Test 2 Review Questions

Lucille verbalizes concern about Mrs. Moreno losing her independence as an older adult. She is fearful about her mother's decline in cognitive function. Which of the following ethical principles would be impacted by this decline? A. Autonomy B. Justice C. Fidelity D. Beneficence

ANS: A Rationale: Autonomy refers to a person's independence and becomes complicated when the patient is cognitively impaired by age or disease. Justice refers to the principle of fairness. Fidelity refers to the agreement to keep promises and is based on the virtue of caring. The principle of beneficence promotes taking positive, active steps to help others.

Effective documentation is one of the best defenses for: A. legal claims. B. ineffective communication. C. inaccurate assessment information. D. reimbursement issues.

ANS: A Rationale: Because jurors usually rely on information documented in the medical record to determine the patient care provided, effective documentation is one of the best defenses for legal claims associated with health care. Record keeping is the professional responsibility of the nurse and is not an option in practice. Charting has an impact on the reimbursement an agency receives.

It is acceptable practice to proceed with surgery on a minor patient without obtaining informed consent from the parents. A. True B. False

ANS: A Rationale: In an emergency situation health care providers may provide care to patients without consent as long as it is presumed that a reasonable person would have agreed to the same or similar treatment. In this case the plan should be discussed with Lynette and the hospital's legal department should be consulted.

While caring for Lynette, David makes a medication error involving the wrong dose. In this incident there is no apparent harm. Who is held responsible if David causes harm while caring for a patient? A. David B. His nursing instructor C. The primary staff nurse D. The facility

ANS: A Rationale: Nursing students are responsible for all of their actions that cause harm to a patient. If a patient is injured as a direct result of the actions of the student, the student, the instructor, the staff nurses, and the facility may all share some liability.

The oil-retention enema did not work so Vickie obtained an order for a manual disimpaction. Vickie understands the following could occur during removal of a fecal impaction, owing to vagal stimulation. A. Bradycardia B. Hypertension C. Atelectasis D. Cardiac tamponade

ANS: A Rationale: Removing a fecal impaction manually may result in stimulation of the vagus nerve, which can cause bradycardia and hypotension. Hypertension, atelectasis, and cardiac tamponade are not associated with vagal nerve stimulation.

Jeff discusses ways Victoria and Joe can foster spiritual development in their children. He explains to them that spiritual development in children is best accomplished by: A. role modeling through parental behaviors. B. teaching the children about their religion. C. sending the children to a private Christian school. D. reading the bible each night with the children.

ANS: A Rationale: The parents play a key role in the development of a child's spirituality. This is best accomplished by role modeling desirable behaviors. Teaching the children about their religion through enrollment in a Christian school and reading the bible are important pieces to fostering spiritual development, but spirituality is fully developed through learning about life, self, and God from parental behavior.

Which of the following aspects of documentation are considered to be of good quality? (Select all that apply.) A. Factual and accurate B. Documentation is crossed out per policy. C. Documentation is inserted in blank spaces so nothing is forgotten. D. Complete, current, and organized E. Time gaps are apparent

ANS: A and D Rationale: Quality documentation and reporting have five important characteristics: factual, accurate, complete, current, and organized. Problems arise when a record is reviewed in a malpractice suit and there are time gaps, information is squeezed between lines or crossed out, or key facts are omitted.

A comprehensive physical assessment involves the use of which of the following skills? A. Inspection B. Palpation C. Environment D. Auscultation E. Equipment

ANS: A, B and D Rationale: A comprehensive physical assessment involves the use of five skills: inspection, palpation, percussion, auscultation, and olfaction. A physical examination requires privacy and a comfortable environment for the patient. The person performing the assessment should assemble the necessary equipment prior to beginning.

Abnormal breath sounds are also known as _____________.

ANS: Adventitious Rationale: Abnormal sounds result from air passing through moisture, mucus, or narrowed airways. They also result from alveoli suddenly reinflating or from an inflammation between the pleural linings of the lung. Adventitious sounds often occur superimposed over normal sounds. The four types of adventitious sounds are crackles, rhonchi, wheezes, and pleural friction rub.

Nursing students may obtain jugular venous pressure measurements with the patient sitting at a 45-degree angle. A. True B. False

ANS: B Rationale: An advanced practice nurse completes the specific measurement of jugular venous pressure. To measure venous pressure, inspect the jugular veins with the patient in the supine position (normally veins protrude), when standing (normally veins are flat), and when sitting at a 45-degree angle (jugular veins are distended only if patient has right-sided heart failure).

Once the patient goes into surgery, David performs documentation of the events that occurred. He files an incident report electronically. In the nursing notes David should be sure to include the incident report number. A. True B. False

ANS: B Rationale: Occurrence reports are not a part of the patient's medical record and could be used as evidence in a lawsuit. It should never be documented in the medical record that an occurrence or incident report was completed.

Mrs. Vallero is anxious each time she gets catheterized. Sandy should facilitate the catheter insertion by asking Mrs. Vallero to: A. bear down. B. take deep breaths. C. turn to the side. D. hold her labia open.

ANS: B Rationale: Sandy should ask Mrs. Vallero to breathe deeply during the catheter insertion. This will help relax the urinary sphincter. Bearing down isn't recommended during catheter insertion. Turning to the side or holding the labia open won't ease insertion and could cause contamination of the sterile field.

Sandy provides education to Mrs. Vallero about urinary incontinence. She knows Mrs. Vallero understands, when she states: A. "Urinary incontinence is a normal part of the aging process." B. "Urinary incontinence isn't a disease." C. "Urinary incontinence is not treatable." D. "Urinary incontinence is a disease."

ANS: B Rationale: Urinary incontinence isn't a disease. It may be caused by medications or certain medical conditions. It is not a normal part of aging nor is it a disease. Many patients with urinary incontinence can be treated or cured.

_____________is the study of a particular branch of ethics.

ANS: Bioethics Rationale: The study of bioethics represents a particular branch of ethics. Nursing professionals play a vital role in the practice of bioethics, because nurses bring a unique point of view into the discussion about patient care.

The nurse in the clinic has access to a medical social worker and suggests a consultation between Lucille and the social worker. The nurse explains that her intent is to evaluate the situation and provide Lucille with resources to care for her mother in the event that her mental status is declining. She provides support to her and verbalizes that she understands that it must be difficult to face the failing health of her elderly mother. In the case of Mrs. Moreno, the nurse refuses to write a letter that is based on false information. What is the principle that guides the nurse? A. Competency B. Responsibility C. Accountability D. Respect for confidentiality

ANS: C Rationale: Accountability refers to the ability to answer for your actions and is the principle that guides the nurse in this situation. Responsibility refers to the performance of duties associated with the nurse's role. Competency and confidentiality are not the guiding principles in this situation.

Victoria goes to church regularly and seeks comfort from her faith in God. Faith is best defined as: A. a practice associated with all aspects of a person's life. B. an organized belief system about a higher power. C. belief in something even though there is no proof or material evidence. D. a positive outlook even in bleak times.

ANS: C Rationale: Faith is a belief in something even when there is no proof or material evidence. Spiritual beliefs are practices associated with all aspects of a person's life. Religion is an organized belief about a higher power. A positive outlook even in bleak times is hope.

