Review Questions for Exam 1

a nurse is reviewing hand hygiene techniques with a group of assistive personnel (ap). Which of the following instructions should the nurse include when discussing handwashing? (Select all that apply.) a. apply 3 to 5 ml of liquid soap to dry hands. B. Wash the hands with soap and water for at least 15 seconds. c. rinse the hands with hot water. d. use a clean paper towel to turn off hand faucets. e. allow the hands to air dry after washing.

b, d

A nurse has performed a physical examination of the patient and reviewed the laboratory results and diagnostics on the patient's chart. The nurse is performing which specific nursing function? a. Diagnosis b. Assessment c. Education d. Advocacy

Answer: b The nurse is performing the first step in the nursing process—assessment.

Which factors affect the nursing shortage? (Select all that apply.) a. Aging faculty b. Increasing elderly population c. Job satisfaction due to adequate number of nurses d. Aging nursing workforce e. Greater autonomy for nurses

Answers: a, b, d The nursing workforce and nursing faculty are aging. The entire population is aging, which increases the need for more nurses. The insufficient number of nurses leads to job dissatisfaction and burnout.

Which statements describe a component discussed in nursing theories? (Select all that apply.) a. Optimal functioning of the patient b. Interaction with components of the environment c. The conceptual makeup of the administration of the hospital d. The illness and health concept e. Safety aspect of medication administration

Answers: a, b, d There are four components that a nursing theory discusses: (1) the patient, (2) health, (3) environment, and (4) nursing—not the hospital administration.

Which are included in the ANA standards? (Select all that apply.) a. Standards of professional performance b. Code of ethics c. Standards of practice d. Legal scope of practice e. Licensure requirements

Answers: a, c ANA standards have two parts: One is standards of professional performance, and the other is standards of practice. ANA has a separate document that is a code of ethics. Nurse practice acts are a legal scope of practice.

Of the following hospitalized patients, who is most at risk for acquiring a health care-associated infection? a. A 60-year-old who smokes two packs of cigarettes per day b. A 40-year-old who has an indwelling urinary catheter in place c. A 65-year-old who is a vegetarian and slightly underweight d. A 60-year-old who has a white blood cell count of 6000

b. Hospital-acquired infections are associated with indwelling urinary catheters. A normal white blood cell count, smoking cigarettes, or being a vegetarian has not been associated with hospital-acquired infections.

A nurse is caring for a client diagnosed with severe acute respiratory syndrome (SArS).the nurse is aware that healthcare professionals are requiredto report communicable and infectious diseases. Which of the following illustrate the rationale for reporting? (Select all that apply.) A. Planning and evaluating control and prevention strategies B. Determining public health priorities c. ensuring proper medical treatment D. Identifying endemic disease e. Monitoring for common‐source outbreaks

A, B, C, E

A nurse educator is reviewing with a newly hired nurse the difference in manifestations of a localized versus a systemic infection. the nurse indicates understanding when she states that which of the following are manifestations of a systemic infection? (Select all that apply.) A. fever B. Malaise c. edema D. Pain or tenderness e. Increase in pulse and respiratory rate

A, B, E

A nurse is instructing a client who has diabetes mellitus about foot care. Which of the following guidelines should the nurse include? (Select all that apply.) A. inspect the feet daily. B. Use moisturizing lotion on the feet. C. Wash the feet with warm water and let them air dry. D. Use over‐the‐counter products to treat abrasions. e. Wear cotton socks.

A, B, E

A nurse is planning care for a client who develops dyspneaand feels tired after completing her morning care. Which of the following actions should the nurse include in the client's plan of care? A. Schedule rest periods during morning care. B. Discontinue morning care for 2 days. C. Perform all care as quickly as possible. D. Ask a family member to come in to bathe the client.

A. CORRECT: Planning for rest periods during morning care will help prevent fatigue and continue to foster independence.

A nurse is beginning a complete bed bath for a client. After removing the client's gown and placing a bath blanket over him, which of the following areas should the nurse wash first? A. Face B. Feet C. Chest D. Arms

A. CORRECT: The greatest risk to a client during bathing is the transmission of pathogens from one area of the body to another. The nurse should begin with the cleanest area of the body and proceed to the least clean area. The face is generally the cleanest area, and washing it first follows a systematic head‐to‐toe approach to client care.

A nurse is performing mouth care for a client who is unconscious. Which of the following actions should the nurse take? A. Turn the client's head to the side. B.Place two fingers in the client's mouth to open. C. Brush the client's teeth once per day. D. inject a mouth rinse into the center of the client's mouth.

A. CORRECT: The nurse should position the client's head on the side, unless contraindicated, to reduce the risk of aspiration.

When caring for a patient with rubella, in addition to standard precautions, which precautions would be used? a. Droplet precautions b. Airborne precautions c. Contact precautions d. Universal precautions

ANS: A An illness transmitted by large-particle droplets, like rubella, requires droplet precautions in addition to standard precautions. Airborne precautions are used for illness transmitted via small particles, such as tuberculosis, varicella, and rubeola. Universal precautions are a part of standard precautions.

Which assessment finding by the nurse indicates a complication from oxygen via nasal cannula? a. Dry nasal passages b. Inability to speak clearly c. Increased nasal drainage d. Skin breakdown on the chin

ANS: A Oxygen via nasal cannula can be drying to the nares. Use of a nasal cannula does not affect the patient's ability to speak and should not increase drainage. Pressure areas from a nasal cannula may include the nares, the cheeks, and the top front crease of the auricle of the ear but not the chin.

The student nurse learns that the components of the chain of infection include which of the following? (Select all that apply.) a. Infectious agent b. Mode of transmission c. Portal of entry d. Reservoir e. Vehicle of movement

ANS: A, B, C The six components of an infection are the infectious agent, the source of infection, the portal of exit, the mode of transmission, the portal of entry, and the susceptible host

Which statements are correct concerning bathing a hospitalized patient? (Select all that apply.) a. A complete bed bath is for patients who are bedridden. b. All hospitalized patients need a complete bed bath. c. Bathing removes dead skin, bacteria, and body fluids. d. Male personnel must always perform male perineal care. e. Keeping skin clean and dry helps prevent breakdown.

ANS: A, C, E Bedridden patients need complete bed baths. Bathing keeps skin clean and helps prevent breakdown while removing skin, bacteria, and bodily fluids. Each patient is assessed to determine the level of care and bathing assistance needed. Personnel can perform perineal care on patients of the opposite sex, treating the patient with dignity and professionalism.

