse is caring for the dying mother of a 7-year-old child. What is important for the nurse to understand regarding the child? a. The child believes his or her own death cannot be avoided. b. The child lacks understanding of the concept of death. c. The child associates death with aggression. d. The child understands death as the inevitable end of life.

c. The child associates death with aggression. (A child from 5 to 9 years old understands that death is final, believes one's own death can be avoided, associates death with aggression or violence, and believes wishes or unrelated actions can be responsible for death. A child between the ages of 9 to 12 years understands that death is the inevitable end of life.)

The nurse counsels the immobilized patient in regard to prevention of muscle atrophy and contractures. What will the nurse be sure to include when counseling this patient? a. The need for additional protein b. The need for additional calcium c. The need for some type of exercise d. The need for a special protective bed

c. The need for some type of exercise

During and admission assessment, the nurse collects objective and subjective data, What is an example of subjective data? a. The patient is coughing. b. The patient has cyanosis of the lips c. The patient complains of generalized discomfort d. The patient experience tachypnea.

c. The patient complains of generalized discomfort. ( Subjective data is what they patient says and what cannot be measured or observed by the nurse.)

Which of the following would lead the home health nurse to make a patient problem of unresolved grief for a patient who was widowed 5 months ago? Assessing that the patient eats out frequently rather than cooking at home. b. The patient says that she attends church three times a week. c. The patient said tearfully, "I can't believe he is gone." d. Seeing that the patient keeps a picture of the husband by her bed.

c. The patient said tearfully, "I can't believe he is gone."

A health care provider orders a patient to be placed in the Trendelenburg's position. How will the nurse position the bed? a. Tilted with the foot of the bed down b. Parallel with the floor c. Tilted with the head of the bed down d. On the floor

c. Tilted with the head of the bed down

What skills should health care workers frequently attend in-services about to ensure that staff has competent skills and risk for falls can be decreased? a. Amulating b. Bathing c. Transferring d. Feeding

c. Transferring (The majority of patient falls occur during transfer.)

What is important safety precaution should the home health nurse teach parents in order to prevent burns to small children? a. Never leave them unattended b. Turn hot water on first when filling the bathtub c. Turn pot handles on stoves away from reach d. Keep side rails up on the crib

c. Turn pot handles on the stoves away from reach(To protect infants and children from burns, turn the pot handles on stoves away from the child's reach.)

A patient with a urinary tract infection is assessed using a clinical pathway. When a projected outcome is not met by a predetermined date, it is determined that what has occured? a. Failure b. Omission c. Variance d. Error

c. Variance (A variance occurs when a projected outcome is not met.)

The nurse is educating a patient regarding a tub bath. What is the maximum length of time the nurse should instruct the patient to remain in the water? a. 30 to 40 minutes b. 20 to 30 minutes c. 5 to 10 minutes d. 10 to 20 minutes

d. 10 to 20 minutes

What is the average resting respiratory rate for a 12-month-old child? a. 15 breaths/min b. 20 breaths/min c. 50 breaths/min d. 30 breaths/min

d. 30 breaths/min

What is a patient problem considered when a problem is suspected but data to support it are lacking? a. A "risk for" diagnosis b. A syndrome patient problem c. An actual patient problem d. A possible patient problem

d. A possible patient problem. (A possible patient problem requires additional data to confirm a problem or to complete a data cluster so that it can be related to a NANDA-1 label.)

Patients have expectations regarding the health care services they receive. To protect these expectations, which of the following has become law? a. The joint Commission's rights and responsibilities of patients b. American Hospital Association's Standards of care c. Self-Determination Act d. American Hospital Association's Patient's Bill of Rights

d. American Hospital Patient's Bill of Rights (Patient's have expectations regarding the health care services they receive. In 1972, the American Hospital Association(AHA) developed the Patient's Bill of Rights. The Self-Determination Act, American Hospital Association's Standards of Care, and the Joint Commission's rights and responsibilities do not address patients' expectations regarding health care.)

How often should the nurse cleanse the meatal-catheter junction of a patient with an indwelling catheter? a. At least once a day b. Each shift c. At bedtime d. At least twice a day

d. At least twice a day

Which family pattern is least open to outside influence? a. Matriarchal family pattern b. Democratic family pattern c. Patriarchal family pattern d. Autocratic family pattern

d. Autocratic family pattern (In the autocratic family pattern the relationships are unequal. The parents attempt to control the children with strict, rigid rules and expectations. This family pattern is least open to outside influence.)

How does an interdisciplinary approach to patient treatment enhance care? a. By shortening hospital stay b. By reducing the number of caregivers c. By improving efficiency of care d. By preventing the fragmentation of care

d. By preventing the fragmentation of care. (An interdisciplinary approach prevents fragmentation of care. An interdisciplinary approach does not improve the efficiency of care, reduce the number of caregivers, or shorten hospital stay.)

What stage of family development involves the grown children departing from home? a. Expectant stage b. Senescence stage c. Establishment stage d. Disengagement stage

d. Disengagement stage

What must the nurse do before applying a safety reminder device? (SRD) a. Get permission from the family b. Explain the SRD to the patient c. Assess patient's skin condition d. Get a health care provider's order

d. Get a health care provider's order (Initially, an order is necessary that specifies the type of SRD and the duration of its application.)

Why is documentation especially significant in managed care? a. Patients might bring lawsuits if care was not given. b. The hospital needs to show that employees care for patients. c. Documents may become part of a lawsuit. d. Institutions are reimbursed only for patient care that is documented.

d. Institutions are reimbursed only for patient care that is documented. ( Cost reimbursement rates by government plans (Medicare, Medicaid) are based on the prospective payment system of diagnosis-related groups(DRGs): a system that classifies patients by age, diagnosis surgical procedure, and other information with hundreds of different categories to predict the use of hospital resources, including length of stay, resulting in a fixed payment amount.)

What does documentation of type of care, time of care, and signature of the person prove? a. No litigation can be brought against the person who signed. b. The patient's response to the intervention was positive. c. The person who signed the documentation did all the work noted. d. Interventions were implemented to meet the patient's needs.

d. Interventions were implemented to meet the patient's needs. (Documenting type of care, time of care and signature of the person results in recording the interventions that are implemented to meet the patient's needs. Many charting entries include health care provider's visits, presence of family, or interventions by other departments. Patient response to some interventions are not always positive.)

What additional complication does a disease caused by a virus have compared to a disease caused by bacteria? a. Multiplies rapidly. b. Returns frequently. c. Is unable to be cultured. d. Is not killed by antibiotics.

d. Is not killed by antibiotics.

How is a durable power of attorney helpful to an incapacitated patient? a. It can only be executed by an attorney. b. It gives power to an agent to make decisions regarding health, property, and other assets. c. It directs treatment in accordance with the patient's wishes. d. It directs an agent to make health care decisions.

d. It directs an agent to make health care decisions.

What is the family pattern in which the female assumes primary dominance in the areas of childcare and homemaking, as well as financial decision making? a. Autocratic family pattern b. Patriarchal family pattern c. Democratic family pattern d. Matriarchal family pattern

d. Matriarchal family pattern

The nurse caring for a patient in the acute care setting assumes responsibility for a patient's care What is this legally binding situation? a. Standard of care b. Advocacy c. Accountability d. Nurse-patient relationship

d. Nurse-patient relationship ( When the nurse assumes responsibility for a patient's care, the nurse-patient relationship is formed. This is a legally binding "contract" for which the nurse must take responsibility. Accountability is being responsible for one's own actions. An advocate is one who defends or pleads a cause or issue on behalf of another. Standards of care define acts whose performance is required, permitted, or prohibited.)