Vickie obtains an order for an oil-retention enema for Mr. Gutierrez. She correctly administers the enema by doing which of the following? A. Administering 500 to 1000ml of solution B. Administering 200 ml of tap water C. Instructing the patient to retain the enema for at least 30 seconds D. Administering the enema while Mr. Gutierrez is sitting on the toilet

ANS: C Rationale: Mr. Gutierrez should be instructed to retain the enema for at least 30 seconds. Oil-retention enemas are usually administered with 150 to 200ml of solution. Tap water is used for a tap-water enema, not an oil-retention enema. Administering the enema while Mr. Gutierrez is on the toilet will not facilitate the need for him to retain the enema for 30 seconds after administration.

Which of the following clinical findings indicates central cyanosis? A. Pain in the legs B. Oxygen saturation of 98% C. Bluish discoloration of the lips and mouth D. Bounding femoral artery pulses

ANS: C Rationale: The presence of cyanosis requires special attention. Heart disease sometimes causes central cyanosis (bluish discoloration of the lips, mouth, and conjunctivae), indicating poor arterial oxygenation. Blue lips, earlobes, and nail beds are signs of peripheral cyanosis, which indicates peripheral vasoconstriction. When cyanosis is present, consult with a health care provider to have laboratory testing of oxygen saturation, to determine severity of the problem. Examination of the nails involves inspection for clubbing (a bulging of the tissues at the nail base), resulting from insufficient oxygenation at the periphery. Pain in the legs and bounding femoral pulses are not indicative of central cyanosis.

Jane is preparing to perform a physical assessment on Mr. Neal. Which of the following interventions will be helpful in the physical preparation of the patient? (Select all that apply.) A. Ask Mr. Neal if he is anxious or stressed. B. Obtain an interpreter. C. Offer to assist Mr. Neal to the restroom. D. Provide privacy and warm blankets if needed. E. Assist Mr. Neal to a position of comfort.

ANS: C, D and E Rationale: The patient's physical comfort is vital for a successful examination. Before starting, ask if the patient needs to use the restroom. Physical preparation involves being sure the patient is dressed or covered properly, providing warm blankets if needed, and assisting the patient to assume a position of comfort. Psychological preparation of the patient involves assessing for stress or anxiety and providing an interpreter if needed.

Mrs. Vallero voices frustration and embarrassment about her urinary incontinence. Sandy educates Mrs. Valero about bladder retraining and includes information about which intervention? A. Establishing a predetermined fluid intake pattern B. Increasing the time between voiding C. Restricting fluid intake to reduce the need to void D. The assessment of current elimination patterns

ANS: D Rationale: Bladder retraining interventions include assessing current elimination patterns such as fluid intake, voiding patterns, and reasons for episodes of incontinence. Fluid intake will not have an effect on her incontinence. A voiding schedule will be established after assessment.

Jeff will care for patients from many different cultures throughout his nursing career. Jeff understands which of the following practices will help him meet the spiritual needs of his patients? A. Using Jeff's spiritual beliefs to assess the needs of the patient B. Studying the bible C. Approaching each patient in the same manner D. Learning about various religious and cultural traditions

ANS: D Rationale: It is important for Jeff to learn about various spiritual practices so he can familiarize himself with the beliefs that might affect his patient's care. Jeff's should incorporate the patient's spiritual beliefs into the assessment and plan of care. Studying the bible is one dimensional and will not meet the needs of all patients. Approaching each patient in the same manner does not allow for individualization of care based on the patient's own spiritual needs.

Vickie educates Mr. Gutierrez about a bowel training program. She knows he understands her when he states: A. "I need to decrease the fiber in my diet." B. "I should only drink about 1000ml of fluid per day." C. "I will give myself an enema every day to stimulate a bowel movement." D. "I should allow ample time to have a bowel movement."

ANS: D Rationale: Mr. Gutierrez must allow ample time for bowel evacuation, usually 20 to 30 minutes. He should increase his fluid intake to 2500 to 3000ml. A high fiber diet is recommended as part of the program. Daily enemas are not recommended in a bowel program.

What are legal guidelines for minimally safe and adequate nursing practice? A. Interrogatories B. Common laws C. Nurse Practice Acts D. Standards of care

ANS: D Rationale: Standards of care are legal guidelines for minimally safe and adequate nursing practice. They are partially defined by the State Nurse Practice Acts. Common laws are based on judicial decisions or case law. Interrogatories are sets of written information requiring answers under oath.

Victoria explains her children have been tearful lately. Which statement by Victoria indicates her daughter, Valerie, is in spiritual distress? A. "Valerie hasn't felt like going out much lately but she did go see a movie with her boyfriend last night." B. "Valerie said she wishes she had cancer instead of me." C. "Valerie has asked if she can see a therapist." D. "Valerie refuses to go to church with us. She says it is a waste of time."

ANS: D Rationale: Victoria has indicated that church has been an integral part of Valerie's upbringing. For her to suddenly not want to go because she feels it is a waste of time is an indication of spiritual distress. Not feeling like going out is a symptom of normal grief. Valerie wishing she had cancer instead of her mom is a normal response to grief and depression. Asking to go to a therapist demonstrates Valerie is seeking support.

Quality nursing care depends upon accurate ______________ in the patient's medical record.

ANS: Documentation Rationale: The health care environment creates many challenges for accurately documenting and reporting patient care. Quality nursing care depends on your ability to communicate effectively verbally and in writing, and nurses are held accountable for the accuracy of the documentation that is entered in the patient's medical record.

Nursing documentation that is completed on a flow sheet to indicate normal findings or routine interventions is known as charting by __________________.

ANS: Exception Rationale: Charting by exception is an innovative approach to reduce time required to complete documentation. It involves completing a flow sheet that incorporates standard assessment criteria and interventions. A check mark is used to indicate normal findings or routine interventions.

Use the most appropriate terms to fill in the blanks of the statement: Nurses (and nursing students) are (1) __________ and __________ obligated to keep information about patients confidential. Only members of the health care team who are (2) __________ in a patient's care have legitimate access to that patient's health care record. Information about a patient's diagnosis, treatment, or assessment should be discussed only with members of the health care team who are specifically involved in a patient's care.

Answer: (1) legally, ethically, (2) directly involved. Under HIPAA, the Privacy Rule requires that disclosure or requests regarding health information are limited to the specific information required for a particular purpose and only those directly involved with a patient's care. Nurses and other health care professionals are legally and ethically bound to maintain the privacy and confidentiality of protected health information (PHI). Privacy is the individual's right to limit access to his or her health care information. Confidentiality is the expectation that information shared with the health care

A nurse is caring for a patient with a history of urinary retention. Which findings indicate the need to use a bladder scanner to measure postvoid residual? (Select all that apply.) 1. Dribbling urine while experiencing urgency 2. Absence of voiding in more than 6 hours 3. Reports of pain with palpation of the bladder 4. Swelling over the lower abdomen extending to the umbilicus 5. Visible hematuria noted with the patient's last void

Answer: 1, 2, 3, 4. A bladder that is distended to the umbilicus indicates a very full bladder. Patients report pain with palpation, dribbling of urine because of urinary retention, and the urge to void

A new nurse on your unit brings up a concern during a staff meeting about a patient on your unit. The nurse thought the patient was male based on the patient's name and the notes in the medical record. However, during her initial assessment, she discovered that the patient has female anatomy. The nurse has never been assigned to care for a transgender person and is uncomfortable taking care of this patient. The manager listens to the nurse's concerns but states that she cannot reassign this patient without making sure that another nurse is willing and available to take the assignment. Otherwise, the assignment will need to stand as is. She promises to conduct an in-service about caring for transgender patients as soon as possible. Which of the following accurately describes the ethical principles reflected in the nurse manager's response? (Select all that apply.) 1. The nurse manager demonstrates fidelity, the professional promise to the patient for quality care and a refusal to abandon the patient. 2. The nurse's willingness to make a change in assignment reflects her willingness to do no harm to staff nurses, or nonmaleficence. 3. The nurse manager is trying to take a positive action to help the new nurse as well as the work unit as a whole, which is an example of beneficence. 4. By taking into account the new nurse's discomfort, the nurse manager strives to respect the autonomy of the nurse as a provider, while at the same time respecting the autonomy of the patient. 5. The best way to ensure the principle of justice for this patient would be to consult with an attorney about local laws pertaining to transgender individuals.