A team meeting of providers and nurses is convened to discuss a specific patient's problems and to determine goals for the patient. During the meeting, specific accountability related to patient care for both the providers and nurses involved is established. All members of the meeting show mutual respect by valuing each other's clinical competence that is necessary to provide quality patient care. Of the following functions of a nurse, which one is demonstrated in the above example? a. Delegation b. Advocacy c. Collaboration d. Managemen

ANS: C This is an example of the dynamic interpersonal process of collaboration in which health care professionals constructively solve problems and learn from each other. Delegation is the process of entrusting or transferring the responsibility for certain tasks to other personnel. Advocacy is speaking for the patient when he or she is not able to. Management is overseeing a group of people.

Which measures can the nurse teach to prevent poisoning of children? (Select all that apply.) a. Install safety latches on reachable cabinets. b. Keep syrup of ipecac on hand. c. Use childproof caps on medications. d. Use a plunger rather than a chemical drain cleaner. e. Keep cleaning supplies under the kitchen sink.

Answers: a, c, d Child locks for cabinets and childproof caps on medication bottles are recommended to prevent poisoning. The use of alternatives (e.g., plungers) rather than toxic chemicals (e.g., Drano) is recommended to prevent ingestion of deadly substances. Syrup of ipecac has been used in the past to treat poisoning after it occurred and is not considered a preventive measure. Keeping cleaning supplies under the kitchen sink is dangerous because the area is within reach of children.

Which actions by the nurse concerning oral care for an unconscious patient are considered safe? (Select all that apply.) a. Performing oral care with the patient in a supine position b. Performing oral care with the patient turned to the side c. Installing suction equipment at the bedside d. Providing oral care every 2 hours e. Using a hard-bristle toothbrush

Answers: b, c, d Oral care on an unconscious patient is performed with the patient turned to one side so fluid can drain out of the side of the mouth. Suction equipment is used to remove fluid and secretions during oral care on an unconscious patient. Oral care should be provided at least every 2 hours for patients who are unconscious, receiving nothing by mouth (NPO), intubated, or receiving oxygen by a mask. An unconscious patient may aspirate if oral care is done in the supine position. A hard-bristle brush may damage the oral mucosa.

Which statements are true regarding back massage? (Select all that apply.) a. Only a licensed massage therapist can perform back massage. b. Back massage may stimulate the deep muscles. c. Massage provides relaxation and comfort. d. Tapotement stimulates the skin. e. A massage may promote sleep.

Answers: b, c, d, e Back massage provides relaxation, increases circulation, stimulates the skin and deep muscles, and promotes sleep. Nursing personnel can perform a back massage during care, before bedtime, or any other time to help the patient relax.

a nurse has prepared a sterile field for assisting a provider with a chest tube insertion. Which of the following events should the nurse recognize as contaminating the sterile field? (Select all that apply.) A. The provider drops a sterile instrument onto the near side of the sterile field. B. The nurse moistens a cotton ball with sterile normal saline and places it on the sterile field. C. The procedure is delayed 1 hr because the provider receives an emergency call. D. The nurse turns to speak to someone who enters through the door behind the nurse. E. The client's hand brushes against the outer edge of the sterile field.

B, C, D

A nurse is contributing to the plan of care for a client who is being admitted to the facility with a suspected diagnosis of pertussis. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. B. Wear a mask when providing care within 3 ft of the client. c. Place a surgical mask on the client if transportation to another departmentis unavoidable. D. Use sterile gloves when handling soiled linens. e. Wear a gown when performing care that might result in contamination from secretions.

B, C, E

A nurse is preparing to perform denture care for a client. Which of the following actions should the nurse plan to take? A. Pull down and out at the back of the upper denture to remove. B. Brush the dentures with a toothbrush and denture cleaner. C. Rinse the dentures with hot water after cleaning them. D. Place the dentures in a clean, dry storage container after cleaning them.

B. CORRECT: Brushing the dentures thoroughly with a toothbrush and denture cleaner removes debris that accumulates on and between the teeth.

a nurse manager is reviewing with nurses on the unit the care of a client who has had a seizure. Which of the following statements by a nurse requires further instruction? a. "i will place the client on his side." B. "i will go to the nurses' station for assistance." C."i will administer his medications." D."i will prepare to insert an airway."

B. CORRECT: During a seizure, the nurse should stay with the client and use the call light to summon assistance.

a nurse is caring for a client who fell at a nursing home. the client is oriented to person, place, and time and can follow directions. Which of the following actions should the nurse take to decrease the risk of another fall? (Select all that apply.) a. Place a belt restraint on the client when he is sitting on the bedside commode. b. Keep the bed in its lowest position with all side rails up. c. Make sure that the client's call light is within reach. d. Provide the client with nonskid footwear. e. Complete a fall‐risk assessment.

C, D, E

a nurse is wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects can the nurse touch without breaching sterile technique? (Select all that apply.) a. a bottle containing a sterile solution b. The edge of the sterile drape at the base of the field c. The inner wrapping of an item on the sterile field d. an irrigation syringe on the sterile field e. One gloved hand with the other gloved hand

C, D, E

a nurse observes smoke coming from under the door of the staff's lounge. Which of the following actions is the nurse's priority? a. extinguish the fire. B. activate the fire alarm. C. Move clients who are nearby. D. Close all open doors on the unit.

C. CORRECT: the greatest risk to this client is injury from the fire. therefore, the priority intervention is to rescue the clients. the nurse should protect and move clients in close proximity to the fire.

Telehealth devices can be used to provide which types of patient care? (Select all that apply.) A. Evaluating weight loss B. Medication administration C. Video assessment of wounds D. Monitoring peak flow meter results E. Real-time blood pressure assessment

Correct Answer: A. Evaluating weight loss B. Medication administration C. Video assessment of wounds D. Monitoring peak flow meter results E. Real-time blood pressure assessment Rationale: Telehealth enables the nurse to provide distance assessment, planning, intervention, and evaluation of outcomes of nursing care using technologies such as the Internet, digital assessment tools, and telemonitoring equipment. Among the many uses of telehealth are monitoring patients with chronic or critical conditions and helping patients manage symptoms.

a charge nurse is assigning rooms for the clients to be admitted to the unit. to prevent falls, whichof the following clients should the nurse assign to the room closest to the nurses' station? A. a middle adult who is postoperative following a laparoscopic cholecystectomy B. a middle adult who requires telemetry for a possible myocardial infarction C. a young adult who is postoperative following an open reduction internal fixation of the ankle D. an older adult who is postoperative following a below‐the‐knee amputation

D. CORRECT: the nurse should assign this client to a room near the nurses' station due to risk factors that include client's age plus the immobility and balance issues that result from this type of surgery. the client will also receive analgesics, which increase the risk for drowsiness, dizziness, and confusion.

Of the following assessment findings, which signs indicate to a nurse that a patient has a surgical site infection? (Select all that apply.) a. Redness or warmth at the affected site b. Purulent drainage at the incision site c. Tenderness and localized pain d. Wound with well-approximated edges e. White blood cell count 6500 cells/mm3

a, b, c, Purulent drainage, tenderness, localized pain, and redness or warmth are results of the inflammatory response to an infection. Well-approximated edges are a desired outcome of wound healing. The normal white blood count for adults is 4500 to 10,500 cells/mm3.

