TEST 2 (manager of care)

Which number of alternative solutions should be included when conducting ethical decision-making? A. One B. Two C. Three D. Four

C. Three

Which statement should the nurse include when educating older adult patients about dementia? A. "Dementia causes impaired judgment." B. "Dementia causes fluctuations in alertness." C. "Symptoms of dementia cause day-night reversal." D. "Symptoms of dementia do not last more than one month."

A. "Dementia causes impaired judgment."

Which questions should the nurse ask when conducting an assessment to determine if the patient has any high-risk cultural behaviors? Select all that apply. A. "Do you smoke tobacco products?" B. "How many alcoholic beverages do you drink each day?" C. "Who makes the health-care decisions within your family?" D. "Do you use any herbal medications that we should be aware of?" E. "Are there any foods you would like to include in your diet during hospitalization?"

A. "Do you smoke tobacco products?" B. "How many alcoholic beverages do you drink each day?"

The nurse is instructing a patient with heart failure about a prescribed sodium-restricted diet. Which patient statement indicates that additional teaching is required? A. "I can use as much salt substitute as I want." B. "I have to read the labels on foods to find out the sodium content." C. "I have to limit the intake of food with baking soda or baking powder." D. "I can use spices and lemon juice to add flavor to food when cooking."

A. "I can use as much salt substitute as I want."

The nurse is providing care for a postpartum patient who states, "I know my rights and you have to do what I tell you!" Which response by the nurse is appropriate? A. "I don't mind doing anything within reason, but you have a responsibility to be considerate to the staff as well." B. "That statement is not included in your patient rights; don't yell at me." C. "Why do you feel angry ... did I do something you did not like?" D. "Do you want me to take the baby to the nursery so you can calm down?"

A. "I don't mind doing anything within reason, but you have a responsibility to be considerate to the staff as well."

Which intravenous (IV) fluid should the nurse prepare when a patient requires an isotonic solution? A. 0.9% normal saline B. 2.5% dextrose in water C. 0.33% sodium chloride D. 5% dextrose in Lactated ringers

A. 0.9% normal saline

The nurse is providing care to a trauma patient who will require the rapid administration of large volumes of fluid in addition to a blood transfusion. Which gauge should the nurse use when initiating intravenous (IV) access for this patient? A. 18 B. 20 C. 22 D. 24

A. 18

In trauma patients, enteral nutrition via nasogastric tube feedings into the small bowel is best initiated within what time frame following the injury? A. 24 hours B. 48 hours C. 7 days D. 72 hours

A. 24 hours

In addition to residual stomach volume, what other evidence suggests feeding intolerance? A. Abdominal distention B. Absence of tympany on percussion C. Active bowel sounds D. Elevated blood glucose by fingerstick

A. Abdominal distention

Which should the nurse consider when assessing for health disparities within the community? Select all that apply. A. Age B. Gender C. Ethnicity D. Disability E. Education

A. Age B. Gender C. Ethnicity D. Disability

Which of the following statements is true about insulin and parenteral nutrition? (Select all that apply.) A. Amount of parenteral insulin is adjusted based on the previous 24-hour laboratory values. B. Insulin may be added to a parenteral nutrition solution. C. Subcutaneous insulin is used on a sliding scale during parenteral nutrition. D. Supplemental insulin is rarely required for patients receiving parenteral nutrition. E. Lingering hyperglycemia after parenteral nutrition has been stopped requires continuing insulin.

A. Amount of parenteral insulin is adjusted based on the previous 24-hour laboratory values. B. Insulin may be added to a parenteral nutrition solution. C. Subcutaneous insulin is used on a sliding scale during parenteral nutrition.

The nurse is caring for several pediatric patients with numerous cultural backgrounds. Which patients would the nurse anticipate will be encouraged to express themselves? Select all that apply. A. An Appalachian adolescent B. A British school-age child C. An Arab school-age child D. An Asian-Indian adolescent E. A Japanese pre-adolescent

A. An Appalachian adolescent B. A British school-age child

The nurse is providing care to an older adult patient who is diagnosed with a vitamin B deficiency. The patient tells the nurse, "I feel so tired all the time and my daughter says I look pale." Based on this data, which should the nurse suspect? A. Anemia B. Osteoporosis C. Atrophic gastritis D. Gastroesophageal reflux disease (GERD)

A. Anemia

The nurse is providing care to an infant who is experiencing colic. The infant's family immigrated to the United States six months ago. The mother explains that she believes that an herbal remedy, prepared by the village doctor, is the best way to treat the infant's colic. Which action by the nurse is most appropriate? A. Ask the mother what the ingredients are in the remedy. B. Give the mother an alternate remedy for colic. C. Explain how herbal ingredients may be harmful to the infant. D. Tell the mother not to use the remedy because there is no way to know what the ingredients' scientific effect may be.

