NCLEX Questions for Nursing 102 Exam #2

A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake" This is an example of what type of outcome? A. Cognitive B. Psychomotor C. Affective D. Physical Change

A. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; affective outcomes pertain to changes in patient values, beliefs, and attitudes; and physical changes are actually bodily changes in the patient

A public health nurse is leaving the home of a young mother who has a special needs baby. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's BEST response to the neighbor? A. "New mothers need support" B. "The lack of a father is difficult" C. "How are you today?" D. "It is a very sad situation"

A. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles

A hospice nurse is caring for a patient with end-stage cancer. What action demonstrates this nurse's commitment to the principle of autonomy? A. The nurse helps the patient prepare a durable power of attorney document B. The nurse gives the patient undivided attention when listening to concerns C. The nurse keeps a promise to provide a counselor for the patient D. The nurse competently administers pain medication to the paitent

A. The principle of autonomy obligates nurses to provide information and support patients and their surrogates need to make decisions that advance their interests. Acting with justice means giving each person his or her due, acting with fidelity involves keeping promises to patients, and acting with nonmaleficence means avoiding doing harm to patients

A nurse is caring for a patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnosis for this patient? Select all that apply. A. Bronchial pneumonia B. Impaired gas exchange C. Ineffective airway clearance D. Potential complication: sepsis E. Infection related to pneumonia F. Risk for septic shock

B, C, F. Nursing diagnoses are actual or potential health problems that can be prevented or resolved by independent nursing interventions, such as impaired gas exchange, ineffective airway clearance, or risk of septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? A. Every 3 hours B. Every 4 hours C. Daily D. As needed

B. PRN means "as needed"- not every 3 hours, every 4 hours or once daily

Nurses use the NIC Taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure? A. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions B. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings C. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention D. A complete list of reimbursable charges for each nursing intervention

B. The NIC Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges

A nurse is providing instruction to a patient regarding the procedure to change a colostomy bag. During the teaching session, the patient asks, "What type of foods should I avoid to prevent gas?" The patient's question allows for what type of communication on the nurse's part? A. A closed ended answer B. Information clarification C. The nurse to give advice D. Assertive behavior

B. The patient's question allows he nurse to clarify information that is new to the patient or that requires further explanation

A medication order reads: "K-Durr, 20 mEq po BID" When and how does the nurse correctly give this drug? A. Daily at bedtime by subcutaneous route B. Every other day by mouth C. Twice a day by the oral route D. Once a week by transdermal patch

C. The abbreviation BID refers to twice a day administration; po (by mouth) refers to administration by the oral route

A state attorney decides to charge a nurse with manslaughter for allegedly administering a lethal medication. This is an example of what type of law? A. Public law B. Private law C. Civil law D. Criminal law

D. Criminal law concerns state and federal criminal statues, which define criminal actions such as murder, manslaughter, criminal negligence, theft, and illegal possession of drugs. Public law regulates relationships between people and the government. Private or civil law includes laws relating to contracts, ownership of property, and the practice of nursing, medicine, pharmacy, and dentistry

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? A. Admission sheet B. Admission nursing assessment C. Flow sheet D. Graphic record

D. While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequential recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign documentation, and neither does the flow sheet

Read the following scenario and identify the adjective used to describe the characteristics of patient date that are numbered below. Place your answers on the lines provided. The nurse is conducting an initial assessment of a 79 year old female patient admitted to the hospital with a diagnosis of dehydration. The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive assessment and gather the appropriate patient data. (2) First the nurse asks the patient about the most important details leading up to her diagnosis. Then the nurse (3) collects as much information as possible to understand the patients health problems; (4) collects the patient data in an organized manner; (5) verifies that the data obtained is pertinent to the patient care plan; and (6) records the data according to facilities policy. (1)_______________________ (2)______________________ (3)______________________ (4)______________________ (5)______________________ (6)________________________

(1) Purposeful: the nurse identifies the purpose of the nursing assessment (comprehensive) and gathers the appropriate data (2) Prioritized: the nurse gets the most important information first (3) Complete: the nurse gathers as much data as possible to understand the patient health problem and develop a care plan (4) Systemic: the nurse gathers the information in an organized manner (5) Accurate and relevant: the nurse verifies that the information is reliable (6) Recorded in a standard format: the nurse records the data according to the facilities policy so that all caregivers can easily access what is learned

Read the following patient scenario and identify the step of the nursing process represented by each numbered and boldfaced nursing activity. Annie seeks the help of the nurse in the student health clinic because she suspect that her roommate, Angela, suffered date rape. She is concerned because Angela chose not to report the rape and doe not seem to be coping well. (1) After talking with Annie, the nurse learns that although Angela blurted out that she had been raped when she first came home, since then she has refused verbalization about the rape ("I don't want to talk or think about it"), has stopped attending all college social activities (a marked change in behavior), and seems to be having nightmares. After analyzing the data, the nurse believe that Angela might be experiencing (2) rape trauma syndrome: silent reaction. Fortunately, Angela trusts Annie and is willing to come tot he student health center for help. A conversation with Angela confirms the nurse's suspicions, and problem identification begins. The nurse talks further with Angela (3) To develop some treatment goals and formulate outcomes. The nurse also begins to think about the types of nursing interventions most likely to yield the desired outcomes. In the initial meeting with Angela, (4) the nurse encourages her expression of feelings and helps her to identify personal coping strategies and strengths. The nurse and Angela decide to meet in 1 week (5) to assess her progress toward achieving targeted outcome. If she is not making progress, the care plan might need to be modified. (1)_______________ (2)______________ (3)______________ (4)________________ (5)________________

(1) assessing: the collection of patient data (2) identification of a nursing diagnosis: a health problem that independent nursing intervention can resolve (3) planning: outcome identification and related nursing interventions (4) implementing: carrying out the care plan (5) evaluation: measuring the extent to which Angela has achieved target outcomes

A nurse caring for patients in a critical care unit knows that providing good oral hygiene is an essential part of nursing care. What are some of the benefits of providing this care? Select all that apply. A. It promotes the patients sense of wellbeing B. It prevents deterioration of the oral cavity C. It contributes to decreased incidence of aspiration pneumonia D. It eliminates the need for flossing E. It decreases oropharyngeal secretions F. It helps to compensate for an inadequate diet

A, B, C. Adequate oral hygiene is essential for promoting the patients sense of well-being and presenting deterioration of the oral cavity. Diligent oral hygiene care can also improve oral health and limit the growth of pathogens in oropharyngeal recreations, decreasing the incidence of aspiration pneumonia and other systemic disease. Oral care does not eliminate the need for flossing, decrease oropharyngeal secretions, or compensate for poor nutrition

A nurse is preparing medications for patients in the ICU. The nurse is aware that there are patient variables that may affect the absorption of these medications. Which statements accurately describe these variables? Select all that apply. A. Patients in certain ethnic groups obtain therapeutic responses at lower doses or higher doses than those usually prescribed B. Some people experience the dame response with a placebo as with the active drug used in studies C. People with liver disease metabolize drugs more quickly than people with normal liver functioning D. A patient who receives a pain medication in a noisy environment may not receive full benefit from the medications effects E. Oral medications should not be given with food as the food may delay the absorption of the medications F. Circadian rhythms and cycles may influence drug action

A, B, D, F. Nurses need to know about medications that may produce varied responses in patients from different ethnic groups. The patients expectations of the medication may affect the response to the medication, for example, when a placebo is given and a patient has a therapeutic effect. The patients environment may also influence the patients response to medications, for example, sensory deprivation and overload may affect drug responses. Circadian rhythms and cycles may also influence drug action. The liver is the primary organ for drug breakdown, thus pathologic conditions that involve the liver may slow metabolism and alter the dosage of the drugs needed to reach a therapeutic level. The presences of food in the stomach can delay the absorption of orally administered medications. Alternately, some medications should be given with food to prevent gastric irritation, and the nurse should consider this when establishing a patient's medication schedule. Other medications may have enhance absorption if taken with certain foods

The three types of responses to pain are physiologic, behavioral and affective. Which are examples of behavioral responses to pain? Select all that apply. A. A patient cradles a wrist that was injured in a car accident B. A child is moaning and crying due to a stomachache C. A patients pulse is increased following a myocardial infraction D. A patient in pain strikes out at a nurse who attempts to provide a bath E. A patient who has chronic cancer pain is depressed and withdrawn F. A child pulls away from a nurse trying to give an injection

A, B, F. Protecting or guarding a painful area, moaning and crying, and moving away from painful stimuli are behavioral responses. Examples of a physiologic or involuntary response would be increased blood pressure or dilation of pupils. Affective responses such as anger, withdrawal, and depression, are psychological in nature

The nurse collects objective and subjective data when conducting patient assessments. Which patient situations are examples of subjective data? Select all that apply. A. A patient tells the nurse that she is feeling nauseous. B. A patient's ankles are swollen. C. A patient tells the nurse that she is nervous about her test results. D. A patient complains that the skin on her arms is tingling. E. A patient rates his pain as a 7 on a scale of 1 to 10. F. A patient vomits after eating supper.