Answer: 1, 2, 3, 4. The Code of Ethics for Nurses guides nurses to commit to respect for all patients even when the nurse has different beliefs or is otherwise uncomfortable with the patient's character or situation. In no case can a nurse justify abandoning a patient

A patient is being discharged to an acute rehabilitation facility. You need to print some information from the patient's health care record and fax it to that facility. What actions do you take to maintain privacy and confidentiality of the patient's information in providing the health care record information to the acute rehabilitation facility? (Select all that apply.) 1. Confirm that the fax number you have for the acute rehabilitation facility is correct before sending the fax. 2. Use a cover sheet that indicates the specific person at the acute rehabilitation facility to whom you are directing the patient information. 3. Utilize the encryption feature on the fax machine to encode the information making it impossible for staff at the acute rehabilitation facility to read the information you fax unless they have the encryption key. 4. Rip up the information you printed out to fax and place it in a standard trash can. 5. Place the information you printed out to fax in the patient's paper-based chart. 6. Place the information you printed out to fax in a secure canister marked for shredding.

Answer: 1, 2, 3, 6. Nurses have the legal and ethical obligation to safeguard any patient information that is printed or extracted from the electronic (or paper) health care record for reporting purposes. This information is considered protected health information (PHI). Best practice is to use all measures to fax information securely and to shred any printed health care record material after it has been used for the purpose intended

Which of these is a nursing safety consideration before insertion of a Foley catheter? (Select all that apply.) 1. Identify if patient is at risk for a latex allergy. 2. Identify if patient has an allergy to povidone-iodine (Betadine). 3. Follow asepsis principles when performing catheter insertion. 4. Teach the patient Kegel exercises. 5. Discard the first voided specimen.

Answer: 1, 2, 3. Identify if the patient is at risk for a latex allergy or has an allergy to povidone-iodine (Betadine). Follow asepsis principles when performing catheter insertion

A nurse is caring for a 32-year-old patient with Down syndrome, a genetic disorder that includes impaired cognition. The patient's parents are deceased. He lives in a group home and works part time as a bagger at a grocery store. What actions does the nurse take during discharge planning to show respect for the patient's inherent dignity and worth? (Select all that apply.) 1. Make sure written materials are written at an appropriate reading level 2. Contact the group home to ensure that a caregiver is involved with discharge plans 3. Allow the patient extra time for return demonstrations of your teaching plan 4. Assume he is unable to understand instruction and focus on needs other than education 5. Let his supervisor at the grocery story know about the patient's discharge medications

Answer: 1, 2, 3. Showing respect for patient dignity and worth for all patients is a nursing obligation. Providing appropriate patient education and speaking with the patient's caregivers about discharge instructions shows respect for the patient. Sharing information with the supervisor without patient permission violates confidentiality, and making assumptions about the patient's ability to learn without assessing the patient first do not show respect for the patient

What factors increase the risk of urinary tract infections? (Select all that apply.) 1. Poor perineal hygiene practices 2. Presence of an indwelling catheter 3. Diets high in carbohydrate 4. Urinary retention 5. Fecal incontinence

Answer: 1, 2, 4, 5. Risk for urinary tract infection (UTI) increases in the presence of any instrumentation in the urinary tract including an indwelling catheter. Urinary retention, urinary incontinence, and poor perineal hygiene practices are also factors associated with UTIs

How would a nurse complete passive ROM assessment on a patient? (Select all that apply.) 1. Have the patient relax and the nurse moves the joint for the patient. 2. The nurse moves the joint in the appropriate directions. 3. The patient uses muscles and presses back against the nurse's hand. 4. Have the patient ambulate down the hallway and the nurse observes gait.

Answer: 1, 2. Passive ROM involves having the patient relax. The nurse conducting the assessment moves the joint through ROM.

At the end of a shift, a nurse is giving a hand-off report about a patient named Mrs. Lennon to another nurse. Which pieces of information are appropriate to include in the hand-off report? (Select all that apply.) 1. "Mrs. Lennon is 45 years old. She was admitted yesterday after an open cholecystectomy." 2. "Mrs. Lennon has really been difficult today. She has been using her nurse call system constantly, and nothing I've done has pleased her." 3. "Mrs. Lennon is allergic to strawberries, fentanyl, and sulfa medications." 4. "Mrs. Lennon has a urethral catheter in place that has drained 450 mL of clear, light yellow urine." 5. "Mrs. Lennon has received tramadol 100mg PO every 8 hours for pain and has consistently rated her pain from 5 to 6 on a 1-to-10 scale this shift. 6. "Mrs. Lennon has a dressing over her right upper quadrant incision that has a moderate amount of old, dark red drainage. I was not able to change the dressing this shift because of inadequate staffing."

Answer: 1, 3, 4, 5, 6. Legal and ethical guidelines for documentation and reporting require you to keep what you write in the health care record and what you state about a patient objective and factual. You do not write or state critical or retaliatory comments about a patient or care provided by other health care professionals.

You are a new graduate nurse talking to a nursing student about the standards of care on the cardiac unit. The student nurse asks you if the standards of care are set by the State Board of Nursing. Your answer to the student nurse is that the standards of care incorporate which of the following? (Select all that apply.) 1. State Nurse Practice Acts 2. Health care provider orders 3. Recommendations from professional nursing organizations 4. Policies and procedures of the health care agency 5. Evidence-based practice recommendations

Answer: 1, 3, 4, 5. Standards of care come from State Nurse Practice Acts, recommendations from professional and specialty organizations, formal policies and procedures of health care facilities, and evidence-based practice recommendations. Provider orders do not create a standard of care

You decide to write an editorial to your local newspaper expressing your opinion about disparities in access to health care in your community. Which provisions from the ANA Code of Ethics for Nurses could you use to strengthen your editorial? (Select all that apply.) 1. Provision 2: The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population. 2. Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. 3. Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. 4. Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. 5. The ANA Code of Ethics for Nurses applies to nursing practice, and it is therefore inappropriate to refer to specific provisions when discussing public policy.

Answer: 1, 3, 4. The Code of Ethics for Nurses encourages nurses to fulfill their professional obligation for advocacy by engaging in issues of public policy. The ethical justifications include commitment to reduce health disparities and to work collectively to articulate nursing values

The nurse provides teaching and answers the patient's questions related to skin care at home. Which statements made by the patient indicate the teaching has been effective? (Select all that apply.) 1. "I will perform the examination in a well lit room and use a mirror." 2. "It is okay if I have drainage from a mole as long as it is not bloody." 3. "The best time for me to avoid the sun is from 10 a.m. to 4 p.m." 4. "Indoor tanning beds are okay to use as long as the use is not excessive." 5. "Some medications can make me more sensitive to the sun."

