Fundementals Exam #5

Before the end of the shift, the nurse records the occurrences for each patient in the electronic medical record. Which statement below indicates that the nurse understands the main principle of accurate charting? a) "Charting communicates to members of the healthcare team the patient's care and responses during my shift." b) "Charting is important so that I may share with the healthcare team my opinions of what happened with the patient." c) "Charting allows the other nurses to understand the patient care provided during my shift." d) "Charting is important to comply with practice guidelines and institutional policies."

a) "Charting communicates to members of the healthcare team the patient's care and responses during my shift."

Which statement(s) by the new graduate nurse indicates a need for further instruction about documentation? Select all that apply. a) "I can wait until the end of the shift to document my care." b) "Charting every 2 hours is the most appropriate way to document nursing care." c) "I find it easier to chart before I go to lunch, and then after my shift report." d) "I should chart as soon as possible after nursing care is given."

a) "I can wait until the end of the shift to document my care." b) "Charting every 2 hours is the most appropriate way to document nursing care." d) "I should chart as soon as possible after nursing care is given."

Which statement(s) by the student nurse indicates an understanding of the nursing Kardex? Select all that apply. a) "It pulls data from multiple areas of the patient's chart." b) "It is usually kept at the patient's bedside." c) "It is used to document patient response to interventions." d) "It summarizes the plan of care and guides nursing care."

a) "It pulls data from multiple areas of the patient's chart." d) "It summarizes the plan of care and guides nursing care."

The nursing instructor is teaching the student about occurrence reports. Which statement by the student indicates an understanding of the purpose of occurrence reports? a) "Occurrence reports track problems and identify areas for quality improvement." b) "Occurrence reports are required by the Food and Drug Administration (FDA) to report drug errors." c) "The Joint Commission requires occurrence reports for all client falls." d) "Occurrence reports provide legal information should the patient seek legal action after an unusual occurrence."

a) "Occurrence reports track problems and identify areas for quality improvement."

What is the deadline after admission for using the Minimum Data Set to evaluate a newly admitted resident is of a long-term care facility? a) 14 days b) 3 days c) 2 days d) 24 hours

a) 14 days

Why is the information obtained from a swab culture of a wound limited? a) A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria. b) A negative culture may not indicate infection because chronic wounds are often colonized with bacteria. c) Most wound infections are viral, so the swab culture would not be indicative of a wound infection. d) A swab culture result does not include bacterial sensitivity information necessary to provide treatment.

a) A positive culture does not necessarily indicate infection because chronic wounds are often colonized with bacteria.

The patient with a colostomy has been incorrectly applying his ostomy appliance. The continuous contact with liquid stool has caused a skin wound around the ostomy. The nurse assesses bleeding and purulent drainage that has extended into the dermis. How will the nurse classify and document this contaminated wound? a) Acute, full-thickness, open b) Chronic, partial-thickness, closed c) Acute, partial-thickness, closed d) Chronic, unstageable, open

a) Acute, full-thickness, open

Your patient has a deep wound on the right hip, with tunneling at the 8 o'clock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? a) Alginate dressing b) Dry gauze dressing c) Hydrogel d) Hydrocolloid dressing

a) Alginate dressing

Which is not a professional value identified by the American Association of Colleges of Nursing (AACN)? a) Altruism b) Equality c) Education d) Honesty

a) Altruism

The nurse on night shift is caring for a patient who is confused and gets out of bed frequently. The nurse pushes him into a chair and states, "Do not get out of this chair or I will tie you up and leave you alone for hours." The nurse's action is an example of: a) Assault and battery b) Libel c) False imprisonment d) Safe nursing practice

a) Assault and battery

The emergency department nurse cares for a 17-year-old adolescent who is diagnosed with cervical cancer secondary to human papillomavirus. The patient declines treatment, saying, "I don't want my parents to know I have been sexually active, and if they find out about the cancer, they'll figure out the rest of it." The nurse explains the risk of death if the cancer is not treated, but the patient continues to refuse therapy. What conflicting principles is this nurse facing as the result of this patient's choices? a) Autonomy versus nonmaleficence b) Autonomy versus veracity c) Fidelity versus justice d) Veracity versus beneficence

a) Autonomy versus nonmaleficence

The nurse's obligations in ethical decisions include which of the following? Select all that apply. a) Be a patient advocate. b) Involve institutional ethics committees. c) Improve one's own ethical decision making. d) Respect patient confidentiality.

a) Be a patient advocate. b) Involve institutional ethics committees. c) Improve one's own ethical decision making. d) Respect patient confidentiality.

The nurse is caring for a patient who experienced a stroke leaving the left side of the body paralyzed. The patient says, "I can still bathe myself," but the nurse performs the bath to make certain the patient gets clean. What ethical principles is the nurse violating with this behavior? Select all that apply. a) Beneficence b) Fidelity c) Autonomy d) Veracity e) Nonmaleficence

a) Beneficence c) Autonomy e) Nonmaleficence

Pressure ulcers are directly caused by which of the following conditions at the site? a) Compromised blood flow b) Edema c) Shearing forces d) Inadequate venous return

a) Compromised blood flow

The nurse is facing a moral dilemma and applies the MORAL model to decision making. After writing down all the possible options to solve the problem, what will the nurse do next? a) Consider all the options and choose the best one. b) Implement the chosen option. c) Evaluate the effectiveness of the action. d) Consider the dilemma and whom it involves.

a) Consider all the options and choose the best one.

A patient with attention deficit disorder is admitted to the hospital with type 1 diabetes. Which nursing diagnosis is commonly yet inappropriately used but should be avoided for this type of patient? Assume there are data to support all the diagnoses. a) Deficient Recall (disease process) b) Impaired Ability to Learn related to Fear and Anxiety c) Difficulty Learning related to Cognitive Developmental Level d) Lack of Motivation to Learn related to Feelings of Powerlessness

a) Deficient Recall (disease process)

A registered nurse administers the wrong medication to a patient. She does not notify anyone of the error and documents that the correct medication was administered. The nurse was reported to the state board of nursing. Which of the following actions can the state board of nursing take against the nurse in this situation? a) Disciplinary action against the nurse's license to practice b) Criminal misdemeanor charges against the nurse c) Medical malpractice lawsuit against the nurse d) Employment release from the institution

a) Disciplinary action against the nurse's license to practice

Which actions would the nurse take when emptying the patient's closed-wound drainage system? Select all that apply. a) Don sterile gloves and personal protective equipment. b) Inspect the drainage tube site and sutures. c) Check that tubing to drainage system is intact. d) Test the suction apparatus at prescribed pressure. e) Document the color, type, and amount of drainage.

a) Don sterile gloves and personal protective equipment. b) Inspect the drainage tube site and sutures. c) Check that tubing to drainage system is intact. d) Test the suction apparatus at prescribed pressure. e) Document the color, type, and amount of drainage.

What are the elements that the plaintiff must establish in a malpractice lawsuit? Select all that apply. a) Duty b) Breach of duty c) Intent to harm d) Assault e) Causation f) Injury

a) Duty b) Breach of duty e) Causation f) Injury

Prior to discharge, a patient with diabetes needs to learn how to check a finger-stick blood sugar reading before taking insulin. Which action will best help the patient remember proper technique? a) Encouraging the patient to check the blood sugar each time the nurse gives insulin b) Providing feedback after the patient takes his blood sugar reading for the first time c) Verbally instructing the patient about how to obtain a finger-stick blood sugar reading d) Offering a brochure that describes the technique for checking a blood sugar reading

a) Encouraging the patient to check the blood sugar each time the nurse gives insulin

The nurse is administering medications to patients using a bar-scanning device that scans the patient's identification bracelet and the medication to be administered to avoid a medication error. What types of errors does this bar-scanning device prevent? Select all that apply. a) Errors of commission b) Errors of omission c) Errors in planning d) Errors in execution e) Errors in assessment

a) Errors of commission d) Errors in execution

Which intervention by the nurse would be best to motivate a patient newly diagnosed with hypertension to learn about the prescribed treatment plan? a) Explain that when left untreated, hypertension may lead to stroke. b) Ask the patient to let you know when he is ready to learn. c) Encourage the patient to learn about various treatment options. d) Reassure the patient that adhering to the treatment produces a good outcome.

a) Explain that when left untreated, hypertension may lead to stroke.