A. Ask the mother what the ingredients are in the remedy.

When the nurse receives a telephone order from the health-care provider's office, which guidelines are used to ensure the order is correct? Select all that apply. A. Ask the prescriber to speak slowly. B. Read the order back to the prescriber. C. Know agency policy for telephone orders. D. Sign the prescriber's name and credentials. E. Ask the prescriber to repeat or spell out medication.

A. Ask the prescriber to speak slowly. B. Read the order back to the prescriber. C. Know agency policy for telephone orders. E. Ask the prescriber to repeat or spell out medication.

The nurse is caring for a patient with a central venous catheter used for intermittent medication administration. When flushing the catheter prior to administering the next dose of medication, which initial action by the nurse is the most appropriate? A. Aspirating the patient's catheter for blood B. Positioning the patient in reverse Trendelenburg position C. Flushing the catheter, using as much force as required in order to clear the line D. Obtaining a 3 mL syringe and filling it with normal saline for flushing the line

A. Aspirating the patient's catheter for blood

Which statement(s) about total parenteral nutrition is (are) true? (Select all that apply.) A. Assessing fluid volume status and preventing infection are important nursing considerations. B. Fingerstick glucose levels are assessed every 6 hours and prn. C. Total parenteral nutrition is administered through a feeding tube and pump. D. Total parenteral nutrition, with added lipids, provides adequate levels of protein, carbohydrates, and fats. E. Soy-based lipids should not be given if propofol is prescribed.

A. Assessing fluid volume status and preventing infection are important nursing considerations. B. Fingerstick glucose levels are assessed every 6 hours and prn. D. Total parenteral nutrition, with added lipids, provides adequate levels of protein, carbohydrates, and fats. E. Soy-based lipids should not be given if propofol is prescribed.

Which senescence term should the nurse use to describe the wasting away of muscle mass that occurs with the aging process? A. Atrophy B. Stenosis C. Sclerosis D. Calcification

A. Atrophy

Which ethical principle is the nurse assessing when asking who benefits from the actions of others? A. Beneficence B. Autonomy C. Justice D. Fidelity

A. Beneficence

A patient tells the nurse, "I don't really like the nurse on the first shift; she treats me bad." Which action by the nurse is appropriate in order to advocate for this patient? A. Call the agency patient advocacy department. B. Confront the nurse when she comes to work. C. Tell the patient he or she has the right to switch nurses. D. Call the local authorities.

A. Call the agency patient advocacy department.

Which patient population should the nurse plan care based on individualistic cultural attributes? A. Canadian B. Latino C. Filipino D. Hindu

A. Canadian

The nurse is providing care to patient who is receiving total parenteral nutrition (TPN). During the shift assessment, the nurse notes that the patient is lethargic and has an elevated temperature and white blood cell count. The nurse suspects the patient is septic. Which actions by the nurse are appropriate in this situation? Select all that apply. A. Changing the IV tubing B. Saving the remaining TPN C. Notifying the health-care provider D. Recording the lot number of the TPN E. Replacing the TPN with a normal saline solution

A. Changing the IV tubing B. Saving the remaining TPN C. Notifying the health-care provider D. Recording the lot number of the TPN

The nurse is performing venipuncture to initiate intravenous (IV) therapy. Which indicators should the nurse use when choosing the site for IV therapy? Select all that apply. A. Choosing a straight vein B. Avoiding a sclerotic vein C. Looking for sites distal to joints D. Using the dominant arm, whenever possible E. Choosing a vein that is visible in addition to palpable

A. Choosing a straight vein B. Avoiding a sclerotic vein C. Looking for sites distal to joints

The nurse is caring for a patient with congestive heart failure who is admitted to the medical-surgical unit with acute hypokalemia. Which prescribed medication may have contributed to the patient's current hypokalemic state? A. Cortisol B. Demerol C. Skelaxin D. Nonsteroidal anti-inflammatory drugs (NSAIDs)

A. Cortisol

Which traditional Chinese medical treatment involves the use of a heated cup used to treat joint pain? A. Cupping B. Moxibustion C. Acupuncture D. Skin pinching