Answer: 1, 3, 5. A skin examination should be performed in a well-lit room and a mirror should be used to assist the patient to observe areas he or she has difficulty seeing. From 10 a.m. to 4 p.m. is when the sun is most dangerous and should be avoided. Different medications can make patients more sensitive to the sun.

The nurse recognizes which assessment findings are considered abnormal? (Select all that apply.) 1. Bowel sounds occurring 60 times per minute 2. Lymph nodes not visible in the neck area 3. Dyspnea present 4. S1 and S2 present 5. Slow reaction time in an 89 year old patient

Answer: 1, 3. Bowel sounds should occur 5 to 35 times per minute; therefore 60 would be too many and abnormal. Dyspnea is an abnormal finding in which a patient experiences breathlessness. Lymph nodes not visible in the neck area, the presence of S1 and S2, and slow reaction time in an elderly patient all are expected and normal findings.

You are working on an adolescent unit and know that some minors can legally give consent for their health care. Which of the following minors could give consent for a procedure? (Select all that apply.) 1. A 17-year-old who is in the armed forces 2. A 16-year-old whose grandmother has custody of him 3. A 15-year-old with a chronic medical condition 4. A 17-year-old who is married 5. A 14-year-old seeking treatment for a sexually transmitted infection

Answer: 1, 4, 5. Minors can legally consent to treatment if they meet certain requirements including if the minor is emancipated per court order, married, or in active military service. Minors with certain health conditions may also consent such as when seeking treatment for sexually transmitted infections, pregnancy, substance abuse, or a mental health condition

In which situation would a nurse be using the skill of auscultation? (Select all that apply.) 1. Assessing bowel sounds 2. Assessing oxygen saturation 3. Assessing the size of the liver 4. Assessing for a carotid bruit 5. Assessing orientation

Answer: 1, 4. The skill of auscultation uses a stethoscope and listening. Assessing bowel sounds and assessing for a carotid bruit both require the use of a stethoscope and auscultation

Which of the following actions illustrate accountability? (Select all that apply.) 1. A patient undergoes a surgical procedure that is new to the agency. The nurse asks the manager to provide an in-service about the procedure. 2. A health care provider writes orders for pain management medication even though the patient has been free of pain for 3 days. Out of respect for the health care provider's authority, a nurse administers the medications. 3. During annual budget preparation at an agency, a nurse advocates for annual pay increases for the staff. 4. A patient reports she does not have health insurance and will not be able to pay for her discharge medications. A nurse requests that a social worker meet with this patient to find a way to maximize available health care benefits. 5. The policy on a patient care unit requires repositioning of patients every 2 hours. During busy shifts, the nursing staff is unable to keep up with the practice requirement. Whenever this happens, a nurse notifies the manager and discusses possible remedies.

Answer: 1, 5. Accountability is a fundamental characteristic of a professional nurse. A nurse's expression of accountability is found in many kinds of actions. Asking for a pay raise and helping patients obtain their medications at discharge are focused on advocacy. Remaining informed and helping solve clinical problems reflect accountability

The nurse is assessing the spiritual beliefs of a 15-year-old patient. Based on the patient's developmental stage, what should the nurse expect to see? 1. The patient questions why prayer is needed. 2. The patient values the support of peers. 3. The patient feels guilty for missing church. 4. The patient requests to speak to the chaplain.

Answer: 1. According to Erickson's developmental stages, 15-year-olds (adolescents) are in the "Identity versus identity confusion" stage. In this stage, the adolescent questions spiritual practices and often questions or discards parents' beliefs. They begin to form their own opinions on multiple topics including religion and spirituality.

You are discussing the advantages of using computerized provider order entry (CPOE) with one of your nursing colleagues. Which statement best indicates that you understand the major advantage of a CPOE system? 1. "CPOE improves patient safety by reducing transcription errors." 2. "CPOE reduces the time necessary for health care providers to write orders." 3. "CPOE allows order entry from any computer that has Internet access." 4. "CPOE decreases the time needed for nurses to communicate with health care providers."

Answer: 1. Although the other answers loosely describe some positive aspects of CPOE, the first statement provides the best description of the major advantage that CPOE offers to patient safety, is the reduction of transcription errors, which creates a safer patient care environment and reduces medical errors

You stop at a motor vehicle collision on the side of the road to assist an injured person. You apply pressure to bleeding wound until the paramedics arrive. If you are unable to stop the bleeding, what legal provisions protect you from being sued for malpractice? 1. Good Samaritan laws 2. State Nurse Practice Act 3. Professional liability insurance 4. Professional organization standards of care

Answer: 1. Good Samaritan laws limit liability and offer legal immunity if a nurse helps at the scene of an accident. The laws protect the nurse if he or she is acting within accepted standards, even if proper equipment is not available. If the patient subsequently develops complications as a result of the actions, the nurse is immune from liability as long as there was no gross negligence

A patient who has heart failure is complaining of shortness of breath. Which assessment finding is the nurse most concerned about? 1. Moist crackles in the base of bilateral lungs 2. Respiratory rate of 20 3. 1+ edema in lower extremities 4. Bronchovesicular sounds over posterior thorax

Answer: 1. Moist crackles are lower, moist sounds heard during middle of inspiration and are not cleared with coughing. This finding could mean fluid buildup.

The nurse is caring for a patient who has just had a near-death experience (NDE) following a cardiac arrest. Which intervention by the nurse best promotes the spiritual well-being of the patient after the NDE? 1. Allowing the patient to discuss the experience 2. Referring the patient to pastoral care 3. Having the patient talk to another patient who had a NDE 4. Offering to pray for the patient

Answer: 1. Patients who experience a near-death experience (NDE) are often reluctant to speak of the experience. Allowing the patient to discuss the experience helps the patient find acceptance and meaning of the event. Allowing the patient to speak of the event helps the patient to explore what happened and promotes spiritual well-being.

The nurse instructs a female patient how to perform Kegel exercises. Which patient statement indicates she can perform the exercises correctly? 1. "I squeeze the anus as if I am holding in gas for 2 or 3 seconds" 2. "I push like I need to have a bowel movement" 3. "I squat down and squeeze my thighs together for 5 to 10 seconds" 4. "I contract my abdomen and buttocks for 2 or 3 seconds"

Answer: 1. Teaching the patient to squeeze the anus as if to hold in gas ensures the patient is contracting the correct muscle. Kegel exercises can be quick flicks squeezing the muscles for 2 to 3 seconds or sustained contractions squeezing the muscles for 5 to 10 seconds

The nurse is teaching a patient to care for a newly placed urostomy. Which patient statement indicates that the patient may be experiencing self-concept concerns? 1. "Can I hide this thing somehow under the dressing when I want to have sex?" 2. "I am scared I will mess this up, but the more I practice the better I feel about it." 3. "I was having trouble doing this dressing change the first day; however, my husband has been supportive and helpful." 4. "How will I know if this becomes infected?"

Answer: 1. The patient statement indicating concern about having a sexual relationship with the urostomy suggests possible self-concept issues

When caring for a patient with fecal incontinence, what is the best way for the nurse to protect the patient's skin? 1. Cleanse the skin with a no-rinse cleanser and apply a barrier cream 2. Scrub the skin with antimicrobial cleanser using a soft washcloth 3. Cleanse skin with soap and water and apply talcum powder 4. Wipe stool away with toilet paper and apply petrolatum ointment

Answer: 1. Using a no-rinse cleanser and an effective barrier cream is gentle to fragile and possibly irritated skin and adheres well to protect from future episodes of incontinence

The nurse prepares to conduct a general survey on an adult patient. Which assessment is performed first while the nurse initi- ates the nurse-patient relationship? 1. Appearance and behavior 2. Measurement of vital signs 3. Observing specific body systems 4. Conducting a detailed health history

Answer: 1. The first part of the general survey is assessment of the appearance and behavior of the patient. As you are initiating the nurse-patient relationship, observe gender and race, age, signs of distress, body type, posture, gait, body movement, hygiene and grooming, dress, affect and mood, speech, and signs of patient abuse.