A, C, D, E. Subjective data are information perceived only by the affected person; these data cannot be perceived or verified by another person. Examples of subjective data are feeling nervous, nauseated, tingling, and experiencing pain. Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them. Examples of objective data are an elected temperature reading, edema, and vomiting

A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. A. Basing patient care on continuous healing relationships B. Customizing care to reflect the competencies of the staff C. Using evidence based decision making D. Having a charge nurse as the source of control E. Using safety as a system priority F. Recognizing the need for secrecy to protect patient privacy

A, C, E. Care should be based on continuers healing relationships and evidence based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for transparency should be recognized

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. A. Monitoring patient status every hour B. Using intuition to troubleshoot patient problems C. Turning a patient on bed rest every 2 hours D. Becoming a nurse mento to a student nurse E. Administering pain medication ordered by the physician F. Becoming involved in community nursing events

A, C, E. Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They are established by authority, custom, or consent. Standards would include monitoring patient status every hour, turning a patient on bed rest every 2 hours and administering pain medication ordered by the physician. Using intuition to troubleshoot patient problems, becoming a nurse mentor to a student nurse, and becoming involved in community nursing events are not patient care standards

A nurse is teaching a patient how to use a meter-dosed inhaler to control asthma. What are appropriate guidelines for this procedure? Select all that apply. A. shake the inhaler well and remove the mouthpiece covers from the MDI and spacer B. Take shallow breaths when breathing through the spacer C. Depress the canister releasing one puff into the spacer and inhale slowly and deeply D. After inhaling, exhale quickly through pursed lips E. Wait 1 to 5 minutes as prescribed before administering the next puff F. Gargle and rinse with salt water after using the MDI

A, C, E. The correct procedure for using a meter-dosed inhaler is: shake the inhaler well and remove the mouthpiece cover; breath normally through the spacer; depress the canister releasing one puff into the spacer and inhale slowly and deeply; after inhaling hold breath for 5 to 10 seconds, or as long as possible and then exhale slowly through pursed lips; wait 1 to 5 minutes as prescribed before administering the next puff; and gargle and rinse with tape water after using the MDI

A nurse is providing foot care for patients in a long term care facility. Which actions are recommended guidelines for this procedure? Select all that apply. A. Bathe the feet thoroughly in a mild soap and tepid water solution B. Soak the feet in warm water and bath oil C. Dry feet throughly, including the area between the toes D. Use an alcohol rub if the feet are dry E. Use an anti fungal foot powered if necessary to prevent fungal infections F. Cute the toenails at the lateral corners when trimming the nail

A, C, E. The following are recommended guidelines for foot care: bathe the feet throughly in a mild soap and tepid water solution; dry feet throughly, including the area between the toes; and use an anti fungal foot powered if necessary to precent fungal infections. The nurse should avoid soaking the feet, use moisturizer if the feet are dry, and avoid digging into or cutting the toenails at the lateral corners when trimming the nails

A student nurse begins a clinical rotation in a long term care facility and quickly realized that certain residents have unmet needs. The student wants to advocate for these residents. Which statements accurately describe this concept? Select all that apply. A. Advocacy is the protection and support of another rights B. Patient advocacy is primarily performed by nurses C. Patients with special advocacy needs include the very young and he older adult, those who are seriously ill, and those with disabilities D. Nurse advocates make good health care decisions for patients and residents E. Nurse advocates do whatever patients and residents want F. Effective advocacy may entail becoming politically active

A, C, F. Adcocacy is the protection and support of another's rights. Among the patients with special advocacy needs are the very young and older adult, those who are seriously ill, and those with disabilities; this is not a comprehensive list. Effective advocacy may entail becoming politically active. Patient advocacy is the responsibility of every member of the professional caregiving team-not just nurses. Nurse advocated do not make health care decisions for their patients and residents. Instead, they facilitate patient decision making. Advocacy does not entail supporting patients in all their preferences.

Nurses performing skin assessments on patients must pay careful attention to cleanliness, color, texture, temperature, turgor, moisture, sensation, vascularity, and lesions. Which guidelines should nurses follow when performing these assessments? Select all that apply. A. Compare bilateral parts for symmetry. B. Proceed in a toe-to-head systematic manner. C. Use standard terminology to report and record findings. D. Do not allow data from the nursing history to direct the assessment. E. Document only skin abnormalities on the patient record. F. Perform the appropriate skin assessment when risk factors are identified.

A, C, F. When performing a skin assessment, the nurse should compare bilateral parts for symmetry, use standard terminology to report and record findings, and perform the appropriate skin assessment when risk factors are identified. The nurse should proceed in a head to toe systematic manner, and allow date from the nursing history to direct the assessment. When documenting a physical assessment of the skin, the nurse should describe exactly what is observed or palpated, including appearance, texture, size, location or distribution, and characteristics of any findings

A nurse is using critical pathway methodology for choosing interventions for a patent who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. A. The nurse uses a minimal practice standard and is able to alter care to meet the patients individual needs B. The nurse uses a binary decision tree for stepwise assessment and intervention C. The nurse is able to measure the cause and effect relationship between pathway and patient outcomes D. The nurse uses broad, research based practice recommendations that may or may not have been tested in clinical practice E. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has even validated through research F. The nurse uses a decision tree that provides intense specificity and no provider flexibility

A, C. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause and effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity an not provider flexibility. Guidelines are broad, research based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research

During a nursing staff meeting, the nurses resolve a problem of delayed documentation by agreeing unanimously that they will make sure all vital signs are reported and charted within 15 minutes following assessment. This is an example of which characteristics of effective communication? Select all that apply. A. Group decision making B. Group leadership C. Group power D. Group identity E. Group patterns of interaction F. Group cohesiveness

A, D, E, F. Solving problems involves group decision making; ascertaining that the stage completes a task on time and that all members agree the task is important is a characteristic of group identity; group patterns of interaction involve honest communication and member support; and cohesiveness occurs when members generally trust each other, have a high commitment to the group, and a high degree of cooperation. Group leadership occurs when groups use effective styles of leadership to meet goals; with group power, sources of power are recognized and used appropriately to accomplish group outcomes

A nurse is monitoring patients in a hospital setting for acute and chronic pain. Which patients would most likely relieve analgesics for chronic pain from the nurse? Select all that apply. A. A patient is receiving chemotherapy for bladder cancer B. An adolescent is admitted to the hospital for an appendectomy C. A patient is experiencing a ruptured aneurysm D. A patient who has fibromyalgia requests pain medication E. A patient has back pain related to an accident that occurred last year F. A patient is experiencing pain from second degree burns

A, D, E. Chronic pain is pain that may be limited, intermittent, or persistent bu that lasts beyond the normal healing period. Examples are cancer pain, fibromyalgia pain, and back pain. Acute pain is generally rapid in onset and varies in intensity from mild to severe, as occurs with an emergency appendectomy, a ruptured aneurysm, and pain from burns

A nurse is teaching a student nurse how to cleanse the perineal area of bath male and female patients. What are accurate guidelines when performing this procedure? Select all that apply. A. For male and female patients, wash the groin area with a small amount of soap and water and rinse B. For a female patient, spread the labia and move the washcloth from the anal area toward the pubic area C. For male and female patients, always proceed from the most contaminated area to the least contaminated area D. For male and female patients, use a clean portion of the washcloth for each stroke E. For a male patient, clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward F. In an uncircumcised male patient, do not retract the foreskin (prepuce) while washing the penis

A, D, E. Wash and rinse the groin area (both male and female patients) with a small amount of soap and water, and rinse. For male and female patients, always proceed from he least contaminated area to the most contaminated area and use a clean portion of the washcloth for each stroke. For a male patient, clean the time of the penis first, moving the washcloth in a circular motion from he meatus outward. For a female patient, spread the labia and move the washcloth from the pubic area toward the anal area. In an uncircumcised male patient (teenage or older), retract the foreskin while washing the penis

A nurse who is administering medications to patients in an acute care setting studies the pharmacokinetics of the drugs being administered. Which statements accurately describe these mechanisms of action? Select all that apply. A. Distribution occurs after a drug has been absorbed into the bloodstream and is made available to body fluids and tissues. B. Metabolism is the process by which a drug is transferred from its site of entry into the body to the bloodstream. C. Absorption is the change of a drug from its original form to a new form, usually occurring in the liver. D. During first-pass effect, drugs move from the intestinal lumen to the liver by way of the portal vein instead of going into the system's circulation. E. The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug absorption. F. Excretion is the process of removing a drug, or its metabolites (products of metabolism), from the body.

A, D, F. Distribution occurs after a drug has been absorbed into the bloodstream and the drug is distributed throughout the body, becoming available to body fluids and body tissues. Some drugs move from the intestinal lumen to the liver by way of the portal vein and do not go directly into the systemic circulation following oral absorption. This is called the first pass effect, or hepatic first pass. Excretion is the process of removing a drug or its metabolites (products of metabolism) from he body. Absorption is the process by which a drug is transferred from its site of entry into the body to the bloodstream. Metabolism, or biotransformation, is the change of a drug from its original form to a new form. The liver is the primary site for drug metabolism. The gastrointestinal tract, as well as sweat, salivary, and mammary glands, are routes of drug excretion

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. A. The nurse carefully removes the bandages from a burn victims arm B. The nurse assesses a patient to check nutritional status C. The nurse formulates a nursing diagnosis for a patient with epilepsy D. The nurse turns a patient in bed every 2 hours to prevent pressure injuries E. The nurse checks a patients insurance coverage at the initial interview F. The nurse checks for community resources for a patient with dementia

A, D, F. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes; promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step

Newly hired nurses in a busy suburban hospital are required to read the state Nurse Practice Act as part of their training. Which topics are covered by this act? Select all that apply. A. Violations that may result in disciplinary action B. Clinical procedures C. Medication administration D. Scope of practice E. Delegation policies F. Medicare reimbursement

A, D. Each state has a nurse practice act that protects the public by broadly defining the legal scope of nursing practice. Practicing beyond those limits makes nurses vulnerable to charges of violating the state nurse practice act. Nurse practice acts also list the violations that can result in disciplinary actions against nurses. Clinical procedures are covered by the health care institutions themselves. Medication administration and delegation are topics covered by the board of nursing. Laws governing medicare reimbursement are enacted through federal legislation

The nurse is admitting a 35 year old pregnant woman to the hospital for treatment of preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when the doctor just did one?' Which statements best explain the primary reasons a nursing assessment is performed? Select all that apply. A. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths" B. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!" C. "I'm as student nurse and need to develop the skill of assessing your health status and need for nursing care" D. "We want to make sure that your responses to the medical exam are consistent and that all our data are accurate" E. "We need to check your health status and see what kind of nursing care you may need" F. "We need to see if you require a federally to a physician or other health care professional"

A, E, F. Medical assessments target data pointing to pathologic conditions, whereas nursing assessments focus on the patients responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patients health status, the ability to manage his or her own health care and the need for nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on the patients strengths and promotes optimum functioning, independence, and well being, and enables the nurse to refer the patient to a physician or other health care professional, if indicated. The fact that this is hospital policy is a secondary reason, and although it may be true that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs a nursing history and exam. The assessment is not performed to check the accuracy of the medical examination.