What is the stage of family development that begins at the birth or adoption of the first child? a. Engagement/commitment stage b. Establishment stage c. Expectant stage d. Parenthood stage

d. Parenthood stage

What is the family pattern in which the male usually assumes the dominant role and functions in the work role, controls the finances, and makes most of the decisions? a. Democratic family pattern b. Autocratic family pattern c. Matriarchal family pattern d. Patriarchal family pattern

d. Patriarchal family pattern

A 5-year-old who has an imaginary friend with whom he converses frequently is displaying characteristics consistent with which of Piaget's stages of cognitive development? a. Formal operations stage b. Concrete operations stage c. Operational stage d. Preoperational stage

d. Preoperational stage (Piaget's preoperational stage describes the preschooler as imaginative and egocentric, believing in magical thinking.)

What is the documentation format that uses the acronym SOAPE? a. Traditional b. Focused c. Crisis d. Problem-oriented

d. Problem-oriented (The problem-oriented medical record uses the acronym SOAPE to format and for focus charting on a list of patient problems.)

An older adult is admitted to he hospital with numerous bodily bruises, and they nurse suspects elder abuse. What is the best nursing action? a. Cover the bruises with bandages b. Ask the patient if anyone has hit her c. Take photographs of the bruises d. Report the bruises to the charge nurse

d. Report the bruises to the charge nurse

What is known as the last stage in the life cycle? a. Establishment stage b. Disengagement stage c. Expectant stage d. Senescence stage

d. Senescence stage

The patient in isolation may experience psychological or emotional deprivation. What should the nurse do to help minimize these feelings? a. Protect the patient from additional infection. b. Be cheerful. c. Answer the call light quickly. d. Spend extra time with the patient.

d. Spend extra time with the patient.

What bacteria can lie dormant when conditions for growth are not favorable? a. Capsules b. Residue c. Flagella d. Spores

d. Spores

One reason the nurse focuses on oral hygiene is to maintain a healthy state of the oral cavity. What is another reason to promote oral hygiene? a. To restore tooth destruction b. To improve self-esteem c. To assist with periodontitis d. To stimulate appetite

d. To stimulate appetite

Which question below is open-ended? a. "What are you most looking forward to in Europe?" b. "Are you sailing to Europe?" c. "Have you been to Europe before?" d. "Are you going to Europe this fall?"

a. "What are you most looking forward to in Europe?" (Allows an unlimited answer)

Although the patient denies pain, the nurse observes the patient breathing rapidly with clenched fists and facial grimacing. What is the nurse's best response to these observations? a. "What you are saying and what I am observing don't seem to match." b. "Where do you hurt?" c. "It makes me uncomfortable when you are not honest with me." d. "I am glad you are feeling better and have no discomfort."

a. "What you are saying and what I am observing don't seem to match." (The nonverbal communication should be clarified to prevent miscommunication.)

The nurse assesses a red blister over the right superior iliac area of a patient. What stage is this decubitus injury? a. 2 b. 4 c. 3 d. 1

a. 2

A nurse is observing isolation precautions by wearing a mask while performing complex patient care. How often should the nurse change masks? a. 20 to 30 minutes b. 30 to 40 minutes c. 10 to 20 minutes d. 5 to 10 minutes

a. 20 to 30 minutes

A nurse is caring for a neonate who weighs 7 lb 3 oz at birth. What should the infant's weight be at 1 year? a. 21 lb 9 oz b. 28 lb 12 oz c. 10 lb 3 oz d. 14 lb 6 oz

a. 21 lb 9 oz

What is a nursing program considered when certified by a state agency? a. Approved b. Provisional c. Accredited d. Exemplified

a. Approved (Approved means certified by a state agency for having met minimum standards; accredited means certified by the NLN for have met more complex standards. Provisional and exemplified are not terms used in regard to nursing program certification)

The nurse considers the feelings and needs of a patient by stating, "I know you are concerned about your surgery tomorrow. How can I help you?" What type of communication is this? a. Assertive b. Intrusive c. Closed d. Aggressive

a. Assertive (Assertive communication takes a patient's feelings and needs into account, yet honors the patient's rights as an individual.)

What should the nurse do to protect his or her back when lifting or moving a patient? a. Bending knees and hips b. Lowering the height of the bed c. Holding the back straight with locked knees d. Getting the patient to the side of the bed

a. Bending knees and hips

A nurse assessing a toddler should consider which finding abnormal? a. Cyanotic nail beds b. A protruding abdomen c. A convex lumbar curve d. Lumbar lordosis

a. Cyanotic nail beds (Normal assessment findings in a toddler include lumbar lordosis (convex lumbar curve) and a protruding abdomen. Cyanotic nail beds are an abnormal finding.)

Which is an example of a medical diagnosis? a. Diabetes mellitus b. Impaired skin integrity c. Constipation d. Altered nutrition: less than body requirements

a. Diabetes mellitus (Standing at the bed side with the patient in bed may imply that the nurse has power.)

What is the system that classifies patients by age, diagnosis, surgical procedure, and produces 300 different categories used for predicting the use of hospital resources? a. Diagnosis-related groups b. Quality assurance c. Resource assessment d. Quality improvement

a. Diagnosis-related groups (Cost reimbursement rates under government plans are based on diagnosis-related groups(DRGs), which is a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources, including length of stay.)

The nurse is preparing and Orthodox Jewish patient's tray during passover. What intervention is appropriate for this patient? a. Encourage time for prayer b. Avoid fish dishes c. Offer the patient leavened products. d. Encourage the use of loud music in celebration.

a. Encourage time for prayer (Orthodox Jews say prayers over the bread and wine before meals. Time and a quiet environment should be provided for this. During Passover, no leavened products are eaten.)

The nurse informs a group of college students that young adults will face which challenges in this particular time of life? (Select all that apply.) a. Establishing intimacy b. Job security c. Selecting housing d. Relations with extended family e. Starting a family

a. Establishing intimacy b. Job security c. Selecting housing d. Relations with extended family e. Starting a family (All options are developmental tasks of the young adult of today.)

The nurse is instructing a patient about the most important preventive technique for breaking the chain of infection. What technique is the patient learning about? a. Hand hygiene b. Standard Precautions c. Medical asepsis d. Sterilization

a. Hand hygiene

What is the nurse required to do to adhere to the concept of confidentiality for the patient's medical record? a. Have a clinical reason for reading the record. b. Provide information only to another nurse c. Share information only with the family d. Provide information only to an attorney.

a. Have a clinical reason for reading the record. (The nurse should not read the patient's medical record unless there is a clinical reason for doing so.)

A mother asks the nurse when she should introduce solid foods into her infant's diet. What would be the most correct response? a. Introduce only one new food at a time. b. Mix foods to allow the infant variety. c. Introduce fruits and vegetables first. d. Introduce new foods at 24-hour intervals.

a. Introduce only one new food at a time. (Only one new food should be introduced at a time, followed by several days between new foods. Cereals should be introduced first, followed by fruits and vegetables, and last meats. Food should not be mixed to allow the infant to develop interest in different foods and tastes.)

Which of the following measures would be included in a teaching plan to instruct new parents on reducing the incidence of sudden infant death syndrome? a. Keep an infant's room well ventilated. b. Place soft bedding and pillows in an infant's crib. c. Bottle-feed an infant at night. d. Place infants on their stomach to sleep.

a. Keep an infant's room well ventilated.

What is the site of the most common strain injury acquired by the nurse when working? a. Lumbar muscle group b. Trapezius muscle group c. Thigh muscle group d. Thoracic muscle group

a. Lumbar muscle group

A nurse in considering purchasing malpractice insurance. What should the nurse be aware of regarding Malpractice insurance provided by the hospital? a. Only offers protection while on duty b. Can be terminated at any time c. Is difficult to renew d. is limited in the amount of coverage

a. Only offers protection while on duty

What is the termination of tube feedings to a dying patient considered? a. Passive euthanasia b. Terminal care c. Holistic care d. Active euthanasia

a. Passive euthanasia

What does the nurse use as a basis for documentation in focus charting? a. Patient problems b. Evaluation c. Problem list d. Nursing orders

a. Patient problems (In focus charting, instead of using the problem list, modified patient problems are used as an index for nursing documentation.)