In which situations does the nurse wear clean gloves as part of standard precautions? (Select all that apply.) a. In the care of a patient diagnosed with an infectious process b. When the patient is diaphoretic c. During perineal care of each individual under treatment in the facility d. In the presence of urine or stool e. When taking the patient's blood pressure

a, c, d The nurse uses standard precautions for situations in which an infectious disease is known or when there is a possibility of contact with blood or body fluids (except perspiration). Gloves are not necessary when taking the blood pressure of a patient who is not in isolation and who does not have any other risk factors.

a nurse is caring for a client who has a history of falls. Which of the following actions is the nurse's priority? a. Complete a fall‐risk assessment. B. educate the client and family about fall risks. C. eliminate safety hazards from the client's environment. D. Make sure the client uses assistive aids in his possession.

a. CORRECT: the first action the nurse should take using the nursing process is to assess or collect data from the client. therefore, the priority action is to determine the client's fall risk. this will guidethe nurse in implementing appropriate safety measures.

The nurse is caring for a patient who had abdominal surgery and has developed an infection in the wound while hospitalized. Which agent is most likely the cause of the infection? a. Virus b. Bacterium c. Fungus d. Spore

b. The cause of an infection in the surgical wound in a hospitalized patient who has had abdominal surgery is most likely bacteria because it is present on the skin as normal flora. Fungi and spores are the focus of removal during the surgical preparation. Viruses are target specific and do not usually live on the skin.

When entering a client's room to change a surgical dressing, a nurse notes that the client is coughing and sneezing. Which of the following actions should the nurse take when preparing the sterile field? a. Keep the sterile field at least 6 ft away from the client's bedside. B. instruct the client to refrain from coughing and sneezing during the dressing change. c. place a mask on the client to limit the spread of micro‐organisms into the surgical wound. d. Keep a box of facial tissues nearby for the client to use during the dressing change.

c. CORRECT: placing a mask on the client prevents contamination of the surgical wound during the dressing change.

The nurse is providing patient education on infection prevention. Which definition of an infection does the nurse use as a teaching point? a. An illness resulting from living in an unclean environment b. A result of lack of knowledge about food preparation c. A disease resulting from pathogens in or on the body d. An acute or chronic illness resulting from traumatic injury

c. A disease resulting from pathogens in or on the body is the definition of an infection. An illness resulting from living in an unclean environment, from lack of knowledge about food preparation, or from trauma can lead to an infection but does not define an infection.

A patient develops food poisoning from contaminated food. What is the means of transmission for the infectious organism? a. Direct contact b. Vector c. Vehicle d. Airborne

c. Contaminated food is a vehicle for transmitting an infection. Direct contact requires close proximity between the susceptible host and an infected person. A vector is a nonhuman carrier. In airborne transmission, the organism is carried through the air on a small droplet or dust particles.

What is the proper order of removal of soiled personal protective equipment when the nurse leaves the patient's room? a. Gown, goggles, mask, gloves, and exit the room b. Gloves, wash hands, remove gown, mask, and wash hands c. Gloves, goggles, gown, mask, and wash hands d. Goggles, mask, gloves, gown, and wash hands

c. Gloves are removed before the rest of personal protective equipment because they usually are the most contaminated. Protective eyewear or goggles are removed next by grasping them by the earpieces. Gowns are removed by untying the waist and then the neck and grasping inside the neck. The mask is removed last because it prevents the spread of respiratory microorganisms. Hands should be washed thoroughly after the equipment has been removed and before leaving the room.

A new patient is admitted to a medical unit with Clostridium difficile. Which type of precautions or isolation does the nurse know is appropriate for this patient? a. Airborne precautions b. Droplet precautions c. Contact precautions d. Protective isolation

c. Contact precautions are used with C. difficile because transmission of a contagious disease is possible through contact with the patient or with the equipment or items in the patient's room. Airborne precautions are used when a contagious disease is spread by small droplets that remain suspended in the air for a long period. Droplet precautions are used when a disease is spread by large droplets in the air. Protective isolation is used for patients who are immunosuppressed.

A nurse is preparing to change a sterile dressing and has donned a pair of sterile gloves. To maintain surgical asepsis, what else must the nurse do? a. Keep the amount of splashes on the sterile field to a minimum. b. If a sneeze is imminent, cover the nose and mouth with a gloved hand. c. With a moist saline sponge, use the dominant hand to clean the wound and then apply a dry dressing. d. Regard the outer 1 inch of the sterile field as contaminated

d. Considering the outer 1 inch of the sterile field as contaminated is a principle of sterile technique. Moisture contaminates the sterile field. Sneezing or coughing would contaminate the sterile glove and necessitate replacing the contaminated glove with a new sterile one. The hand used to clean the wound would not be used to apply a dry dressing. The hand would have to be regloved.

a nurse has removed a sterile pack from its outside cover and placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first? a. The flap closest to the body B. The right side flap c. The left side flap d. The flap farthest from the body

d. CORRECT: The priority goal in setting up a sterile field isto maintain sterility and thus reduce the risk to the client's safety. unless the nurse pulls the top flap (the one farthest from her body) away from her body first, she risks touching part of the inner surface of the wrap and thus contaminating it.

Of the following patients, which patient is at a higher risk of infection? a. 27 year old who is an athlete b. 60 year old with arthritis c. 12 year old with a broken leg d. 36 year old with HIV

ANS: D The patient with HIV has an incompetent immune system, which makes her at risk for infection. The other patients all should have healthy immune functioning.

Which statement accurately describes proper technique for performing male perineal care? The nurse: a. washes the patient from the back of the perineum toward the penis. b. washes with a circular motion starting with the urinary meatus. c. places the patient in the prone position with supporting pillows. d. places the patient in the dorsal recumbent position.

ANS: B During male perineal care, the penis is cleansed with soap and water using a circular motion starting at the urinary meatus in order to keep pathogens away from the urinary tract. The shaft of the penis is then cleansed using firm downward strokes. The patient is usually in the supine position with the bed either flat or the head of the bed raised.

A patient diagnosed with head lice has an order for pediculicidal shampoo. Which statement is true about this shampoo? a. It can be used only on patients with the ability to stand in the shower. b. It can cause central nervous system side effects, including dizziness. c. It is used by pregnant women and young children. d. It is safe for patients with seizures or epilepsy.

Answer: b Pediculicidal shampoos can have central nervous system side effects, including dizziness, headache, and seizures. Their use is contraindicated for patients with a history of seizures and for pregnant women and young children.