A. Cupping

Which changes associated with aging should the nurse identify as possible inhibitors to medication adherence and safety? Select all that apply. A. Decreased memory B. Decreased visual acuity C. Decreased hearing acuity D. Decreased sense of smell E. Decreased physical strength

A. Decreased memory B. Decreased visual acuity E. Decreased physical strength

An older adult patient, who lives in a long-term care facility, presents in the emergency department (ED) due to fever, nausea, and vomiting over the past two days. The patient denies thirst. The urine dipstick indicates a decreased urine specific gravity. Which medical diagnosis should the nurse anticipate when planning care for this patient? A. Dehydration B. Hypertension C. Fluid overload D. Congestive heart failure

A. Dehydration

Which is the priority nursing action for the ethical decision-making process? A. Determine exactly what needs to be decided. B. Formulate alternatives to solve the issue. C. Implement an action to achieve the greatest benefit with the least amount of risk. D. Ascertain if new information is available regarding the issue.

A. Determine exactly what needs to be decided.

The nurse is concerned that an older adult patient is at risk for developing acute renal failure. Which information in the patient's history support the nurse's concern? Select all that apply. A. Diagnosed with hypotension B. Recent aortic valve replacement surgery C. Total hip replacement surgery five years ago D. Taking medication for type 2 diabetes mellitus E. Prescribed high doses of intravenous antibiotics

A. Diagnosed with hypotension B. Recent aortic valve replacement surgery E. Prescribed high doses of intravenous antibiotics

The community nurse visits the home of a young child who is home from school because of sudden onset of nausea, vomiting, and lethargy. The nurse suspects acute renal failure. Which clinical manifestations support the nurse's suspicions? Select all that apply. A. Edema B. Wheezing C. Hematuria D. Postural hypotension E. Elevated blood pressure

A. Edema C. Hematuria E. Elevated blood pressure

The hospice nurse is providing care to a terminal patient who has asked about guidance and support in ending life. Which should the nurse recognize in regards to making an ethical and moral decision in this circumstance? A. Euthanasia has legal implications along with moral and ethical ones. B. Passive euthanasia is an easy decision to arrive at. C. Active euthanasia is supported in the Code for Nurses. D. Assisted suicide is illegal in all states.

A. Euthanasia has legal implications along with moral and ethical ones.

Which priority safety concerns should the nurse assess when providing care to older adult patients? Select all that apply. A. Falls B. Neglect C. Depression D. Polypharmacy E. Poor dietary intake

A. Falls B. Neglect D. Polypharmacy

An adolescent patient diagnosed with leukemia decides to stop chemotherapy treatments. The patient's parents, however, want the health-care team to continue all treatments. Which action by the nurse is appropriate when providing care to this patient and family? A. Helping the family by providing information and allowing them to voice their concerns B. Confronting the parents and telling them not to be "selfish" in their child's time of need C. Calling the authorities immediately D. Obtaining a court order to determine the patient is legally able to make his or her own decisions

A. Helping the family by providing information and allowing them to voice their concerns

Which electrolyte imbalance should the nurse monitor an older adult patient for when a diuretic is prescribed? A. Hypokalemia B. Hyponatremia C. Hypocalcemia D. Hypomagnesemia

A. Hypokalemia

The nurse is working with a number of patients at a free clinic. Which population is at the highest risk for low levels of health care? A. Immigrants B. Adolescents C. Older adults D. Newborns

A. Immigrants

The hospital's nurse case manager has been extensively involved with a shooting victim and members of the patient's family in coordinating care of providers from many disciplines as the patient progressed from the emergency department (ED) to the intensive care unit (ICU), and then onto the medical-surgical unit. After three weeks of hospitalization, the case manager is helping to prepare the patient for discharge to a rehabilitation center where treatment will continue. Which outcomes have been documented in the literature as benefits of such collaboration? Select all that apply. A. Improved patient outcomes B. Decreased duplication of health-care services C. Increased overall cost of health-care services D. Decreased patient morbidity and mortality E. Decreased level of job satisfaction

A. Improved patient outcomes B. Decreased duplication of health-care services D. Decreased patient morbidity and mortality

When discussing the importance of interprofessional collaboration, which advantages should the nurse include? Select all that apply. A. Improved team member satisfaction B. Increased division among team members C. Increased safety with medication administration D. Enhanced communication among team members E. Increased patient satisfaction with discharge transition process

