NCLEX Questions- Foundations

35: A 56-year-old male patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating his appetite? a. Administering pain medication after meals. b. Encouraging food from home when possible. c. Scheduling his respiratory therapy before each meal. d. Reinforcing the importance of his eating exactly what is delivered to him.

b. Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply.

11: Read the following scenario and identify the term for the characteristics of patient data 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 asks the patient about the most important details leading up to her diagnosis, (3) collects as much information as possible to understand the patient's 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 agency policy.

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 plan of care. 4. systematic The nurse gathers the information in an organized manner. 5. factual and accurate The nurse verifies that the information is reliable. 6. recorded in a standard manner The nurse records the data according to agency policy so that all caregivers can easily access what is learned.

1: Nursing is recognized increasingly as a profession based on which defining criteria? Select all that apply. a. Well defined body of general knowledge b. Interventions dependent upon the medical practice c. Recognized authority by a professional group d. Regulation by the medical industry e. Code of ethics f. Ongoing research

c, e, f. Nursing is recognized increasingly as a profession based on the following defining criteria: well-defined body of specific and unique knowledge, strong service orientation, recognized authority by a professional group, code of ethics, professional organization that sets standards, ongoing research, and autonomy and self-regulation.

1: One of the four broad aims of nursing practice is to restore health. Which examples of nursing interventions reflect this goal? Select all that apply. a. A nurse counsels adolescents in a drug rehabilitation program. b. A nurse performs range-of-motion exercises for a patient on bedrest. c. A nurse shows a diabetic patient how to inject insulin. d. A nurse recommends a yoga class for a busy executive. e. A nurse provides hospice care for a patient with end-stage cancer. f. A nurse teaches a nutrition class at a local high school.

a, b, c. Activities to restore health focus on the individual with an illness and range from early detection of a disease to rehabilitation and teaching during recovery. These activities include drug counseling, teaching patients how to administer their medications, and performing range-of-motion exercises for bedridden patients. Recommending a yoga class for stress reduction is a goal of preventing illness, and teaching a nutrition class is a goal of promoting health. A hospice care nurse helps to facilitate coping with disability and death.

35: A nurse is evaluating patients to determine their need for total parenteral nutrition (TPN). Which patients would be the best candidates for this type of nutritional support? Select all that apply. a. A patient with irritable bowel syndrome who has intractable diarrhea b. A patient with celiac disease not absorbing nutrients from the GI tract c. A patient who is underweight and needs short-term nutritional support d. A patient who is comatose and needs long-term nutritional support e. A patient who has anorexia and refuses to take foods via the oral route f. A patient with burns who has not been able to eat adequately for 5 days

a, b, f. Assessment criteria used to determine the need for TPN include an inability to achieve or maintain enteral access; motility disorders; intractable diarrhea; impaired absorption of nutrients from the GI tract (patient with celiac disease) and when oral intake has been or is expected to be inadequate over a 7- to 14-day period. TPN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet. Oral intake is the best method of feeding; the second best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will.

34: 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 patient's pulse is increased following a myocardial infarction. d. A patient in pain strikes out at a nurse who attempts to bathe him. e. A patient who has chronic cancer pain is depressed and withdrawn. f. A child pulls away from a nurse trying to give him 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 the pupils. Affective responses, such as anger, withdrawal, and depression, are psychological in nature.

23: In addition to standard precautions, the nurse would initiate droplet precautions for which patients? Select all that apply. a. A patient diagnosed with rubella b. A patient diagnosed with diptheria c. A patient diagnosed with varicella d. A patient diagnosed with tuberculosis e. A patient diagnosed with MRSA f. An infant diagnosed with adenovirus infection

a, b, f. Rubella, diphtheria, and adenovirus infection are illnesses transmitted by large-particle droplets and require droplet precautions in addition to standard precautions. Airborne precautions are used for patients who have infections spread through the air with small particles, for example, tuberculosis, varicella, and rubeola. Contact precautions are used for patients who are infected or colonized by a multidrug-resistant organism (MDRO), such as MRSA.