A child who has just begun to demonstrate egocentric thinking is in which of the Piaget's stages of cognitive development? a. Preoperational thought b. Concrete operational thought c. Formal operational thought d. Sensorimotor

a. Preoperational thought (The Piaget's preoperational stage of cognitive development includes the development of egocentric thinking (understanding the world from only one perspective, that of the self).)

What is the best way for a nurse to avoid a lawsuit? a. Provide compassionate, competent care b. Spend time with patient c. Carry malpractice insurance d. Answer all call lights quickly

a. Provide compassionate, competent care.

What assessment does the nurse recognize as an inflammatory response in a surgical wound on the leg of a patient? a. Rubor and edema appear around the wound. b. A foul drainage is coming from the wound. c. The affected leg is cooler than the other leg. d. There are raised, red, pruritic welts on the leg.

a. Rubor and edema appear around the wound.

What is classified as information provided by the family when a patient is unable to provide data during assessment? a. Secondary b. Biased c. Unreliable d. Primary

a. Secondary (secondary sources include family members)

Which of the five aspects of human functioning must a nurse address when dealing with a grieving person? (Select all that apply.) a. Spiritual b. Financial c. Physical d. Intellectual e. Emotional

a. Spiritual c. Physical d. Intellectual e. Emotional

During an admission, the nurse collects objective and subjective data. What is an example of objective data? a. The patient is jaundiced. b. The patient states, "I am nervous." c. The patient complains of palpitations. d. The patient denies dizziness when ambulating.

a. The patient is jaundiced. (Objective data is data that can be observed by the nurse and is measurable.)

During an admission assessment, the nurse collects objective and subjective data. What is an example of objective data? a. The patient is pacing back and forth which chanting b. The patient complains of feeling depressed c. The patient states," I hear voices in my head." d. the patient complains of auditory hallucinations.

a. The patient is pacing back and forth and chanting ( Objective data are observable and measurable signs.)

The health care provider orders a patient to be placed in the reverse Trendelenburg's position. How should the nurse place the bed? a. Tilted with the foot of the bed down b. On the floor c. Parallel with the floor d. Tilted with the head of the bed down

a. Tilted with the foot of the bed down

A patient does not speak English; therefore, the nurse cannot use words to provide comfort during a painful procedure. What is another intervention that may provide comfort to this patient? a. Touch b. Restating c. Listening d. Silence

a. Touch (Holding the hand of a non-English-speaking patient is effective and comforting.)

What type of fire extinguisher should the nurse use when they oxygen concentrator machine malfunctions and causes and electric fire? a. Type C b. Type B c. Type A d. Type D

a. Type C (type C is for electric fires)

How may a newly licensed LPN?LVN practice? a. Under the supervision of a health care provider or RN b. As a sole health care provider in a clinic setting c. With an experienced LPN/LVN d. Independently in a hospital setting

a. Under the supervision of a health care provider or RN (And LPN/LVN practices under the supervision of a health care provider, dentist, OD, or RN)

A nurse instructs a unlicensed assistive personnel about the proper use of a gait belt and is observing a return demonstration. What action by the unlicensed assistive personnel should cause the nurse to intervene? a. Unlicensed assistive personnel is walking on the patient's strong side b. Unlicensed assistive personnel is grasping the handles of the gait belt while the patient ambulates. c. Unlicensed assistive personnel is walking to side of the patient. d. Unlicensed assistive personnel is securing the gait belt securely around the patient's waist.

a. Unlicensed assistive personnel is walking on the patient's strong side (A gait belt should be securely applied around the patient's waist. It has handles attached for the nurse to grasp while the patient ambulates. The nurse should walk on the patient ambulates. The nurse should walk on the patient's weaker side so that assistance may be given in the patient starts to fall.)

A young nurse caring for a dying patient hastens through the care and leaves the room as quickly as possible. What common reaction to the care of the dying is the nurse exhibiting? a. Withdrawal b. Anger c. Efficiency d. Anxiety

a. Withdrawal

The nurse is assisting a patient to clarify values by encouraging the expression of feelings and thoughts related to the situation. What is the most appropriate action for the nurse? a. Withhold an opinion b. Give advice c. Compare values with those of the patient d. Make a judgment

a. Withhold an opinion (The nurse can assist the patient in values clarification without giving an opinion.)

What is the stage of family development that begins when the couple acknowledges that they are considering marriage? a. Engagement/commitment stage b. Parenthood stage c. Expectant stage d. Establishment stage

a.Engagement/commitment stage

The nurse recognizes that during the first 5 months of life, an infant is expected to gain approximately how many pounds per month? a. 2 b. 1.5 c. 0.5 d. 1

b. 1.5

What should the water temperature be when preparing a tepid bath for a patient? a. 100.2°F (37.8°C) b. 98.6°F (37°C) c. 110.4°F (43.5°C) d. 104.8°F (40.4°C)

b. 98.6°F (37°C)

What organized approach might the nurse use when performing a complete physical examination? a. Maslow's hierarchy of needs b. A head-to-toe assessment c. Objective data collection d. Subjective data collection

b. A head-to-toe assessment. (A head-to-toe format provides a systematic approach.)

The nurse is sitting in a chair near the patient's bed, leaning forward to hear what the patient is saying, and does not interrupt. What is the nurse demonstrating? a. interest b. Active listening c. Caring d. Support

b. Active listening (When demonstrating active listening, the nurse must give his or her full attention and make an effort to understand both the verbal and nonverbal message.)

What role is the nurse who diligently works for the protection of patients' interest playing? a. Caregiver b. Advocate c. Health care administrator d. Health care evaluator

b. Advocate (A nurse accept the role of advocate when, in addition to general care, the nurse protects the patient's interest. Caregiver, health care administrator, and health care evaluator are not terms for the nurse who diligently works for the protection of patients.)

The nurse is transporting a patient in respiratory isolation to the radiology department. What intervention should the nurse implement? a. Cover the patient with a sheet. b. Apply a mask to the patient. c. Call x-ray to come and get the patient. d. Take the patient down the service elevator.

b. Apply a mask to the patient.

What should the nurse do before approaching a grieving family member? a. Offer sympathy b. Assess level of resolution c. Encourage the family member to return to normal activities d. Give assurance that the pain will pass

b. Assess level of resolution (The nurse should assess each aspect of grieving to fully understand where family members are in their grief in order to offer the most effective assistance.)

What organization, established during World War 2, provided nursing education and training? a. Public health department b. Cadet Nurse Corps c. Frontier Nursing Service d. Nightingale school

b. Cadet Nurse Corps

The nurse spends a great deal of time in the room of a dying 12-year-old because the nurse knows that most children are aware of their condition and want the nurse to do which of the following? a. Keep them clean. b. Care about them. c. Keep them comfortable. d. Help them eat.

b. Care about them. (Children, like adults, fear abandonment as death approaches and gain comfort from the presence of the nurse.)

Where should the nurse place the load when carrying heavy objects? a. With another's assistance b. Close to the body midline c. In a low position d. To the side of the body

b. Close to the body midline

When a nurse protects the information in a patient's record , what ethical responsibility is the nurse fulfilling? a. Absolute secrecy b. Confidentiality c. Disclosure d. Privacy

b. Confidentiality ( The nurse has an ethical and legal duty to protect information about a patient and preserve confidentiality. Some disclosures are legal and anticipated, and may not be subject to the rules of confidentiality. None of the information in a chart is considered a secret.)

When a nurse informs a patient's spouse that the patient has died, the spouse states, "You must be mistaken." Which of Kübler-Ross's stages of dying is the spouse demonstrating? a. Depression b. Denial c. Anger d. Bargaining

b. Denial

Separation anxiety includes which stages? (Select all that apply.) a. Anger b. Despair c. Protest d. Detachment e. Withdrawal

b. Despair c. Protest d. Detachment

The nurse is preparing to perform perineal care for the female patient. What is the best method for using a bath blanket to drape the patient? a. Rectangular position b. Diamond position c. Square position d. Long position

b. Diamond position

What will the nurse implement when an error is made when documenting in a patient's chart? a. Erase the error completely b. Draw a single line through the error c. Apply correction fluid d. Scratch out the error

b. Draw a single line through the error ( A nurse should not erase, apply correction fluid, or scratch out errors made while recording in a patient's chart. Instead, the nurse should draw a single line through the error , write the word "error" above it, and sign her name or initials.)