The nurse is caring for a patient who has been diagnosed with methicillin-resistant Staphylococcus aureus located in her incision. What transmission-based precautions will the nurse implement for the patient? a. Private room b. Private, negative-airflow room c. Mask worn by the staff when entering the room d. Mask worn by the staff and the patient when leaving the patient's room

A. A private room decreases the chance of another patient contracting the infection. The other precautions (i.e., private room with negative airflow, mask worn by staff when entering the room, and mask worn by staff and patient when leaving the patient's room) are airborne precautions, which are not necessary in managing this patient.

For a school-age child who enjoys riding a bicycle, which is the priority Nursing diagnosis? a. Risk for injury b. Risk for acute pain c. Risk for impaired skin integrity d. Risk for impaired mobility

ANS: A Until additional information is gathered, the nurses' first concern for a school-age child who rides a bike is risk for injury, as the parents and child may have insufficient knowledge of safety precautions. Nurses need to ensure that the patient and the family receive adequate education about the need for wearing helmets and other protective equipment during bicycling. Risk for acute pain, risk for impaired skin integrity, and impaired mobility would only be concerns if the child were to experience a bicycling-related injury.

Which hygienic care instructions by the nurse would be given to a patient who is being discharged on an anticoagulant? (Select all that apply.) a. Use an electric razor for shaving. b. Brush teeth with a soft toothbrush. c. Trim beard with double blade safety razor. d. Use caution when trimming nails with clippers. e. Deeply massage unused muscles while bathing.

ANS: A, B, D Due to the risk of bleeding, only electric razors should be used by patients on anticoagulants for trimming facial hair and shaving. A soft toothbrush reduces the risk of damage to the gums. Other sharp instruments such as nail clippers are used with caution to avoid cutting skin. Deep massage may cause bruising in patients on anticoagulants.

A nurse is planning a program for educating a Hispanic community regarding nutritional practices. What would be the most important aspects that the nurse takes into consideration first? (Select all that apply.) a. Change theory and Health Belief Model b. Previous educational programs c. Cultural influences d. Hospital admissions from this community e. Vital statistics such as death rates

ANS: A, C Since the nurse will be discussing nutrition to a specific cultural group, the nurse needs to understand the cultural influences on their nutritional practices. In addition, the nurse needs to understand change theory to plan her education if she is attempting to have the group make changes in their nutritional practices. The Health Belief Model would also help in understanding the community's perceptions regarding barriers that facilitate or discourage adoption of the promoted behaviors. Vital statistics are not essential.

Which behavior by the nurse during medication administration is most likely to cause a medication error? (Select all that apply.) a. Verifies the patient's identity calling the patient by name. b. Calls the pharmacist to check on the medication dosage. c. Takes a telephone call while preparing the medication. d. Fails to weigh the patient prior to giving the medication. e. Double-checks the right route before administering medication.

ANS: A, C Two forms of identification should always be used to check the patient's identity prior to administering medications. Thus, calling the patient by name is an inadequate means of properly identifying a patient prior to med administration. Taking a phone call is an interruption in the process of medication administration that can result in an error. Double-checking the route and calling the pharmacist to ensure the dosage is proper for this patient are means by which medication errors can be reduced. Finally, for most adult patients, weight-based dosing is not performed.

Which clients present concerns for suffocation to the nurse? (Select all that apply.) a. A toddler who is eating grapes b. A school-age child eating a hot dog c. A teenager who plays the "choking game" d. An older adult who inadequately chews food e. A middle aged adult with dentures

ANS: A, C, D Toddlers are an at-risk group for suffocation from choking on food such as a grape, which can become lodged in the trachea. Suffocation and unintentional death can result from the "choking game," which has been on the rise in school-age children and teens. Older adults can die from choking on food lodged in the trachea that has been inadequately chewed. School-age children are not typically at the highest risk for suffocation from choking when foods are properly chewed. If dentures fit reasonably well, they should not cause problems eating.

The nurse is caring for a patient who has of methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection-control practices should the nurse implement for this patient? (Select all that apply.) a. Wear a protective gown when entering the patient's room. b. Don a particulate respirator mask when administering medication. c. Ensure that all staff serving the patient's meal trays don gloves prior to delivery. d. Instruct all visitors to wear a surgical mask when entering the room. e. Use sterile gloves when performing dressing changes. f. Use a face shield before irrigating the patient's wounds.

ANS: A, C, F Wearing a gown, wearing gloves when delivering trays, and using a face mask will ensure staff, patient, and visitor safety and will protect the individual from transmitting the infection from the patient to him/herself or others. Use of a particulate respirator mask is necessary when encountering someone on airborne precautions, and this organism is not transmitted via air. The use of sterile gloves is not necessary with this type of infection.

Which statement by a patient with the Nursing diagnosis of Self-Care Deficit would indicate attainment of the goal: Patient will actively participate in bathing within 24 hours after surgery? a. "I need help with my bath." b. "I was able to wash my own feet today." c. "I am going to need assistance at home." d. "Could you help me brush my teeth this morning?"

ANS: B An increase in the patient's ability to care for his/her own hygienic needs indicates achievement of goals related to self-care deficit. The other statements indicate continued dependence with activities of daily living.

A nurse is making a home visit to a family of five children. The youngest, aged 5, has a temperature of 101.1°F, is lethargic, and has a poor appetite. This assessment leads you to suspect influenza. Which instruction by the nurse is inconsistent with knowledge about influenza? a. Keep children home from day care and school while symptoms are present. b. Remind family that they only need to wash their hands if they are visibly dirty. c. Do not share tissues, dishes, or personal care items to reduce the risk of transmission. d. Encourage the family to receive their annual influenza vaccine.

ANS: B The family needs to wash their hands frequently, especially after eating, coughing, sneezing, or touching contaminated material such as a tissue. Keeping the children home from day care and school while symptoms are present and not sharing personal items, such as towels and toothbrushes, as well as dishes, are good rules of thumb for individuals with an airborne infection. The family should be encouraged to receive annual influenza vaccines.

How might a nurse as a researcher approach the care of the patient? (Select all that apply.) a. Performing technical skills as learned b. Looking for problems and questioning practices c. Incorporating research into practice d. Carrying out procedures according to policy e. Designing and conducting research studies

ANS: B, C By looking for problems and questioning practices, the nurse is identifying problems that can be researched. By incorporating any new research into practice, the nurse is involved in evidence-based practice. Performing skills as learned and following policies are not part of the researcher's role (although policies should always be followed they should also be changed when needed). The bedside nurse is not an appropriate person to design and conduct research; this would take a higher level of education.

What is the nurse's role as patient advocate? (Select all that apply.) a. Explain to the patient the nurse's viewpoint. b. Communicates the patient's wishes to other health care providers. c. Accept the patient's decision and support his or her wishes. d. Give the patient the provider's viewpoint. e. Provide education to the patient and evaluate understanding.