11: The nurse collects objective and subjective data when conducting patient assessments. Which patient conditions 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 of having a rash on her arm that is itchy. 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, itchy, or chilly 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 elevated temperature reading (e.g., 101°F), edema, and vomiting.

23: A nurse is caring for patients in an isolation ward. In which situations would the nurse appropriately use an alcohol-based handrub to decontaminate the hands? Select all that apply. a. The nurse is providing a bed bath for a patient. b. The nurse has visibly soiled hands after changing the bedding of a patient. c. The nurse removes gloves when patient care is completed. d. The nurse is inserting a urinary catheter for a female patient. e. The nurse is assisting with a surgical placement of a cardiac stent. f. The nurse removes old magazines from a patient's table.

a, c, d, f. It is recommended to use an alcohol-based handrub in the following situations: before direct contact with patients; after direct contact with patient skin; after contact with body fluids if hands are not visibly soiled; after removing gloves; before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement; before donning sterile gloves prior to an invasive procedure; if moving from a contaminated body site to a clean body site; and after contact with objects contaminated by the patient.

15: 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 mentor 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.

15: 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 continuous 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.

13: A nurse is using critical pathway methodology for choosing interventions for a patient 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 patient's 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 been 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 and no 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.

34: One of the most common distinctions of pain is whether it is acute or chronic. Which examples describe chronic pain? 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 but 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.

14: 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 victim's 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 ulcers. e. The nurse checks a patient's insurance coverage at the initial interview. f. The nurse checks for community resources for a patient with dementia.

a, d, f. Dkluring 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.

11: 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 a 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 referral 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 patient's responses to health problems. The initial comprehensive nursing assessment results in baseline data that enable the nurse to make a judgment about a patient's 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 patient's 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.

14: 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 with 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 delegating 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 plan of care. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

12: To determine the significance of a blood pressure reading of 148/100, it is first necessary for the nurse to: 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 patient's blood pressure reading, appropriate standards include normative values for the patient's age group, race, and illness category. Deviation from an appropriate norm may be the basis for writing a diagnosis.

15: 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 changes

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 actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

34: Mr. Wright is recovering from abdominal surgery. When the nurse assists him to walk, she observes that he grimaces, moves stiffly, and becomes pale. She is aware that he has consistently refused his 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. Mr. Wright's immediate problem is his pain that is unrelieved because he refuses to take his pain medication for an unknown reason. The other nursing diagnoses are plausible, but not a priority in this situation.

1: Nurse practice acts are established in each state of the United States to regulate nursing practice. What is a common element of every state practice act? a. Defining the legal scope of nursing practice b. Providing continuing education programs c. Determining the content covered in the NCLEX examination d. Creating institutional policies for health care practices

a. Nurse practice acts are established in each state to regulate the practice of nursing by defining the legal scope of nursing practice, creating a state board of nursing to make and enforce rules and regulations, define important terms and activities in nursing, and establish criteria for the education and licensure of nurses. The acts do not determine the content covered on the NCLEX, but they do have the legal authority to allow graduates of approved schools of nursing to take the licensing examination. The acts also may determine educational requirements for licensure, but do not provide the education. Institutional policies are created by the institutions themselves.

14: A school nurse notices that a female adolescent student is losing weight and decides to perform a focused assessment of her nutritional status to determine if she has an eating disorder. How should the nurse proceed? a. Perform the focused assessment. This is an independent nurse-initiated intervention. b. Request an order from Jill's physician since this is a physician-initiated intervention. c. Request an order from Jill's physician 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.

35: A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? Remove the tray from the room. Administer an antiemetic and encourage the patient to take small amounts. Explore with the patient why she does not want to eat her food. Offer high-calorie snacks such as pudding and ice cream.

a. The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect.

34: 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 physiologic 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.

11: 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.

35: A 62-year-old male patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition? a. Vitamin B malnutrition b. Obesity c. Dehydration d. Vitamin C deficiency

a. The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.

13: 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 a 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.