A nurse is caring for an adolescent with severe acne. Which recommendations would be most appropriate to include in the teaching plan for this patient? Select all that apply. A. Wash the skin twice a day with a mild cleanser and warm water B. Use cosmetics liberally to cover blackheads C. Use emollients on the area D. Squeeze blackheads at they appear E. Keep hair off the face and wash hair daily F. Avoid sun-tanning booth exposure and use sunscreen

A, E, F. Washing the skin removes oil and debris, hair should be kept off the face and washed daily to keep oil from the hair off the face, and sunbathing should be avoided when using acne treatments. Liberal use of cosmetics and emollients can clog the pores. Squeezing blackheads is always discouraged because it may lead to infection

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all the apply. A. The nurse uses critical thinking skills to plane care for a patient B. The nurse correctly administers IV saline to a patient who is dehydrated C. The nurse assists a patient to fill out an informed consent form D. The nurse learns the correct dosages for patient pain medications E. The nurse comforts a mother whose baby was born with down syndrome F. The nurse uses the proper procedure to catheterize a female patient

A,D. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? A. 2, 4, 1, 3 B. 3, 1, 4, 2 C. 2, 4, 3, 1 D. 3, 2, 4, 1

A. 2,4,1,3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self actualization needs. #2 is an example of physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self esteem need, and #3 is an example of a self actualization need

A nurse notices a patient is walking to the bathroom with a stooped gait, facial grimacing, and gasping sounds. Based on these nonverbal clues, for which condition would the nurse assess? A. Pain B. Anxiety C. Depression D. Fluid volume deficit

A. A patient who presents with nonverbal communication of a stooped gait, facial grimacing, and gasping sounds is most likely experiencing pain. The nurse should clarify this nonverbal behavior

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: A. Clinical judgement B. Clinical reasoning C. Critical thinking D. Blended competencies

A. Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to there result or outcome of critical thinking or clinical reasoning- in this case, the recommendation to meet with nutritionist. Clinical reasoning usually refers tow ays of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reading becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? A. Intuitive problem solving comes with years of practice and observation, and nonie nurses should base their care on scientific problem solving B. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning C. The emphasis on logical, scientific, evidence based reasoning has held nursing back for years; it it time to champion intuitive, creative thinking! D. It it simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers

A. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference

A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right sided paresis. What is an example of this type of outcome? A. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body B. By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself C. Following physical therapy, patient will begin to gradually participate in walking/running events D. By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events

A. Clinical outcomes describe the exprected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describes the person's ability to function in relation to the desired usual activities. Quality of life outcomes (c) focus on key factors that affect someones ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

A nurse is removing rigid gas permeable (RGP) contact lenses from the eyes of a patient who is unable to assist with removal. The nurse notices that one of the lenses is not centered over the cornea. What would be the nurse's first action in this procedure? A. Apply gentle pressure on the lower eyelid to center the lens prior to removing it B. Move the eyelids toward one another to cause the lens to slide out between the eyelids C. Do not attempt to remove the lens as it should only be removed by an eyesore specialist D. Have the patent look forward, retract the lower lid, and move the lens down on the sclera

A. If the lens is not centered over the cornea, the nurse should apply gentle pressure on the lower eyelid to center the lens, gently pull the outer corner of the eye toward the ear, position the hand below the lens to relieve it, and ask the patient to blink. Moving the eyelids toward one another to cause the lens to slid out between the eyelids is a later step in the procedure. Having the patient look forward, retracting the lower lid and moving the lens down on the sclera occurs during removal of soft contact lenses. It is not necessary to call in an eyesore specialist unless there is damage to the eye

A nurse is administering phenytoin via a gastric tube to a patient who is receiving tube feedings. What would be an appropriate action of the nurse in this situation? A. Discontinue the tube feeding and lave the tube clamped for required period of time before and after medication administration B. Notify the primary care provider that medication cannot be given to the patient at this time via the gastric tube C. Remove the tube in place and replace it with another tube prior to administering the medication D. Flush the tube with 60mL of water prior to administering the medication

A. If the patient is receiving tube feedings, the nurse should review information about the drugs to be administered. Absorption of some drugs, such as phenytoin, is affected by tube feeding formulas. The nurse should discontinue a continuous tube feeding and leave the tube clamped for the required period of time before and after the medication has been given, according to the reference and facility protocol

When the initial nursing assessment revealed that a patient had not had a bowel movement for 2 days, the student nurse wrote the diagnostic label "constipation." What would be the instructor's BEST response to this student's diagnosis? A. "Was this diagnosis derived from a cluster of significant data or a single clue?" B. "This early diagnosis will help us manage the problem before it becomes more acute." C. "Have you determined if this is an actual or a possible diagnosis?" D. "This condition is a medical problem that should not have a nursing diagnosis."

A. Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue. A data cluster is a grouping of patient data or cues that point to the existence of a patient health problem. There may be a reason for the lack of a bowel movement for 2 days, or it might be this person normal pattern

A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? A. Perform the focused assessment as this is an independent nurse initiated intervention B. Request an order from Jill's physician since their is a physician intimated intervention C. Request an order from Jill's physical since this is a collaborative intervention D. Request an order from the nutritionist since this is a collaborative intervention

A. Performing a focused assessment is an independent nurse initiated intervention; thus the nurse does not need an order from the physician or the nutritionist

A quality assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, "We'd better find the people responsible for these errors and see if we can replace them." This is an example of: A. Quality by inspection B. Quality by punishment C. Quality by surveillance D. Quality by opportunity

A. Quality by inspection focuses on finding deficient workers and removing them. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Quality by punishment and quality by surveillance are not quality assurance methods used in the health care field

A nurse is caring for patients in a hospital setting. Which patient would the nurse place at risk for pain related to the mechanical activation of pain receptors? A. an older adult on bedrest following cervical spine surgery B. a patient with a severe sunburn being treated for dehydration C. an industrial worker who has burns caused by a caustic acid D. a patient experiencing cardiac disturbances from an electrical shock

A. Receptors in the skin and superficial organs may be stimulated by mechanical thermal, chemical, and electrical agents. Friction from bed linens causing pressure sores is a mechanical stimulant. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. An electrical shock is an electrical stimulant

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response? A. Tell the RN that he or she lacks the technical competencies to change the dressing independently B. Assemble the equipment for the procedure and follow the steps in the procedure manual C. Ask another student nurse to work collaboratively with him or her to change the dressing D. Report the RN to his or her instructor for deleting a task that should not be assigned to student nurses

A. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the care plan. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so

When interacting with a patient, the nurse answers, "I am sure everything will be fine. You have nothing to worry about." This is an example of what type of inappropriate communication technique? A. Cliche B. Giving advice C. Being judgmental D. Changing the subject

A. Telling a patient that everything is going to be all right is a cliche. This statement gives false assurance and gives the patient the impression that the nurse is not interested in the patients condition

The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the BEST tool to use with this patient? A. CRIES scale B. COMFORT scale C. FLACC scale D. FACES scale

A. The CRIES pain scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiological factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC scale (F-faces, L-legs, A-activity, C-cry, C-consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES scale is used for children who can compare their pain to the faces depicted on the scale

A nurse is using the SOAP format to document care of a patient who is diagnoses with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? A. A patient problem list B. Narrative notes describing the patients condition C. Overall trends in patient status D. Planned interventions and patient outcomes

A. The SOAP formation (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes of a POMR. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Overall trends in patient status can be seen immediately when using CBE, not SOAP charting. Planned interventions and patient-expected outcomes are the focus of the case management model

An older nurse asks a younger coworker why the new generation of nurses just aren't ethical anymore. Which reply reflects the BEST understanding of moral development? a. "Behaving ethically develops gradually from childhood; maybe my generation doesn't value this enough to develop an ethical code." b. "I don't agree that nurses were more ethical in the past. It's a new age and the ethics are new!" c. "Ethics is genetically determined...it's like having blue or brown eyes. Maybe we're evolving out of the ethical sense your generation had." d. "I agree! It's impossible to be ethical when working in a practice setting like this!"

A. The ability to be ethical, to make decisions, and to act in an ethically justified manner begins in childhood and develops gradually

A student nurse tells the instructor that a patient is fine and has "no complaints." What would be the instructor's best response? A. "You made an inference that she is fine because she has no complaints. How did you validate this?" B. "She probably just doesn't trust you enough to share what she is feeling. I'd work on developing a trusting relationship." C. "Sometimes everyone gets lucky. Why don't you try to help another patient?" D. "Maybe you should reassess the patient. She has to have a problem—why else would she be here?"

A. The instructor is most likely to challenge the inference that the patient is "fine" simply because she is telling you that she has no problems. It is appropriate for the instructor to ask how the student nurse validated this inference. Jumping to the conclusion that the patient does not trust the student nurse is premature and is an invalidated inference. Answer c is wrong because it accepts the invalidated inference. Answer d is wrong because it is possible that the condition is resolving

A nurse is administering a pain medication to a patient. In addition to checking his identification bracelet, the nurse correctly verifies the patient's identity by performing which action? A. asking the patient his name and birthdate B. Reading the patient name on the sign over the bed C. Asking the patient's roommate to verify his name D. Asking, "Are you Mr. Brown"

A. The nurse should ask the patient to state his name and birthdate based on facility policy. A sign over the patients bed may not always be current. The roommate is an unsafe source of information. The patient may not hear his name but may reply in the affirmative anyway (e.g. a person with a hearing deficit)

An attorney is representing a patient's family who is suing a nurse for wrongful death. The attorney calls the nurse and asks to talk about the case to obtain a better understanding of the nurse's actions. How should the nurse respond? A. "I'm sorry, but I can't talk with you; you will have to contact my attorney" B. "I will answer your questions so you'll understand how the situation occurred" C. "I hope I won't be blame for the death because it was so busy that day" D. "First tell me why you are doing this to me. This could ruin my career!"

A. The nurse should not discuss the case with anyone at the facility (with the exception of the risk manager), with the plaintiff, with the plaintiff's lawyer, with anyone testifying for the plaintiff, or with reporters. This is one of the cardinal rules for sure defendants

When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse is aware that the patient has consistently refused pain medication. What would be a priority nursing diagnosis for this patient? A. Acute Pain related to fear of taking prescribed postoperative medications B. Impaired Physical Mobility related to surgical procedure C. Anxiety related to outcome of surgery D. Risk for Infection related to surgical incision

A. The patients immediate problem is the pain that is unrelieved because the patent refuses to take pain medication for an unknown reason. The other nursing diagnoses are plausible, but not a priority in this situation

A nurse caring for a patient who is hospitalized following a double mastectomy is preparing a discharge plan for the patient. Which action should be the focus of this termination phase of the helping relationship? A. determining the progress made in achieving established goals B. clarifying when the patient should take medications C. reporting the progress made in teaching to the staff D. including all family members in the teaching session

A. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning coordinates with the termination phase of a helping relationship. The nurse should determine the progress made in achieving the goals related to the patient care

The nurse records a patient's blood pressure as 148/100. What is the priority action of the nurse when determining the significance of this reading? A. Compare this reading to standards B. Check the taxonomy of nursing diagnoses for a pertinent label C. Check a medical text for the signs and symptoms of high blood pressure D. Consult with colleagues

A. a standard, or a norm, is a generally accepted rule, measure, pattern, or model to which data can be compared in the same class or category. For example, when determining the significance of a patients blood pressure reading appropriate standards include normative values for the patients age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis

When may a health institution release a PHI for purposes other than treatment, payment, and routine health care operations, without the patient's signed authorization? Select all that apply. A. News media are preparing a report on the condition of a patient who is a public figure. B. Data are needed for the tracking and notification of disease outbreaks. C. Protected health information is needed by a coroner. D. Child abuse and neglect are suspected. E. Protected health information is needed to facilitate organ donation. F. The sister of a patient with Alzheimer's disease wants to help provide care.