You are caring for a patient with renal failure. His morning laboratory results reveal an abnormal potassium level of 6.8. This value is higher than it was on the previous day, when the level was within normal limits. You page the patient's provider, but he does not return your call right away. You become busy with another patient and forget to notify the provider again and fail to mention the critical laboratory value to the oncoming nurse during shift report. Which of the following does this scenario illustrate? Select all that apply. a) Failure to implement a plan of care b) Failure to evaluate c) Malpractice d) Failure to assess and diagnose

a) Failure to implement a plan of care b) Failure to evaluate d) Failure to assess and diagnose

A 4-year-old child is brought to the emergency department by his mother. He has a large bruise on his left chest and multiple contusions on his face. His mother tells you her boyfriend intentionally pushed the child down the stairs in anger. The child appears to be in a great deal of pain. Which of the following four correct items should the nurse do first? a) Notify the nursing supervisor of the suspected physical abuse. b) Complete a physical assessment of the child. c) Obtain an order for pain medication. d) Notify Child Protective Services of the suspected abuse.

b) Complete a physical assessment of the child.

7. The home health nurse learns that an elderly patient isn't able to get to the grocery store. She doesn't have much food in her home, and eats and drinks little. Most of her time is spent sitting in her chair watching television, often not realizing that she has bladder leakage. Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply. a) Help her to get out of the chair every 2 hours. b) Change her clothing frequently. c) Bath the patient using soap and water. d) Promote intake of green tea throughout the day. e) Encourage her to wear incontinence products.

a) Help her to get out of the chair every 2 hours. b) Change her clothing frequently. e) Encourage her to wear incontinence products.

The nurse knows that iron deficiency anemia is caused by low levels of iron in the body that can be improved by a diet high in iron. Based on this information, the best nursing diagnosis is: a) Imbalanced nutrition: less than body requirements for iron r/t possible Deficient Recall of dietary needs b) Deficient Recall r/t imbalanced nutrition due to less than body requirements of iron c) Imbalanced nutrition: less than body requirements r/t inability to access information d) Inability to access information r/t Deficient Recall about dietary needs for iron

a) Imbalanced nutrition: less than body requirements for iron r/t possible Deficient Recall of dietary needs

Why is an accurate description of the location of a wound important? Select all that apply. a) Influences the rate of healing b) Determines the appropriate treatment choice c) Will affect the frequency of dressing changes d) Affects patient movement and mobility

a) Influences the rate of healing b) Determines the appropriate treatment choice d) Affects patient movement and mobility

When applying heat or cold therapy to a wound, what should the nurse do? a) Leave the therapy on each area no longer than 15 minutes. b) Leave the therapy on each area no longer than 30 minutes. c) When using heat, ensure the temperature is at least 135°F (57.2°C) before applying it. d) When using cold, ensure the temperature is less than 32°F (0°C) before applying it.

a) Leave the therapy on each area no longer than 15 minutes.

Which action by the nurse breaches patient confidentiality? Select all that apply. a) Leaving patient data displayed on a computer screen where others may view it b) Remaining logged on to the computer system after documenting patient care c) Faxing a patient report to the nurses' station where the patient is being transferred d) Informing the nurse manager of a change in the patient's condition

a) Leaving patient data displayed on a computer screen where others may view it b) Remaining logged on to the computer system after documenting patient care

The nurse is giving you the shift report. She states the client's diagnoses, treatments, and course of hospitalization. When describing the client she states, "Whenever I try to teach him something, he becomes difficult and argumentative." What client information about patient teaching should you ask? Select all that apply. a) Level of literacy b) Primary language c) Need for humor d) Level of anxiety e) Questions answered

a) Level of literacy b) Primary language d) Level of anxiety e) Questions answered

The nurse receives a prescription to begin a morphine drip for a patient who is to be taken off the ventilator, and to increase the infusion rate as needed to maintain the patient's comfort. The nurse refuses to carry out the order because the morphine will depress respirations and the nurse believes this is equivalent to killing the patient. Which concept best describes what this nurse is demonstrating? a) Moral agency b) Morals c) Bioethics d) Clinical decision making

a) Moral agency

Which classification system promotes standardized language that will improve computer interoperability in nursing? a) NANDA-I nursing diagnoses b) National Patient Safety Goals c) QSEN competencies d) Patient Bill of Rights

a) NANDA-I nursing diagnoses

Why might a healthcare provider choose narrative charting instead of using forms or checklists? a) Narrative charting tracks the client's changing health status as it occurs. b) Free form documentation is inconsistent among healthcare providers. c) Less charting time by healthcare provider is needed for narrative charting. d) Less interdisciplinary discussion occurs with the narrative style of charting.

a) Narrative charting tracks the client's changing health status as it occurs.

What do negligence and malpractice have in common? Select all that apply. a) Negligence and malpractice are unintentional torts. b) Negligence and malpractice are felonies. c) Malpractice is the professional form of negligence. d) Negligence and malpractice involve the intent to do harm to a patient.

a) Negligence and malpractice are unintentional torts. c) Malpractice is the professional form of negligence.

A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it? a) Partial-thickness wound b) Penetrating wound c) Superficial wound d) Full-thickness wound

a) Partial-thickness wound

The nurse is using an EHR system. Which feature does not improve the safety of patient care delivered by the nurse? a) Physician order entry b) Decision support tools c) Elimination of poor handwriting d) Improved accessibility

a) Physician order entry b) Decision support tools c) Elimination of poor handwriting d) Improved accessibility

The nurse logs on to the electronic health record to enter the admission orders for a patient seen in the physician's office. However, when attempting to retrieve the patient's health history, the nurse keeps getting error messages. What is the likely problem? a) Poor interoperability b) Lack of connectivity c) Improperly transmitted information d) Network failure e) Incorrect password

a) Poor interoperability b) Lack of connectivity c) Improperly transmitted information d) Network failure e) Incorrect password

Which of the following are main functions of a computer? Select all that apply. a) Process b) Storage c) Memory d) Output

a) Process b) Storage d) Output

The nurse takes a telephone order from a primary care provider for 40 mEq potassium chloride in 100 mL of sterile water for injection to be infused over 4 hours. Which action must the nurse take to ensure the accuracy of the order? a) Repeat the order to the prescriber even if she believes she understood the order correctly. b) Immediately notify the pharmacy of the order and verify it with a pharmacist. c) Ask the unit secretary to listen to the prescriber on the phone to verify the order. d) Transcribe the order on notepaper and verify the dosage in a drug handbook.

a) Repeat the order to the prescriber even if she believes she understood the order correctly.

Which of the following is an example of whistleblowing? Select all that apply. a) Reporting fraudulent billing practices b) Reporting patient's health status against the patient's wishes c) Reporting unsafe work practices d) Reporting a coworker for working under the influence of drugs

a) Reporting fraudulent billing practices c) Reporting unsafe work practices d) Reporting a coworker for working under the influence of drugs

Which of the following are examples of invasion of privacy by nurses? Select all that apply. a) Searching a patient's belongings without permission b) Reviewing the plan for patient care in the lunchroom c) Discussing healthcare issues for an unconscious patient with the person who holds his power of attorney d) Releasing patient health information to local newspaper reporters

a) Searching a patient's belongings without permission b) Reviewing the plan for patient care in the lunchroom d) Releasing patient health information to local newspaper reporters

A preschool-age child is scheduled for a tonsillectomy. Which strategy might help lessen the child's anxiety before surgery? a) Show the child a short, animated video (DVD) about the hospital visit and procedure. b) Give the child a tour of the hospital a week before the surgery is scheduled. c) Allow the child to use online sources of information to teach him about the procedure. d) Provide one-to-one instruction about the care he will need after surgery.

a) Show the child a short, animated video (DVD) about the hospital visit and procedure.