12: 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." Which of the following comments is the nurse most likely to hear from the instructor? a. "Hold on a minute . . . Nursing diagnoses should always be derived from clusters of significant data rather than from a single cue." b. "Job well done . . . you've identified this problem early and we can manage it before it becomes more acute." c. "Is this an actual or a possible diagnosis?" d. "This is a medical, not a nursing problem."

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

13: A nurse is preparing a clinical outcome for a 32-year-old female runner who is recovering from a stroke that caused right-sided paresis. An example of this type of outcome is: a. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. b. By 8/15/15, 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 8/15/15, patient will verbalize feeling sufficiently prepared to participate in running events.

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

1: World War II had a tremendous effect on the nursing profession. Which development occurred during this period? a. The role of the nurse was broadened. b. There was a decreased emphasis on education. c. Nursing was practiced mainly in hospital settings. d. There was an overabundance of nurses.

a. During World War II, large numbers of women worked outside the home. They became more independent and assertive, which led to an increased emphasis on education. The war itself created a need for more nurses and resulted in a knowledge explosion in medicine and technology. This trend broadened the role of nurses to include practicing in a wide variety of health care settings.

15: 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 folks 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 (d) focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Answers b and c are distractors.

34: An elderly patient is confined to bedrest following cervical spine surgery to treat nerve pinching. The nurse is vigilant about turning the patient and assessing the patient regularly to prevent the formation of pressure ulcers. What type of agent is the stimulus for pressure ulcers? a. Mechanical b. Thermal c. Chemical d. Electrical

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 and pressure from a cast are mechanical stimulants. Sunburn is a thermal stimulant. An acid burn is the result of a chemical stimulant. The jolt from a lightening bolt is an electrical stimulant.

35: A nurse is feeding an elderly patient who has dementia. Which intervention should the nurse perform to facilitate this process? a. Stroke the underside of the patient's chin to promote swallowing. b. Serve meals in different places and at different times. c. Offer a whole tray of various foods to choose from. d. Avoid between-meal snacks to ensure hunger at mealtime.

a. To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.

35: A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly? a. The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site. b. The nurse wets a washcloth and washes the area around the tube with soap and water. c. The nurse adjusts the external disk every 3 hours to avoid crusting around the tube. d. The nurse tapes a gauze dressing over the site after cleansing it.

a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube, but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air unless there is drainage. If there is drainage, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry.

13: A nurse is planning care for a male adolescent patient who is admitted to the hospital for treatment of a drug overdose. Which nursing actions 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 expected 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 patient's mental status. f. The nurse evaluates the patient's 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 plan of nursing care. Although all these steps may overlap, formulating and validating nursing diagnoses occurs 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.

14: An RN working on a busy hospital unit delegates patient care to unlicensed assistive personnel (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 registered nurse. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

34: 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 physician 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 (1979, p. 11) 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 he (or she) says it does." 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, 1994). 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 the pain can be found. Pain may be classified according to its duration, its location or source, its mode of transmission, or its etiology.

12: A nurse is caring for an older adult patient who presents with labored respirations, productive cough, and fever. What would be appropriate nursing diagnoses 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 for septic shock. Bronchial pneumonia and infection are medical diagnoses, and "potential complication: sepsis" is a collaborative problem.

13: 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 patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy 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.

12: A registered nurse is writing a diagnosis for a 28-year-old male patient who is in traction due to 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 collected in the nursing assessment. c. The nurse develops a care plan for the patient. d. The nurse points out the patient's strengths. e. The nurse assesses the patient's 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.

23: A nurse is performing hand hygiene after providing patient care. The nurse's hands are not visibly soiled. Which steps in this procedure are performed correctly? Select all that apply. a. The nurse removes all jewelry including a platinum wedding band. b. The nurse washes hands to one inch above the wrists. c. The nurse uses approximately two teaspoons of liquid soap. d. The nurse keeps hands higher than elbows when placing under faucet. e. The nurse uses friction motion when washing for at least 15 seconds. f. The nurse rinses thoroughly with water flowing toward fingertips.

b, e, f. Proper hand hygiene includes removing jewelry with the exception of a plain wedding band, wetting the hands and wrist area with the hands lower than the elbows, using about one teaspoon of liquid soap, using friction motion for at least 15 seconds, washing to one inch above the wrists with a friction motion for at least 15 seconds, and rinsing thoroughly with water flowing toward fingertips.