B, C, D, E. According to the HIPAA, a health institution is not required to obtain written patient authorization to release PHI for tracking disease outbreaks, infection control, statistics related to dangerous problems with drugs or medical equipment, investigation and prosecution of a crime, identification of victims of crimes or disaster, reporting incidents of child abuse, neglect or domestic violence, medical records released according to a valid subpoena, PHI needed by coroners, medical examiners, and funeral directors, PHI provided to low enforcement in the case of a death from a potential crime, or facilitating organ donations. Under no circumstance can a nurse provide information to a news reporter without the patients express authorization. an authorization form is still needed to provide PHI for a patient who has Alzheimers disease.

A nurse caring for patients in a skilled nursing facility performs risk assessments on the patients for foot and nail problems. Which patients would be at a higher risk? Select all that apply. A. A patient who is taking antibiotics for chronic bronchitis B. A patient diagnosed with type 2 diabetes C. A patient who is obese D. A patient who has a nervous habit of biting his nails E. A patient diagnosed with prostate cancer F. A patient whose job involves frequent handwashing

B, C, D, F. Variables known to cause nail and foot problems include deficient self care abilities, vascular disease, arthritis, diabetes mellitus, history of biting nails or trimming them improperly, frequent or prolonged exposure to chemicals or water, trauma, ill-fitting shoes, and obesity

A nurse caring for patients in the intensive care unit develops values form experience to form a personal code of ethics. Which statements best describe this process? Select all that apply. A. People are born with values B. Values act as standards to guide behavior C. Values are ranked on a continuum of importance D. Values influence beliefs about health and illness E. Value systems are not related to personal codes of conduct F. Nurses should not let their values influence patient care

B, C, D. A value is a belief about the worth of something, about what matters, which acts as a standard to guide ones behavior. A value system is an organization of values in which each is ranked along a continuum of importance's often leading to a personal code of conduct. A person's values influence beliefs about human needs, health, and illness; the practice of health behaviors; and human responses to illness. Values guide the practice of nursing care. An individual is not born with values; rather, values are formed during a lifetime from information from the environment, family, and culture

A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actins are related to the outcome identification and planning step of the nursing process? Select all that apply. A. The nurse formulates nursing diagnoses B. The nurse identifies expect patient outcomes C. The nurse selects evidence based nursing interventions D. The nurse explains the nursing care plan to the patient E. The nurse assesses the patients mental status F. The nurse evaluates the patients outcome achievement

B, C, D. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence based nursing interventions, and communicate the nursing care plan. Although all these steps may overlap, formulating and validating nursing diagnoses occur a=most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process

An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. A. Performing the initial patient assessments B. Making patient beds C. Giving patients bed baths D. Administering patient medications E. Ambulating patients F. Assisting patients with meals

B, C, E, F. Performing the initial patient assessment and administering medications are the responsibility of the RN. In most cases, patient hygiene, bed making, ambulating qateinets, and helping to feed patients can be delegated to a UAP

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. A. It functions independently of nursing standards, ethics, and state practice acts. B. It is based on the principles of the nursing process, problem solving, and the scientific method. C. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. D. It is not designed to compensate for problems created by human nature, such as medication errors. E. It is constantly re-evaluating, self-correcting, and striving for improvement. F. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

B, C, E. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve (Alfaro-LeFevre, 2014)

A nurse answers a patient's call light and finds the patient on the floor by the bathroom door. After calling for assistance and examining the patient for injury, the nurse helps the patient back to bed and then fills out an incident report. Which statements accurately describe steps of this procedure and why it is performed? Select all that apply. A. An incident report is used as disciplinary action against staff members. B. An incident report is used as a means of identifying risks. C. An incident report is used for quality control. D. The facility manager completes the incident report. E. An incident report makes facts available in case litigation occurs. F. Filing of an incident report should be documented in the patient record

B, C, E. Incident reports are used for quality improvement and should not be used for disciplinary action against staff members. They are a means of identifying risks and are filled out by the nurse responsible for the injured party. An incident report makes facts available in case litigation occurs; in some states, incident reports may be used in court as evidence. A health care provider completes the incident form with documentation of the medical examination of the patient, employee, or visitor with an actual or potential injury. Documentation in the patient record should don't include the fact that an incident report was filed

A nurse instructor is teaching a class of student nurses about the nature of pain. Which statements accurately describe this phenomenon? Select all that apply. A. Pain is whatever the health care provider treating the pain says it is B. Pain exists whenever the person experiencing it says it exists C. Pain is an emotional and sensory reaction to tissue damage D. Pain is a simple, universal, and easy to describe phenomenon E. Pain that occurs without a known cause is psychological in nature F. Pain is classified by duration, location, source, transmission, and etiology

B, C, F. Margo McCaffery offers the classic definition of pain that is probably of greatest benefit to nurses and their patients, "Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does" (1968, p. 95). The International Association for the Study of Pain (IASP) further defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage (IASP, 2014b). Pain is an elusive and complex phenomenon, and despite its universality, its exact nature remains a mystery. Pain is present whenever a person says it is, even when no specific cause of pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. A. A nurse sits down with a patient and prioritizes existing diagnoses. B. A nurse assesses a woman for postpartum depression during routine care. C. A nurse plans interventions for a patient who is diagnosed with epilepsy. D. A busy nurse takes time to speak to a patient who received bad news. E. A nurse reassesses a patient whose PRN pain medication is not working. F. A nurse coordinates the home care of a patient being discharged.

B, D, E. Informal planning is a link between identifying a patients strength or problem and providing an appropriate nursing response. This occurs, for example, when a nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged

A registered nurse is writing a diagnosis for a patient who is in traction because of multiple fractures from a motor vehicle accident. Which nursing actions are related to this step in the nursing process? Select all that apply. A. The nurse uses the nursing interview to collect patient data B. The nurse analyzes data collect in the nursing assessment C. The nurse develops a care plan for the patient D. The nurse points out the patients strengths E. The nurse assesses the patients mental status F. The nurse identifies community resources to help his family cope

B, D, F. The purposes of diagnosing are to identify how an individual, group, or community responds to actual or potential health and life processes; identify factors that contribute to or cause health problems (etiologies); and identify resources or strengths the individual group, or community can draw on to prevent or resolve problems. In the diagnosing step of the nursing process, the nurse interprets and analyzes data gathered from the nursing assessment, identifies patient strengths, and identifies resources the patient can use to resolve problems. The nurse assesses and collects patient data in the assessment step and develops a care plan in the planning step of the nursing process

A nurse who is working in a hospital setting uses value clarification to help understand the values that motivate patient behavior. Which examples denote "prizing" in the process of values clarification? Select all that apply. A. A patient decides to quit smoking following a diagnosis of lung cancer. B. A patient shows off a new outfit that she is wearing after losing 20 pounds. C. A patient chooses to work fewer hours following a stress-related myocardial infarction. D. A patient incorporates a new low-cholesterol diet into his daily routine. E. A patient joins a gym and schedules classes throughout the year. F. A patient proudly displays his certificate for completing a marathon.

B, F. Prizing something one values involves pride, happiness, and public affirmation, such as losing weight or running a marathon. When choosing, one chooses freely from alternatives after careful consideration of the consequences of each alternative, such as quitting smoking and working fewer hours. Finally, the person who values something acts on the value by combining choice and behavior with consistency and regularity, such as joint a gym for the year and following a low cholesterol diet faithfully.

A nurse working in a community health clinic writes nursing diagnoses for patients and their families. Which nursing diagnoses are correctly written as three part nursing diagnoses? 1. Disabled Family Coping related to lack of knowledge about home care of child on ventilator 2. Imbalanced Nutrition: Less Than Body Requirements related to inadequate caloric intake while striving to excel in gymnastics as evidenced by 20-lb weight loss since beginning the gymnastic program, and greatly less than ideal body weight when compared to standard height-weight charts 3. Need to learn how to care for child on ventilator at home related to unexpected discharge of daughter after 3-month hospital stay as evidenced by repeated comments "I cannot do this," "I know I'll harm her because I'm not a nurse," and "I can't do medical things" 4. Spiritual Distress related to inability to accept diagnosis of terminal illness as evidenced by multiple comments such as "How could God do this to me?" "I don't deserve this," "I don't understand. I've tried to live my life well," and "How could God make me suffer this way?" 5. Caregiver Role Strain related to failure of home health aides to appropriately diagnose needs of family caregivers and initiate a plan to facilitate coping as evidenced by caregiver's loss of weight and clinical depression A. 1 and 3 B. 2 and 4 C. 1, 2, and 3 D. 1, 2, 3, 4, and 5

B. (1) is a two part diagnosis, (3) is written in terms of needs and not an unhealthy response, and (5) is a legally inadvisable statement which blames home health aides for the patients problem. Statements that may be interpreted as libel or that imply nursing negligence are legally hazardous to all the nurses caring for the patient. Assigning blame in the written record is problematic

A nurse makes a clinical judgment that an African American man in a stressful job is more vulnerable to developing hypertension than a white man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis? A. Actual B. Risk C. Possible D. Wellness

B. A clinical judgment that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation is a risk nursing diagnosis

A nurse assisting with a patient bed bath observes that an older female adult has dry skin. The patient states that her skin is always "itchy" Which nursing action would be the nurses best response? A. Bathe the patient more frequently B. Use an emollient on the dry skin .C. Massage the skin with alcohol D. Discourage fluid intake

B. An emollient soothes dry skin, whereas frequent bathing increases dryness, as does alcohol. Discouraging fluid intake leads to dehydration and, subsequently, dry skin

A nurse is collecting more patent data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? A. Actual B. Possible C. Risk D. Collaborative

B. An intervention for a possible diagnosis is to collect more patient data to confirm or run out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse and physician prescribed interventions

Review of a patient's record revealed that no one obtained informed consent for the heart surgery that was performed on the patient. Which intentional tort has been committed? A. Assault B. Battery C. Invasion of privacy D. False imprisonment

B. Assault is a threat or an attempt to make bodily contact with another person without that person's consent. Battery is an assault that is carried out. Every person is granted freedom from bodily contact but another person unless consent is granted. The fourth Amendment gives citizens the right of privacy and the right to be left alone; a nurse who disregards these rights is guilty of invasion of privacy. Unjustified retention or prevention of the movement of another person without proper consent can constitute fake imprisonment

A nurse is scheduling hygiene for patients on the unit. What is the priority consideration when planning a patient's personal hygiene? A. When the patient had his or her most recent bath B. The patients usual hygiene practices and preferences C. Where the bathing fits in the nurse's Schedule D. The time that is convenient for the patient care assistant

B. Bathing practices and cleaning habits and rituals vary widely. The patients preferences should plays be taken into consideration, unless there is a clear threat to health. The patient and nurse should work together to come to a mutually agreeable time and method to accomplish the patients personal hygiene. The availability of staff to assist may be important, but the patients preference are a higher priority

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? A. Administer pain medication B. Reassess the patient C. Prepare the equipment D. Explain the procedure to the patient

B. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and if necessary, administer pain medications

A nurse in the rehabilitation division states to the head nurse: "I need the day off and you didn't give it to me!" The head nurse replies, "Well, I wasn't aware you needed the day off, and it isn't possible since staffing is so inadequate." Instead of this exchange, what communication by the nurse would hav been more effective? A. "I placed a request to have 8th of August off, but I'm working and I have a doctor's appointment" B. "I would like to discuss my schedule with you. I requested the 8th of August off for a doctor's appointment. Could I make an appointment?" C. "I will need to call in on the 8th of August because I have a doctor's appointment" D. "Since you didn't give me the 8th of August off, will I need to find someone to work for me?"