What is a fixed concept of how all members of an ethnic group act or think? a. Holistic nursing b. Ethnic stereotypes c. Identical practices d. Variations within a cultural group

b. Ethnic stereotypes (Ethnic stereotypes are fixed concepts of how all members of an ethnic group act or think.)

According to Piaget, what is the cognitive developmental level of the adolescent? a. Concrete operational stage b. Formal operational stage c. Preoperational stage d. Sensorimotor stage

b. Formal operational stage

Clear water is used to cleanse the eyes. It is important to use proper technique when cleansing the eyes to prevent infection. What direction will the water flow when cleansing a patient's eyes? a. Upward toward the forehead b. From the inner toward the outer canthus c. Downward toward the chin d. From the outer toward the inner canthus

b. From the inner toward the outer canthus (the eye is cleansed from the inner to outer canthus.)

In in response to the patient statement, "I am upset about all this lab work" the nurse responds, "You're upset?" What is this an example of? a. Paraphrasing b. Restating c. Reflecting d. An open-ended question

b. Restating ( Restating is one of the most effective methods of therapeutic communication to encourage the patient to offer more information.)

A nurse frequently looks at her watch when giving a patient a bed bath. What message is most likely conveyed to the patient from the nurse? a. She desires to spend more time with a patient. b. She is feeling hurried. c.She likes her watch d. She is anxious to listen to the patient's concerns.

b. She is feeling hurried (Frequently looking as one's watch while interacting with a patient conveys to the patient that the nurse is in a hurry and really has no desire to spend time with him or her.)

Which of the following must the nurse recognize regarding the health care deliver system? a. Insurance companies are not involved b. The major goal is to achieve optimal levels of health care. c. It includes all states d. It affects the illness of patients.

b. The major goal is to achieve optimal levels of health care. (The nurse must recognize that in a health care delivery system, the major goal is to achieve optimal levels of health care. The health care system consists of a network of agencies, facilities, and providers involved with health care in a specified geographic area. Insurance companies do have involvement in the health care system. The illness of patients in not necessarily affected by the health care system.)

The nurse is performing passive range of motion (ROM) for the patient. How will the nurse move the joint through ROM? a. Relax the patient. b. The point of pain. c. The fullest extent. d. Place the joint in normal position.

b. The point of pain.

A nurse instructs a unlicensed assistive personnel about moving older adult patients in bed. When should the nurse intervene when observing the unlicensed assistive personnel perform a return demonstration? a. The unlicensed assistive personnel is using simple language. b. The unlicensed assistive personnel is pulling the patient across bed linens. c. The unlicensed assistive personnel is avoiding sudden movements. d. The unlicensed assistive personnel is avoiding jerky movements.

b. The unlicensed assistive personnel is pulling the patient across bed linens.

The nurse is instructing a bioterrorism class regarding anthrax. How can anthrax be transmitted? a. By exposure to animals that have anthrax b. Through inhalation of the spores c. Through microscopic skin punctures d. From person to person

b. Through inhalation of the spores (Anthrax is contracted by inhaling the spores.)

Culture varies from patient to patient. Why is it important that the nurse understand and accept each person as an individual? a. To develop a plan of care b. To provide holistic care c. To support each patient d. To identify differences

b. To provide holistic care (Accepting each person as an individual is the first step in providing holistic care.)

What implementation might the nurse use to improve safety during a transfer? a. Weighing the patient first b. Using a transfer belt c. Putting shoes on the patient d. Supporting a flaccid arm

b. Using a transfer belt

Which nursing intervention is complete and correct? a. "Unlicensed assistive personnel will serve 8oz glass of juice at each meal, 5/10." b. "May 10: Unlicensed assistive personnel will ambulate patient. A. Nurse" c. "Day nurse will cleanse wound and change dressings everyday. May 10, A. Nurse" d. "P.M. nurse will ensure that heel protectors are in place before bedtime."

c. "Day nurse will cleanse wound and change dressings every day. May 10, A. Nurse" (Nursing orders must be signed, dated, and have specific designation as to who will perform intervention and specifics about time or frequency of the intervention.)

A nurse is caring for a patient who is experiencing excruciating pain and requires frequent administration on analgesics. What statement would be an example of the nurse demonstrating aggressive communication? a. "Please let me know when you start to have pain." b. "Let's try repositioning you." c. "I will only medicate you every 4 hours." d. Let's practice some guided imagery."

c. "I will only medicate you every 4 hours." (Aggressive communication is when a person interacts with another in an overpowering and forceful manner to meet his or her own personal needs at the expense of the other. By Only medicating a patient every 4 hours for excruciating pain, the nurse meets his or her own needs at the expense of the patient.)

When a mother asks the nurse about introducing solid foods into the child's diet, which of the following would be the best answer? a. "Introduce solid foods by adding strained food to the infant's bottle." b. "Introduce meat first." c. "Introduce one solid food at a time several days apart." d. "Introduce solid foods by mixing two or three foods together."

c. "Introduce one solid food at a time several days apart." (The best advice is to introduce one solid at a time, allowing several days between. Cereals should be introduced first, followed by fruits and vegetables. Meats should be introduced last. Avoid mixing foods to allow the infant to develop an interest in different tastes. Strained foods should not be added to a bottle.)

The nurse explains that the purpose of a sitz bath is to reduce inflammation in the perineal and anal area. What is the least amount of time the nurse will instruct for a sitz bath? a. 30 to 40 minutes b. 10 to 15 minutes c. 20 to 30 minutes d. 1 hour

c. 20 to 30 minutes

A newborn baby weighs 7 lb at birth. What does the nurse anticipate the baby's weight will be at 1 year of age? a. 14 lb b. 25 lb c. 21 lb d. 17 lb

c. 21 lb (By 1 year, birth weight is expected to triple. Thus, the weight at 1 year would be 7 lb times three, which would equal 21 lb.)

The 125-lb nurse is preparing to lift a heavy object. What is the maximum amount of weight considered safe for the nurse to lift? a. 75 lb b. 125 lb c. 50 lb d. 100 lb

c. 50 lb

All of the following patients have been admitted to the acute care setting. On admission, which patient should receive a focused assessment? a. 40-year-old admitted for possible bowel obstruction. b. 76-year-old admitted for a knee replacement. c. 53-year-old admitted with a perforated ulcer d. 5-year-old admitted for the implant of grommets in the middle ear.

c. 53-year-old admitted with a perforated ulcer. (A patient with a perforated ulcer is considered to be critically ill. Therefore, this patient should receive a focused assessment. The remaining options are not considered critical illness.)

The mother of a 5-month-old child is concerned because the child cannot sit by himself. The nurse explains that sitting alone is not expected until the baby reaches what age? a. 6 months b. 9 months c. 7 months d. 8 months

c. 7 months

Which theory of aging suggests that the older person who is more socially active is more likely to adjust well to aging? a. Wear-and-tear theory b. Autoimmunity theory c. Activity theory d. Disengagement theory

c. Activity theory

The home health nurse assesses that the goal of grief resolution has been accomplished when the nurse observes that a widow has performed which activities? (Select all that apply.) a. Put financial affairs in order. b. Acquired a job. c. Adjusted to an environment without the spouse. d. Made plans for a lengthy trip. e. Sought new relationships.

c. Adjusted to an environment without the spouse. e. Sought new relationships.

How should the nurse assist the patient with moving when pain is anticipated? a. Apply heat before moving them. b. Be supportive. c. Administer medication before ambulation. d. Obtain assistance if the patient is heavy.

c. Administer medication before ambulation.

The emergency department nurse is assessing a puncture wound of the foot. What is the most likely type of infection in this wound? a. Aerobic bacterial infection b. Fungal infection c. Anaerobic bacterial infection d. Viral infection

c. Anaerobic bacterial infection (An anaerobic bacterial infection is one that grows in an oxygenated environment.)