12: A nurse assesses a patient and formulates the following nursing diagnosis: Risk for Impaired Skin Integrity related to prescribed bedrest as evidenced by reddened areas of skin on the heels and back. Which phrase represents the etiology of this diagnostic statement? a. Risk for Impaired Skin Integrity b. Related to prescribed bedrest c. As evidenced by d. As evidenced by reddened areas of skin on the heels and back

b. "Related to prescribed bedrest" 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.

12: A nurse writes nursing diagnoses for patients and their families visiting a community health clinic. 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-pound 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. All of the above

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.

12: A nurse makes a clinical judgment that an African American male patient in a stressful job is more vulnerable to developing hypertension than White male patients in the same or 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.

35: A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 pounds. What would the nurse document as his BMI? a. 50.5 b. 52.4 c. 54.5 d. 55.2

b. BMI = weight in pounds / (height in inches)(height in inches) x 703

14: 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.

23: A school nurse is performing an assessment of a student who states: "I'm too tired to keep my head up in class." The student has a low-grade fever. The nurse would interpret these findings as indicating which stage of infection? a. Incubation period b. Prodromal stage c. Full stage of illness d. Convalescent period

b. During the prodromal stage, the person has vague signs and symptoms, such as fatigue and a low-grade fever. There are no obvious symptoms of infection during the incubation period, and they are more specific during the full stage of illness, before disappearing by the convalescent period.

11: A nurse is performing an initial comprehensive assessment of an 84-year-old male 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 patient's 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.

34: 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 the 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.

34: When assessing a patient receiving a continuous opioid infusion, the nurse immediately notifies the physician when the patient has: 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 physician, but is not the priority in this situation.

1: The National Advisory Council on Nurse Education and Practice identifies critical challenges to nursing practice in the 21st century. What is a current health care trend contributing to these challenges? a. Decreased numbers of hospitalized patients b. Older and more acutely ill patients c. Decreasing health care costs due to managed care d. Slowed advances in medical knowledge and technology

b. The National Advisory Council on Nurse Education and Practice identifies the following critical challenges to nursing practice in the 21st century: A growing population of hospitalized patients who are older and more acutely ill, increasing health care costs, and the need to stay current with rapid advances in medical knowledge and technology.

14: Nurses use the Nursing Interventions Classification Taxonomy structure as a resource when planning nursing care for patients. What information would be 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 Nursing Interventions Classification 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.

13: A nurse is caring for an elderly male 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 patient's fluid intake will total at least 2,000 mL. c. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/15 d. At the next visit, 12/23/15, the patient will know that he should drink at least 3 liters 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 1/3/15." The outcome in d makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing goals include "know," "understand," "learn," and "become aware."

1: A nurse is caring for a patient in the ICU who is being monitored for a possible cerebral aneurysm following a loss of consciousness in the emergency room. The nurse anticipates preparing the patient for ordered diagnostic tests. This nurse's knowledge of the diagnostic procedures for this condition reflects which aspect of nursing? a. The art of nursing b. The science of nursing c. The caring aspect of nursing d. The holistic approach to nursing

b. The science of nursing is the knowledge base for care that is provided. In contrast, the skilled application of that knowledge is the art of nursing. Providing holistic care to patients based on the science of nursing is considered the art of nursing.

15: 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 individuals, and has no end points. Its goal is improving quality rather than assuring quality. Answers c and d are types of quality-assurance programs

23: A nurse who is caring for a patient diagnosed with HIV/AIDS incurs a needlestick injury when administering the patient's medications. What would be the priority action of the nurse following the exposure? a. Report the incident to the appropriate person and file an incident report. b. Wash the exposed area with warm water and soap. c. Consent to postexposure prophylaxis at appropriate time. d. Set up counseling sessions regarding safe practice to protect self.

b. When a needlestick injury occurs, the nurse should wash the exposed area immediately with warm water and soap, report the incident to the appropriate person and complete an incident injury report, consent to and await the results of blood tests, consent to postexposure prophylaxis, and attend counseling sessions regarding safe practice to protect self and others.