The nurse is caring for a patient newly diagnosed with diabetes. The patient tells the nurse, "After searching the Internet, I found out that I don't need insulin. All I need to do to control blood sugar is drink a mixture of vinegar and apple juice." What teaching should the nurse provide? a) Show the patient how to choose reputable, trustworthy healthcare Web sites. b) Instruct on the importance of adhering to the prescriber's instructions. c) Inform the patient that the healthcare provider is always right and should be trusted. d) Return to the Web site to obtain more detailed information.

a) Show the patient how to choose reputable, trustworthy healthcare Web sites.

Which of the following health information is protected in the electronic health record? Select all that apply. a) Social Security number b) Insurance information c) Physician's name d) Laboratory results

a) Social Security number b) Insurance information d) Laboratory results

In performing a handoff report, the nurse should communicate information on which of the following? Select all that apply. a) Teaching performed b) Any change in client status c) Treatments administered d) Hygiene measures performed

a) Teaching performed b) Any change in client status c) Treatments administered

A client is admitted to a long-term care facility. The nurse knows that federal law requires the use of: a) The Minimum Data Set (MDS) for assessment b) Situation-Background-Assessment-Recommendation (SBAR) for reporting c) Health Care Financing Administration guidelines prior to surgery d) The Joint Commission guidelines for discharge planning

a) The Minimum Data Set (MDS) for assessment

The nurse is preparing to pass the 0900 medications prescribed for her patients. She removes the medications from the automated dispensing unit. When scanning the medication, an alert notifies the nurse that the patient is allergic to this medication. What action should the nurse take? Select all that apply. a) Override the alert and administer the medication. b) Confirm the patient's allergies and type of reaction. c) Notify the prescriber of the patient medication allergy. d) Be sure an antidote is available at the patient's bedside.

b) Confirm the patient's allergies and type of reaction. c) Notify the prescriber of the patient medication allergy.

In informatics, raw, unprocessed numbers, symbols, or words that have no meaning by themselves are called which of the following? a) Information b) Data c) Knowledge d) Wisdom

b) Data

The nurse organizing an Evidence-Based Practice Committee has a computer with Internet access. What else would be most important to the committee when searching for the most current scientific evidence? a) Medical and nursing textbooks b) Database of health journals c) Subscriptions to scholarly journals d) Librarian in the facility

b) Database of health journals

The electronic health record (EHR) is used to document client care management. Which statement(s) below is/are applicable to EHR? Select all that apply. a) Increases the potential for breaches in confidentiality b) Decreases the time spent to complete documentation c) Minimizes medical errors through use of alert systems d) Communicates the client's plan of care to the healthcare team

b) Decreases the time spent to complete documentation c) Minimizes medical errors through use of alert systems d) Communicates the client's plan of care to the healthcare team

What is a common characteristic of aging skin? a) Increased permeability to moisture b) Diminished sweat gland activity c) Reduced oxygen-free radicals d) Overproduction of elastin

b) Diminished sweat gland activity

A nurse is providing care to a patient who is a Jehovah's Witness. Against the patient's wishes, the physician ordered the nurse to give the patient two units of packed red blood cells. The nurse knows that the blood will save the patient's life, but also that it is against the patient's wishes; she is unsure what is the right thing for her to do. The nurse is experiencing a(n): a) Reflection encounter b) Ethical dilemma c) Moral outrage d) Moral distress

b) Ethical dilemma

The nurse enters a patient's room with a portable computer station to assess the patient. The nurse does not log out while assisting a patient to the bathroom. A visitor reads the patient's chart and begins to question the nurse about the patient information. This is an example of: a) Failure to educate the patient b) Failure to maintain patient confidentiality c) Negligence regarding the patient's care d) Failure to educate the visitor

b) Failure to maintain patient confidentiality

Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply. a) Granulation b) Hemostasis c) Epithelialization d) Inflammation

b) Hemostasis d) Inflammation

Why might skin integrity and wound healing be compromised in the client who takes blood pressure medications? Antihypertensives: a) Can cause cellular toxicity b) Increase the risk of ischemia c) Delay wound healing d) Predispose to hematoma formation

b) Increase the risk of ischemia

The nurse reviews the patient's laboratory results. What component of informatics is the nurse viewing? a) Data b) Information c) Knowledge d) Wisdom

b) Information

The Code of Ethics for Nurses: a) Is legally binding b) Is not legally binding c) Is legally binding in some circumstances d) Cannot be used in legal cases

b) Is not legally binding

Which teaching strategy is typically most effective for presenting information to large groups? a) Distributing printed materials b) Lecturing using audiovisual format c) Online sources of information d) Role modeling

b) Lecturing using audiovisual format

A nurse is entering a pharmacy request for patient medication in the patient's electronic health record (EHR) while seated at a computer in the nursing station. A physician approaches her and asks her to access another patient's EHR so that he can look at the patient's laboratory report. Which of the following is the best action for the nurse to take? a) Access the lab report for the physician. b) Log off the computer before proceeding. c) Quickly finish the pharmacy requisition before the physician logs on. d) Allow the physician to access the laboratory report immediately.

b) Log off the computer before proceeding.

How can the nurse best provide teaching for a patient whose primary spoken language is not the same as hers? a) Provide written materials in the patient's primary language. b) Make arrangements to teach using an interpreter. c) Provide a demonstration and request a return demonstration. d) Use visual teaching aids to convey information.

b) Make arrangements to teach using an interpreter.

Upon initial assessment of a 75-year-old patient, you identify bruises and scratches on the patient's arms, legs, and trunk in various stages of healing. You notify your supervisor when you suspect the patient may be a victim of physical abuse. You are complying with which of the following state laws? a) Good Samaritan Law b) Mandatory Reporting Law c) Nurse Practice Act d) Nursing Standards of Practice

b) Mandatory Reporting Law

A patient has a stage II pressure ulcer on her right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound? a) Dry gauze dressing changed twice daily b) Nonadherent dressing with daily wound care c) Hydrocolloid dressing changed as needed d) Wet-to-dry dressings changed three times a day

b) Nonadherent dressing with daily wound care

Under the American Nurses Association (ANA) Code of Ethics, the nurse has the professional responsibility to uphold ethical behavior. Choose the statements below that are accurate about the Code of Ethics. Select all that apply. a) ANA Code of Ethics is a law. b) Nurse actions are to be at the level expected by the profession. c) Nurses are not held accountable for their actions. d) Nurses are professionally bound to give correct information to the patient. e) Nurses do not need to collaborate to meet a patient's healthcare needs. f) ANA Code of Ethics will protect the nurse even if the law is broken.

b) Nurse actions are to be at the level expected by the profession. d) Nurses are professionally bound to give correct information to the patient.

The nurse manager is devising a teaching schedule for the staff who are about to begin using a new type of patient bed in the ICU. Implementation is planned in 6 weeks. When is the best time for the manager to schedule the teaching sessions? a) Immediately b) One week before implementation c) Two weeks before implementation d) Four weeks before implementation

b) One week before implementation

An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and asks the healthcare team to ignore the request. After a great deal of discussion among the physician, nurse, and family, they are no closer to resolution of the conflict. The nurse asks the hospital chaplain to come and help the family and the team understand each other's opposing views. Which step of the MORAL model does this illustrate? a) M—Massage the dilemma b) O—Outline the options c) R—Resolve the dilemma d) L—Look back and evaluate

b) O—Outline the options

The nursing assistive personnel (NAP) informs the nurse that a patient has fallen out of bed and is in pain. The nurse assesses the patient and provides care. Identify the correct documentation of the fall. a) Patient found on floor after falling out of bed and verbalizes (L) hip pain. b) Patient found on floor by NAP Smith and verbalizing (L) hip pain. c) Patient fell out of bed but is currently in bed. d) Patient reminded not to climb OOB after falling.

b) Patient found on floor by NAP Smith and verbalizing (L) hip pain.