What contribution did Joseph Lister introduce to medical practice? a. Isolation of infected patients b. Iodine and alcohol use as disinfectants c. Aseptic technique d. The autoclave

c. Aseptic technique

How frequently should the nurse clean the nares of patients who have a nasogastric tube or are receiving oxygen by nasal cannula? a. At least every 6 hours b. At least every 10 hours c. At least every 8 hours d. At least every 2 hours

c. At least every 8 hours

What premise is maslow's hierarchy of needs based on? a.Self-actualization is a primary need b. All needs are equally important c. Basic needs must be met before the next level of needs can be met d. Individuals prioritize needs the same way

c. Basic needs must be met before the next level of needs can be met (Maslow's hierarchy of needs is based on the premise that basic needs must be met first. It is not based on all needs being equally important or that individuals prioritize needs the same way. Self-actualization is not a primary need according to Maslow.)

What theory claims that there is a hereditary basis for aging? a. Disengagement theory b. Physiologic theory c. Biological programming theory d. Activity theory

c. Biological programming theory

What basic philosophy in the US is relevant to health care? a. Holistic therapy b. Spiritual intervention c. Biomedical therapy d. Folk remedies

c. Biomedical therapy (Most people in the US believe biomedical therapy is the best way to treat disease.)

A 14-year-old male patient has undergone a leg amputation. What should be the primary focus of the patient's care plan? a. Academic progress b. Socialization needs c. Body image d. Nutritional status

c. Body image

The nurse tells a mother that the blueprint for all inherited traits, such as height, is found in which of the following? a. Ovary b. Sperm c. Chromosomes d. Nucleus of the cell

c. Chromosomes

Upon being told of her father's death, the daughter cries out, "No! Oh, God, no!" What stage of grief is the daughter in? a. Anger b. Prayer c. Denial d. Bargaining

c. Denial

What score does the graduate practical nurse require to be issued a license upon completion of the computerized examination? a. This is defined and set by each state b. Within the 75th percentile c. Designated as "pass" d. 70% or better

c. Designated as "Pass" (Pass or Fail)

What makes home health care documentation unique? a. The health care provider's office needs separate charting. b. The health care provider is the pivotal person in the charting. c. Different health care providers need access. d. Some charting is retained at the hospital.

c. Different health care providers need access. (Home health care documentation has unique problems because of the need for different health care workers to access the medical record.)

Which theory of aging suggests that there should be a natural withdrawal between the individual and society? a. Wear-and-tear theory b. Autoimmunity theory c. Disengagement theory d. Free radical theory

c. Disengagement theory

What technique should the nurse use when disposing of linens contaminated with feces? a. Double-bag the sheets b. Don gown, gloves, and mask c. Don gloves only d. Wash hands for 5 minutes after disposal

c. Don gloves only

What is the stage of family development that extends from the wedding until the birth of the first child? a. Engagement/commitment stage b. Expectant stage c. Establishment stage d. Parenthood stage

c. Establishment stage

A nurse examines whether patient interventions have been appropriate and expected outcome have been met. The nurse is demonstrating which step in the nursing process? a. Assessment b. Implementation c. Evaluation d. Planning

c. Evaluation (A nurse evaluates the effectiveness of interventions based on the patient's ability to meet established goals and outcomes.)

When assessing the home for fall risks and increased safety for an 85-year-old, what should be a suggestion of the home health nurse? a. Sponge baths be taken rather than showers. b. Bright lights be kept on at all times. c. Excess furniture be removed. d. Loose, comfortable shoes be worn.

c. Excess furniture be removed. (Clearing the home of excess furniture and scatter rugs, the use of night-lights, and wearing supportive shoes reduce the risk of falls in older adults. It is not necessary to keep bright lights on at all times. It is not necessary to avoid showers.)

Which health belief system is commonly referred to as "third-world" beliefs and practices? a. Alternative/complementary belief system b. Holistic health belief system c. Folk health belief system d. Biomedical health belief system

c. Folk health belief system (The fold health belief system is commonly referred to as "third-world" beliefs and practices. It is often called strange or weird by nurses and other health professionals who are unfamiliar with fold medicine beliefs.)

A child who is able to use a systematic, scientific problem-solving approach is in which of the Piaget's stages of cognitive development? a. Sensorimotor b. Concrete operational thought c. Formal operational thought d. Preoperational thought

c. Formal operational thought

What should the nurse be diligent in to provide a safe environment for the patient? a. Changing the bed linen to diminish microorganisms b. Regulating the temperature to avoid drafts c. Hand hygiene between patient contacts d. Keeping a light on at night to prevent falls

c. Hand hygiene between patient contacts (One of the most important actions is hand hygiene before caring for another patient.)

Which health belief system focuses on restoring balance with physical, social, and metaphysical worlds? a. Alternative/complementary belief system b. Biomedical health belief system c. Holistic health belief system d. Folk health belief system

c. Holistic health belief system (The treatment based on the holistic health belief system is designed to restore balance with physical, social, and metaphysical worlds.)

What is an example of a patient problem? a. Pneumonia b. Diabetes mellitus c. Impaired skin integrity d. Congestive heart failure

c. Impaired skin integrity (All of the other options are medical diagnosis)

What are categories of inadequate documentation that may lead to a malpractice claim. (Select all that apply.) a. Failing to record verbal orders b. Marking out and initialing charting errors. c. Incorrectly recording the time of an event d. Documenting an incorrect date e. Charting events in advance

A,C,D,E (Marking out with a single line and initialing is an acceptable method to indicate a charting error.)

During a lunch break, an emergency department (ED) nurse truthfully tells another nurse about the condition of a patient who came to the ED last night. What is the ED nurse guilty of? (select all that apply) a. HIPAA violation b. Defamation c. Libel d. Invasion of privacy e. Slander

A,D (The disclosure is an invasion of privacy and a violation of HIPAA. Because the information is true and verbal, it cannot be considered slander or libel.)

A newly hired group of graduate practical/vocational nurses are attending orientation at a long-term care facility. What information will be included regarding considerations of mobility and the older adult? (Select all that apply.) a. Older adults sometimes become fearful when hydraulic lifts are used for transfers. b. Weakness and hypertension are common signs and symptoms noted in an older adult on bed rest. c. Always support older adults under the soft tissue when moving them in bed. d. Aging tends to result in loss of flexibility and joint mobility. e. The skin of older adults is more fragile and susceptible to injury.

A,E,D

The nurse receives a patient from the recovery room following total hip replacement surgery. What will the nurse include when assessing neurovascular status on this patient? (Select all that apply.) a. Pupils b. Color c. Sensation d. Skin temperature e. Pain

B,C,D,E

Which are acceptable secondary sources for data? (select all that apply) a. Patient b. Other health professionals c. Textbooks d. Diagnostic reports e. Family members

B,C,D,E (A patient is not a secondary source. The patient is the primary data source.)

The nurse is preparing to make an occupied bed. What procedure will the nurse follow to correctly complete this task? (Select all that apply.) a. Place soiled sheet at end of bed. b. Slide mattress to bottom of bed. c. Place bath blanket over patient on top sheet. d. Remove spread and blanket separately. e. Position patient to far side of bed.

C,D,E

Which is a nursing care error that violate the Health Insurance Portability and Accountability Act (HIPAA)? a. Refusing to give a patient's daughter information over the phone b. Informing the patient's medical power of attorney of medication change c. Leaving a copy of the patient's history and physical in the photocopier d. Administering a stronger dose of drug than was ordered

c. Leaving a copy of the patient's history and physical in the photocopier (Leaving the document in the photocopier could expose it to the public. Inappropriate drug administration is possible malpractice. Sharing information with the power of attorney is legal. Refusing to give a patient's information over the phone is appropriate practice.)

When using electronic(or computerized) documentation, which process should the nurse use to ensure that no one alters the information the nurse has entered? a. Charting in code b. Charting in privacy c. Logging off d. Signing on with a password

c. Logging off (Logging off closes the computer file that was opened with the nurse's password. Any other data entry will require that person to sign on with their password.)