ANS: B, C The nurse as the patient advocate must ensure that the patient's wishes are known to the provider/s. The nurse must also accept the patient's decisions and support them, even if the decision is not one the nurse agrees with. Providing and evaluating education is the educator role. The nurse's and provider's viewpoints are not important as factual education.

How can the nurse reduce procedure-related events? (Select all that apply.) a. Maintaining clean technique when inserting an indwelling catheter b. Checking nasogastric tube placement prior to a feeding c. Identifying anatomical landmarks prior to giving IM injections d. Performing quality control checks on blood glucose monitors e. Using sterile technique when changing surgical dressings

ANS: B, C, D, E Infections and injuries may occur in health care facilities as the result of errors in procedures and malfunction of medical equipment. To prevent these from occurring, use sterile technique to insert indwelling bladder catheters and changing dressings, check NG tube placement prior to feeding to reduce the risk of pneumonia, identify proper landmarks before giving injections, and performing quality checks on glucose monitors.

Which results from a form of pollution? (Select all that apply.) a. Air pollution: hearing loss and elevated blood pressure b. Land pollution: birth defects and cancer c. Water pollution: disease and infection d. Noise pollution: chronic lung disease and allergic symptoms e. Agricultural pollution: birth defects

ANS: B, C, E Air pollution caused by the release of chemicals or by-products of manufacturing into the atmosphere can increase the risk of chronic lung disease and some cancers. Other forms of air pollution include cigarette smoke and exhaust fumes from vehicles, which can produce allergic symptoms. Land pollution is not limited to littering: industrial and agricultural waste is associated with birth defects and cancer. Water can become polluted through improper refuse disposal, animal waste, and industrial by-products, resulting in infection and disease. Noise pollution from sources such as factories, construction sites, trains, planes, loud music, and cheering in sports stadiums is a real concern. Some of the health effects resulting from noise pollution include hearing loss, stress, and elevated blood pressure.

The nurse has delegated care of a patient's dentures to unlicensed assistive personnel. Which statement by the assistive personnel indicates a good understanding of denture care? a. "It is not necessary to use a toothbrush in the patient's mouth since the patient does not have teeth." b. "I will wrap the dentures in a tissue so that they will not get damaged and place them on the bedside table." c. "I will put on clean gloves and brush the dentures gently with a toothbrush and toothpaste." d. "I will soak the dentures in the sink and then place them in a denture cup labeled with the patient's name."

ANS: C Dentures are brushed with a regular toothbrush and toothpaste over a sink that has been padded with a washcloth to prevent breakage if they are accidentally dropped. The patient's mouth should be cleansed with a soft brush or toothette after the dentures are removed and before they are reinserted. Never wrap dentures in a tissue because they may accidentally be discarded. Soaking dentures in a sink where nurses and patients wash their hands is contraindicated because pathogens may be present in the sink.

During normal patient care that does not soil hands, effective hand hygiene between patients requires: a. at least a 20-second soap and water scrub. b. at least a 23-minute scrub with antimicrobial soap. c. use of an alcohol-based antiseptic hand sanitizer. d. wearing a mask while scrubbing is occurring.

ANS: C Hands that are not visibly soiled can be cleaned with an alcohol-based hand sanitizer. A mask or antiseptic soap is not necessary in this situation.

Select the most appropriate side rail regime for an elderly patient who intermittently calls for assistance: a. one top side rail raised on the patient's dominant side. b. two top side rails raised to promote bed mobility. c. three side rails up with bottom rail closest to bathroom down. d. four side rails up to prevent the patient getting up without assistance.

ANS: C Keeping three side rails up with the rail closest to the bathroom down is the best option for this patient. One side rail will be inadequate to promote some patient independence with bed mobility. While two side rails are supportive of some independent bed mobility, elevating a third rail can serve as an additional support for bed mobility and a reminder not to get up alone. Raising all four side rails is considered a form of physical restraint, requiring an order from a primary care provider. Patients are at risk for strangulation, entrapment, and entanglement injuries and death when all four side rails are up. A bed alarm should also be applied to alert the staff when the patient is attempting to get up alone.

When a fire occurs in a health care agency in which sequence should actions be performed? a. Pull the alarm. Assist patients. Secure area by closing doors. Spray extinguisher. b. Remove oxygen source. Aerate the fire. Call the operator. Evacuate patients. c. Rescue the patients. Alarm sounded. Contain the fire. Extinguish fire. d. Remove fire source. Alarm sounded. Close the doors. Evacuate patients.

ANS: C Remember what the letters of the RACE acronym stand for and that your first priority is the safety of the patients. First, "R" involves rescuing patients in close proximity to the fire. Second, "A" indicates that the fire alarm must be sounded and the exact location of the fire reported. Third, "C" involves containing the smoke and the fire, which include the closing of doors and turning off oxygen. Finally, the "E" indicates after all patients are rescued and if the fire is small enough, an attempt may be made to extinguish it.

Nursing students all belong to the National Student Nurses Association when they are attending a specific nursing program. This is an important aspect of their socialization to the profession as it demonstrates which criteria of a profession? a. Providing service to society b. Accepting responsibility for actions and omissions c. Participating in an organization that supports and advances the profession d. Making independent decisions based on their scope of practice

ANS: C Students begin their socialization to the profession by participating in an organization, which is one criteria of a profession.

Which patient appears to be at greatest risk for falls? a. 66 year old post-op, oriented x 3, taking opioid pain meds b. 71 year old with pneumonia, oriented x 2, on oxygen and IV c. 76 year old with acute confusion, knows name, incontinent, has an IV d. 80 year old post-op, oriented x 3, has a cast, opioid pain medications

ANS: C The 76 year old with acute confusion and incontinence with a continuous IV appears to be at greatest risk for falls. While the other patients also have sources of tethering (e.g., oxygen and IV tubing) and opioid pain medications, the acute confusion and incontinence along with the IV tethering produce the most significant risk.

Which nursing action is necessary for patient safety during a bed bath? a. All four side rails are always kept in the raised position during the bath. b. The bed is always in the low and locked position while bathing the patient. c. The top side rail is raised opposite the side where the nurse is standing. d. The bed is always kept in a flat position with a pillow under the patient's head.

ANS: C The bed is raised to a comfortable working position and the side rail is lowered on the side where the nurse is standing. It is important to leave the bed in the low and locked position with the top side rails up when the bath is finished and the nurse is leaving the room. The position of the bed and the patient during the bath is dependent on the patient's condition and comfort level.

Nurses are most likely to utilize theories from which of the following individuals in their leadership role? a. Maslow b. Rosenstock c. Lewin d. Erikson

ANS: C The nurse will use Lewin's change theory most often in the leadership role. Maslow's hierarchy of needs, Erikson's developmental theory, and the Rosenstock's Health Belief Model will be utilized most during patient care and education.