A. Improved team member satisfaction D. Enhanced communication among team members E. Increased patient satisfaction with discharge transition process

Which older adult patient diagnoses should the nurse include information regarding cachexia into the plan of care? Select all that apply. A. Lung cancer B. Osteoporosis C. Gastroesophageal reflux disorder (GERD) D. Acquired immune deficiency syndrome (AIDS) E. Chronic obstructive pulmonary disease (COPD)

A. Lung cancer D. Acquired immune deficiency syndrome (AIDS) E. Chronic obstructive pulmonary disease (COPD)

A local hospital formed a neurotrauma (NT) team with the following members: acute care nurses, physicians, other care partners (e.g., physical therapists, social workers, case managers, dieticians), and representatives from the NT outpatient clinic. This team is led by a physician who makes treatment decisions based on the treatment plans developed by individual team members who each communicate with the patients, asking the same or similar questions to obtain data needed for their treatment plan. Which type of communication and action is represented in the scenario described? A. Parallel communication B. Parallel functioning C. Information exchange D. Coordination and consultation

A. Parallel communication

According to Provision 2 of the American Nurses Association (ANA) Code of Ethics, which member of the health-care team is the nurse's primary commitment? Select all that apply. A. Patient B. Family C. Physician D. Community E. Surgeon

A. Patient B. Family D. Community

The nurse is assessing an intravenous (IV) insertion site noting redness, warmth, and mild swelling. The patient reports a burning pain along the course of the vein during medication administration. Which term should the nurse use when documenting these findings in the medical record? A. Phlebitis B. Infiltration C. Extravasation D. Inflammation

A. Phlebitis

Which component should the nurse anticipate will be prescribed for a patient with severe thrombocytopenia? A. Platelets B. Albumin C. Fresh frozen plasma D. Packed red blood cells

A. Platelets

A hospice nurse is providing care to a patient diagnosed with ovarian cancer. The patient is concerned that her two daughters are at an increased risk for cancer and asks the nurse for help. Which actions by the nurse are appropriate? Select all that apply. A. Provide the family with information on hereditary cancer risks. B. Assure the client that ovarian cancer is not hereditary. C. Offer to refer the daughters to a genetic counselor. D. Arrange for the client to have genetic testing. E. Tell the client that her additional worrying is too stressful.

A. Provide the family with information on hereditary cancer risks. C. Offer to refer the daughters to a genetic counselor. D. Arrange for the client to have genetic testing.

Which items found by a nurse during a home health visit increase the older adult patient's risk for physical safety issues? Select all that apply. A. Rugs B. Electrical cords C. Nonskid appliance in bathtub D. Medications stored in a weekly divider E. Telephone with emergency numbers listed

A. Rugs B. Electrical cords

The nurse is providing care to a patient who is receiving a blood transfusion. Ten minutes after the infusion is initiated, the patient reports a headache. Upon further assessment the nurse notes that the patient is experiencing dyspnea and feels warm to the touch. Which is the priority nursing action by the nurse? A. Stop the transfusion. B. Prepare for a full resuscitation. C. Notify the health-care provider. D. Decrease the rate of the transfusion.

A. Stop the transfusion.

Which are ethical issues for the nurse to consider prior to deciding whether or not to honor the picket line during a strike situation? Select all that apply. A. The need to support coworkers in their efforts to improve working conditions B. The need to ensure that clients receive care and are not abandoned C. The desire to take some time off D. Loyalty to the nurse's employer E. The need for higher pay

A. The need to support coworkers in their efforts to improve working conditions B. The need to ensure that clients receive care and are not abandoned D. Loyalty to the nurse's employer

A patient diagnosed with acquired immune deficiency syndrome (AIDS) is admitted to the acute care floor. Which stance regarding the care for this patient is supported by the American Nurses Association (ANA) Code of Ethics? A. The nurse is morally obligated to care for the patient unless the risk exceeds responsibility. B. The nurse has the responsibility to ensure the patient gets adequate medical care. C. The patient has the right to choose not to disclose his or her condition to staff. D. The patient is morally bound to disclose every aspect of his or her condition to staff.

A. The nurse is morally obligated to care for the patient unless the risk exceeds responsibility.

Which patients may benefit from central intravenous (IV) access? Select all that apply. A. The patient receiving caustic IV therapy. B. The patient requiring long-term IV therapy. C. The patient who is afraid of needles and does not want a catheter in the peripheral extremity. D. The patient requiring numerous IV infusions that are not compatible and cannot be infused together. E. The unstable patient requiring reliable IV access for administration of medications required. immediately.