A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient's indwelling urinary catheter but forgets to unclamp it. The patient develops a urinary tract infection. What do the nurse's actions exemplify? a. Battery b. Assault c. Malpractice d. Neglect of duty

c. Malpractice

A nurse fails to irrigate a feeding tube as ordered, resulting in harm to the patient. This nurse could be found guilty of: a. Negligence b. Harm to the patient c. Malpractice d. Failure to follow the nurse practice act

c. Malpractice (The nurse can be held liable for malpractice for acts of omission.)

A patient states, "My husband had told me how he feels about my having a mastectomy." The nurse nods and says, "Go on." This is an example of: a. Restating b. Clarifying c. Minimal encouraging d. Focusing

c. Minimal encouraging (The nurse uses minimal encouragement to lead the patient to provide more information.)

An LPN/LVN is asked by the RN to administer an IV chemotherapeutic agent to a patient in the acute care setting. What law should this nurse refer to before initiating this intervention? a. American Nurses' Association Code b. Standards of care c. Nurse practice Act d. Regulation of practice

c. Nurse practice Act ( It is the nurse's responsibility to know the nurse practice act in his or her state. Standards of care, regulation of practice, and the American Nurses' code are not laws that the nurse should refer to before initiating this treatment.)

What is the basis for designing and selecting nursing interventions to meet patient needs? a. Care Plan b. Nurse's notes c. Patient problem d. Health care provider's orders

c. Patient problem (The patient problem is the basis for developing nursing interventions.)

What is the title of the American Hospital Association's 1972 document that outlines the patient's expectations to be treated with dignity and compassion.? a. Code of Ethics b. OBRA c. Patient's Bill of Rights d. Advance directives

c. Patient's Bill of Rights (Patient expectations are outlined by the Patient's Bill of Rights. Patient expectations are not outlined in the Code of Ethics, OBRA, or advance directives.)

What is the process used to appraise the practice of an individual nurse known for? a. OBRA b. Incident reporting c. Peer review d. Quality assurance

c. Peer review (Peer review is an in-house department study that may appraise the nursing practice of individual nurses.)

The emergency department nurse admits a victim of poisoning. Who should the nurse call the receive the best assistance for dealing with this victim? a. Fire department paramedics b. American Red cross c. Poison control center d. Civil defense office

c. Poison control center

A nurse is standing at the bedside with the patient lying in bed. What can the nurse be construed as demonstrating? a. Caring b. Interest c. Power d. Support

c. Power (Standing at the bedside with the patient in bed may imply that the nurse has power.)

Recognizing the stages of an infection assists the nurse in identifying the progression of an infection. What is the nonspecific to specific symptom stage of an infection? a. Incubation b. Convalescent c. Prodromal d. Illness

c. Prodromal

What type of organism causes malaria? a. Bacterium b. Fungus c. Protozoan d. Virus

c. Protozoan (Malaria is caused by the introduction of protozoa from the bite of a mosquito.)

The nurse is delivering a meal tray to a female Muslim patient. What intervention is most appropriate for this patient? a. Offering her bacon and eggs b. Offering her a ham and cheese sandwich c. Providing her with a female nurse d. Providing her with a male nurse.

c. Providing her with a female nurse. (When caring for Muslims, same-sex health care providers should be used if at all possible. Ham and bacon are not appropriate items to offer a Muslim patient, since they do not consume pork products.)

A patient is recovering from a hemorrhoidectomy and experiences dizziness within 5 minutes when taking a sitz bath. What action should the nurse implement? a. Stay with the patient until the full time for the bath has elapsed. b. Assess vital signs every 5 minutes during the remainder of the sitz bath. c. Remove the patient from the sitz bath and return to bed. d. Cover the patient to prevent chilling.

c. Remove the patient from the sitz bath and return to bed.

A nurse is caring for a patient who is a Latter-Day Saint. The nurse is aware members of this faith may wear sacred undergarments. What intervention is appropriate for the nurse caring for this patient? a. Instruct the patient to remove the undergarments. b. Allow the patient to wear the undergarments only during the day. c. Remove the undergarments in emergency situations only. d. Allow the patient to wear the undergarments only at night.

c. Remove the undergarments in emergency situations only. (For observant Latter-Day Saints a sacred undergarment may be worn at all time and should be removed only in emergency situations.)

What fundamental principle must the nurse first observe when confronted with an ethical decision? a. Nonmaleficence b. Autonomy c. Respect for people d. Beneficence

c. Respect for people (The first fundamental principle is respect for people. Autonomy, beneficence, and nonmaleficence are not the first fundamental principles to observe when confronted with an ethical decision.)

What therapeutic communication technique requires a great deal of skill and is not used as frequently as other communication techniques? a. Summarizing b. Touch c. Silence d. Listening

c. Silence ( Silence is an extremely effective therapeutic communication skill that is frequently underused because the nurse feels uncomfortable applying it.)

What is the most dependable and practical method to use when sterilizing instruments for the operating room? a. Chemical solution b. Boiling water c. Steam under pressure d. Dry heat

c. Steam under pressure (Steam under pressure is the most practical and dependable method for destruction of all microorganisms.)

What is the term for a generalization about a form of behavior, an individual, or a group? a. Dialect b. Religion c. Stereotype d. Ethnicity

c. Stereotype (A stereotype is a generalization about a form of behavior, an individual, or a group.)

The infection control officer is observing hospital staff for appropriate use of aseptic technique. What observation demonstrates the need for more instruction on surgical asepsis? a. Facing the sterile field b. Placing a sterile dressing on a sterile field c. Touching the edges of the sterile field with sterile gloves d. Keeping gloved hands above the waist

c. Touching the edges of the sterile field with sterile gloves

The nurse is caring for a Muslim patient. What dietary selection should the nurse serve to this patient? a. Ham and cheese sandwich b. Pork and fried rice c. Bacon, eggs, and toast d. Chicken and rice

d. Chicken and rice (Muslims practice avoidance of foods that include pork products. Bacon, pork, and ham are all pork products. Only the chicken and rice meal does not include a pork product.)

A lumbar puncture was performed on a patient without a signed informed consent form. This patient might sue for: a. Punitive damages b. Nothing; no violation has occurred c. Assault d. Civil battery

d. Civil battery (Civil battery charges can be brought against someone performing and invasive procedure without the patient's informed consent legally documented.)

A nurse assesses an area of sustained redness on the coccyx area of a resident in long-term care. What is the most likely cause of this pressure area? a. Collapse of skin tissue b. Heat from pressure c. Friction from pressure d. Collapse of blood vessels

d. Collapse of blood vessels (A pressure injury occurs when there is sufficient pressure to collapse the blood vessels.)

Which theory of aging suggests that previously developed coping abilities and the ability to maintain previous roles and activities are critical to adjustment to old age? a. Wear-and-tear theory b. Autoimmunity theory c. Disengagement theory d. Continuity theory

d. Continuity theory

During a physical examination, the nurse discovers that the patient demonstrates signs of flushed, dry, hot skin; dry oral mucous membranes; and temperature elevation. The nurse should treat this data as the basis of a patient problem plan. What does this data represent? a. Urinary retention b. Symptoms c. Signs of fluid overload d. Data clustering

d. Data clustering (The nurse organizes data, and those that are related are referred to as clustering.)

When asked to perform a procedure that the nurse has never done before, what should the nurse do to legally protect himself or herself? a. Asked another nurse who has performed the procedure. b. Refuse to perform it, citing lack of knowledge. c. Go ahead and do it d. Discuss it with the charge nurse, asking for direction.

d. Discuss it with the charge nurse, asking for direction (The nurse cannot use ignorance as an excuse for nonperformance. The nurse should ask for direction from the charge nurse, explaining she has never performed the procedure independently.)