Which procedure is correct when making an occupied bed? a. The bed is left in the low and locked position for patient safety. b. The bed is made starting at the head and working toward the feet. c. Soiled linen is loosened on one side of the bed and rolled under the patient. d. Making an occupied bed cannot be delegated to unlicensed assistive personnel.

ANS: C When making an occupied bed, one side of the bed is stripped and made first while the patient is rolled to the opposite side. The patient is then rolled over the linens and the second side is made. Bed making may be delegated to unlicensed assistive personnel after reviewing specific patient limitations.

Which area of the body is most likely to be excoriated? a. Elbows b. Facial skin c. Cervical spine d. Perineum

ANS: D Areas of the body that are prone to excoriation are those exposed to bodily fluids such as stool, urine, gastric juices, or sweat, as well as where skin touches skin.

What is an example of Nightingale's contributions to nursing? a. Graduated as the first trained U.S. nurse b. Practiced nursing in the Civil War c. Established the American Red Cross d. Emphasized respect for patients' needs and rights

ANS: D Clara Barton practiced nursing in the Civil War and established the Red Cross. Linda Richards was the first U.S. trained nurse. Nightingale emphasized patients' needs and rights.

Which statement is most accurate about hearing aid and ear care for hospitalized patients who are hard of hearing? a. Hard of hearing patients should wear hearing aids at all times while hospitalized. b. Hearing aids should be cleansed daily with soap and water before reinsertion. c. Cerumen is removed with a cotton-tipped applicator before inserting hearing aids. d. Hearing aids are cleansed with a dry cloth and stored in a labeled container.

ANS: D Hearing aids are an electronic device and therefore are cleansed with only a dry cloth. Some patients prefer to remove their hearing aids while sleeping. Using cotton-tipped applicators is contraindicated in any patient because the cerumen may be pushed further into the ear canal. When not in use, hearing aids are stored in a container labeled with the patient's name to prevent misplacement.

A new nurse is caring for a patient who is restrained. Which action shows a good understanding of caring for this patient? a. Remove restraints q1h and inspect the skin. b. Check on the patient every 30 minutes and ensure needs are met. c. Renew restraint orders every shift. d. Remove restraints as soon as patient's condition allows.

ANS: D Restraints are used today only when necessary for the protection of the patient and/or the nurse. Thus, nurses should remove restraints ASAP when the patient is no longer a danger to him/herself or others. The frequency with which restraints need to be released and assessments for complications performed is every 2 hours. The patient also needs to be checked every hour to ensure that basic needs are met (e.g., food, fluids, toileting). Restraint orders must be renewed every 24 hours.

A nurse has graduated from a nursing school and is participating in a new graduate program at a local hospital as a continuing socialization to the role of the nurse. At what level is the nurse functioning at this point in the nurse's career? a. Expert b. Competent c. Novice d. Advanced beginner

ANS: D The nurse is an advanced beginner for 2 to 3 years after graduating and doesn't reach the level of competence until the end of that time period. An expert has an intuitive grasp of situations. A novice is rigid and rule-bound because he or she has no experience.

A nurse is caring for an overweight 60-year old woman with a reddened area over her coccyx. The priority Nursing diagnosis for this patient is: a. Impaired Nutritional Intake related to immobility b. Impaired Mobility related to pain and discomfort. c. Chronic Pain related to overweight. d. Risk for Infection related to altered skin integrity.

ANS: D The priority diagnosis is focused on the risk of developing an infection due to altered skin integrity. Impaired nutritional intake, impaired physical mobility, and chronic pain, all related to overweight, are potential or problem diagnoses that require the attention of the nurse after implementing care for the initial diagnosis.

Which nursing diagnosis is a priority for a patient who needs assistance with activities of daily living? a. Self-Care Deficit b. Lack of Knowledge c. Activity Intolerance d. Able to Perform Self-Care

Answer: a A patient who has an impaired ability to complete bathing, mouth care, toileting, grooming, dressing, and eating without assistance has a Self-Care Deficit. Lack of Knowledge implies that the patient does not have certain information. Activity Intolerance may be a concern if a patient's level of activity is reduced, but this nursing diagnosis is not necessarily related to needing assistance. A diagnosis of Able to Perform Self-Care means that the patient is ready to perform activities to enhance health.

What other health care professional should the nurse consult first when a patient has difficulty with activities of daily living (ADLs) such as bathing and dressing and why? a. Occupational therapist to evaluate the ability to perform ADLs b. Physical therapist to evaluate the patient's need for assistive devices c. Social worker to arrange for needed assistive devices d. Area agency on aging to arrange for Meals on Wheels

Answer: a An evaluation by an occupational therapist (OT) is the first step in identifying the details of the safety concerns for activities of daily living. Other evaluations and services may be warranted and arranged after the OT evaluation reveals some basic needs.

When teaching a patient about fire safety, which activity does the nurse know is the leading cause of fire-related death? a. Cooking b. Playing with matches c. Smoking d. Heating with kerosene heaters

Answer: a Cooking has been the leading cause of residential fires for the last decade, followed by heating, electrical malfunction, and other unintentional causes or carelessness.

An elderly client residing in the community with cardiopulmonary compromise and impaired ability to perform activities of daily living (ADLs) presents safety concerns to the nurse. Which is the greatest concern? a. Ability to obtain and take medications correctly b. Ability to safely get on and off a toilet c. Ability to safely procure food and prepare meals d. Ability to safely eat without choking

Answer: b A patient with cardiopulmonary compromise may exhibit symptoms such as shortness of breath, leading to subsequent activity intolerance and difficulty performing activities of daily living. An individual may be unable to safely get off and on a toilet, leading to an increased risk for falling, which is the primary concern of the nurse. Although the other concerns may apply, they are less likely to be related to cardiopulmonary compromise.

Which restraint-free alternative is best for the nurse to use for an 84-year-old patient after hip replacement who has confusion and incontinence? a. A room near the nurses' station and decreased sensory stimuli b. A pressure sensor alarm and a room near the nurses' station c. Side rails up and decreased sensory stimuli d. A 24-hour sitter and the patient's favorite TV program

Answer: b Patients with confusion may not remember to call for assistance before getting up, especially if they have had an episode of incontinence. A pressure sensor alarm that can be used in a bed or chair should be implemented as a priority intervention along with moving the patient to a room near the nurses' station, where the patient can be more closely monitored. Although decreasing sensory stimuli may help a patient with confusion, it is not a priority intervention. A 24-hour sitter is costly and used only after all other restraint-free alternatives are exhausted.

Which action by a female patient lets the nurse know the patient has understood perineal care teaching? a. The patient washes her perineum with a circular motion beginning at the urinary meatus. b. The patient washes her perineum from front to back using a clean washcloth. c. The patient washes her perineum from back to front with long, firm strokes. d. The patient washes her perineum lightly to prevent tissue damage.