A patient refuses a dose of medication. How should the nurse document the event? a) Patient is uncooperative and refuses the prescribed dose of digoxin. b) Patient refuses the 0900 dose of digoxin. c) Patient is belligerent, argumentative, and refuses the 0900 dose of digoxin. d) 0900 dose of digoxin not given.

b) Patient refuses the 0900 dose of digoxin.

At the end of a 12-hour shift, the nurse gives a verbal report to the oncoming nurse. This face-to-face reporting, using the acronym "CUBAN," does which of the following? a) Ensures that the nurse is able to finish the shift as quickly as possible b) Provides a guide for the nurse's report to the oncoming nurse c) Requires the nurses to engage in walking rounds for the report d) Provides a detailed cultural report for Latino patients

b) Provides a guide for the nurse's report to the oncoming nurse

Identify the third step in the MORAL decision-making model. a) Reassess the dilemma. b) Resolve the dilemma. c) Review the problem. d) Recall the history of the problem.

b) Resolve the dilemma.

A man was involved in a motor vehicle accident yesterday. He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time? a) Risk for Infection related to subcutaneous injuries b) Risk for Impaired Skin Integrity related to immobility c) Impaired Tissue Integrity related to ventilator dependency d) Impaired Skin Integrity related to ventilator dependency

b) Risk for Impaired Skin Integrity related to immobility

The nurse in the emergency department admits a patient with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see on the dressing? a) Serous b) Sanguineous c) Purosanguineous d) Purulent

b) Sanguineous

A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is: a) Primary intention healing b) Secondary intention healing c) Tertiary intention healing d) Approximation healing

b) Secondary intention healing

While assessing a new wound, the nurse notes red, watery drainage. How should the nurse describe this type of drainage when documenting? a) Sanguineous b) Serosanguineous c) Serous d) Purosanguineous

b) Serosanguineous

Which of the following aspects of a computer determine its power? Select all that apply. a) User-friendliness b) Speed of operations c) Accessibility for the user d) Data storage capacity

b) Speed of operations d) Data storage capacity

The nurse witnesses the patient's signature on a consent form to participate in her physician's research study. After the physician leaves the room, the patient tells the nurse she really doesn't want to participate but didn't have the heart to turn down the request because of fear that the physician would be upset. What should the nurse do to advocate for this patient? a) Tell the patient the physician will not be upset. b) Tell the physician why the patient agreed to participate. c) Explain the importance of the research study to the patient. d) Ask the patient what she would like you to do.

b) Tell the physician why the patient agreed to participate.

Which statement by the patient demonstrates health literacy? a) "I speak and understand little English but will do what I am told." b) "I will take my medications after I ask the nurse a few questions." c) "I have not taken my prescribed antibiotics because I can't read the labels." d) "I stopped my medications when I started feeling better."

b) "I will take my medications after I ask the nurse a few questions."

The nurse notifies the primary care provider that the patient is experiencing pain. The provider gives the nurse a telephone prescription for morphine 4 mg intravenously every hour as needed for pain. How should the nurse document this telephone order? a) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain. Kay Andrews, RN b) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN c) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain V.O.: Dr. D. Kelly/Kay Andrews, RN d) 09/02/16 0845 morphine 4 mg intravenously q 1 hour V.O. Kay Andrews, RN

b) 09/02/16 0845 morphine 4 mg intravenously q 1 hour prn pain T.O.: Dr. D. Kelly/Kay Andrews, RN

Of the following, which is the best choice for performing wound irrigation? a) Water jet irrigation b) 35-mL syringe with a 19-gauge angiocatheter c) 5-mL syringe with a 23-gauge needle d) Bulb syringe

b) 35-mL syringe with a 19-gauge angiocatheter

A patient had abdominal surgery. The incision has been closed by primary intention, and the staples are intact. To provide more support to the incision site and decrease the risk of dehiscence, it would be appropriate to apply which of the following? a) Steri-Strips b) Abdominal binder c) T-binder d) Paper tape

b) Abdominal binder

The nurse explains to a patient that dressing changes will improve healing and decrease infection and then demonstrates the correct aseptic technique to the patient. The patient is asked to return a demonstration of this dressing change and to describe the reasons for it to the nurse. This example includes what learning domain(s)? Select all that apply. a) Affective b) Active c) Cognitive d) Psychomotor e) Passive

b) Active c) Cognitive d) Psychomotor

Which prescription below is not consistent with the standards established by The Joint Commission? a) Administer Lasix 20 mg PO daily at 1000. b) Administer Lasix 10.0 mg PO daily at 1000. c) Administer digoxin 10 mg PO daily at 1000. d) Administer digoxin 0.3 mg IV daily at 1000.

b) Administer Lasix 10.0 mg PO daily at 1000.

A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching session(s)? a) Within 10 minutes after his next dose of oral pain medication b) After the patient wakes up from a restful nap c) Before the surgeon debrides the wound d) Before the patient undergoes flow studies of his affected leg

b) After the patient wakes up from a restful nap

The surgeon enters a computerized order for a patient in the postoperative period after a unilateral thoracotomy for lung cancer. The order states: OOB in AM. Which action indicates that the nurse is following the surgeon's order? The nurse: a) Performs oral care b) Assists the patient out of bed c) Assists the patient with bathing d) Changes the patient's operative dressings

b) Assists the patient out of bed

What database would the nurse use to restrict the search to nursing articles only? a) MEDLINE b) CINAHL c) PsycINFO d) ProQuest

b) CINAHL

A patient has asked the nurse to explain her laboratory results. The nurse informs the patient that he must first assist another patient to the bathroom and then he will return to explain the results. After assisting the other patient to the bathroom, the nurse returns to explain the results to the patient. What ethical principle has the nurse displayed? a) Nonmaleficence b) Autonomy c) Beneficence d) Fidelity

d) Fidelity

A mentally competent patient has an extremely low blood count and will likely die without a blood transfusion. The patient knows the risk, but continues to refuse the blood. Which action by the nurse is the most appropriate? a) Assume the patient is confused and give the blood anyway. b) Request a psychological evaluation to ensure that the patient understands the risk. c) Ask family members to intervene and make the patient consent to receiving blood. d) Follow the patient's wishes and do not administer a blood transfusion.

d) Follow the patient's wishes and do not administer a blood transfusion.

The nurse working in the emergency department is preparing heat therapy for one of the patients in the unit. Which one is it most likely to be? a) Is actively bleeding b) Has swollen, tender insect bite c) Has just sprained her ankle d) Has lower back pain

d) Has lower back pain

Your patient has multiple open wounds that require treatment. When performing dressing changes, you should: a) Remove all of the soiled dressings before beginning wound treatment b) Cleanse wounds from most contaminated to least contaminated c) Treat wounds on the patient's side first, then the front and back of the patient d) Irrigate wounds from least contaminated to most contaminated

d) Irrigate wounds from least contaminated to most contaminated

The patient is struggling with a decision whether or not to receive experimental treatment. What is the nurse's role when caring for this patient? a) Provide recommendations for decision making. b) Teach the patient how to apply logic to the situation. c) Advocate for the patient with the primary healthcare provider. d) Listen to the patient's thoughts, ask questions, and provide support.

d) Listen to the patient's thoughts, ask questions, and provide support.

CINAHL is a(n): a) Popular periodical b) Internet site c) Scholarly journal d) Literature database

d) Literature database

A client admitted to the inpatient medical-surgical unit has suffered sudden respiratory failure. The client's condition is getting worse; he is cyanotic (turning blue) with periods of labored breathing. What action should the nurse take first? a) Study the discharge plan. b) Check the graphic data for vital signs. c) Examine the history and physical examination. d) Look for an advance directive.

d) Look for an advance directive.