What is an important consideration when developing a care plan? a. Ensure interventions will be easy to implement b. Ensure the number of interventions is limited c. Ensure evaluation of the patient problems is possible d. Ensure the patient is involved in the process.

d. Ensure the patient is involved in the process (Plans are more effective when the patient is involved in the process. The care plan is not limited in terms of the number of interventions, nore do they have to be easy. The patient problems are not evaluated; the patient's progress toward the outcome is)

What type of assessment is performed continuously throughout nurse-patient contact? a. Subjective b. Body systems c. Complete d. Focused

d. Focused (Focused assessments are performed continuously throughout nurse-patient contact based on the nursing care plan.)

A nurse assessing a 4-month-old infant would expect the infant to do which of the following? a. Walk upright with a waddling gait. b. Creep on the floor at least 30 ft. c. Crawl up the stairs. d. Hold head at a 90-degree angle while prone.

d. Hold head at a 90-degree angle while prone.

How will the nurse correctly replace a patient's dentures after cleaning? a. Inserting both dentures together b. Inserting the lower denture first c. Asking the patient to insert them d. Inserting the upper denture first

d. Inserting the upper denture first

Who is the legal owner of the patient's medical record? a. Patient b. Health care provider c. State d. Institution

d. Institution (Ownership of a medical record belongs to the institution in the case of a hospitalized patient, or the health care provider in the case of private office visits.)

What would be the best method for a literate, English-speaking patient on a ventilator to communicate his or her needs? a. Computer b. Eye blinking for "yes" and "no" c. Message boards or cards d. Magic slate or paper and pencil

d. Magic slate or paper and pencil (Writing devices are preferred as they do not limit the patient's messages compared to a message board or cards. Eye blinks are tiring and time-consuming. Computers require space and the ability to type.)

How may a nurse caring for a pediatric patient best be perceived as nonthreatening? a. Standing at the bedside b. Maintaining a tense posture c. Tightly crossing her arms d. Maintaining an open posture

d. Maintaining an open posture (standing at the beside looking down at the patient in the bed places the nurse in a position of authority and control. The patient is likely to experience this as intimidating and condescending. Whenever possible, the nurse should be level with the patient; this is especially important with pediatric patients. Sitting at the bedside in a relaxed and open posture is one example.)

What is the term used to describe cultures in which women make the decisions about health care and provide the care and discipline to the children? a. Biological b. Cultural c. Patriarchal d. Matriarchal

d. Matriarchal (In a matriarchal society, women make the decisions about health care. In patriarchal society, the men make decisions about health care. There is no such thing as biological or cultural cultures.)

What is a method used to kill all microorganisms, including spores? a. Using an antiseptic b. Using chlorine bleach c. Disinfecting d. Sterilizing

d. Sterilizing (Sterilization refers to methods used to kill all microorganisms and spores.)

What is true about nurse practice acts? a. Only some states have adopted a nurse practice act. b. They provide for unlimited scope of nursing practice. c. They informally define the scope of nursing practice d. The nurse must know the nurse practice act within his or her state

d. The nurse must know the nurse practice act within his or her own state. (Specifics they contain often vary between states)

During an admission assessment, the nurse collects objective and subjective data. what is an example of objective data? a. The patient complains of felling faint. b. The patient states, "I feel nauseous." c. The patient complains of chest pain. d. The patient is short of breath on exertion.

d. The patient is short of breath on exertion. (Objective data are observable and measurable signs.)

What is the purpose of a QA(quality assurance)? a. To screen employment applications b. To conduct in-services for "quality documentation" c. To report deviation from standards to the state health department. d. To evaluate care results against accepted standards.

d. To evaluate care results against accepted standards. (QA is an in-house department that evaluates care services and results against accepted standards.)

The nurse is caring for a patient with a do-not-resuscitate (DNR)order. Although the nurse may disagree with this order, what is his or her legal obligation? a. To question the health care provider b. To discuss it with the patient c. To seek advice from the family d. To follow the order

d. To follow the order (When a DNR order is written in the chart, the nurse has a duty to follow the order. Questioning the health care provider, seeking advice from the family, and discussing it with the patient are not legal obligations of the nurse.)

How can the nurse demonstrate warmth and acceptance when listening to a patient? a. Tightly crossing her arms b. Facing away from the patient c. Tightly crossing her legs d. Uncrossing her arms

d. Uncrossing her arms (The way that an individual sits, stands, and moves is called posture. Posture has the potential to convey warmth and acceptance, or distance and disinterest. An open posture is demonstrated with a relaxed stance with uncrossed arms and legs while facing the other individual. A slight shift in body position toward an individual, a smile, and direct eye contact caring. Closed posture is a more formal, distant stance, person will often interpret closed posture as disinterest, coldness, and even nonacceptance.)

The nurse is caring for an African-American patient. Who would the nurse expect to be the primary decision make in the patient's family? a. Grandparents b. Clergy c. Men d. Women

d. Women (when caring for African-Americans, women are primarily the decision makers in the family and are frequently the head of the household.)

What is true about the use of silence in therapeutic communication? (Select all that apply.) a. The ability to use silence effectively requires skill and timing. b. The sender often becomes uncomfortable when using silence. c. Purposeful use of silence often conveys lack of respect. d. Maintaining silence is generally overused in therapeutic communication. e. Maintaining silence is an effective therapeutic communication technique. f. Prolonged periods of misunderstood silence can cause tension.

A, B, E, F ( Maintaining silence is an extremely effective therapeutic communication technique, and yet tends to be quite underused. Because silence often feels awkward in American society, people tend to feel the need to "fill" it. This impulse does not always allow the people involved in an interaction time to organize their thoughts sufficiently to communicate what they would like. It is common for a person to need several seconds after hearing a verbal message to interpret what has been stated and to formulate the most appropriate response. Unfortunately, the receiver often does not get the amount of time before a response is necessary. In many cases, the sender becomes uncomfortable with the silence and begins speaking again before the receiver has had an opportunity to formulate a response and is really ready to deliver it. The ability to use silence effectively requires skill and timing. It is easy for prolonged periods of misunderstood silence to cause uneasiness and tension. However, in many cases, purposeful use of silence conveys respect, understanding, caring, and support, and it is often used in conjunction with therapeutic touch.)

A nurse working in a long-term care facility is admitting an 85-year-old resident of Hispanic descent diagnosed with Alzheimer's disease. What should this nurse take into consideration when caring for the resident?(Select all that apply) a. Home remedies may have value even if harmful. b. Cultural background has an important role in determining the resident's status. c. The resident will have a strong sense of trust for health care workers. d. Communication should involve gesturing whenever possible e. The resident will be culturally sensitive to caregivers.

A,B (Cultural background has an impact on family dynamics and plays an important role in determining the role and status of the older person. Some older adults are less tolerant of other cultures as a result of influences or experiences early in their lives, which raises the possibility of misunderstandings and distrust when the caregiver is of a cultural group different than that of the older person. Communication should suit the individual needs of the resident and does not necessarily involve gesturing.)

A person can spread a bacterial infection by which actions? (Select all that apply.) a. Leaving used tissue on the lavatory b. Kissing others c. Sneezing at work d. Coming in contact with blood products e. Donating blood

A,B,C

What should the culturally sensitive nurse do for a muslim woman being treated in the hospital? (select all that apply) a. Assign only female staff to care for her b. Keep her head and extremities covered as much as possible c. Allow privacy for prayer d. Let her make decisions relative to her care e. Arrange for family to bring specially prepared pork dishes.

A,B,C (Muslim women are not accustomed to making decisions, leaving it to the head of the house or the family as a whole. Muslims do not eat pork.

How can the medical record be used in litigation(select all that apply) a. Proof of adherence to standards b. Evidence of omission of care c. Public record d. Documentation of time lapses e. Evidence by only the plaintiff

A,B,C,D

Which are considered phases of the nursing process? (select all that apply.) a. Assessment b. Implementation c. Evaluation d. Outcome identification e. Prediction f. Diagnosis

A,B,C,D,F ( The nursing process consists of six dynamic and interrelated phases: diagnosis, assessment, outcome identification, planning, implementation, and evaluation. Prediction is not a phase of the nursing process.)