Answer: b The female perineum is always washed from front to back, washing the area near the urinary meatus first and working back to the anus to avoid introducing organisms into the urinary tract. A circular motion is used for a male patient, washing around the urinary meatus first and then washing down the shaft of the penis. Firm strokes can be used so that the area is well cleaned.

The nurse is performing a fall risk assessment on a newly admitted patient. Which finding is a greater known risk factor for falls? a. Taking aspirin b. Urinary incontinence c. Multiple comorbidities d. Malnutrition

Answer: b Urinary incontinence, a known factor that increases fall risk, is included on the Johns Hopkins Hospital Fall Assessment Tool and Hendrich II Fall Risk Model. Although the effects of specific medications (e.g., antiepileptics, narcotics) may increase the risk for falls, the medication aspirin alone does not. Comorbidities may increase fall risk, but the total number of comorbidities does not have an independent effect. Malnutrition alone does not increase fall risk, but conditions resulting from it, such as muscle wasting and deconditioning leading to weakness, can increase fall risk.

What specific aspect of a profession does the development of theories provide? a. Altruism b. Body of knowledge c. Autonomy d. Accountability

Answer: b Theories establish a specific nursing body of knowledge that is unique to the discipline, which is one criterion of a profession.

Which safety precaution is a priority for the nurse when bathing a patient with peripheral neuropathy? a. Keeping the top two side rails up during the bath b. Checking the bath water temperature before the bath c. Encouraging independence with perineal care during the bath d. Facilitating range-of-motion exercises and dangling before the bath

Answer: b The patient with peripheral neuropathy may not be able to distinguish extremes of hot and cold. To prevent burns from extremely hot water, the nurse checks the water temperature before beginning the bath and each time clean water is obtained. It is important to keep the top two side rails up when not at the bedside to facilitate turning and positioning. Facilitating range-of-motion exercises and as much independence as possible is important for all patients rather than being a specific safety concern for the patient with peripheral neuropathy. Dangling is important to implement with patients who have been bedridden and may experience orthostatic hypotension.

Health care workers are discussing a diverse group of patients respectfully and are being responsive to the health beliefs and practices of these patients. What important aspect of nursing professional practice are they exhibiting? a. Autonomy b. Accountability c. Cultural competence d. Autocratic leadership

Answer: c The nurse and other health care workers are exhibiting cultural competence by being responsive to patients' health beliefs and practices that are influenced by the individual's culture.

A nurse makes a medication error, immediately assesses the patient, and reports the error to the nurse manager and the primary care provider (PCP). Which characteristic of a professional is the nurse demonstrating? a. Autonomy b. Collaboration c. Accountability d. Altruism

Answer: c The nurse is demonstrating accountability by taking responsibility for the error and reporting it after an initial assessment of the patient. Criteria of a profession include altruism (public service over personal gain), autonomy (independence), accountability, and diversity; however, in this case, the nurse is demonstrating accountability. Although collaboration is important for the health care team, it is not a criterion for a profession.

Which activity would be most appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for fall risk and complications of restraint use b. Evaluating the patient's ability to perform activities of daily living (ADLs) c. Assisting with or performing the patient's ADLs d. Teaching the patient use of assistive devices

Answer: c Unlicensed assistive personnel (UAP), such as patient care technicians and nursing assistants, provide hands-on care for patients who may require complete care or total assistance with their activities of daily living (ADLs). However, registered nurses (RNs) are responsible for supervising and guiding the UAP so direct care is provided in a safe manner. RNs are responsible for performing patient assessments, and the OT evaluates the patient's ability to perform ADLs. A physical therapist evaluates mobility and initially teaches the patient to use an assistive device. If use of assistive devices needs reinforcement, the RN does the teaching.

The nurse is aware that parents are being safety advocates when they do which of the following? a. Keep a rear-facing car seat until the child is at least 12 months old. b. Limits the amount of TV and video viewing of school age children to 3 to 4 hours per day. c. Asks the teenager to turn the headphone volume down when the music is audible to others. d. Avoid painting in a house unless the temperature is above 60 degrees Fahrenheit.

Answer: c Using earphones while listening to loud music can cause permanent hearing damage. The level of the music should be no louder than normal conversation to be considered safe, so being able to hear it audibly by others means it is too loud and volume should be reduced. Infants and toddlers should be rear facing until they are at least 2 years old or reach the highest weight or height allowed by the car seat manufacturer. School-age children should be limited to no more than 2 hours per day of sedentary screen time (TV, computer, gaming). There are no safety recommendations for temperature and painting.

An alert and oriented elderly male patient has been admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). He is unshaven, has unkempt hair, and has a foul body odor. Asking which hygiene-related assessment question is a priority for the nurse? a. "Do you have friends or family nearby?" b. "Can you raise your arms up to brush your teeth?" c. "Do you become short of breath during your shower?" d. "Are you able to get in and out of your bed at home?"

Answer: c Knowing the COPD patient's activity tolerance helps the nurse formulate a plan for ongoing hygiene care in the hospital and after discharge. Having friends and family nearby may be helpful, but until the activity tolerance is known, his need for outside assistance is not known. A complete assessment of physical capabilities, including his ability to brush his teeth and whether he can get in and out of bed, is important after his activity tolerance has been assessed.

In comparing the American Nurses Association (ANA) and the International Council of Nurses (ICN) definitions of nursing, what component does the ICN mention that is not included in ANA's definition and is indicative of a more global focus? a. Advocacy b. Health promotion c. Shaping health policy d. Prevention of illness

Answer: c The ICN's definition of nursing expands on the ANA's definition by providing for the concept of shaping health policy as a responsibility of nursing.

What should the nurse do before leaving a patient's room after giving a complete bed bath? a. Place the call light within reach so the patient can call for help if needed, and leave the bed as it was during the bath. b. Lower the bed to its lowest position, raise all four side rails so that the patient does not fall out of bed, and place the call light within reach. c. Lower the bed to its lowest position, raise the top two side rails to assist the patient in turning and positioning, and place the call light within reach. d. Leave the bed in a position that is comfortable for the caregiver because more care will be needed, raise the top two side rails, and place the call light within reach.

Answer: c The bed is always left in the lowest position so it is closer to the floor. The top two side rails aid the patient in turning and positioning. The call light is placed within reach of the patient so that the nurse can be called if needed. Leaving the bed in a working or higher position increases the danger of falling if the patient tries to get out of bed. Raising all four side rails is considered a restraint.

Which core competency of advanced practice nursing is the Master of Science in Nursing (MSN) nurse educator exhibiting when counseling a student in therapeutic communication techniques? a. Leadership b. Ethical decision making c. Direct clinical practice d. Expert coaching

Answer: d A nurse educator who is teaching and counseling students is practicing expert coaching and guidance. A nurse educator with a master's degree practices the other competencies of leadership and ethical decision making in other situations. Although a nurse educator may also work as a nurse involved in direct patient care, this is not part of the educator role.