B. Effective communication by the sender involved the implementation of nonthreatening information by showing respect to the receiver. The nurse should identify the subject of the meting and be sure it occurs at a mutually agreed upon time

A nurse wants to call an ethics consult to clarify treatment goals for a patient no longer able to speak for himself. The nurse believes his dying is being prolonged painfully. The patient's doctor threatens the nurse with firing if the nurse raises questions about the patient's care or calls the consult. What ethical conflict is this nurse experiencing? A. Ethical uncertainty B. Ethical distress C. Ethical dilemma D. Ethical residue

B. Ethical distress results from knowing the right thing to do but finding it almost impossible to execute because of institutional or other constraints (in this case, the nurse fears the loss of job). Ethical uncertainty results from felling troubled by a situation but not knowing if it is an ethical problem. Ethical dilemmas occur when the principles of bioethics justify two or more conflicting courses of action. Ethical residue is what nurses experience when they seriously compromise themselves or allow themselves to be compromised

A nurse is performing an initial comprehensive assessment of a patient admitted to a long term care facility from home. The nurse begins the assessment by asking the patient, "How would you describe your health status and well being?" The nurse also asks the patient, "What do you do to keep yourself healthy?" Which model for organizing data is this nurse following? A. Maslow's human needs B. Gordon's functional health patterns C. Human response patterns D. Body system model

B. Gordon's functional health patterns begin with the patients perception of health and well being and progress to data about nutritional metabolic patterns, elimination patterns, activity, sleep/rest, self perception, role relationship, sexuality, coping, and values/beliefs. Maslow's model is based on the human needs hierarchy. Human responses include exchanging, communicating, relating, valuing, choosing, moving, perceiving, knowing, and feeling. The body system model is based on the functioning of the major body systems

When assessing pain in a child, the nurse needs to be aware of what considerations? A. Immature neurologic development results in reduced sensation of pain B. Inadequate or inconsistent relief of pain is widespread C. Reliable assessment tools are currently unavailable D. Narcotic analgesic use should be avoided

B. Health care personnel are only now becoming aware of pain relief as a priority for children in pain. The evidence supports the fact that children do indeed feel pain and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? A. Systematic B. Interpersonal C. Dynamic D. Universally applicable in nursing situations

B. Interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process

Applying the gate control theory of pain, what would be an effective nursing intervention for a patient with lower back pain? A. Encouraging regular use of analgesics B. Applying a moist heating pad to the area at prescribed intervals C. Reviewing the pain experience with the patient D. Ambulating the patient after administering medication

B. Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control theory

A student nurse attempts to perform a nursing history for the first time. The student nurse asks the instructor how anyone ever learns all the questions the nurse must ask to get good baseline data. What would be the instructor's best reply? A. "There's a lot to learn at first, but once it becomes part of you, you just keep asking the same questions over and over in each situation until you can do it in your sleep!" B. "You make the basic questions a part of you and then learn to modify them for each unique situation, asking yourself how much you need to know to plan good care." C. "No one ever really learns how to do this well because each history is different! I often feel like I'm starting afresh with each new patient." D. "Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."

B. Once a nurse learns what constitutes the minimum data set, it can be adapted to any patient situation. It is not true that each assessment is the same even when using the same minimum data set, nor is it true that each assessment is uniquely different. Nurses committed to thoughtful, person centered practice tailor their questions to the uniqueness of each patient and situation. Answer d is incorrect because relying solely on standard facility assessment tools does not allow for individualized patient care or critical thinking

A patient requires 40 units of NPH insulin and 10 units of regular insulin daily subcutaneously. What is the correct sequence when mixing insulins? A. Inject air into the regular insulin vial and withdraw 10 units; then, using the same string, inject air into the NPH vial and withdraw 40 units of NPH insulin B. Inject air into the NPH insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the regular insulin vial and withdraw 10 units; then, withdraw 40 units of NPH insulin C. Inject air into the regular insulin vial, being careful not to allow the solution to touch the needle; next, inject air into the NPH insulin vial and withdraw 40 units; then, withdraw 10 units of regular insulin D. Inject air into the NPH insulin vial and withdraw 40 units; then, using the same string, inject air into the regular insulin vial and withdraw 10 units of regular insulin

B. Regular or short-acting insulin (unmodified insulin) should never be contaminated with NPH or any insulin modified with added protein. Placing air in the NPH vial first without allowing the needle to contact the solution ensures that the regular insulin will not be contaminated

A nurse assesses a patient and formulates the following nursing diagnosis: risk for impaired skin integrity related to prescribed bed rest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? A. Risk of impaired skin integrity B. Related to prescribed bed rest C. As evidenced by D. As evidenced by reddened areas of skin on the heels and back

B. Related to prescribed bed rest is the etiology of the statement. The etiology identifies the contributing or causative factors of the problem. "risk for impaired skin integrity" is the problem, and "as evidenced by reddened areas of skin on the heels and back" are the defining characteristics of the problem

A nurse is assessing a patient receiving a continuous opioid infusion. For which related condition would the nurse immediately notify the primary care provider? A. A respiratory rate of 10/min with normal depth B. A sedation level of 4 C. Mild confusion D. Reported constipation

B. Sedation level is more indicative of respiratory depression because a drop in level usually precedes it. A sedation level of 4 calls for immediate action because the patient has minimal or no response to stimuli. A respiratory level of 10 with normal depth of breathing is usually not a cause for alarm. Mild confusion may be evident with the initial dose and then disappear; additional observation is necessary. Constipation should be reported to the health care provider, but is not the priority in this situation

A nursing student asks the charge nurse about legal liability when performing clinical practice. Which statement regarding liability is true? A. Students are not responsible for their acts of negligence resulting in patient injury B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse C. Hospitals are exempt from liability for student negligence if the student nurse is properly supervised by an instructor D. Most nursing programs carry group professional liability making student personal professional liability insurance unnecessary

B. Student nurses are held to the same standard of care that would be used to evaluate the actions of a registered nurse. Student nurses are responsible for their own acts of negligence if these result in patient injury. A hospital may also be held liable for the negligence of a student nurse enrolled in a hospital controlled program because the student is considered an employee of the hospital. Nursing instructors may share responsibility for damages int he event of patient injury if an assignment called for clinical skills beyond a students competency or the instructor failed to provide reasonable and prudent clinical supervision. Most nursing programs require students to carry personal professional liability insurance

A nurse caring for patients in an institutional setting expresses a commitment to social justice. What action best exemplifies this attribute? A. Providing honest information to patients and the public B. Promoting universal access to health care C. Planning care in partnership with patients D. Documenting care accurately and honeslty

B. The American Association of Colleges of Nursing lists promoting universal access to health care as an example of social justice. Providing honest information and documenting care accurately and honeslty are examples of integrity, and plan Ning care in partnership with patients is an example of autonomy

Ms. Hall has an order for hydromophone, 2 mg, intravenously, q 4 course PRN pain. The nurse notes that according to Ms. Hall's chart, she is allergic to hydromophone. The order for medication was signed by Dr. Long. What would be the correct procedure for the nurse to follow in this situation? A. Administer the medication; the doctor is responsible for medication administration B. Call Dr. Long and ask that the medication be changed C. Ask the supervisor to administer the medication D. Ask the pharmacist to provide a medication to take the place of hydromophone

B. The nurse is responsible for medications given and must inform the doctor of the patient's allergy to the drug. The nurse should not give the medication and might speak with the supervisor only if uncomfortable with the health care providers answer when notified. The nurse is legally unable to order a replacement medication, as is the pharmacist

A nursing student is preparing to administer morning care to a patient. What is the MOST important question that the nursing student should ask the patient about personal hygiene? A. "Would you prefer a bath or a shower?" B. "May I help you with a bed bath now or later this morning?" C. "I will be giving you your bath. Do you use soap or shower gel?" D. "I prefer a shower in the evening. When would you like your bath?"

B. The nurse should ask permission to assist the patient with a bath. This allows for consent to assist the patient with care that invades the patient's private zones

A friend of a nurse calls and tells the nurse that his girlfriend's father was just admitted to the hospital as a patient, and he wants the nurse to provide information about the man's condition. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? A. "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." B. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks." C. "Because of HIPAA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" D. "Why do you think Sue isn't talking about her worries?"

B. The nurse should immediately clarify what he or she can and cannot do. Since the primary reson for refusing to help is linked to the responsibility to protect patient privacy and confidentiality, the nurse should not begin by mentioning the real penalties, linked to abuses of privacy. Finally, it is appropriate to ask about sue and her worries, but this should be done after the nurse clarifies what he or she is able to do

A nurse is documenting the care given to a patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changes was performed on the left leg. What would be the best action of the nurse to correct the is documentation? A. Erase or use correcting fluid to completely delete the error B. Mark the entry "mistaken entry"; add correct information; date and initial C. Use a permanent marker to block out the mistaken entry and rewrite it D. Remove the page with the error and rewrite the data on that page correctly

B. The nurse should not use dittos, erasures, or correcting fluids when correcting documentation; block out a mistake with a permanent marker; or remove a page with an error and rewrite the data on a new page. To correct an error after it has been entered the nurse should mark the entry "mistaken entry" add the correct information, and date and initial the entry. If the nurse records information in the wrong chart, the nurse should write "mistaken entry---wrong chart" and sign off. The nurse should follow similar guidelines in electronic records

A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? A. Offer the patient 60-mL fluid every 2 hours while awake B. During the next 24 hour period, the patients fluid intake will total at least 2,000 mL C. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20 D. AT the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day

B. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: "offer the patient 60 mL fluid every 2 hours while awake" Correct: "The patient will drink 60 mL fluid every 2 hours while awake, beginning 1/3/20". The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs are to be avoided when writing outcomes include "know", "understand", "learn", and "become aware"

A Patient reports abdominal pain that is difficult to localize. The nurse documents this as which type of pain? A. Cutaneous B. Visceral C. Superficial D. Somatic

B. The patients pain would be categorized as visceral pain, which is poorly localized and can originate in body organs in the abdomen. Cutaneous pain (superficial pain) usually involves the skin or subcutaneous tissue. A paper cut that produces sharp pain with a burning sensation is an example of cutaneous pain. Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain.