A. The patient receiving caustic IV therapy. B. The patient requiring long-term IV therapy. D. The patient requiring numerous IV infusions that are not compatible and cannot be infused together. E. The unstable patient requiring reliable IV access for administration of medications required. immediately.

The nurse managers in a community hospital have been charged with reviewing job descriptions of unlicensed assistive personnel (UAPs) and have questions about the delegation of certain patient care activities to UAPs by nurses. To which group, organization, or individual would committee members direct their questions to obtain definitive answers about the parameters of nurse delegation to UAPs? A. The state board of nursing B. The American Nurses Association C. The hospital's Chief Nursing Officer D. The hospital's Chief Executive Officer

A. The state board of nursing

What statement is true about calorie dense feedings? (Select all that apply.) A. They are most useful in heart failure and liver disease. B. They are most useful in malabsorption syndromes. C. They contain 2 kcal/mL and 70 g protein/L. D. They include increased fiber. E. They are especially good for patients with lung disease

A. They are most useful in heart failure and liver disease. C. They contain 2 kcal/mL and 70 g protein/L.

The nurse is caring for a patient admitted with hypertension and chronic renal failure who receives hemodialysis three times per week. The nurse is assessing the patient's diet and notes the use of salt substitutes. When teaching the patient to avoid salt substitute, which rationale supports this teaching point? A. They can potentiate hyperkalemia. B. They will cause the client to retain fluid. C. They will increase the risk of AV fistula infection. D. They will interact with the client's antihypertensive medications.

A. They can potentiate hyperkalemia

Which health-care practices are anticipated when providing care to a patient of German descent? Select all that apply. A. Traditional practices as the first line of defense B. Self-medicating with over-the-counter drugs C. Use of liberal pain medication D. Use of medications ordered from other countries E. Mental health issues hold a stigma and are hidden

A. Traditional practices as the first line of defense B. Self-medicating with over-the-counter drugs C. Use of liberal pain medication

Which of these should the nurse focus on to decrease health disparities among Hispanic patients? A. Translation services B. Nutritional education C. Pediatric immunizations D. Hypertension prevention

A. Translation services

Which clinical manifestation should the nurse anticipate when providing care to an older adult patient who is diagnosed with Parkinson disease? A. Tremors B. Paralysis C. Vision impairment D. Right-sided weakness

A. Tremors

The nurse is caring for a patient with a central venous catheter (CVC). Which nursing actions should the nurse implement to prevent an air embolism? Select all that apply. A. Using Luer-locked connections B. Frequently checking connections C. Wearing sterile gloves when accessing any connections D. Clamping catheters and injection sites when not in use E. Placing the patient in low-Fowler position to remove the CVC

A. Using Luer-locked connections B. Frequently checking connections D. Clamping catheters and injection sites when not in use

When communicating with a patient who is of Vietnamese descent, which action by the nurse is appropriate? A. Using the patient's surname with a title B. Being straightforward with the patient C. Maintaining direct eye contact with the patient D. Sharing intimate life details with the patient

A. Using the patient's surname with a title

Which nursing action supports The Joint Commission (TJCs) safety goals for providing home care to an older adult patient? A. Verifying the patient's first and last name during each visit B. Administering all prescribed medications to the patient during scheduled visits C. Recommending the use of throw rugs on hard wood floors to prevent patient falls D. Asking family members to smoke in another room when oxygen is in use by the patient

A. Verifying the patient's first and last name during each visit

Which data collected by the nurse during the health history of an older adult patient increases the risk for heart disease? A. Dependent edema B. Diabetes insipidus C. Cigarette smoking D. Diminished hearing

C. Cigarette smoking

What important nutritional consideration should be addressed in the elderly population? A. Decreased protein requirements. B. Increasing caloric requirements with age. C. Potential for drug-nutrient interaction related to polypharmacy. D. Presence of other diseases that decrease caloric needs.

C. Potential for drug-nutrient interaction related to polypharmacy.

Which statement regarding the American Nurses Association (ANA) Code of Ethics for professional nurses is accurate? A. "It is used by all health-care professionals." B. "It guides nurses in their professional behavior and relationships." C. "It forms the basis for possible lawsuits." D. "It is the only code of ethics available for nurses."