12: 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.

23: A nurse is using personal protective equipment (PPE) when bathing a patient diagnosed with C. difficile infection. Which nursing action related to this activity promotes safe, effective patient care? a. The nurse puts on PPE after entering the patient room. b. The nurse works from "clean" areas to "dirty" areas during bath. c. The nurse personalizes the care by substituting glasses for goggles. d. The nurse removes PPE prior to leaving the patient room.

b. When using PPE, the nurse should work from "clean" areas to "dirty" ones, put on PPE before entering the patient room, always use goggles instead of personal glasses, and remove PPE in the doorway or anteroom.

13: A nurse is collecting more patient data to confirm a diagnosis of emphysema for a 68-year-old male patient. What type of diagnosis does this intervention seek to confirm? a. Actual b. Possible c. Risk d. Collaborative

b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule 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.

34: 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.

23: A nurse teaches a patient at home to use clean technique when changing a wound dressing. This practice is considered: a. The nurse's preference b. Safe for the home setting c. Unethical behavior d. Grossly negligent

b. In the home setting, where the patient's environment is more controlled, medical asepsis is usually recommended, with the exception of self-injection. This is the appropriate procedure for the home and is neither unethical nor grossly negligent.

11: 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 agency has its own assessment form you must use."

b. Once you learn what constitutes the minimum data set, you can adapt this to any patient situation. It is not true that each assessment is the same even when you are 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 agency assessment tools does not allow for individualized patient care or critical thinking.

34: A patient complains of 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 patient's 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.

1: Which phrase describes a purpose of the ANA's Nursing's Social Policy Statement? Select all that apply. a. To describe the nurse as a dependent caregiver b. To provide standards for nursing educational programs c. To define the scope of nursing practice d. To establish a knowledge base for nursing practice e. To describe nursing's social responsibility f. To regulate nursing research

c, d, e. The ANA Social Policy Statement (2010) describes the social context of nursing, a definition of nursing, the knowledge base for nursing practice, the scope of nursing practice, standards of professional nursing practice, and the regulation of professional nursing.

14: 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 physician. 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 plan of care, 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 physician. Consulting with a psychiatrist is a collaborative intervention.

15: A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient appreciates or 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 describe the patient's achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

34: A nurse uses a whirlpool to relax a patient following intense physical therapy to restore movement in her 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 pain-blocking chemicals that have prolonged 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.

23: A nurse is preparing a sterile field using a packaged sterile drape for a confused patient who is scheduled for a surgical procedure. When setting up the field, the patient accidentally touches an instrument in the sterile field. What is the appropriate nursing action in this situation? a. Ask another nurse to hold the hand of the patient and continue setting up the field. b. Remove the instrument that was touched by the patient and continue setting up the sterile field. c. Discard the supplies and prepare a new sterile field with another person holding the patient's hand. d. No action is necessary since the patient has touched his or her own sterile field.

c. If the patient touches a sterile field, the nurse should discard the supplies and prepare a new sterile field. If the patient is confused, the nurse should have someone assist by holding the patient's hand and reinforcing what is happening.

23: The nurse assesses patients to determine their risk for health care-associated infections. Which hospitalized patient is most at risk for developing this type of infection? a. A 60-year-old patient who smokes two packs of cigarettes daily b. A 40-year-old patient who has a white blood cell count of 6,000/mm3 c. A 65-year-old patient who has an indwelling urinary catheter in place d. A 60-year-old patient who is a vegetarian and slightly underweight

c. Indwelling urinary catheters have been implicated in most health care-associated infections. Cigarette smoking, a normal white blood cell count, and a vegetarian diet have not been implicated as risk factors for HAIs.