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: A. Quality assurance B. Quality improvement C. Process evaluation D. Outcome evaluation

B. Unlike quality assurance, quality improvement is internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than people, and has no end points. Its goal is improving quality rather than assuring quality. Process evaluation and outcome evaluation retypes of quality assurance programs

After assessing a patient who is recovering from a stroke in a rehabilitation facility, a nurse interprets and analyzes the patient data. Which of the four basic conclusions has the nurse reached when identifying the need to collect more data to confirm a diagnosis of situational low self-esteem? A. No problem B. Possible problem C. Actual nursing diagnosis D. Clinical problem other than nursing diagnosis

B. When a possible problem exists, such as situational low self esteem related to effects of stroke, the nurse must collect more data to confirm or disprove the suspected problem. The conclusion "no problem" means no nursing response is indicated. When an actual problem exists, the nurse begins planning, implementing, and evaluating care to prevent, reduce, or resolve the problem. A clinical problem other than nursing diagnosis requires that the nurse consult with the appropriate health care professional to work collaboratively on the problem

A nurse is caring for a 25 year old male patient who is comatose following a head injury. The pattens has several piercings in his ears and nose. The piercing in his nose appears to be new and is crusted and slightly inflamed. Which action would be appropriate when caring fort this patients piercings? A. Do not remove or wash the piercings without permission from the patient B. Rinse the sites with warm water and remove crusts with a cotton swab C. Wash the sites with alcohol and apply an antibiotic ointment D. Remove the jewelry and allow the sites to heal over

B. When providing care for piercings, the nurse should perform hand hygiene and put on gloves, then cleanse the site of all crusts and debris by rinsing the site with warm water, removing the crusts with a cotton swab. The nurse should then apply a dab of liquid medication cleanser to the area, turn the jewelry back and forth to work the cleanser around the opening, rinse well, remove gloves, and perform hand hygiene. The nurse should not use alcohol, peroxide, or ointments at the site or remove the piercings unless it is absolutely necessary (e.g., when an MRI is ordered )

A health care provider orders a pain medication for a postoperative patient that is a PRN order. When would the nurse administer this medication? A. A single dose during the postoperative period B. Doses administered as needed for pain relief C. One dose administered immediately D. Doses routinely administered as a standing order

B. When the prescriber writes a PRN order (as needed) for medication, the patient receives medication when it is requested or required. With a single or one time order, the directive is carried out only once at a time specified by the prescriber. A stat order is a single order carried out immediately. A standing order (or routine order) is carried out as specified until it is canceled by another order

During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after communicating the nursing care plan. What would be appropriate nurse responses in this situation? Select all that apply. A. fill the silence with lighter conversation directed at the patient B. use the time to perform the care that is needed uninterrupted C. discuss the silence with the patient to ascertain its meaning D. allow the patient time to think and explore inner thoughts E. determine if the patient's culture requires pauses between conversation F. arrange for a counselor to help the patient cope with emotional issues

C, D, E. The nurse can use silence appropriately by taking the time to wait for the patient to initiate or to continue speaking. During periods of silence, the nurse should reflect on what has already been shared and observe the patient without having to concentrate simultaneously on the spoken word. In due time, the nurse might discuss the silence with the patient in order to understand its meaning. Also, the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to too much talking by the nurse, and excessive talking tends to place the focus on the nurse rather than on the patient. The nurse should not assume silence requires a consult with a counselor

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. A. A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia B. A nurse consults with a psychiatrist for a patient who abuses pain killers C. A nurse checks the skin of bedridden patients for skin breakdown D. A nurse orders a kosher meal for an orthodox jewish patient E. A nurse records the I&O of a patient as prescribed by his health care provider F. A nurse prepares a patient for minor surgery according to facility protocol

C, D, F. Nurse initiated interventions, or independent nursing actions, involve carrying out nurse prescribed interventions resulting from their assessment of patient needs written on the nursing care plans, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply. A. 6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN B. 6/12/20 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN C. 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN D. 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN E. 6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 house. M. Patrick, RN F. 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

C, D, F. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date an both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "patient's response to pain appears to be exaggerated" or "seems to be comfortable" The nurse should never document an intervention before carrying it out

The nurse is administering a medication to a patient via an enteral feeding tube. Which are accurate guidelines related to this procedure?Select all that apply. A. Crush the enteric coated pill for mixing in a liquid B. Flush open the tube with 60 mL of very warm water C. Use the recommended procedure for checking tube placement in the stomach or intestine D. Give each medication separately and flush with water between each drug E. Lower the head of the bed to prevent reflux F. Adjust the amount of water used if patient's fluid intake is restricted

C, D, F. The nurse should use the recommended procedure for checking tube placement prior to administering medications. The nurse should also give each medication separately and flush with eater between each drug and adjust the amount of water used if fluids are restricted. enteric coated medications should not be crushed, the tube should be flushed with 15 to 30 ML of water, and the head of the bed should be elevated to prevent reflux

A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concept" that are being diagrammed in this plan? A. Protocols for treating the patient B. Standardized treatment guidelines C. The nurse's ideas about the patient problem and treatment D. Clinical pathways for the treatment of sickle cell anemia

C. A concept map care plan is a diagram of patient problems and interventions. The nurse's ideas about patient problems and treatments are the "concepts" that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patients situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients

A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? A. Cognitive B. Psychomotor C. Affective D. Physical changes

C. Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; Psychomotor outcomes described the patients achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone)

A nursing student is nervous and concerned about working at a clinical facility. Which action would BEST decrease anxiety and ensure success in the student's provision of patient care? A. determining the established goals of the institution B. Ensuring that verbal and nonverbal communication is congruent C. Engaging in self talk to plan the day and decrease fear D. Speaking with fellow colleagues about how they feel

C. By engaging in self-talk, or interpersonal communication, the nursing student can plan her day and enhance her clinical performance to decrease fear and anxiety

A nurse pleads guilty to a misdemeanor negligence charge for failing to monitor a patient's vital signs during routine eye surgery, leading to the death of the patient. The nurse's attorney explained in court that the nurse was granted recognition in a specialty area of nursing. What is the term for this type of credential? A. Accreditation B. Licensure C. Certification D. Board approval

C. Certification is the process by which a person who has met certain criteria established by a nongovernmental association is granted recognition in a specified practice area. Nursing is one of the groups operating under state laws that promote the general welfare by determining minimum standards of education through accreditation of schools of nursing. Licensure is a legal document that permits a person to offer to the public skills and knowledge in a particular jurisdiction, where such practice would otherwise be unlawful without a license. State board of approval ensures that nurses have received the proper training to practice nursing

A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in the patient's legs. What is a potent pain-blocking neuromodulator, released through relaxation techniques? A. Prostaglandins B. Substance P C. Endorphins D. Serotonin

C. Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: A. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice B. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice C. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice D. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

C. Evidence based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice

A nurse administers a dose of an oral medication for hypertension to a patient who immediately vomits after swallowing the pill. What would be the appropriate initial action of the nurse in this situation? A. Readminister the medication and notify the primary care provider B. Readminister the pill in a liquid form if possible C. Assess the vomit, looking for the pill D. Notify the primary care provider

C. If a patient vomits immediately after swallowing an oral pill, the nurse should assess the vomit for the pill or fragments of it. The nurse should then notify the primary care provider to see if another dosage should be administered

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the health care provides order sheet. What is the nurse's BEST response? A. State: "Thank you for taking care of this! I'll be happy to document the order on the health care provider's order sheet" B. Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have not nurses sign it C. State: "I am sorry, but VOs can only be given in an emergency situation that prevent us from writing them out. I'll bring the chart and we can do this quickly" D. Try calling another resident for the order or wait until the next shift

C. In most facilities the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician or nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. Trying to call another resident for the order or waiting until the next shift would be inappropriate; the patient should not have to wait for the pain medication, and a resident is available who can immediately write the order

When developing the care plan for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain not related to cancer or palliative/end of life care is not effectively relieved through which method? A. Using the highest effective dose of an opioid on a PRN (as needed) basis B. Using nonopijoid drugs conservatively C. Using consistent nonpharmacologic and nonopijoid pharmacologic therapies D. Administering a continuous intravenous infusion on a regular basis

C. Nonpharmacologic and nonopijoid pharmacologic therapies are the preferred choices for chronic pain that is not related to active cancer, palliative care, or end of life care. If profession to opioids become necessary, the lowest effective dose of an immediate release opioid should be initiated first. Ongoing assessment and careful monitoring should guide the prescription of opioids for the management of chronic pain (Dowell et al., 2016). A PEN (as needed) drug regimen has not been proven effective for people experiencing chronic or acute pain. In the early postoperative period, when pain is expected, this protocol may result in an intense pain experience for the patient. Later, however, in the postoperative course, a PRN schedule may be acceptable to relieve occasional pain episodes

The nurse is helping a patient turn in bed and notices the patients heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? A. Initial planning B. Standardized planning C. Ongoing planning D. Discharge planning

C. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared are plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self care behaviors competently at home

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? A. Patient-centered care B. Evidence-based practice Quality improvement Informatics

C. Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making

A nurse is assisting an older adult with an unsteady gait with a tub bath. Which action is recommended in this procedure? A. Add bath oil to the water to prevent dry skin B. Allow the patient to lock the door to guarantee privacy C. Assist the patient in and out of the tub to precent falling D. Keep the water temperature very warm because older adults chill easily

C. Safe nursing practice requires that the nurse assist a patient with an unsteady gait in and out of the tub. Adding Alpha Keri oil to the bath water is dangerous for this patient because it makes the tub slippery. Although privacy is important, if the patient locks the door, the nurse cannot help if there is an emergency. The water should be comfortable warm at 43 to 46 degrees Celsius. Older adults have an increased susceptibility to burns due to diminished sensitivity