The nurse is caring for a patient who is very depressed and decides to complete a spiritual assessment using the FICA tool. Match the following assessment questions with the correct component in the FICA statement. ___1. Faith or belief ___2. Importance of spirituality ___3. Individual's spiritual community ___4. Interventions to address spiritual needs a. What gives meaning to your life? b. Who is most important to you? c. How have your beliefs influenced how you take care of yourself? d. What can I do to help you with your spiritual needs?

Answer: 1c, 2a, 3b, 4d

The nurse is performing an abdominal assessment on a patient. In what order does the nurse perform the steps? 1. Percussion 2. Inspection 3. Auscultation 4. Palpation

Answer: 2, 3, 4, 1. The order of an abdominal examination differs slightly from previous assessments. Begin with inspection and follow with auscultation. By using auscultation before palpation there is less chance of altering the frequency and character of bowel sounds.

The nurse is caring for a woman who is recovering from a total hip replacement. During the assessment, the nurse learns that the patient is Roman Catholic. The patient tells the nurse is she very nervous about starting therapy. Based on this information, which of the following interventions does the nurse implement to enhance the patient's spiritual health? (Select all that apply.) 1. Giving the patient an antianxiety medication 2. Asking the patient if she would like to pray with the Nurse 3. Asking the patient if she would like pastoral care to visit 4. Providing the patient privacy while she is praying the rosary 5. Telling the patient that therapy will help her get home

Answer: 2, 3, 4. Praying with someone, encouraging participation in spiritual rituals, and establishing presence with a person have the potential to decrease anxiety and enhance spiritual health.

Which statements describe accurate completion of a vascular assessment? (Select all that apply.) 1. Simultaneously palpate the carotid arteries. 2. Measure blood pressure. 3. Ask about any pain, cramping, or discomfort in the legs. 4. Count an irregular pulse for 30 seconds and multiply by 2. 5. Rate the strength of a pulse of a scale of 0 to 4.

Answer: 2, 3, 5. A blood pressure measurement is part of the vascular assessment. Asking about pain, cramping, and discomfort in the legs can give insight regarding blood flow to lower extremities and is part of the vascular assessment. During a vascular assessment the rate and strength of a pulse are evaluated on a scale of 0 to 4. Never simultaneously palpate the carotid arteries; they are palpated one at a time. Counting an irregular pulse is part of the vital sign assessment.

Which statements best explain features of the ANA Code of Ethics for Nurses? (Select all that apply.) 1. The Code is designed to guide nurse managers and nurse administrators so that they can set the proper tone in the workplace. The Code does not directly apply to new staff nurses. 2. National nurse leaders compose the Code in collaboration with health care leaders from around the world, including the United Nations, World Medical Association, and International Council of Nurses. 3. The newest version of the Code was published in 2015 and includes provisions that encourage nurse participation in public policy and advocacy for resolution of disparities in health care outcomes. 4. The Code is a legal document that nurses are required to sign whenever beginning a job at a new agency. 5. The Code sets clear obligations for personal accountability for a nurse's personal practice.

Answer: 2, 3, 5. The Code of Ethics for Nurses may seem lofty and not relevant to the practice of a new nurse, but it describes fundamental values of nursing practice. All nurses need to know it and work within its parameters

A nurse is instructing a patient about collecting a 24-hour urine specimen. Which guidelines does the nurse include? (Select all that apply.) 1. Do not refrigerate the 24-hour specimen container. 2. Discard the first voided specimen. 3. Keep the 24-hour urine specimen on ice or in a cool area. 4. Forgetting to collect all urine voided during the prescribed time is acceptable. 5. The 24-hour specimen container must be full of urine for the test to be valid.

Answer: 2, 3. When collecting a 24-hour urine specimen you discard the first voided specimen, keep the container cool by placing it on ice, and avoid contaminating the specimen with toilet paper and stool.

What lifestyle changes would the nurse include in a teaching plan for a patient who reports occasional constipation? (Select all that apply.) 1. Daily laxative use 2. Increased fluid intake 3. Decreased fluid intake 4. Regular exercise 5. High-fiber diet 6. More fruits and vegetables in the diet

Answer: 2, 4, 5, 6. With mild or occasional constipation, increased fluid intake, increased fruits and vegetables to add fiber to the diet, and regular exercise are the appropriate recommendations

A nurse is caring for a 36-year-old patient with a brain tumor who is dying. The patient has undergone surgery and chemotherapy, but nothing has worked so far to stop the growth of the tumor. The physician offered the patient one further treatment plan that could prolong life for a few weeks, but the treatment has painful side effects. The patient tells his nurse that he is at peace with the prognosis and wants to stop all further treatment. The nurse is troubled by the patient's response. She feels confident that the side effects could be managed, and, for her, refusing treatment violates a belief in the sanctity of life. Which of the following accurately describes ethical principles at stake in this situation? (Select all that apply.) 1. Even though the patient does not want it, making sure that the patient gets all possible treatments including experimental treatments will show a commitment to justice for this patient. 2. Respect for the patient's autonomy is a fundamental ethical commitment and needs to be taken into consideration when making clinical decisions with a patient. 3. The principle of beneficence implies that the providers need to ensure the patient receives the treatment because it could possibly work to the patient's benefit. 4. The nurse will remain committed to advocacy for this patient, speaking for the patient's point of view even though it conflicts with her own beliefs. Her commitment reflects a professional commitment to fidelity. 5. The nurse's concern about managing difficult side effects represents the practice of non maleficence, the commitment to do no harm.

Answer: 2, 4, 5. Differences in religious or spiritual practices should be accommodated and respected in the health care setting. Ethical practice guides the nurse to act accordingly, such as being a patient advocate and ensuring safe management of treatment side effect

Place the following steps for application of a condom catheter to a male patient in appropriate order. 1. Apply clean gloves, provide perineal care, and dry thoroughly. 2. Identify patient using at least two identifiers. 3. Assess penis for erythema, rashes, or open areas. 4. Secure condom catheter according to manufacturer directions. 5. Apply condom catheter. 6. Clip hair at base of penile shaft as necessary. 7. Connect drainage tubing to end of condom catheter. 8. Perform hand hygiene, prepare condom catheter, and help patient to a supine or sitting position

Answer: 2, 8, 1, 3, 6, 5, 4, 7. This is the correct order in which to apply a condom catheter.

Which statement best explains how ethics differs from the law? 1. Laws are written down and publicly determined, and a code of ethics is a verbal and private agreement. 2. Laws are written by public officials and describe required behaviors enforced by legal consequences. A code of ethics is a list of recommended behaviors that a professional group agrees to that is enforced by social or professional consequences. 3. Ethics are religiously determined, and the law is politically determined. 4. A code of ethics is applied only to providers who work in the health care field. The law pertains to all people who reside in the district of the law.

Answer: 2. A code of ethics is written by a group of people with shared values and represents guidelines. The law is publicly determined and enforced by codified consequences.