The nurse cares for a patient who is diagnosed with a sexually transmitted infection (STI). The patient is upset and asks the nurse not to share this information with anyone. The nurse explains to the patient that this must be reported to the local Health department based on which regulation? a) Americans with Disabilities Act (ADA) b) Whistleblower's law c) Good Samaritan Law d) Mandatory reporting

d) Mandatory reporting

The nurse preparing a teaching plan ensures that the information is tailored to the client's life experiences and learning level. These are examples of which right of teaching? a) Time b) Context c) Content d) Method

d) Method

The nurse believes that abortion is murder of the unborn child. While at work, the nurse is assigned a woman with septicemia following an abortion. Which concept most specifically requires the nurse to provide high-quality care for this patient? a) Ethics b) Morals c) Bioethics d) Nursing ethics

d) Nursing ethics

The nurse is looking for the most current evidence related to safe medication administration. What source provides the most reliable information? a) Peer-reviewed scholarly journals b) Popular periodicals c) Social media Internet sites d) Online drug formulary

d) Online drug formulary

Nursing codes of ethics support which of the following? a) Patients can receive emergency treatment regardless of their ability to pay. b) Nurses will educate patients about advance directives. c) Nurses with HIV must disclose their condition to their employer. d) Patients have the right to dignity, privacy, and safety.

d) Patients have the right to dignity, privacy, and safety.

The nurse would question a prescription for application of cold therapy to which patient? The patient with a: a) Wound oozing blood b) Sprained wrist c) Infected wound d) Pressure ulcer

d) Pressure ulcer

A student nurse makes the following comments to her preceptor: "I love getting information from the chart. Everything related to the patient's problem is together and addressed by various members of the healthcare team." The student nurse has been introduced to which type of charting system? a) Narrative b) Focus c) Source oriented d) Problem oriented

d) Problem oriented

What is(are) the primary benefit(s) of computer physician order entry (CPOE)? a) Increased privacy b) Improved access to patient data c) Cost savings d) Reduced medication errors

d) Reduced medication errors

The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client a) Begins an aggressive exercise program b) Follows a diet plan of 1,200 calories per day c) Is fitted for deep-depth diabetic footwear d) Remains free of foot wounds

d) Remains free of foot wounds

During advanced cardiac life support (ACLS) training, a nurse performs defibrillation using a mannequin. Which teaching strategy is being employed? a) One-to-one instruction b) Computer-assisted instruction c) Role modeling d) Simulation

d) Simulation

A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as? a) Stage I pressure ulcer, healing b) Stage II pressure ulcer, healing c) Stage III pressure ulcer, healing d) Stage IV pressure ulcer, healing

d) Stage IV pressure ulcer, healing

A patient has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound "heals a little more" he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing? a) Primary intention b) Regenerative healing c) Secondary intention d) Tertiary intention

d) Tertiary intention

The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: a) The ulcer is completely healed with minimal scarring b) The patient reports no pain at the site c) A minimal amount of drainage is noted d) The wound bed contains 100% granulated tissue

d) The wound bed contains 100% granulated tissue

Which statement describes the primary purpose of an incident report? a) This report is used by nurse managers to discipline the nurse for her errors. b) It is imperative that this report be kept in the patient's medical record in case of a lawsuit. c) A copy should be provided to the patient to promote open communication. d) This report is used by risk management to prevent the incident from reoccurring.

d) This report is used by risk management to prevent the incident from reoccurring.

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as? a) Stage II pressure ulcer b) Stage III pressure ulcer c) Stage IV pressure ulcer d) Unstageable pressure ulcer

d) Unstageable pressure ulcer

A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss? a) Draw a circle around the area of drainage on a dressing. b) Classify drainage as less or more than the previous drainage. c) Weigh the patient at the same time each day on the same scale. d) Weigh dressings before they are applied and after they are removed.

d) Weigh dressings before they are applied and after they are removed.

The American Nurses Association (ANA) believes nurses should not participate in active euthanasia (and assisted suicide) because such acts violate ____. a) the Patient Self-Determination Act b) civil laws c) the Good Samaritan laws d) the Code of Ethics for Nurse

d) the Code of Ethics for Nurse

A patient who is being discharged asks the nurse, "Can I take you out for dinner to show my appreciation for all that you have done for me? I really like you." The nurse's best response is which of the following? a) "Yes, that would be nice. It is really great to be appreciated." b) "No, and please do not ask again. You should have been told that already." c) "Thank you; however, I have to refuse, even though the thought is appreciated." d) "We will have to wait 3 days after you have been discharged to have a relationship."

c) "Thank you; however, I have to refuse, even though the thought is appreciated."

At 1000 on 11/14/16, the nurse takes a telephone prescription for "metoprolol 5 mg intravenously now." What is the latest date and time the nurse will expect the prescriber to countersign the order? a) 11/14/16 at 1200 b) 11/14/16 at 2200 c) 11/15/16 at 1000 d) 11/16/16 at 1000

c) 11/15/16 at 1000

An older adult patient who underwent bowel resection is recovering from surgery without complication. He ambulates in the hallway and requires little analgesia for pain. During the healthcare team's morning rounds, the surgeon informs the patient that the lesion removed was cancerous. Which factor will likely be the patient's most significant obstacle for learning? a) The patient's baseline physical condition b) A negative environmental influence c) Anxiety associated with the new diagnosis d) Reduced ability to understand the diagnosis

c) Anxiety associated with the new diagnosis

The nurse is a member of the ethics committee. An alert, oriented, and competent 87-year-old man has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and requests the ethics committee to intervene on their behalf. The ethics committee would most likely use which model in this patient's case? a) Social justice b) Patient benefit c) Autonomy d) DNAR (AND) determination

c) Autonomy

What are two risk assessment tools used in the United States to evaluate a patient's risk for pressure ulcers? Select all that apply. a) Pressure Ulcer Healing Chart b) PUSH tool c) Braden scale d) Norton scale

c) Braden scale d) Norton scale

Assume all of the following written instructions about digoxin provide correct information for patient care. Which one is best worded for patient understanding? a) Obtain your radial pulse every morning before taking your digoxin dose. b) Return to your healthcare provider for monthly laboratory studies of your digoxin levels. c) Call your provider if you notice that objects look yellow or green. d) Always take the same brand of medication because certain brands may not be interchangeable.

c) Call your provider if you notice that objects look yellow or green

A client is admitted to the birthing unit to rule out preterm labor. The nurse charts only abnormal findings. This type of charting is a form of: a) Narrative charting b) Charting by inclusion c) Charting by exception d) Source oriented charting

c) Charting by exception

The nurse admits an older adult patient to the long-term care facility. When assessing for pressure ulcer risk, what should the nurse do after conducting the first Braden scale assessment? a) Apply transparent film dressings to buttocks. b) Reassess using the Braden Q scale. c) Conduct another assessment in 3 days. d) Massage areas over the bony prominences.

c) Conduct another assessment in 3 days.

A hospital uses a source-oriented medical record. What is a major disadvantage of this charting system? a) It involves a cooperative effort among various disciplines. b) The system requires diligence in maintaining a current problem list. c) Data may be fragmented and scattered throughout the chart. d) It allows the nurse to provide information in an unorganized manner.

c) Data may be fragmented and scattered throughout the chart.

Which technique is best for teaching a nursing assistant how to perform finger-stick glucose testing? a) Provide a manufacturer's pamphlet with detailed instruction. b) Explain the best technique for performing glucose testing. c) Demonstrate the procedure; then ask for a return demonstration. d) Suggest that the assistant watch a DVD showing the procedure.

c) Demonstrate the procedure; then ask for a return demonstration.

The nurse is preparing to conduct a literature search to find evidence related to care of a patient with diabetes experiencing neuropathy. Which of the following keywords would the nurse use to best identify the information searched for? a) Caring for diabetics b) Nursing care of neuropathy c) Diabetic neuropathy d) Complications of diabetes

c) Diabetic neuropathy

What intervention would be most appropriate for a wound with a beefy red wound bed? a) Mechanical debridement b) Autolytic debridement c) Dressing to keep the wound moist and clean d) Removal of devitalized tissue and a sterile dressing

c) Dressing to keep the wound moist and clean

It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about his medications. How can the nurse most efficiently use her time and provide this education? a) Write down instructions so the patient can read them at home. b) Discuss the information while assisting the patient with his bath. c) Educate the patient about his medications as each one is given. d) Follow up with the patient after discharge with a phone call.

c) Educate the patient about his medications as each one is given.