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." the nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? A. The nurse judges whether the patient database is adequate to address the problem B. The nurse considers whether or not to suggest a counseling session for the patient C. The nurse reassesses the patient and decides how best to intervene in her care D. The nurse identifies several options for intervening in the patients care and critiques the merit of each option

C. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision

A nurse uses the classic elements of evaluation when caring for patients: (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting your judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what you are looking for when you evaluate- i.e., expected patient outcomes) Which item below places them in their correct sequence? A. 1,2,3,4,5 B. 3,2,1,4,5 C. 5,2,1,3,4 D. 2,3,1,4,5

C. The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards; (2) collecting data to determine whether these criteria and standards are met; (3) interpreting and summarizing findings; (4) documenting your judgment; (5) terminating, continuing, or modifying the plan

A nurse is assisting a patient with dementia with bathing. Which guideline is recommended in this procedure? A. Shift the focus of the interaction to the "process of bathing" B. Wash the fact and hair at the beginning of the bath C. Consider using music to soothe anxiety and agitation D. Do not perform towel baths or alternate forms of bathing with which the patient is unfamiliar

C. The nurse should consider the use of music to soothe anxiety and agitation. The nurse should also shift the focus of the interaction from the "task of bathing" to the needs and abilities of the patient, and focus on comfort, safety, autonomy, and self-esteem, in addition to cleanliness. The nurse should wash the face and hair at the end of the bath or at a separate time. Water dripping in the face and having a wet head are often the most upsetting parts of the bathing process for people with dementia. The nurse should also consider other methods for bathing. Showers and tub baths are not the only options in bathing. Towel baths, washing under clothes, and bathing "body sections" one day at a time are other possible options

The nurse is surprised to detect an elevated temperature (102) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the priority nursing action? A. Inform the charge nurse B. Inform the surgeon C. Validate the finding D. Document the finding

C. The nurse should first validate the finding if it is unusual, deviates from normal, and is unsupported by other data. Should the initial recording prove to be in error, it would have been premature to notify the charge nurse or the surgeon. The nurse should be sure that all data recorded are accurate; thus, all data should be validated before documentation if there are any doubts about accuracy

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? A. Allow the UAPs to do the admission assessment and report the findings to the RN. B. Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. C. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. D. Contact his or her labor representative to report this practice to the state board of nursing.

C. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration

A nurse who gives subcutaneous and intramuscular injections to patients in a hospital setting attempts to reduce discomfort for the patients receiving the injections. Which technique is recommended? a. The nurse selects a needle of the largest gauge that is appropriate for the site and solution to be injected. b. The nurse injects the medication into contracted muscles to reduce pressure and discomfort at the site. c. The nurse uses the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track. d. The nurse applies vigorous pressure in a circular motion after the injection to distribute the medication to the intended site.

C. The nurse should use the Z-track technique for intramuscular injections to prevent leakage of medication into the needle track, thus minimizing discomfort. The nurse should select a m=needle of the smaller game that is appropriate for the site and solution to be injected, and select the correct needle length. The nurse should also inject the medication into relaxed muscles since there is more pressure and discomfort if medication is injected into contracted muscles. The nurse should apply gentle pressure after injection, unless this technique is contraindicated

A nurse discovers that a medication error occurred. What should be the nurse's first response? A. record the error on the medication sheet B. notify the physician regarding course of action C. check the patients condition to note any possible effect of the error D. Complete an incident report, explaining how the mistake was made

C. The nurse's first responsibility is the patient--careful observation is necessary to assess for any effect of the medication error. The other nursing actions are pertinent, but only after checking the patient's welfare

A nurse in a NICU fails to monitor a premature newborn according to the protocols in place, and is charged with malpractice. What is the term for those brining the charges against the nurse? A. Appellates B. Defendants C. Plaintiffs D. Attorneys

C. The person or government bringing suit against another is called the plaintiff. Appellates are courts of law, defendants are the ones being accused of a crime or tort, and attorneys are the lawyers representing both the plaintiff and defendant

A nurse is bout to bathe a female patient who has an intravenous access in place in her forearm. The patient's gown, which does not have snaps on the sleeves, needs to be removed prior to bathing. What is the appropriate nursing action? A. Temporarily disconnect the IV tubing at a point close to the patient and thread it through the gown sleeve B. Cut the gown with scissors to allow arm movement C. Thread the bad and tubing through the gown sleeve, keeping the line intact D. Temporarily disconnect the tubing from the IV container, threading it through the gown

C. Threading the bag and tubing through the gown sleeve keep the system intact. Opening an IV line, even temporarily, causes a break in a sterile system and introduces the potential for infection. Cutting a gown is not an alternative except in an emergency

A nurse develops a detailed care plan for a 16 year old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? A. "You know your personal situation better than I do, so I will respect your wishes." B. "If you don't accept these services, your baby's health will suffer" C. "Let's take a look at the plan again and see if we can adjust it to fit your needs" D. "I'm going to assign your case to a social worker who can explain the services better"

C. When a patient does not follow the care plan despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the care plan is adequate, the nurse must identify and remedy the factors contributing to the patients noncompliance

A nurse is administering heparin subcutaneously to a patient. What is the correct technique for this procedure? A. aspirate before giving an gently massage after the injection B. do not aspirate; massage the site for 1 minute C. do not aspirate before or massage after the injection D. massage the site of the injection; aspiration is not necessary but will do no harm

C. when giving heparin subcutaneously, the nurse should not aspirate or massage, so as not to cause trauma or bleeding in the tissues

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a patient who has been prescribed morphine via a patient controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR Order. A. "I am calling about Mr. Sanchez in room 202 who is receiving morphine via a PCA pump for pancreatic cancer" B. "Mr. Sanches has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump" C. "You want me to discontinue the PCA pump until you see him tonight at patient rounds" D. "I am Rosa Clark, and RN working on the second floor of South Street Hospital" E. "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer" F. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered"

D, A, E, B, F, C. The order for ISBARR is: Identify/Introduction Situation Background Assessment Recommendation Read back

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? A. "I'm sorry, but patients are not allowed to copy their medical records" B. "I can make a copy of your record for you right now" C. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules" D. "I will need to check with out records department to get you a copy"

D. According to HIPAA, patients have a right to see and copy their health record; update their health record; get a list of the disclosures a health care institution has made independent of disclosures made fr the purposes of treatment, payments and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of facility policies regarding the patient's right to access and copy records

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? A. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge B. By 6/12/20, the patient will correctly demonstrate application of. wet to dry dressing on leg ulcer C. By 6/19/20, the patients ulcer will begin to show signs of healing (e.g. size shrinks from 3 to 2.5 inches) D. By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer

D. Affective outcomes describe changes in the patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patients achievement of new skills; and (c) is an outcome describing a physical change in the patient

A nurse is counseling a patient who refuses to look at or care for a new colostomy. The patient tells the nurse "I don't care what I look like anymore, I don't even feel like washing my hair, let alone changing this bag". The nurse diagnoses altered health maintenance. This is an example of what type of problem? A. Collaborative problem B. Interdisciplinary problem C. Medical problem D. Nursing problem

D. Altered health maintenance is a nursing problem, because the diagnosis describes a problem that can be treated by nurses within the scope of independent nursing practice. Collaborative and interdisciplinary problems require a teamwork approach with other health care professionals to resolve the problem. A medical problem is a traumatic or disease condition validated by medical diagnostic studies

A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The pateint's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patients care? A. Explain to the patient that there is not enough time to wash her hair today because of her busy schedule B. Schedule the testing and meal planning first and complete hygiene as time permits C. Perform the dressing changes first, schedule the testing and counseling and complete hygiene last D. Arrange to wash the patients hair first, perform hygiene, and schedule diagnostic testing and counseling

D. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patients hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse patient relationship

A nurse is performing oral care on a patient who is in traction. The nurse notes that the mouth is extremely dry with crusts remaining after the oral care. What should be the nurse's next action? A. make a recommendation for the patient to see an oral surgeon B. Report the condition to the primary care provider C. Gently scrape the oral cavity with a tongue depressor D. Increase the frequency of the oral hygiene and apply mouth moisturizer to oral mucosa

D. If the mouth is extremely dry with crusts that remain after oral care provided, the nurse should increase frequency of oral hygiene, apply mouth moisturizer to oral mucosa, and monitor fluid intake and output to ensure adequate intake of fluid. It is not necessary to report this condition prior to providing the interventions mentioned above. The crusts should not be scraped with a tongue depressor

A veteran nurse, pleaded guilty to a misdemeanor negligence charge in the case of a 75 year old woman who died after slipping into a coma during routine outpatient hernia surgery. The nurse admitted failing to monitor the woman's vital signs during the procedure. The surgeon who performed the procedure called the nurse's action pure negligence, stating that the patient could have been saved. The patient was a vibrant grandmother of 10 who had walked three quarters of a mile the morning of her surgery and had sung in her church choir the day before. What criteria must be established to prove that the nurse is guilty of malpractice or negligence in this case? A. The surgeon who performed the procedure called the nurse's action pure negligence, saying that the patient should not have died B. The fact that this patient should not have died since she was a health grandmother of 10, who was physically active and involved in her community C. The nurse intended to harm the patient and was willfully negligent, as evidenced by the tragic outcome of routine hernia surgery D. The nurse had a duty to monitor the patient's vital signs, due to the nurse's failure to perform this duty in this circumstance, the patient died

D. Liability involves four elements that must be established to prove that malpractice or negligence has occurred: duty, breach of duty, causation, and damages. Duty refers to an obligation to use due care (what a reasonably prudent nurse would do) and is defined by the standard of care appropriate for the nurse- patient relationship. Breach of duty is the failure to meet the standard of care. Causation, the most difficult element of liability to prove, shows that the failure to meet the standard of care (breach) actually caused the injury. Damages are the actual harm or injury resulting to the patient

A medication order reads: "Hydromophones, 2 mg IV every 3 to 4 hours PRN pain." The profiled cartridge is available with a label reading "Hydromophone 2 mg/1mL" The cartridge contains 1.2 mL of hydromophone. What should the nurse do? A. Give all the medication in the cartridge because it expanded when it was mixed and this is what the pharmacy sent B. Call the pharmacy and request the proper dose C. Refuse to give the medication and document refusal in the EHR D. Dispose of 0.2 mL before administering the drug; verify the water with another nurse