Which assessment finding by the nurse correctly describes a vesicle? 1. Irregularly shaped, 2cm raised nevi 2. 0.5cm elevation of the skin filled with serous fluid 3. Thinning of skin that is shiny and transparent 4. Small, flat, nonpalpable change in skin color

Answer: 2. A vesicle is a circumscribed elevation of the skin filled with serous fluid and smaller than 1cm, such as herpes or chickenpox.

You are documenting your assessment of a patient's respiratory system in an electronic health record (EHR). You use the mouse to select the following "WNL" statement to document your findings: "Breath sounds clear to bases bilaterally, respiratory effort deep and unlabored, no cough, Sao2 greater than 95% on room air." This is an example of using the documentation format of: 1. Care plan 2. Charting by exception (CBE) 3. Narrative documentation 4. Problem list

Answer: 2. CBE is a unique documentation format designed with the philosophy that all standards are met unless otherwise documented. Many computerized nursing documentation systems have incorporated a CBE design. Exception-based documentation systems incorporate clearly defined criteria for nursing assessment and documentation of "normal" findings. Predefined statements used to document "normal" assessment of body systems are called "within defined limits" (WDL) or "within normal limits" (WNL) definitions. They consist of written criteria for a "normal" assessment for each body system. Automated documentation within a computerized documentation system allows nurses to select a WDL statement or to choose other statements from a drop-down menu.

When a patient has an ileostomy, the digestive process ends in the terminal ileum. Patient education by the nurse should include the need for the person to ingest more of which dietary component? 1. More food 2. Fluids and salt 3. Less sugar and artificial sweetener 4. Fiber to firm the stool

Answer: 2. Digestion of food is adequate in the small intestine. Education about the need for fluid and salt supplementation is necessary to prevent dehydration, as this is a primary function of the large intestine

A nurse is changing the dressing on the wound of a patient who had abdominal surgery yesterday. Assessment shows new findings that are different than what was documented by the previous nurse. After documenting specifics about the wound, the nurse contacts the surgeon to communicate the changes. What is the most appropriate way to document this conversation? 1. "Health care provider notified about change in assessment of abdominal incision. A. Carron, RN" 2. "10-3-16, 18:30: Contacted Dr. Sylvana by phone. Notified about new 2-cm opening at bottom of abdominal incision and large amount of serosanguineous drainage. No orders received. Dr. Sylvana stated she would be in to assess patient within the next hour. A. Carron, RN" 3. "10-3-16: Notified health care provider by phone that there is a new opening in the patient's incision. A. Carron, RN." 4. "18:30: Contacted Dr. Sylvana by phone. Notified about changes in abdominal incision. A. Carron, RN."

Answer: 2. Document every phone call you make to a health care provider. Your documentation should include when the call was made, who made it (if you did not make the call), who was called, to whom information was given, what information was given, and what information was received

The philosophy sometimes called the ethics of care suggests that ethical dilemmas can best be solved by attention to which of the following? 1. Patients 2. Relationships 3. Ethical principles 4. Code of Ethics for Nurses

Answer: 2. Ethics of care is the concept that focuses on understanding relationships. Ethics of care was first developed by nurse ethicists and has become a common language for all health care providers

Which of the following questions asked by the nurse assesses the patient's fellowship and community? 1. "How happy are you with your life?" 2. "Who was your greatest support while you were recovering from your previous surgery?" 3. "How has your illness impacted your life?" 4. "What spiritual practices can I help you continue while you are in the hospital?"

Answer: 2. Fellowship and community are focused on the relationships that individuals have with other people. This includes family, close friends, church members, coworkers, and neighbors. There is a sense of community in these relationships. Asking about social support during illness or other challenging situations assesses fellowship and community.

When taking a telephone order from a health care provider, it is common for most organizations to require the nurse to: 1. Photocopy a telephone order to be kept in personal records for legal purposes. 2. Record the order in the health care record, read it back to the health care provider for verification, and document "telephone order read-back" in the health care record. 3. Record the order in the health care record and wait to implement the order until it has been physically signed by the health care provider. 4. Implement the telephone order but insist that the health care provider come to the patient care unit to personally enter the order into the patient's health care record within 24 hours.

Answer: 2. Guidelines from TJC require a read-back on all telephone (and verbal) orders. The nurse reads a telephone order back word for word and receives confirmation that the order is correct from the health care provider who gave the order.

When completing an abdominal assessment, which action should the nurse perform first? 1. Palpate the large and small intestines. 2. Assess for bowel sounds. 3. Percuss gas within the four quadrants of the abdominal cavity. 4. Focus on areas of pain.

Answer: 2. Inspect and auscultate first, then palpate and percuss. Save the patient's painful area for last

The nurse is providing care for a patient who reports no bowel movement for 5 days except for small amounts of liquid stool. Which immediate intervention will most likely be ordered for the patient? 1. Laxatives at bedtime 2. Manual removal of a fecal impaction 3. Instruction in high-fiber diet 4. Increase in her ambulation from 1 to 2 times a day

Answer: 2. Small amounts of liquid stool may seep around the fecal mass that accumulates in the rectum after 5 days without a bowel movement

Involuntary leakage of small amounts of urine that occurs when coughing or getting up from a chair is an example of ______________ urinary incontinence. 1. Overflow 2. Reflex 3. Stress 4. Urge

Answer: 2. Stress urinary incontinence is an involuntary leakage of small amounts of urine related to either urethral hypermobility or an incompetent urinary sphincter muscle

A patient has an unexpected weight loss of 10 lb in the last 2 months, occasional blood in the stool, and a change in the caliber of stool. Based on these symptoms, which condition would you suspect? 1. Hemorrhoids 2. Rectal cancer 3. Clostridium difficile infection 4. Fecal impaction

Answer: 2. The American Cancer Society encourages anyone with the symptoms of weight loss, blood in the stool, and change in stool caliber to seek medical evaluation for rectal cancer

The nurse received an order to administer an enema to a patient. Place the steps for giving an enema in the correct order. 1. Clamp tubing 2. Withdraw tubing 3. Position the patient on his or her side 4. Instill solution 5. Separate the buttocks 6. Release clamp 7. Insert lubricated tip of enema container in the anus

Answer: 3, 5, 7, 6, 4, 1, 2. This order of steps describes the way to give an enema

The nurse would encourage which female patient to have a mammogram? 1. 53year old who had a mammogram completed 6 months ago 2. 20year old with a positive family history of breast disease 3. 41year old at an annual visit who has no complaints 4. 32year old with no family history of breast cancer

Answer: 3. The American Cancer Society guidelines recommend that after 40 years of age, women may begin screening mammograms

A nurse is caring for a confused patient who swings his arms at anyone who approaches him. The nurse enters the room and is almost hit by the patient. The nurse responds by stating, "If you hit me, I'll hit you back!" Has the nurse violated any legal principle? 1. No, the nurse is acting in self-defense and is justified. 2. No, the nurse is merely trying to make sure that the patient stops swinging his arms at people. 3. Yes, the nurse may have committed an assault on the patient by verbally threatening him. 4. Yes, the nurse may have committed malpractice by violating the duty to care for him as a reasonable nurse would.

Answer: 3. An assault is any verbal or nonverbal threat that places the recipient in reasonable fear of imminent danger. Stating that the nurse will hit the patient is a verbal threat. Even though the patient is confused, the nurse may still be committing the act of assault.