A 56-year-old man who has been staying at a cabin while hunting arrives at the emergency department with complaints of dizziness, light-headedness, and nausea. What does the nurse initially suspect? a. Lead poisoning b. Radon exposure c. Food poisoning d. Carbon monoxide poisoning

Answer: d Symptoms of carbon monoxide poisoning are nausea, dizziness, and light-headedness. Carbon monoxide poisoning can result from using camp stoves inside and burning objects in poorly vented fireplaces. Lead poisoning resulting in neurologic symptoms is more common in children exposed to lead-based paints. Symptoms of radon exposure include persistent cough, hoarseness, and breathing difficulties. Symptoms of food poisoning usually include nausea, vomiting, and diarrhea.

An ambulatory diabetic patient states that she is unable to reach her feet to clip her toenails. The patient's toenails are long and thick. What is the next step the nurse should take? a. Soak the patient's feet, and trim her toenails using clippers. b. Delegate foot care of this patient to the unlicensed assistive personnel (UAP). c. Assess the patient's self-care abilities. d. Ask the primary care provider (PCP) for a referral to a podiatrist.

Answer: d Referral to a podiatrist is appropriate when the diabetic patient is unable to care for her feet. Soaking is contraindicated for patients with diabetes due to the risk for skin breakdown. Clippers are not appropriate if nails are thick. Delegation of nail care to the UAP is inappropriate for patients with peripheral neuropathy. The nurse already knows the patient's self-care status abilities in regard to her feet.

Which statement indicates an understanding by the unlicensed assistive personnel of eye care during a patient's bath using washcloths and a bath basin? a. "The eyes are washed with soap and water from the inner canthus to the outer canthus." b. "The eyes should always be washed using sterile normal saline and a gauze sponge." c. "The eyes are washed from the outer canthus to the inner canthus using water only." d. "The eyes are washed with water using a clean part of the washcloth for each eye."

Answer: d Eyes are washed with water only from the inner canthus to the outer canthus to prevent the spread of pathogens into the tear ducts. A clean section of the washcloth is used for each eye to avoid cross-contamination. Soap is irritating to the eye and is therefore contraindicated. It is unnecessary to use sterile saline for routine cleansing of the eye.

When working with radiation diagnostics or treatments, which preventive measures should be followed to avoid exposure? (Select all that apply.) a. Using lead shielding of patients and staff b. Keeping staff at the farthest distance possible from the radiation source c. Limiting the length of exposure d. Wearing a badge to monitor the length of exposure e. Following procedures and safety checks

Answers: a, b, c, d, e All of these preventive measures can be taken to avoid radiation exposure. Lead shielding should be used for patients and staff. Staff should be kept at the farthest distance possible from the radiation source, and the length of exposure should be limited. To track exposure and ensure safety, health care professionals working with radiation or radioactive materials should wear a device or badge that is periodically turned in to monitor cumulative radiation exposure levels. All equipment should be maintained and properly used according to manufacturers' guidelines.

A profession has specific characteristics. In regard to how nursing meets these characteristics, which criteria are consistent and standardized processes? (Select all that apply.) a. Code of ethics b. Licensing c. Body of knowledge d. Educational preparation e. Altruism

Answers: a, b, c, e Nursing as a profession has a code of ethics, licensing, a body of knowledge, and altruism. Because there are multiple paths of education for nursing and not a standard entry into practice, this is one criterion of a profession that is not standard and consistent.

When nurses disagree about the effectiveness of a commonly practiced nursing intervention, the best evidence for determining which intervention to use is: A. a systematic review of randomized controlled trials. B. a qualitative research study with a large sample size. C. a methodological Internet search using key medical terms. D. anecdotal evidence retrieved from two or more case studies.

Correct Answer: A. a systematic review of randomized controlled trials. Rationale: Systematic reviews of randomized controlled trials (RCTs) are considered the strongest level of evidence to answer questions about interventions (i.e., cause and effect).

What factor has been clearly identified as influencing the future of nursing practice? A. Aging of the American population and increases in chronic illnesses B. Increasing birth rates coupled with decreased average life expectancy C. Increased awareness of determinants of health and improved self-care D. Apathy around health behaviors and the relationship of lifestyle to health

Correct Answer: Aging of the American population and increases in chronic illnesses Rationale: The American population is aging at the same time that the incidence of chronic health conditions is increasing. There is no noted increase in the overall awareness of the determinants of health, but at the same time, observers have not identified apathy as a predominant attitude. Life expectancy is increasing, not decreasing.

When the nurse encourages a patient with heart failure to alternate rest and activity periods to reduce cardiac workload, which phase of the nursing process is being used? a. Diagnosis b. Planning c. Implementation d. Evaluation

Correct Answer: c. Implementation Rationale: Carrying out a specific, individualized plan constitutes the implementation phase of the nursing process. The nurse's action of encouragement and instruction to the patient is part of carrying out a plan of action.

When planning care for a patient, the nurse may use a visual diagram of patient problems and interventions to illustrate the relationships among pertinent clinical data. This format is called a: A. concept map. B. critical pathway. C. clinical pathway. D. nursing care plan.

Correct Answer: concept map. Rationale: A concept map is another method of recording a nursing care plan. In a concept map, the nursing process is recorded in a visual diagram of patient problems and interventions. A clinical (critical) pathway is a prewritten plan that directs the entire interprofessional care team in the daily care goals for select health care problems.

A nurse is monitoring all the patients in an outpatient procedure area for complications of administering IV fluids. What type of nursing function is the nurse demonstrating? A. Dependent B. Independent C. Autonomous D. Collaborative

Correct Answer: D Collaborative Rationale: A collaborative nursing function is demonstrated when the nurse monitors patients for complications of acute illness, administers IV fluids and medications per health care provider's orders, and implements nursing interventions such as providing emotional support or teaching about specific procedures. Nursing functions may be dependent, collaborative, or independent. The nurse functions dependently when carrying out medical orders. Physician-initiated nursing functions may include administering medications, performing or assisting with certain medical treatments, and assisting with diagnostic tests and procedures. Independent nursing functions include interventions such as promotion and optimization of health, prevention of illness, and patient advocacy.

A nurse is caring for a client who presents with linear clusters of fluid‐containing vesicles with some crustings. the nurse should identify the client has manifestations of which of the following conditions? A. Allergic reaction B. ringworm c. Systemic lupus erythematosus D. Herpes zoster

D

A nurse is caring for a client who reports a severe sore throat, pain when swallowing, and swollen lymph nodes. the client is experiencing which of the following stages of infection? A. Prodromal B. Incubation c. convalescence D. Illness

D