D. Many cartridges are overfilled, and some of the medication needs to be discarded. Always check the volume needed to provide the correct dose with the volume in the syringe. Giving the excess medication in the cartridge may result in adverse effects for the patient. For this dose, it its not necessary to call the pharmacy or refuse to give the medication, provided the order is written correctly. Wasting narcotics typically requires a second RN to witness the waste and verify the amount of narcotic discarded

A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medication following surgery. What would be a correct response by the nurse? A. "It's not a good idea to ask for pain medication regularly as it can be addictive" B. "It is better to wait until the pain is severe before asking for pain medication" C. "It's natural to have to put up with pain after surgery and it will lessen in intensity in a few days" D. "Your doctor has prescribed pain medications for you, which you should request when you have pain"

D. Many pain medications are ordered on a PRN (as needed) basis. Therefore, nurses must be diligent to assess patients for pain and administer medications as needed. A patient should not be afraid to request these medications and should not wait until the pain is unbearable. Few people become addicted to the medications if used for a short period of time. Pain following surgery can be controlled and should not be considered a natural part of the experience that will lessen in time

A nurse administers the wrong medication to a patient and the patient is harmed. The health care provider who ordered the medication did not read the documentation that the patient was allergic to the drug. Which statement is true regarding liability for the administration of the wrong medication? A. The nurse is not responsible because the nurse was following the doctor's orders B. Only the nurse is responsible, because the nurse actually administered the medication C. Only the health care provider is responsible, because the health care provider actually ordered the drug D. Both the nurse and health care provider are responsible for their respective actions

D. Nurses are legally responsible for carrying out the orders of the health care provider in charge of a patient unless an order would lead a reasonable person to anticipate injury if it was carried out. If the nurse should have anticipated injury and did not, both the prescribing health care provider and the administering nurse are responsible for the harms to which they contributed

A nurse notes that a shift report states that a patient has no special skin care needs. The nurse is surprised to observe reddened areas over bony prominences during the patient bath. What nursing action is appropriate? A. Correct the initial assessment form B. Redo the initial assessment and document current findings C. conduct and document an emergency assessment D. Perform and document a focused assessment of skin integrity

D. Perform and document a focused assessment on skin integrity since this is a newly identified problem. The initial assessment stands as is and cannot be redone or corrected. This is not a life threatening event; therefore, there is no need for an emergency assessment

The nurse practitioner is performing a short assessment of a newborn who is displaying signs of jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to report to the primary care provider. What type of assessment has this nurse performed? A. Comprehensive B. Initial C. Time-lapsed D. Quick priority

D. Quick priority assessments (QPAs) are short, focused, prioritized assessments nurses do to gain the most important information they need to have first. The comprehensive initial assessment is performed shortly after the patient is admitted to a health care facility or service. The time lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier

A patient who is having a myocardial infraction reports pain that is situated in the neck. The nurse documents this as what type of pain? A. Transient pain B. Superficial pain C. Phantom pain D. Referred pain

D. Referred pain is perceived in an area distant from its point of origin, whereas transient pain is brief and passes quickly. Superficial pain originated in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically

A Patient states, "I have been experiencing complications of diabetes." The nurse needs to direct the patient to gain more information. What is the MOST appropriate comment or question to elicit additional information? A. "do you think two injections of insulin to decrease the complications?" B. "most health care providers recommend diet and exercise to regulate blood sugar" C. "most complications of diabetes are related to neuropathy" D. "what specific complications have you experienced?"

D. Requesting specific information regarding complications of diabetes will elicit specific information to guide the nurse in further interview questions and specific assessment techniques

A student health nurse is counseling a college student who wants to lose 20 lbs. The nurse develops a plan to increase the student's activity level and decrease her consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the students weight loss monthly. When the student arrives for her first "weigh-in", the nurse discovers that instead of the projected wight loss of 5 lbs, the student has lost only 1 lb. Which is the BEST nursing response? A. Congratulate the student and continue the care plan B. Terminate the care plan since it is not working C. Try giving the student more time to reach the targeted outcome D. Modify the care plan after discussing possible reasons for the students partial success

D. Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the care plan. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the care plan since the student has not met her targeted outcome. The student may need more than just additional time to reach her outcome

A nurse working in a long term facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? A. Travelbee's B. Watson's C. Benner's D. Swanson's

D. Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsiblity" Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model, and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted

A nurse incorporates the "five values that epitomize the caring professional nurse" (identified by the American Association of Colleges of Nursing) into a home health care nursing practice. Which attribute is best described as acting in accordance with an appropriate code of ethics and accepted standards of practice? A. Altruism B. Autonomy C. Human dignity D. Integrity

D. The American Association of Colleges of Nursing defines integrity as acting in accordance with an appropriate code of ethics and accepted standards of practice. Altruism is a concern for the welfare and well-being of others. Autonomy is the right to self-determination, and human dignity is respect for the inherent worth and uniqueness of individuals and populations

During rounds, a charge nurse hears the patient care technician yelling loudly to a patient regarding a transfer from the bed to chair. Upon entering the room, what is the nurse's BEST response? A. "You need to speak to the patient quietly so you don't disturb the other patients." B. "Let me help you with your transfer technique." C. "When you are finished, be sure to apologize for your rough demeanor." D. "When your patient is safe and comfortable, meet me at the desk."

D. The charge nurse should direct the patient care technician to determine the patient's safety. Then the nurse should address any concerns regarding the patient care technician's communication techniques privately. the nurse should direct the patient care technician on aspects of therapeutic communication

A nurse is writing an evaluation statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly? A. "Outcome not met" B. "1/21/20- Patient reports no change in diet" C. "Outcome not met. Patient reports no change in diet or activity level" D. "1/21/20- Outcome not met. Patient reports no change in diet or activity level."

D. The evaluation statement must contain a date; the words "outcome met", "outcome partially met", or "outcome not met"; and the patient data or behaviors that support this decision. the other answer choices are incomplete statements

A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? A. The nurse collects data to identify health problems B. The nurse collects data to identify patient strengths C. The nurse collects data to justify terminating the care plan D. The nurse collects data to measure outcome achievement

D. The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the care plan, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process

A nurse enters a patient's room and examines the patient's IV fluids and cardiac monitor. The patient states, "Well, I haven't seen you before. Who are you?" What is the nurse's BEST response? A. "I'm just the IV therapist checking your IV" B. "I've been transferred to this division and will be caring for you" C. "I'm sorry, my name is John Smith and I am your nurse" D. "My name is John Smith, I am your nurse and I'll be caring for you until 11 PM"

D. The nurse should identify himself, be sure the patient knows what will be happening, and the time period he will be with his patient

When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. After introducing herself to the patient and his wife, what should the nurse do? A. Thank the wife for being present. B. Ask the wife if she wants to remain. C. Ask the wife to leave. D. Ask the patient if he would like the wife to stay.

D. The patient has the right to indicate whom he would like to be present for the nursing history and exam. The nurse should neither presume that he wants his wife there nor that he does not want her there. Similarly, the choice belongs to the patient, not the wife

A 3 year old child is being admitted to a medical division for vomiting, diarrhea, and dehydration. During the admission interview, the nurse should implement which communication techniques to elicit the most information from the parents? A. The use of reflective questions B. The use of closed questions C. The use of assertive questions D. The use of clarifying questions

D. The use of clarifying question or comment allows the nurse to gain an understanding of a patient's comment. When used properly, this technique can avert possible misconceptions that could lead to an inappropriate nursing diagnosis. The reflective question technique involves reporting what the person has said or describing the person's feelings. Open ended questions encourage free verbalization and expression of what the parents believe to be sure. Assertive behavior is the ability to stand up for yourself and others using open, honest, and direct communication

A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone" Which response by the nurse is the most therapeutic action? A. The nurse stands at the patient's beside and states, "I understand how you feel. My mother said the same thing when she was ill" B. The nurse places a hand on the patient's arm and states, "you feel so alone" C. the nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." D. The nurse holds the patient's hand and asks, "What makes you feel so alone?"

D. The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely

A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of what side effect? A. Pruritus B. Urinary retention C. Vomiting D. Respiratory depression

D. Too much of an opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritus, urinary retention, and vomiting may occur but are not life threatening

A patient has an eye infection with a moderate amount of discharge. Which action is an appropriate step for the nurse to perform when cleaning this patient's eyes? A. Use hydrogen peroxide on a clean washcloth to wipe the eyes B. Wipe the eye from the outer canthus to the inner canthus C. Position the patient on the opposite side of the eye to be cleansed D. Cleanse the eye using a different section of the cleaning cloth for each stroke until clean

D. When cleaning the eyes, the nurse should wear gloves during the cleaning procedure, use water or normal saline, and a clean washcloth or compress to clean the eyes. The nurse should dampen a cleaning cloth with the solution of choice and wipe once while moving from the inner canthus to the outer canthus of the eye. This technique minimizes the risk for forcing debris into the area drained by the nasolacrimal duct. The nurse should turn the cleaning cloth and use a different section for each stroke until the eye is clean.

A pediatric nurse is assessing a 5 year old boy who has dietary modifications related to his diabetes. His parents tell the nurse they want him to value good nutritional habits, so they divide to deprive him of a favorite TV program when he becomes angry after they deny him foods not on his diet. This is an example of what mode of value transmission? A. Modeling B. Moralizing C. Laissez-faire D. Rewarding and punishing

D. When rewarding and punishing are used to transmit values, children are rewarded for demonstrating values held by parents and punished for demonstrating unacceptable values. Through modeling, children learn what is of high or low value by observing patents, peers, and significant others. Children whose caregivers use the moralizing mode of value transmission are taught a complete value system by parents or an institution (e.g., church or school) that allows little opportunity for them to weigh different values. Those who use the laissez-faire approach to value transmission leave approach to value transmission leave children to explore values on their own (no single set of values is presented as best for all) and to develop a personal value system

A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correct written as tow part nursing diagnoses? 1. Ineffective coping related to inability to maintain marriage 2. Defensive coping related to loss of job and economic security 3. Altered thought process related to panic state 4. Decisional conflict related to placement of parent in a long term care facility A. 1 and 3 B. 3 and 4 C. 1, 2, and 3 D. 1, 2, 3 and 4

D. each of the four diagnoses is a correctly written two part diagnostic statement that includes the problem or diagnostics Lebel and the etiology or cause

A home health nurse performs a careful safety assessment of the home of a frail older adult to prevent harm to the patient. The nurse's action reflects which principle of bioethics? A. Autonomy B. Beneficence C. Justice D. Fidelity E. Nonmaleficence

E. Nonmaleficence is defined as the obligation to prevent harm. Autonomy is respect for another's right to make decisions, beneficence obligates use to benefit the patient, justice obligates us to act fairly, and fidelity obligates us to keep our promises