What are some characteristics of microorganisms? (Select all that apply.) a. May be infectious. b. Pathogens that cause disease. c. Involved in a life process of their own. d. Nonpathologic organisms that cause disease. e. Can enter the body via skin, air, or blood.

A,B,C,E (Microorganisms are involved in a life process of their own, pathogens cause disease, may be infectious, and can enter the body via skin, air, or blood. Nonpathologic organisms do not cause disease.)

Which are true regarding communicating while using eye contact? (Select all that apply.) a. Extended eye contact can imply aggression. b. Extended eye contact can lead to heightened anxiety. c. Eye contact is responsible for much miscommunication. d. Eye contact always results in a positive outcome. e. Making eye contact generally indicated an interact. f. Eye contact is responsible for much communication.

A,B,C,E,F (Eye contact is responsible for much communication and much miscommunication. Generally, making eye contact communicates an intention to interact. However, the nature of the interaction and the results of eye contact are not necessarily always positive. Extended eye contact sometimes implies aggression and arouses anxiety.)

What are some characteristics that cultures have in common?(select all that apply) a. Economic practices b. Survival modes c. Language d. Transportation systems e. Family systems

A,B,D,E (Language may differ within cultures; the rest are shared characteristics )

The nurse assesses a patient in a Posey safety reminder device (SRD) for which problem that may increase because of the use of SRDs? (select all that apply) a. Immobility b. Risk for impaired circulation c. Lethargy d. Risk for skin impairment e. Incontinence

A,B,D,E (The use of SRDs increase a patient's immobility, risk for skin impairment, risk for impaired circulation, and incontinence. A SRD would not increase lethargy.)

When speaking to a person of a different culture, how should the nurse consider modifying his or her communication style? (select all the apply.) a. Use of eye contact b. Reference of address c. Speak slowly and with increased volume d. Meaning of gestures e. Use of touch

A,B,D,E (Use of touch, eye contact, reference of address, and meaning of gestures all may have cultural significance and connotation. Slow, loud speech would not assist with speaking to a person of a different culture.

What should a medical record provide for all health care providers? (select all that apply.) a. A patient's nursing problems b. Care given to the patient c. Details about any incident reports d. The patient's response to treatment e. Care planned for the patient f. A patient's medical problems

A,B,D,E,F (A medical record should furnish all health care providers with a concise, accurate, written picture of a patient's medical and nursing problems, care planned and give, and the patient's response to treatments.)

A nurse is caring for an Orthodox Jewish woman immediately after she has given birth. What can the nurse expect regarding the spouse's participation in his wife's care? a. He will ask to bathe with the patient. b. He will avoid physical contact with the patient. c. He will touch the patient frequently. d. He will share a bed with the patient.

b. He will avoid physical contact with the patient. ( For Observant Jews, a woman is considered to be in a ritual state of impurity whenever blood is coming from her uterus, such as during menstrual periods and after the birth of a child. During this time, her husband will not have physical contact with her. When this time is completed, she will bathe herself in a pool called a mikvah. Nurses need to be aware of this practice and be sensitive to the husband and wife because the husband will not touch his wife.)

The LPN/LVN assists a patient into the semi-Fowler's position per health care provider order. What would indicate that this patient is in the correct position? a. Knee is drawn toward the chest b. Head of bed is at a 30-degree angle c. Patient is leaning over the bedside table d. Arms are flexed toward the head

b. Head of bed is at a 30-degree angle (The semi-Fowler's position is when the head of the bed is raised approximately 30 degrees. Orthopneic position is when the patient is leaning over the bedside table. Sims position is when the knee is drawn toward the chest. Arms are not flexed toward the head in the semi-Fowler's position.)

A nurse is performing an admission assessment on a patient with suspected tuberculosis. What assessment findings by the nurse are consistent with tuberculosis? a. Hypothermia b. Hemoptysis c. Night terrors d. Weight gain

b. Hemoptysis

What system of comprehensive patient care considers the physical, emotional, and social environment and spiritual needs of a person? a.Health promotion care b. Holistic health care c. Interdependent care d. Illness prevention care

b. Holistic health care (Holistic health care encompasses the physical, emotional, social, and spiritual aspects of the patient.)

If the nurse aggressively says to a patient, "why couldn't you have asked me to give you your pain medication when I was in here earlier?" What feeling is the patient most likely to demonstrate? a. Anger b.Humiliation and worthlessness c.Satisfaction that his needs are met d.Confidence that his request will be granted

b. Humiliation and worthlessness (Aggressive communication is highly destructive. Although anger may eventually come, the patient most likely feels humiliated first.)

What is an example of an appropriate Patient problem? a. Turn a patient every 2 hours. b. Impaired skin integrity c. Skin breakdown noted d. The patient has scabies on his back

b. Impaired skin integrity ("Impaired skin integrity" is an example of a patient problem. "Skin breakdown noted" is and example of a charting entry, "turn patient every 2 hours" is a nursing intervention, and "scabies" is a medical diagnosis.)

A nurse tells a patient, "This PM you are going for an abdominal A&P, and H&H, as well as an IV pyelogram. Please sign these consent forms." What may this use of medical jargon cause? a. Clarity in the message b. Misinterpretation c. Understanding d. Speed in communication

b. Misinterpretation (Jargon is terminology unique to people in a special type of work and is not understood by everyone. Although jargon does speed communication and is clear to those who know it, it may be misinterpreted and not understood by all people.)

Changes in health care reimbursement measures have resulted in which of the following changes regarding care of the terminally ill? a. Patients spend more time in hospitals. b. More patients die at home. c. Patients spend more time in rehab facilities. d. Nurses provide more care in hospitals.

b. More patients die at home.

A patient requests a consultation between the health care provider and a religious leader known as an Imam. What is this patient's cultural belief? a. African American b.Muslim c. Mexican American d. Chinese American

b. Muslim (Muslims may wish to have their health care provider consult with an Imam, a religious leader.)

The nurse is preparing to bathe a patient. What should the room temperature be set at? a. 75°F or warmer (23.8°C) b. No cooler than 68°F (20°C) c. No cooler than 70°F (21.1°C) d. No warmer than 67°F (19.4°C)

b. No cooler than 68°F (20°C) (The recommended room temperature is 68° to 74°F (20° to 23.3°C).)

A nurse communicates with a patient by maintaining eye contact and through the use of touch. What type of communication technique is the nurse demonstrating? a. verbal b. Nonverbal c. Directive d. Persuasive

b. Nonverbal ( Messages transmitted without the use of words (either oral or written) constitute nonverbal communication. Nonverbal cues include tone and rate of voice, volume of speech, eye contact, physical appearance, and the use of touch.)

The nurse discovers during the intake assessment of a 5-year-old child that the child lives with his biological parents and siblings. How would the nurse categorize this family type? a. Extended family b. Nuclear family c. Social family d. Blended family

b. Nuclear family (The nuclear family is considered the traditional family pattern.)

According to Maslow's hierarchy of needs, what is an individual's most basic need? a. Safety and security b. Physiologic c. Self-actualization d. Love/belongingness e. Esteem

b. Physiologic

Who is the person responsible for analyzing and interpreting data to arrive at a patient problem? a. Technician b. RN c. LPN/LVN d. Health care provider

b. RN ( The RN is responsible for analyzing and interpreting data.)

A patient is being admitted to a long-term care facility, Who has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified? a. Health care provider b. Registered nurse c. Licensed practical nurse/licensed vocational nurse d. Unlicensed assistive personnel

b. Registered nurse (The RN has primary responsibility for each patient's initial admission nursing history, physical assessment, and development of the care plan based on the patient problem identified.)

A nurse instructing a group of parents about safety rules for infants and young children should include which of the following measures in the teaching plan? a. Use a plastic covering on the infant's mattress. b. Remove plants from the child's reach. c. Provide the infant with a pillow at night. d. Keep the crib sides up and set the mattress at the highest setting.

b. Remove plants from the child's reach.