What is the most effective practice the nurse uses to prevent the spread of Clostridium difficile infection when caring for a patient with this diagnosis? 1. Wear a mask when assisting with toileting 2. Perform hand hygiene with antimicrobial cleanser before and after every patient contact 3. Perform hand hygiene with soap and water before and after every patient contact 4. Place warning labels on any laboratory specimens obtained from this patient

Answer: 3. C. difficile spores are most effectively eliminated with vigorous handwashing with soap and water

During bar-code medication administration, an alert warning appears on the computer screen stating, "Do not administer dose if patient's apical heart rate is less than 60 beats/min or systolic blood pressure is less than 90 mm Hg." This is an example of what type of system? 1. Electronic health record (EHR) 2. Clinical documentation 3. Clinical decision support system (CDSS) 4. Computerized physician order entry (CPOE)

Answer: 3. CDSS are computerized programs used within the health care setting to provide you with clinical knowledge and relevant patient information to help you make clinical decisions. Nursing CDSS use a complex system of rules for analyzing data and provide alerts (present information) to support clinical decisions made by the nurse

The nurse is assessing intake and output for an alert patient at the end of shift and notes red-colored urine. Which nursing action is appropriate? 1. Immediately call the health care provider 2. Collect a clean-catch urine specimen 3. Review the patient's dietary history for the past 24 hours 4. Review the patient's most recent urinalysis laboratory report

Answer: 3. Eating beets, rhubarb, and blackberries can cause a patient's urine to become red in color. Some medications and diagnostic studies can also discolor urine

The ANA Code of Ethics for Nurses articulates that the nurse "promotes, advocates for, and strives to protect the health, safety, and rights of the patient." This promise to protect includes a promise to protect patient privacy. On the basis of this principle, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you obscured or deleted all patient identifiers? Indicate the right answer with the best rationale. 1. Yes. Patient privacy would not be violated because patient identifiers were removed. 2. Yes. Respect for autonomy implies that you have the autonomy to decide what constitutes privacy. 3. No. A viewer might identify the patient based on other comments that you make online about the patient's condition and your place of work. 4. No. The principle of justice requires you to allocate resources fairly.

Answer: 3. Facebook postings can be shared with friends and groups without oversight by the person making the post. Unintentional identifiers may remain that others could connect to the patient. Comments, photos, and other information on social media can be widely distributed beyond your control and become a risk for violation of privacy

You are completing a spiritual assessment on a 27-year-old man admitted to the hospital following a spinal cord injury. When you ask him if he prays to God, he replies, "I don't pray to God because I don't know if he exists." Based on his reply, this man most likely is an: 1. Agenic. 2. Atheist. 3. Agnostic. 4. Anarchist.

Answer: 3. Individuals who believe that ultimate reality is unknown, or unknowable are agnostics. These individuals do not necessarily believe in a higher being. Rather, agnostics question whether a higher being exists and believe that it cannot be known whether or not that higher being exists. Agnostics believe that we bring meaning to what we do

A male nurse is caring for 45-year-old Vietnamese female postoperative patient with an indwelling catheter. Which nursing response reflects culturally appropriate care when preparing to remove the catheter? 1. "Would you like your family present for this procedure?" 2. "Can I provide you with time for prayer?" 3. "Would you prefer that a female nurse remove your catheter? 4. "Shall I arrange for an interpreter?"

Answer: 3. Iranian, Jewish, Orthodox, Korean, Hindu, and Vietnamese patients value a caregiver of the same gender. These cultures often ban nonrelated men from touching women

The nurse provides care to an infant, born to Orthodox Jewish parents, who had a circumcision 8 days after his birth. The nurse recognizes that this best describes what component of spirituality? 1. Fellowship and community 2. Connectedness 3. Ritual and practice 4. Life satisfaction

Answer: 3. Rituals and practices help you to understand an individual's spirituality. Each religious group has its own rituals and practices. Circumcision for male infants 8 days after birth is practiced by individuals of the Orthodox and Conservative Jewish faith.

When inserting a nasogastric tube, how should the nurse position the patient for the procedure? 1. Lying on the left side 2. Flat on the back with neck extended 3. Sitting upright 4. Flat on the back with neck flexed

Answer: 3. Sitting upright facilitates movement of the tube down the esophagus and allows the patient to safely swallow sips of water during the procedure

Your patient has a discharge order. You check his blood pressure before he gets dressed and find that his blood pressure has decreased significantly from that morning. You call the provider and leave a message about the blood pressure, but no one returns your call. What should you do next? 1. Recheck the patient's blood pressure and complete the discharge process if his blood pressure has returned to normal. 2. Complete the discharge process because the provider would have returned your call if the discharge was cancelled. 3. Notify the nursing supervisor of the need for the patient's discharge to be delayed until the provider returns the call. 4. Complete the discharge process but tell the patient to check his blood pressure in the morning and notify the provider of the results.

Answer: 3. The nurse is responsible for clarifying any questionable orders and for informing the provider of any changes in the patient's condition. In this situation, the nurse must ensure that the provider has received the information about the blood pressure and clarify that the discharge order is still valid. Failure to do this violates the standard of care and could leave the nurse open for a malpractice suit.

The nurse is assessing a patient who returned 1 hour ago from surgery for an abdominal hysterectomy. Which assessment finding would require immediate follow-up? 1. Auscultation of an apical heart rate of 76 2. Absence of bowel sounds on abdominal assessment 3. Respiratory rate of 8 breaths/min 4. Palpation of dorsalis pedis pulses with strength of +2

Answer: 3. In healthy adults the normal respiratory rates vary from 12 to 20 respirations per minute. A rate of 8 breaths/min is too low and could be caused by anesthesia or opioid sedation effects.

The nurse is caring for a hospitalized patient who is of the Hindu faith. Which action by the nursing assistive personnel (NAP) required the nurse to intervene? 1. The NAP gives the patient privacy during a prayer ritual. 2. The NAP plans care around the patient's purity rituals. 3. The NAP encourages the patient's family to visit with the patient. 4. The NAP tells the patient that he or she must remove the amulet while in the hospital.

Answer: 4 Individuals who practice Hinduism allow time for prayer and purity rituals. In the practice of Hinduism, the use of amulets, rituals, and symbols is common. The nurse needs to intervene when the NAP tells the patient that he or she must remove the amulet. Asking the patient to give up an important spiritual symbol is not providing patient-centered care.

Indicate the order in which these steps would best be taken to resolve an ethical dilemma. 1. Clarify your own values about the issue. 2. Call a meeting in which stakeholders can discuss the solutions. 3. State the problem clearly in a way that all involved can understand. 4. Gather information regarding the clinical, social, and spiritual aspects of the dilemma.

Answer: 4, 1, 3, 2. The recommended first step in negotiating an ethical issue is to gather information. By beginning with this step, you can make sure you actually have an ethical dilemma on hand. You may find that the issue is not an ethical dilemma, but rather a misunderstanding about a diagnosis or a legal detail

A patient has just returned from surgery and has an order for insulin, but the patient does not have diabetes. When you ask the nurse, the nurse tells you that the surgeon who ordered it must have felt that the patient needed the medication and to give the insulin. What should you do in this situation? 1. Give the insulin, but document that the patient's nurse was consulted. 2. Give the insulin, but only if the patient agrees to it. 3. Hold the insulin until the patient is able to eat. 4. Hold the insulin until someone clarifies the order with the surgeon.