Which of the following concepts refers to conflicts that arise between two or more ethical principles in patient care scenarios? a) Nursing ethics b) Bioethics c) Ethical dilemma d) Moral distress

c) Ethical dilemma

A registered nurse forgot to put the siderails up for a confused patient. The patient fell out of bed and fractured his hip. The patient sues and wins a judgment (award) for $2 million. The nurse has an occurrence policy with double limit coverage of $3 million/$10 million that covered the time period when the incident occurred. The statement that best describes the nurse's situation is that her insurance policy will do which of the following? a) Not cover her b) Pay $4 million c) Pay $2 million d) Pay 75% of the $2 million

c) Pay $2 million

A patient with a history of hypertension and rheumatoid arthritis is admitted for surgery, a colon resection, for colon cancer. Which integrated plan of care (IPOC) would be most appropriate for the nurse to implement? a) Hypertension b) Rheumatoid arthritis c) Postoperative colon resection d) Follow all three plans

c) Postoperative colon resection

What is the function of the stratum corneum? a) Provides insulation for temperature regulation b) Provides strength and elasticity to the skin c) Protects the body against the entry of pathogens d) Continually produces new skin cells

c) Protects the body against the entry of pathogens

The Health Information Technology for Economic and Clinical Health (HITECH) encouraged implementation of electronic health records (EHR) by what means? a) Fining facilities that did not convert to EHRs by 2015 b) Mandating that all facilities implement EHRs within the year c) Providing incentive payments to facilities that converted to EHRs d) Restricting providers' access to traditional patient health records

c) Providing incentive payments to facilities that converted to EHRs

An alert, oriented, and competent frail older adult man has been told that he is dying and has asked to have a DNAR (AND) prescription put on his chart. The patient's family does not agree with his decision and asks the healthcare team to ignore the request. The healthcare team does not comply with the family's wishes, and after several days the family takes the matter to court. The court sides with the family and orders the healthcare team to remove the DNAR (AND) prescription. This is an example of which of the following? a) An integrity-producing (good) compromise b) An ethically sound compromise c) Settlement of an issue by force d) An effort to keep peace on the unit

c) Settlement of an issue by force

Which set of topics makes up a handoff report given in a recommended format? a) Data-action-response (DAR) b) Subjective-objective-assessment-plan (SOAP) c) Situation-background-assessment-recommendation (SBAR) d) Patient-diagnosis-medications-activity

c) Situation-background-assessment-recommendation (SBAR)

The unit manager stops you in the hallway to discuss your inability to give safe patient care. The conversation is overheard by other nurses. The manager's comments are based on false information reported to her by a patient. This is an example of: a) Collaboration b) Assault and battery c) Slander d) Libel

c) Slander

A mother tells the nurse she is worried that her 20-year-old daughter lacks the understanding regarding the need for follow-up care after her discharge. Which of the following behaviors suggests that the patient needs further discharge teaching? Select all that apply. The patient: a) States she will be on time for her scheduled appointment b) Asks the nurse many questions about her discharge care c) States she does not understand much English d) Watches television while the nurse is speaking to her e) Plans to get medications from the pharmacy on her way home

c) States she does not understand much English d) Watches television while the nurse is speaking to her

The nurse learns in report that the assigned patient has a stage III pressure ulcer. What type of tissue does the nurse expect to find in the wound? Select all that apply. a) Muscle b) Eschar c) Subcutaneous d) Dermis e) Fascia

c) Subcutaneous d) Dermis e) Fascia

The patient experiences extensive third-degree burns. What type of healing does the nurse expect? Healing by: a) Primary intention b) Second intention c) Tertiary intention d) Primary intention if no infection occurs

c) Tertiary intention

The nurse who is not assigned to care for the patient can access the patient's electronic health record in which circumstance? a) The patient is the nurse's son in the emergency department and has pending lab results. b) The nurse had previously provided care to the patient during past hospitalizations. c) The nurse is reporting lab results to the Code Blue team during resuscitation. d) The patient is the nurse's neighbor who asks the nurse to review the chart.

c) The nurse is reporting lab results to the Code Blue team during resuscitation.

The nurse faces a true ethical dilemma and uses several strategies for resolving the issue. What is the likely outcome? a) A satisfying solution will be found if the nurse logically applies more than one strategy for decision making. b) If the nurse involves other members of the healthcare team in the decision-making process, a compromise will be reached that satisfies everyone. c) The nurse will nevertheless probably not be comfortable with any course of action, regardless of the strategy, model, or type of reasoning used. d) A decision can be reached that is comfortable for the nurse if the nurse applies a decision model to the dilemma.

c) The nurse will nevertheless probably not be comfortable with any course of action, regardless of the strategy, model, or type of reasoning used.

When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? a) The patient will need to take antibiotics until the wound is completely healed. b) Because the patient's wound was left open, the wound will likely become infected. c) The patient will have more scar tissue formation than there would be for a wound closed at surgery. d) The patient should expect to remain hospitalized until complete wound healing occurs.

c) The patient will have more scar tissue formation than there would be for a wound closed at surgery.

The nurse overhears a coworker say, "How can an overweight nurse teach proper nutrition? That nurse should practice what is taught." Which concept best describes what the coworker is expressing? a) Morals b) Ethics c) Values d) Compromise

c) Values

The nurse observes a new graduate nurse preparing to place an IV catheter in the patient's arm. The new graduate tells the patient, "You won't feel a thing" before inserting the needle under the skin. What ethical principle did the new graduate violate? a) Beneficence b) Nonmaleficence c) Veracity d) Confidentiality

c) Veracity

The nurse is conducting a literature search. In what instance might the nurse question the reliability of the health information? a) Author has a DNP degree. b) Article has a list of references. c) Web address ends in .net. d) Publication date is 3 years old.

c) Web address ends in .net.

Which phrase is stated as a teaching goal (as compared with an objective) for a patient who had bowel resection with creation of a colostomy? The patient a) Empties the colostomy appliance when half filled b) Performs skin care around the stoma site c) Will perform ostomy self-care within 3 days after surgery d) Applies a new ostomy appliance, making sure it adheres properly

c) Will perform ostomy self-care within 3 days after surgery

For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be? a) Client will maintain intact skin throughout hospitalization. b) Client will limit pressure to wound site throughout treatment course. c) Wound will close with no evidence of infection within 6 weeks. d) Wound will improve prior to discharge as evidenced by a decrease in drainage.

c) Wound will close with no evidence of infection within 6 weeks.

On a patient's admission to the hospital, a nurse asks the patient whether he has a living will or durable power of attorney for healthcare. He states he does and provides a copy for the chart. The basis for the nurse's inquiry is which of the following? a) Code of Ethics for Nurses b) Patient Care Partnership c) Patient Self-Determination Act (PSDA) d) Health Insurance Portability and Accountability Act (HIPAA)

c) Patient Self-Determination Act (PSDA)

What is the primary difference between acute and chronic wounds? Chronic wounds: a) Are full-thickness wounds, but acute wounds are superficial b) Result from pressure, but acute wounds result from surgery c) Are usually infected, whereas acute wounds are contaminated d) Exceed the typical healing time, but acute wounds heal readily

d) Exceed the typical healing time, but acute wounds heal readily

A 60-year-old patient with a treatable form of breast cancer has decided not to pursue radiation or chemotherapy. The nurse believes that the patient should be treated. She coerces her into receiving treatment by continuing to remind the patient about her responsibilities for raising her children. What type of behavior has the nurse displayed? a) Nonmaleficence b) Autonomy c) Paternalism d) Beneficence

c) Paternalism

Knowing that discharge summary information is integral to the client's ongoing care, which of the point(s) regarding discharge summaries must the nurse be aware? Select all that apply. a) The discharge summary is important because many clients require follow-up care. b) A complete discharge summary is a guide for healthcare professionals in the community. c) The nurse can give a verbal transfer report, which is the same as a discharge summary. d) The discharge summary is the final note in the client's health record e) A complete discharge summary must be handwritten using the narrative note format.