13: When helping a patient turn in bed, the nurse notices that his heels are reddened and plans to place him 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 plans of care 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.

34: When developing the plan of care for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain is most effectively relieved when analgesics are administered in what matter? a. On a PRN (as needed) basis b. Conservatively c. Around the clock (ATC) d. Intramuscularly

c. The PRN protocol is totally inadequate for patients experiencing chronic pain. ATC doses of analgesics are more effective, whereas conservative pain management for whatever reason may also prove ineffective. Intramuscular administration is not practical on a long-range basis for a patient with chronic pain.

15: A nurse uses the following classic elements of evaluation when caring for patients. Which item below places them in their correct sequence? (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting one's judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what one is looking for when evaluating, e.g., expected patient outcomes) 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 (what you are looking for when you evaluate, e.g., expected patient outcomes), (2) collecting data to determine whether these criteria and standards are met, (3) interpreting and summarizing findings, (4) documenting your judgment, and (5) terminating, continuing, or modifying the plan.

11: The nurse is surprised to detect an elevated temperature (102°F) in a patient scheduled for surgery. The patient has been afebrile and shows no other signs of being febrile. What is the first thing the nurse should do? 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.

23: A nurse is following the principles of medical asepsis when performing patient care in a hospital setting. Which nursing action performed by the nurse follows these recommended guidelines? a. The nurse carries the patients' soiled bed linens close to the body to prevent spreading microorganisms into the air. b. The nurse places soiled bed linens and hospital gowns on the floor when making the bed. c. The nurse moves the patient table away from the nurse's body when wiping it off after a meal. d. The nurse cleans the most soiled items in the patient's bathroom first and follows with the cleaner items.

c. According to the principles of medical asepsis, the nurse should move equipment away from the body when brushing, scrubbing, or dusting articles to prevent contaminated particles from settling on the hair, face, or uniform. The nurse should carry soiled items away from the body to prevent them from touching the clothing. The nurse should not put soiled items on the floor, as it is highly contaminated. The nurse should also clean the least soiled areas first and then move to the more soiled ones to prevent having the cleaner areas soiled by the dirtier areas.

23: A nurse is finished with patient care. How would the nurse remove PPE when leaving the room? a. Remove gown, goggles, mask, gloves, and exit the room. b. Remove gloves, perform hand hygiene, then remove gown, mask, and goggles. c. Untie gown waiststrings, remove gloves, goggles, gown, mask; perform hand hygiene. d. Remove goggles, mask, gloves, gown, and perform hand hygiene.

c. If an impervious gown has been tied in front of the body at the waist, the nurse should untie the waist strings before removing gloves. Gloves are always removed first because they are most likely to be contaminated, followed by the goggles, gown, and mask, and hands should be washed thoroughly after the equipment has been removed and before leaving the room

14: 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 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 and complain about this practice.

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.

14: A nurse develops a detailed plan of care for a 16-year-old female 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 plan of care 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 plan of care is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.

1: A nurse is practicing as a nurse-midwife in a busy OB-GYN office. Which degree in nursing is necessary to practice at this level? a. LPN b. ADN c. BSN d. MSN

d. A master's degree (MSN) prepares advanced practice nurses. Many master's graduates gain national certification in their specialty area, for example, as family nurse practitioners (FNPs) or nurse midwives.

13: A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. An example of an affective outcome for this patient is: 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 6/12/15, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. c. By 6/19/15, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3″ to 2.5″). d. By 6/12/15, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

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

14: A student nurse is organizing clinical responsibilities for an 84-year-old female 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 patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's 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 patient's 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 patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.

12: A nurse is writing nursing diagnoses for patients in a psychiatrist's office. Which nursing diagnoses are correctly written as two-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 Processes related to panic state (4) Decisional Conflict related to placement of parent in a long-term care facility a. (1) and (2) b. (3) and (4) c. (1), (2), and (3) d. All of the above

d. Each of the four diagnoses is a correctly written two-part diagnostic statement that includes the problem or diagnostic label and the etiology or cause.