B. "It guides nurses in their professional behavior and relationships."

Which statement best describes the American Nurses Association (ANA) Code of Ethics for professional nurses? A. "It alleviates suffering for those cared for by professional nurses." B. "It provides standards for professional nursing practice." C. "It reflects legal judgments in professional nursing practice." D. "It serves as legal standards for professional nursing practice."

B. "It provides standards for professional nursing practice."

The nurse receives shift report on a pediatric medical-surgical unit. The nurse has been assigned four patients for the shift. Which child does the nurse plan to assess first based on the increased risk for dehydration? A. A 4-year-old child with a broken leg B. A 15-month-old child with tachypnea C. A 16-year-old child with migraine headaches D. A 10-year-old child with cellulitis of the left leg

B. A 15-month-old child with tachypnea

The nurse is providing care to a patient following hemodialysis. The patient is experiencing tachycardia and decreased urine output along with skin that is pale and cool to the touch. Which goal of hemodialysis does the nurse determine the patient has not met based on the current data? A. Cardiac decompensation B. A reduction of extracellular fluid C. The effects of rapidly infused intravenous fluids D. The pharmacological effects of a diuretic infused in the dialysate

B. A reduction of extracellular fluid

The nurse is providing care to an adult patient from another country and notices that the patient consults with her mother on all health-care decisions. Which action by the nurse is the most appropriate? A. Ask the patient why the parent is being consulted for every decision. B. Accept the behavior of the patient and family member. C. Ask the patient's mother to leave the room to provide the patient with more privacy. D. Confront the patient's mother to state the importance of the patient making her own decisions.

B. Accept the behavior of the patient and family member.

The nurse is caring for a patient receiving intravenous (IV) medications. After infusing an IV antibiotic, the nurse assesses the IV site and finds it to be red and edematous, and the patient is reporting pain at the site. Which would the nurse document in the nursing notes regarding the infiltration? Select all that apply. A. Incident report B. Actions taken to correct the problem C. Size and location of erythematous area D. Health-care provider notification and any orders received E. Amount of fluid infused per shift on the intake and output record

B. Actions taken to correct the problem C. Size and location of erythematous area

Which component should the nurse anticipate will be prescribed for a patient is not responding to crystalloids for volume expansion? A. Platelets B. Albumin C. Fresh frozen plasma D. Packed red blood cells

B. Albumin

Which nursing action is appropriate when conducting an hourly rounding when providing care to older adult patients? A. Obtaining patient vital signs B. Assisting the patient to the bathroom C. Accounting for all personal items in the patient's room D. Documenting the amount of intake for the last meal eaten by the patient

B. Assisting the patient to the bathroom

The nurse is providing care to an older adult patient with terminal cancer who has opted to discontinue treatment and go home. The patient's family, however, wants to continue treatment. The nurse agrees to be present while the patient tells the family. Which ethical patient principle is the nurse supporting? A. Beneficence B. Autonomy C. Nonmaleficence D. Justice

B. Autonomy

The home care nurse is planning care for a diabetic patient requiring an extensive dressing change twice a day, assistance with activities of daily living (ADLs), and comprehensive education. Which role is the nurse assuming by coordinating the care this patient requires? A. Collaborator B. Case manager C. Health educator D. Health promoter

B. Case manager

Which intervention(s) is (are) critical during intravenous lipid administration? (Select all that apply.) A. Assessing glucose levels B. Changing the tubing every 24 hours C. Holding lipids when administering antibiotics through the same line D. Monitoring triglyceride levels E. Maintaining elevation of the head of the bed

B. Changing the tubing every 24 hours D. Monitoring triglyceride levels

Which should be the focus of an educational session for nurses and other members of the interdisciplinary team when addressing high rates of patient readmission to the health system? A. Medication errors B. Coordination of care C. Adverse clinical events D. Roles of each member providing care

B. Coordination of care

The nurse is providing care to an older adult patient who is diagnosed with osteoporosis. Which age-related cause should the nurse include in the teaching session? A. Decreased speed of foot movements B. Decreased absorption of vitamin D C. Increased intramuscular fat D. Increased subcutaneous fat

B. Decreased absorption of vitamin D

Which is a basic principle of the Patient Protection and Affordable Care Act of 2010 that the nurse should include in a teaching session for members of the health-care team? A. Decreased access B. Decreased cost of care C. Decreased quality of care D. Decreased safety

B. Decreased cost of care

An older adult patient, who appears intermittently confused, is admitted to the hospital after a fall. Based on the current data, which is the patient at an increased risk for developing? A. Brain attack B. Dehydration C. Hemorrhage D. Kidney damage

B. Dehydration

The nurse is providing care to a patient who seeks emergency treatment for headache and nausea. The patient works in a mill without air conditioning. The patient states, "I drink water several times each day but I seem to sweat more than I am able to replace." Which suggestions should the nurse provide to this patient? A. Drink juices and carbonated sodas. B. Eat something salty when drinking water. C. Eat something sweet when drinking water. D. Double the amount of water being ingested.