a) The discharge summary is important because many clients require follow-up care. b) A complete discharge summary is a guide for healthcare professionals in the community. d) The discharge summary is the final note in the client's health record

Effective delegation is a vital part of the nurse's responsibilities. What factor should guide the nurse to correctly delegate a nursing task? a) The education and experience of the delegatee b) The job description of the delegatee c) The patient request for the delegatee d) The staffing levels on a unit

a) The education and experience of the delegatee

The nurse arrives at work to find the unit will be short staffed for the shift because a nurse called in sick at the last minute, leaving no time to find a replacement. What factors contribute to the dilemma faced by the nurse working this shift? Select all that apply. a) The nurse's multiple obligations and relationships b) Value conflicts and lack of clarity within the profession c) Autonomy versus escaping hard choices d) Higher pay versus cost effectiveness e) Caring versus the decreased time to spend with patients

a) The nurse's multiple obligations and relationships b) Value conflicts and lack of clarity within the profession e) Caring versus the decreased time to spend with patients

The nurse is looking for the most current evidence related to a newly FDA-approved medication. Which of the following sources provides the most current information? a) The worldwide Web b) Popular periodicals c) Textbooks d) Scholarly journals

a) The worldwide Web

What is the primary goal that the nurse should establish for a patient with an open wound? a) The wound will remain free of infection throughout the healing process. b) The client will complete antibiotic treatment as ordered. c) The wound will remain free of scar tissue at healing. d) The client will increase caloric intake throughout the healing process.

a) The wound will remain free of infection throughout the healing process.

The implementation of electronic health records (EHRs) allows the nurse to do which of the following? Select all that apply. a) Use trend data to facilitate evidence-based nursing practice b) Promote efficient use of time spent charting c) Reduce the opportunity for interdisciplinary collaboration d) Activate the system's safeguards to promote client safety

a) Use trend data to facilitate evidence-based nursing practice b) Promote efficient use of time spent charting d) Activate the system's safeguards to promote client safety

The nurse manager performs a risk-benefit analysis to determine the minimum number of staff the unit will need over the Christmas and New Year's holiday to allow as many nurses to take time off as possible while maintaining the safety of the patients. What ethical problem-solving approach is this nurse manager using? a) Utilitarianism b) Deontology c) Categorical imperative d) Feminist ethics

a) Utilitarianism

Which of the following are examples of nonselective mechanical debridement methods? Select all that apply. a) Wet-to-dry dressings b) Sharp debridement c) Whirlpool d) Pulsed lavage

a) Wet-to-dry dressings c) Whirlpool d) Pulsed lavage

Which informatics concept concerns the appropriate use of knowledge in managing or solving human problems? a) Wisdom b) Data c) Knowledge d) Information

a) Wisdom

Which of the following describes the difference between dehiscence and evisceration? a) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site. b) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent. c) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue. d) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.

a) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

The nurse assesses assigned patients and determines which patient is at highest risk for altered skin integrity? a) Young adult in traction who has a low-protein diet and dehydration b) Elderly patient diagnosed with well-controlled type 2 diabetes c) Middle-aged adult with metabolic syndrome taking antihypertensives d) Adolescent in bed with influenza having periods of high fever and diaphoresis

a) Young adult in traction who has a low-protein diet and dehydration

The nurse is caring for a patient diagnosed with a brain tumor who is about to undergo surgery to have the tumor removed. Before the surgery, the patient signs a document giving instructions to his family regarding the level and extent of life-prolonging treatments he desires. Which of the choices below describe this legal directive? Select all that apply. a) The document is a durable power of attorney for healthcare. b) The document is a living will. c) The family can make decisions that are consistent with the document if the patient is incompetent. d) The family is able to decide to prolong the patient's life, even if he does not want it. e) The family has guidance on the treatments the patient wants.

b) The document is a living will. c) The family can make decisions that are consistent with the document if the patient is incompetent. e) The family has guidance on the treatments the patient wants.

The nurse believes that abortion is wrong, but applies the MORAL model and decides that caring for patients following an abortion is her ethical duty. When evaluating the effectiveness of the nurse's decision process, what finding would indicate the nurse made the best choice? a) The patient is discharged without experiencing complications from the procedure. b) The nurse believes quality care was delivered and feels satisfied with the decision. c) The nurse manager commends the nurse for providing excellent patient care. d) The patient thanks the nurse for being supportive during a difficult time.

b) The nurse believes quality care was delivered and feels satisfied with the decision.

In which of the following circumstances might the nurse defer obtaining informed consent for care and treatment of a patient? a) The patient is confused and cannot understand or sign the consent form. b) The patient is brought to the emergency department in cardiac arrest; no family is present. c) The surgeon requests that the patient be sent to the surgical suite before the nurse gets the consent form signed. d) An unconscious patient is admitted to the nurse's unit; he is alone.

b) The patient is brought to the emergency department in cardiac arrest; no family is present.

An 87-year-old patient has just been diagnosed with cancer. Her durable power of attorney names her son as her surrogate decision maker. He arrives at the patient's bedside to discuss treatment options with her. The patient is alert and oriented. Her son tells you that he does not want her to receive any treatment (chemotherapy) because of the side effects and her age. The patient tells you that she wants to try the treatment. Which decision should be followed by the nurse? a) The patient's son's b) The patient's c) Both—initially the patient's; then the son's when the medication's side effects become severe d) Neither; this is a legal decision and should be made by a court of law

b) The patient's

A medical provider has prescribed milk of magnesia (magnesium hydroxide) 30 mL, PO bid. Here bid means: a) Once every day b) Two times every day c) Three times every day d) Four times a day

b) Two times every day

Which instruction by a registered nurse should the student nurse clarify with her clinical instructor? "When taking off the provider's orders, you should: a) Write drug names in full—rather than using abbreviations" b) Use apothecary units—instead of metric units" c) Write 'at' or 'each'—rather than use the '@'symbol" d) Write 'mL' or 'milliliters'—in place of the 'cc' abbreviation"

b) Use apothecary units—instead of metric units"

A surgeon refused a patient's request to restart a patient's total parenteral nutrition (giving nutrition through the intravenous route) because he believed that a greater good would be achieved by not using medical resources to prolong the life of a terminally ill patient when the resources could be used for other patients. Which ethical theory best explains the surgeon's rationale? a) Ethics of care b) Utilitarianism c) Deontology d) Categorical imperative

b) Utilitarianism

The patient has shiny ulcerations on a red base over the medial calf of the right leg. There is quite a bit of fluid drainage. He takes anticoagulants because of recurrent deep vein thrombosis. He also reports a sedentary lifestyle. How would the nurse classify this chronic wound? a) Pressure ulcer b) Venous stasis ulcer c) Diabetic foot ulcer d) Arterial ulcer

b) Venous stasis ulcer

For which patient is the nursing diagnosis Deficient Recall most appropriate? a) Adolescent with Down syndrome and newly diagnosed with cardiac problem b) Young adult admitted with acute renal failure who requires hemodialysis c) Middle-aged woman with breast cancer receiving the last round of chemotherapy d) Older adult with a long-standing history of type 1 diabetes admitted with a foot ulcer

b) Young adult admitted with acute renal failure who requires hemodialysis

A pregnant 15-year-old girl presents to the emergency department (ED) of the local private hospital. She has been transported by her mother and appears to be in active labor. The girl is crying uncontrollably and says she is scared and experiencing painful contractions. Her mother states, "We don't have any money or insurance, but this hospital is closer than the public hospital, and she needs help now." What is the first step that the ED staff should take? a) Arrange for an ambulance to transport her to the nearest public hospital. b) Explain to the girl and her mother that the hospital only accepts patients who can pay the hospital bill. c) Examine her to determine whether her condition is stable or whether she requires immediate medical attention. d) Inform her mother that she will need to transport her daughter to the nearest public hospital.

c) Examine her to determine whether her condition is stable or whether she requires immediate medical attention.