34: A patient is postoperative following an emergency cesarean section birth. The patient asks the nurse about the use of pain medications 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 gets unbearable 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 ordered pain medications for you, which you should not be afraid to request any time 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.

11: When you receive the shift report, you learn that your patient has no special skin care needs. You are surprised during the bath to observe reddened areas over bony prominences. What 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.

11: 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 (QPA) 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 agency or service. The time-lapsed assessment is scheduled to compare a patient's current status to baseline data obtained earlier.

34: A female patient who is having a myocardial infarction complains of pain that is situated in her jaw. 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 originates in the skin or subcutaneous tissue. Phantom pain may occur in a person who has had a body part amputated, either surgically or traumatically.

15: A student health nurse is counseling a female college student who wants to lose 20 pounds. The nurse develops a plan to increase the student's activity level and decrease the consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 pounds, the student has lost only 1 pound. Which is the best nursing response? a. Congratulate the student and continue the plan of care. b. Terminate the plan of care since it is not working. c. Try giving the student more time to reach the targeted outcome. d. Modify the plan of care after discussing possible reasons for the student's 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 plan of care. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the plan of care since the student has not met her targeted outcome. The student may need more than time to reach her outcome, which makes (c) the wrong response.

15: A nurse is writing an evaluative statement for a patient who is trying to lower her cholesterol through diet and exercise. Which evaluative statement is written correctly? a. "Outcome not met." b. "1/21/15—Patient reports no change in diet." c. "Outcome not met. Patient reports no change in diet or activity level." d. "1/21/15—Outcome not met. Patient reports no change in diet or activity level."

d. The evaluative 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. Answers a, b, and c are incomplete statements.

15: 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 plan of care. 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 plan of care, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.

11: When a nurse enters the patient's room to begin a nursing history, the patient's wife is there. What should the nurse do? a. Introduce oneself and thank the wife for being present. b. Introduce oneself and ask the wife if she wants to remain. c. Introduce oneself and ask the wife to leave. d. Introduce oneself and 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. You 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.

23: A nurse is caring for an obese 62-year-old patient with arthritis who has developed an open reddened area over his sacrum. What is a priority nursing diagnosis for this patient? a. Imbalanced Nutrition: More Than Body Requirements related to immobility b. Impaired Physical Mobility related to pain and discomfort c. Chronic Pain related to immobility d. Risk for Infection related to altered skin integrity

d. The priority diagnosis in this situation is the possibility of an infection developing in the open skin area. The others may be potential or probable diagnoses for this patient and may also require nursing interventions after the first diagnosis is addressed.

13: A nurse is caring for a patient who is diagnosed with congestive heart failure. Which statement below is not an example of a well-stated nursing intervention? a. Offer patient 60 mL water or juice (prefers orange or cranberry juice) every 2 hours while awake for a total minimum PO intake of 500 mL. b. Teach patient the necessity of carefully monitoring fluid intake and output; remind patient each shift to mark off fluid intake on record at bedside. c. Walk with patient to bathroom for toileting every 2 hours (on even hours) while patient is awake. d. Manage patient's pain.

d. This statement lacks sufficient detail to effectively guide nursing intervention. The set of nursing interventions written to assist a patient to meet an outcome must be comprehensive. Comprehensive nursing interventions specify what observations (assessments) need to be made and how often, what nursing interventions need to be done and when they must be done, and what teaching, counseling, and advocacy needs patients and families may have.

23: A nurse who created a sterile field for a patient is adding a sterile solution to the field. What is an appropriate action when performing this task? a. Place the bottle cap on the table with the edges down. b. Hold the bottle inside the edge of the sterile field. c. Hold the bottle with the label side opposite the palm of the hand. d. Pour the solution from a height of 4 to 6 inches (10 to 15 cm).

d. To add a sterile solution to a sterile field, the nurse would open the solution container according to directions and place the cap on the table away from the field with the edges up. The nurse would then hold the bottle outside the edge of the sterile field with the label side facing the palm of the hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm).

34: A pregnant woman is receiving an epidural analgesic prior to delivery. The nurse provides vigilant monitoring of this patient to prevent the occurrence of: 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.