B. Eat something salty when drinking water.

What are the risks of total parenteral nutrition? (Select all that apply.) A. Diarrhea B. Elevated blood sugar C. Infection at the catheter site D. Volume overload E. Aspiration

B. Elevated blood sugar C. Infection at the catheter site D. Volume overload

In evaluating a patient's nutrition, the nurse would monitor which blood test as the most sensitive indicator of protein synthesis and catabolism? A. Albumin B. BUN C. Prealbumin D. Triglycerides

C. Prealbumin

The nurse is providing care to a patient whose serum calcium levels have increased since a surgical procedure performed three days prior. Which intervention should the nurse implement to decrease the risk for the development of hypercalcemia? A. Monitor vital signs every eight hours B. Encourage ambulation three times a day C. Irrigate the Foley catheter one time a day D. Recommend turning, coughing, and deep breathing every two hours

B. Encourage ambulation three times a day

A patient with acute renal failure has jugular vein distention, lower extremity edema, and elevated blood pressure. Based on this data, which nursing diagnosis is the most appropriate? A. Risk for Infection B. Excess Fluid Volume C. Ineffective Renal Tissue Perfusion D. Risk for Altered Cardiac Perfusion

B. Excess Fluid Volume

A patient is having complications from abdominal surgery and remains NPO. Because enteral tube feedings are not possible, the decision is to initiate parenteral feedings. What are the major complications for this therapy? A. Aspiration pneumonia and sepsis B. Fluid and electrolyte imbalances and sepsis C. Fluid overload and pulmonary edema D. Hypoglycemia and renal insufficiency

B. Fluid and electrolyte imbalances and sepsis

The nurse is providing care to an older adult patient who is receiving intravenous (IV) fluids at 150 mL/hr. The patient is currently exhibiting crackles in the lungs, shortness of breath, and jugular vein distention. Which complication of IV fluid therapy does the nurse suspect the patient is experiencing? A. Speed shock B. Fluid volume excess C. Anaphylactic reaction D. Pulmonary embolism

B. Fluid volume excess

The nurse is reviewing laboratory values for a female patient suspected of having a fluid imbalance. Which laboratory value evaluated by the nurse supports the diagnosis of dehydration? A. Hematocrit 30% B. Hematocrit 53% C. Serum potassium 3.8 mEq/L D. Serum osmolality 230 mOsm/kg

B. Hematocrit 53%

A patient with a history of emphysema, diabetes, and hyperlipidemia is in the critical care unit on a ventilator. The nutrition assessment notes that the patient has a protein and vitamin deficiency and is underweight. Which formula for nutritional assessment is most appropriate? A. Renal specific formula B. Higher protein formula C. High medium-chain triglyceride formula D. Lactose-free formula

B. Higher protein formula

Which electrolyte imbalance should the nurse monitor an older adult patient for due to impaired renal diluting capacity and concentrating ability? A. Hypokalemia B. Hyponatremia C. Hypocalcemia D. Hypomagnesemia

B. Hyponatremia

How does malnutrition contributes to infection risk? A. Hampering normal gastrointestinal motility B. Impairing immune function C. Increasing blood glucose D. Increasing drug interactions

B. Impairing immune function

The nurse is providing care to an older adult patient who is diagnosed with congestive heart failure (CHF). When educating the patient about this disorder, which age-related cardiovascular change should the nurse include? A. Stiffened artery walls B. Increased size of the left atrium C. Reduced number of pacemaker cells in the SA node D. Decreased cardiac responsiveness to beta-adrenergic stimuli

B. Increased size of the left atrium

A patient with acute pancreatitis is started on parenteral nutrition. The student nurse listed possible interventions for this patient. Which intervention needs correction before finalizing the plan of care? A. Change the intravenous tubing every 24 hours. B. Infuse antibiotics through the intravenous line. C. Monitor the blood glucose every 6 hours. D. Monitor the fluid and electrolyte balance.