You are caring for an alert, oriented 47-year-old patient who is recovering from abdominal surgery. The patient becomes angry and upset and says, "I'm leaving this hospital. Remove my IV and surgical drains or I will do it myself." To keep him from removing his lines and leaving the hospital, you apply bilateral wrist restraints until you can contact the physician for an order for patient restraint. This is an example of which of the following? a) Assault and battery b) Felony c) False imprisonment d) Quasi-intentional tort

c) False imprisonment

A patient has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage I pressure ulcer. What would be the most important treatment for this patient? a) Transparent film dressing b) Sheet hydrogel c) Frequent turn schedule d) Enzymatic debridement

c) Frequent turn schedule

While you are admitting an adult patient, he asks you whether he should create an advance directive. To provide him adequate information to make an informed decision, you should tell the patient which of the following? Select all that apply. a) If he is unable to communicate, his family may make changes to his advance directive. b) Once he signs an advance directive, no further care will be provided to him. c) He may change his advance directive by telling his physician or by making changes in writing. d) An advance directive will ensure he gets as much or as little care as he wishes.

c) He may change his advance directive by telling his physician or by making changes in writing. d) An advance directive will ensure he gets as much or as little care as he wishes.

The charge nurse uses a whiteboard located at the nurse's station to write the nurses' patient assignments and the patients' diagnoses. This is a violation of which of the following? a) Americans with Disabilities Act (ADA) b) Patient Self-Determination Act (PSDA) c) Health Insurance Portability and Accountability Act (HIPAA) d) Health Emergency Medical Treatment and Active Labor Act (EMTALA)

c) Health Insurance Portability and Accountability Act (HIPAA)

The nurse is administering the 0900 dose of heparin 5,000 units subcutaneously ordered every 6 hours to a patient with deep vein thrombosis (DVT). At 0800, the patient's laboratory values show partial thromboplastin time (PTT) and clotting times are four times the normal range. The nurse observes petechiae on the patient's buttocks and back and recognizes these as signs of risk for significant bleeding. The correct nursing actions at this time are below. Select all that apply. a) Notify the prescriber before giving the medication. b) Give subcutaneous heparin as ordered. c) Hold the medication dose at this time. d) Chart the reason the medication was not given. e) Assess for other significant signs and symptoms. f) Record abnormal findings in the patient's health record.

c) Hold the medication dose at this time. d) Chart the reason the medication was not given. e) Assess for other significant signs and symptoms. f) Record abnormal findings in the patient's health record.

Which of the following is the most beneficial aspect of electronic documentation systems? a) Assist collaboration b) Provide cautionary reminders c) Improve legibility d) Serve as a resource

c) Improve legibility

Computers are important for evidence-based practice because: a) Computer access is available to all healthcare staff b) Additional training is not required for information retrieval c) Information can be accessed and managed more efficiently d) All of the best evidence is available on the Internet

c) Information can be accessed and managed more efficiently

While applying a wet-to-dry dressing, how would the nurse explain to the patient how this procedure works for promoting healing? A wet-to-dry dressing is a: a) Method of submerging the wound in water, allowing it to soak before drying the wound bed b) Procedure that uses proteolytic agents to break down necrotic tissue in the wound bed c) Means of debriding the wound but also removing granulation tissue from the wound d) Form of debridement that uses an occlusive, moisture-retaining dressing to break down necrotic tissue

c) Means of debriding the wound but also removing granulation tissue from the wound

Which client does the nurse recognize as being at greatest risk for pressure ulcers? a) Infant with skin excoriations in the diaper region b) Young adult with diabetes in skeletal traction c) Middle-aged adult with quadriplegia d) Older adult requiring use of assistive device for ambulation

c) Middle-aged adult with quadriplegia

The charge nurse in a progressive care unit assigns the care of a patient receiving hemodialysis to a newly hired licensed practical nurse (LPN) without checking to see that the nurse has been determined competent to care for hemodialysis patients. The LPN is in orientation and fails to inform the charge nurse that she does not have experience with this type of patient. The actions of the charge nurse would be considered to be which of the following? a) Malpractice b) Incompetence c) Negligence d) Abandonment

c) Negligence

You are a preceptor for a new nursing employee at the local hospital. She needs to access a patient's electronic health record (EHR) to retrieve laboratory results; however, the newly hired nurse has not yet received a computer password. What action should you take? a) Give her your password to use until she obtains her own password. b) Log on and remain with her while she views the record. c) Notify your supervisor that the new employee needs a password. d) Inform her that she will not receive a password until her orientation is complete.

c) Notify your supervisor that the new employee needs a password.

The instructor is teaching the nursing students about electronic health records (EHR). Which student statement indicates the need for further instruction? a) "I have had EHR instruction and understand the basics of the system. If I need assistance, I will ask for it." b) "The EHR integrates the patient's health information documented by the entire healthcare team into one electronic system." c) "The EHR can track problems and errors, which can direct quality improvement efforts in a given institution." d) "I am proficient with a computer; therefore, I am completely prepared to use the EHR in any institution."

d) "I am proficient with a computer; therefore, I am completely prepared to use the EHR in any institution."

An adult patient is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The patient has no problem with rubbing, friction, or shear. What is the Braden score for this patient? a) 0 b) 15 c) 20 d) 23

d) 23

The parents of a 12-year-old boy refuse chemotherapy to treat the child's leukemia, saying they will not ruin what is left of his life with drugs that will make him feel sicker. Which solution to this ethical dilemma would demonstrate compromise, maintaining the integrity of all involved? a) Agreeing to allow the child to avoid chemotherapy b) Explaining to the parents that without chemotherapy the child will die. c) Obtaining a court order to require the parents to allow chemotherapy. d) Agreeing to administer the chemotherapy agent with the fewest side effects.

d) Agreeing to administer the chemotherapy agent with the fewest side effects.

The nurse is caring for a patient with an infected full-thickness wound with moderate drainage and no odor. What type of dressing will be most appropriate for the nurse to apply? a) Alginate b) Antimicrobial petroleum gauze c) Foam dressing d) Antimicrobial collagen dressings

d) Antimicrobial collagen dressings

When the nurse is giving instructions for discharge, he notices that the television is on and he is eating a meal. The best thing for the nurse to do to ensure that the patient's discharge teaching is understood is to: a) Review all important discharge teaching while in the room b) Ask whether the patient has any questions about the discharge c) Inform the patient that the instructions are on the discharge sheet d) Arrange another time with the patient to review the discharge teaching

d) Arrange another time with the patient to review the discharge teaching

Confidentiality will be maintained by a nurse who believes in and values the ethical principle of: a) Fidelity b) Veracity c) Beneficence d) Autonomy

d) Autonomy

The department of nursing at a local hospital is considering changing to charting by exception (CBE). A major disadvantage of CBE is that it: a) Increases the time nurses spend on charting in narrative format b) Does not clearly identify deviations from normal expectations c) Requires all providers to document in the same sections of the chart d) Can increase the risk of omissions in patient care

d) Can increase the risk of omissions in patient care

A patient had a CVA (stroke) 2 days ago, resulting in decreased mobility to her left side. During the assessment, the nurse discovers a stage I pressure area on the patient's left heel. What is the initial treatment for this pressure ulcer? a) Antibiotic treatment for 2 weeks b) Normal saline irrigation of the ulcer daily c) Debridement to the left heel d) Elevation of the left heel off the bed

d) Elevation of the left heel off the bed

What is one advantage of problem-intervention-evaluation (PIE) charting? a) Focuses on a complete list of client problems b) Assesses the client in a comprehensive manner c) Documents the planning portion of the client's care d) Establishes an ongoing plan of care for the client

d) Establishes an ongoing plan of care for the client

A resident in a long-term care facility is unable to provide self-care owing to dementia and is receiving Medicare funds. How often must the nurse document this resident's care? a) Every 2 weeks b) Every shift c) Every week d) Every 3 months

d) Every 3 months