35: A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient? a. Feed the patient solids first and then liquids last. b. Place the head of the bed at a 30-degree angle during feeding. c. Puree all foods to a liquid consistency. d. Provide a thirty-minute rest period prior to mealtime.

d. When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification and food size and/or consistency.

23: The nurse has opened the sterile supplies and put on two sterile gloves to complete a sterile dressing change, a procedure that requires surgical asepsis. The nurse must: a. Keep splashes on the sterile field to a minimum. b. Cover the nose and mouth with gloved hands if a sneeze is imminent. c. Use forceps soaked in a disinfectant. d. Consider the outer 1 inch of the sterile field as contaminated.

d. Considering the outer inch of a sterile field as contaminated is a principle of surgical asepsis. Moisture such as from splashes contaminates the sterile field, and sneezing would contaminate the sterile gloves. Forceps soaked in disinfectant are not considered sterile.

1: Which nurse who was influential in the development of nursing in North America is regarded as the founder of American nursing? a. Clara Barton b. Lillian Wald c. Lavinia Dock d. Florence Nightingale

d. Florence Nightingale elevated the status of nursing to a respected occupation, improved the quality of nursing care, and founded modern nursing education. Clara Barton established the Red Cross in the United States in 1882. Lillian Wald is the founder of public health nursing. Lavinia Dock was a nursing leader and women's rights activist instrumental in womens' right to vote.

12: A nurse is counseling a 60-year-old female patient who refuses to look at or care for a new colostomy. She 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. Nursing Problem, because it 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.

23: The nurse caring for patients in a hospital setting institutes CDC standard precaution recommendations for which category of patients? a. Only patients with diagnosed infections b. Only patients with visible blood, body fluids, or sweat c. Only patients with nonintact skin d. All patients receiving care in hospitals

d. Standard precautions apply to all patients receiving care in hospitals, regardless of their diagnosis or possible infection status. These recommendations include blood; all body fluids, secretions, and excretions except sweat; nonintact skin; and mucous membranes.

1: In early civilizations, the theory of animism attempted to explain the mysterious changes occurring in bodily functions. Which statement describes a component of the development of nursing that occurred in this era? a. Women who committed crimes were recruited into nursing the sick in lieu of serving jail sentences. b. Nurses identified the personal needs of the patient and their role in meeting those needs. c. Women called deaconesses made the first visits to the sick and male religious orders cared for the sick and buried the dead. d. The nurse was the mother who cared for her family during sickness by using herbal remedies.

d. The theory of animism was based on the belief that everything in nature was alive with invisible forces and endowed with power. In this era, the nurse usually was the mother who cared for her family during sickness by providing physical care and herbal remedies. At the beginning of the 16th century the shortage of nurses led to the recruitment of women who had committed crimes to provide nursing care instead of going to jail. In the early Christian period, women called deaconesses made the first organized visits to sick people, and members of male religious orders gave nursing care and buried the dead. The influences of Florence Nightingale were apparent from the middle of the 19th century to the 20th century; one of her accomplishments was identifying the personal needs of the patient and the nurse's role in meeting those needs.

35: A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? a. The patient consumed 75% of the liquids on her breakfast tray. b. The patient tells you she is hungry. c. The patient's abdomen is soft, nondistended, with bowel sounds. d. The patient reports fullness and diarrhea after breakfast.

d. Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray.

35: A nurse is helping an overweight female patient to devise a meal plan to lose 2 pounds per week. How many calories would the patient need to delete per day in order to accomplish this goal? a. 250 calories b. 500 calories c. 750 calories d. 1000 calories

d. 1 lb (0.45 kg) of body fat equals about 3,500 cal. Therefore, to gain or lose 1 lb (0.45 kg) in a week, daily calorie intake should be increased or decreased, respectively, by 500 cal (3,500 cal divided by 7 days = 500 cal/day). Similarly, a weight gain or loss of 2 lb (0.9 kg) per week would require an adjustment of 1,000 cal/day.