Answer: 4. A nurse has a duty to clarify any questionable orders. In this situation, the nurse has a reasonable suspicion that the insulin order was entered on the incorrect patient. Therefore the nurse must clarify the order. Failure to do so violates the standard of care and could leave the nurse open for a malpractice suit

You are caring for a patient who is having her gallbladder removed that afternoon. The operating room staff calls and says that they have time for the patient now and to make sure that she has signed the informed consent before she goes downstairs. The surgeon plans on talking to the patient and her husband before the surgery begins. What is your responsibility? 1. Have the patient and her husband sign the informed consent. 2. Have the patient sign the informed consent, making sure her signature and yours as a witness are both legible. 3. Make sure the patient has watched the informational videos about surgery before signing the consent form. 4. Inform the operating room staff that the patient is unable to sign the form because the surgeon has not yet discussed the procedure with her.

Answer: 4. A nurse's responsibility is to witness the patient's signature on the consent document only after the patient has been fully informed by the health care provider of the risks and benefits of any procedure. The nurse must clarify that the patient has received this education and understands it before witnessing the consent form. In this situation, the patient has not yet spoken with the provider and thus cannot yet sign a consent form

A patient who is recovering after recently experiencing third-degree burns shows connectedness when she states: 1. "My pain medicine helps me feel better." 2. "I know I will get better if I just keep trying." 3. "I see God's grace and become relaxed when I watch the sun set at night." 4. "I feel so much closer to God after I read my Bible and pray."

Answer: 4. Connectedness is a dimension of spirituality that is related to the human need of belonging. Individuals can be connected to themselves, others, God or another Supreme Being, or nature. Individuals often stay connected to God through prayer.

The nurse is conducting a skin assessment on a newly admitted patient. Which finding is consistent with the presence of edema? 1. Bluish color around lips and nail beds 2. Dandruff present when the skin is rubbed gently 3. Hypopigmentation on the palms of bilateral hands 4. Swollen bilateral lower extremities

Answer: 4. Edema is when an area becomes larger, swollen, or fluid filled; therefore swollen bilateral lower extremities would be consistent with edema.

You are a new graduate nurse working on a medical/surgical unit. One morning, you are floated to the labor and delivery unit for the day because it is very short-staffed. You tell your charge nurse that you are uncomfortable working on a unit so different from your own. The charge nurse tells you that the labor and delivery charge nurse will make sure you have easy patients and will help you with anything you need. What should you do? 1. Refuse to accept the assignment and go home for the day. 2. Obtain hand-off report on the new patients and determine whether you can safely care for them. 3. Notify the charge nurse on the labor and delivery unit of your concerns so that all the nurses can help you. 4. Call the nursing supervisor about your concerns and take the assignment only if your concerns are documented in writing.

Answer: 4. Leaving the nursing unit, even with documentation and notice of the situation to your nursing supervisor, may be seen as patient abandonment. Asking the charge nurse for help does not address the situation of the new nurse having to care for patients with conditions for which the nurse does not have the needed knowledge or experience. Documentation of the reasons the nurse is reluctant to take the assignment helps to show an attempt to provide the safest care for the patients

You are caring for a patient who is upset because the nurse who took care of him overnight refused to allow him to take his own medications because it was against hospital policy. He tells you that he is going to sue her for hurting his feelings and making him feel like he didn't know what he was doing. Is this situation one that the nurse should be concerned about? 1. Yes, because a reasonable nurse would have allowed him to take his home medications. 2. Yes, because the patient is in ultimate control of his health care. 3. No, because the patient did not understand that it was against hospital policy. 4. No, because malpractice requires that the patient suffer either physical or financial harm.

Answer: 4. Malpractice requires that a nurse cause physical or financial harm to a patient because of the breach of the duty. Even if a reasonable nurse would have allowed the patient to take his own medications, hurt feelings are not physical or financial harm and thus do not legally qualify as harm for malpractice lawsuits

You work in a health care agency that uses an EHR. Which nursing action is appropriate? 1. Allow a temporary staff member to use your computer user name and password. 2. Remain logged in to a computer when you leave to administer a medication. 3. Allow a health care provider to quickly enter an order using the computer you are currently logged into to document patient care. 4. Prevent others from seeing a display monitor that contains patient information.

Answer: 4. Mechanisms to protect the privacy and confidentiality of protected health information in the EHR include the following: Health care providers, including nurses, should not share passwords, should avoid leaving computers unattended, and should avoid leaving information about a patient displayed on a monitor where others can see it.

The nurse is caring for a patient who had a stroke and has some right-side paralysis. The patient states, "I have been praying to God and I know that he will help me cope with my problems and give me the courage to face my challenges in rehabilitation." Which nursing diagnosis is this patient likely experiencing? 1. Spiritual Distress 2. Ineffective Coping 3. Risk for Spiritual Distress 4. Readiness for Enhanced Spiritual Well-Being

Answer: 4. The diagnosis of Readiness for Enhanced Spiritual Well-Being is used when a patient expresses meaning and purpose in life through connectedness with a power greater than self, which can be strengthened. Patients who experience readiness for enhanced spiritual wellbeing express a desire to enhance prayerfulness and to enhance connectedness to a higher power

You are caring for a patient who is about to have a procedure done. She tells you that she wants to make sure her files are updated because she wants her best friend to make any medical decisions for her if she is unable to make them for herself. What type of document does she need her friend to have? 1. Guardianship 2. Living will 3. Court-approved legal Samaritan 4. Health care proxy

Answer: 4. The health care proxy is a surrogate decision maker chosen by the patient and documented in a legal form dated and signed by the patient and notarized by an impartial notary (in many states). This document formally is known as a durable power of attorney for health care. There is no such characterization known as a legal Samaritan. Guardianship involves a person chosen by a court of law with written documentation describing the guardian status. Guardianship is not limited to health care decisions. A living will is a different type of advance directive that describes what a patient wants done in certain situations such as resuscitation

A hospital uses military time for documentation. At 10:15 p.m. a nurse administered a dose of morphine 1mg IV prn to a patient who reports a pain level of 8 on a 0-to-10 scale. How does the nurse document the administration time of the medication? 1. 1015 hours 2. 10:15 o'clock 3. 10:15 p.m. 4. 2215 hours

Answer: 4. The military clock begins at 1 minute after midnight as 0001 and ends with midnight at 2400. Noon is 1200; 1 p.m. is 1300; 2 p.m. is 1400, 3 p.m. is 1500, and so on.

A patient has a new ileostomy and needs to be taught how to care for the ileostomy. The nurse is seeing the patient on the first postoperative day. The patient has abdominal pain that is rated as 7 out of 10 and about 150mL of dark green effluent in the ileostomy pouch. What skill would be best for the nurse to teach the patient at this time? 1. Care of the peristomal skin 2. Cutting and fitting the ostomy pouch 3. Placing a new ostomy pouch 4. Emptying the pouch

Answer: 4. The pouch would likely not need to be changed on the first postoperative day, and the patient's pain would make it difficult for the patient to concentrate on the teaching or even tolerate the procedure well. However, emptying the pouch will be necessary after it fills with 250 to 300mL of effluent, and the patient could observe and learn by seeing how the nurse does this

When changing an ostomy pouch, how should the nurse cleanse the peristomal skin? 1. Use antimicrobial cleanser and sterile gauze pads 2. Use a baby diaper wipe 3. Spray with perineal skin cleanser 4. Use warm water on a washcloth

Answer: 4. Using warm water is adequate for skin cleansing around a stoma and does not irritate the skin or add moisturizer to the peristomal skin and potentially interfere with the adherence of the pouching system

When conducting an abdominal assessment, the first skill a nurse puts to use is? A) auscultation B) inspection C) palpation D) percussion

B) inspection