B. Infuse antibiotics through the intravenous line.

The correct order of actions for a patient starting enteral nutrition with a feeding tube is: (Put a comma and space between each answer choice.) A. Initiate tube feeding B. Insert feeding tube C. Flush tube to verify patency D. Obtain chest radiograph E. Assess residuals

B. Insert feeding tube D. Obtain chest radiograph C. Flush tube to verify patency A. Initiate tube feeding E. Assess residuals

A patient's serum sodium level is 150 mg/dL. Based on this data, which interventions should the nurse plan for this patient? Select all that apply. A. Elevate the head of the bed. B. Instruct on a low-sodium diet. C. Monitor heart rate and rhythm. D. Administer diuretics as prescribed. E. Administer potassium supplement as prescribed.

B. Instruct on a low-sodium diet. D. Administer diuretics as prescribed.

The Chief Nursing Officer and Chief Medical Officer in an urban teaching hospital are leading a series of meetings with nurses, physicians, hospital lawyers, and risk managers to review and update hospital privileging procedures and requirements for advanced practice RNs and physicians new to the hospital. This is an example of which type of collaborative team? A. Intradisciplinary B. Interdisciplinary C. Multidisciplinary D. Complementary

B. Interdisciplinary

Which traditional Chinese medical treatment includes the application of heat from different sources to various points which allows medicine to be absorbed through the skin? A. Cupping B. Moxibustion C. Acupuncture D. Skin pinching

B. Moxibustion

Which patient population should the nurse focus on to increase access to care that is coordinated, safe, and focused on the patient's unique needs across all care settings? A. Pediatric patients B. Older adult patients C. Young adult patients D. Acute needs patients

B. Older adult patients

Which treatment program should the nurse include in the plan of care for a homeless client whose Type 1 diabetes mellitus (DM) requires daily insulin injections? A. Home health care B. Outpatient clinic C. Partial hospitalization D. Inpatient hospital-based care

B. Outpatient clinic

The nurse is providing care to a client who is considered brain dead. The family has opted to end care and the health-care provider asks the nurse to pull the endotracheal (ET) tube. The nurse is uncomfortable with this request. Which is the reason the nurse is experiencing difficulty with this task? A. An ethical conflict B. Personal values C. Legal issues D. A cultural conflict

B. Personal values

When removing a patient's central line dressing, which action by the nurse is the priority? A. Applying sterile gloves B. Inspecting the insertion site for signs of infection C. Pulling the tape off in the direction of the catheter D. Pressing the catheter into the skin while removing the tape

C. Pulling the tape off in the direction of the catheter

The school nurse is preparing a class session for high school students on ways to maintain fluid balance during the summer months. Which interventions should the nurse recommend Select all that apply. A. Drink diet soda. B. Reduce the intake of coffee and tea. C. Drink more fluids during hot weather. D. Drink flat cola or ginger ale if vomiting. E. Exercise during the hours of 10 am and 2 pm.

B. Reduce the intake of coffee and tea. C. Drink more fluids during hot weather. D. Drink flat cola or ginger ale if vomiting.

The nurse is caring for a patient who is reporting pain of 8/10 on a 1 to 10 numeric pain scale. The nurse administers the prescribed pain medication. When the nurse re-evaluates the patient one hour later, the patient is still reporting pain of 8/10. Which action by the nurse is appropriate at this time? A. Wait for the health-care provider to make rounds to report the problem. B. Report to the health-care provider by telephone. C. Increase the dosage of the medication. D. Include in the nursing report that the medication is ineffective.

B. Report to the health-care provider by telephone.

The nurse adds a medication to an intravenous (IV) fluid container to be hung on the patient's existing IV line. Which is the first action the nurse takes after adding the medication to the container? A. Connect the bag to the tubing. B. Rotate the bag to distribute the medication. C. Place a completed medication-added label to the bag. D. Connect the bag to new tubing and flush the air from the tubing.

B. Rotate the bag to distribute the medication.

Which senescence term should the nurse for a patient who is diagnosed with narrowing of the coronary arteries? A. Atrophy B. Stenosis C. Sclerosis D. Calcification

B. Stenosis

A patient with Type 1 diabetes mellitus has developed an open sore on the shin and is having trouble meeting daily goals for exercising. The patient is scheduled for discharge in a couple of days. When planning for this patient's continued care, who will the nurse notify regarding the patient's needs after discharge? A. The pharmacy B. The case manager C. The physical therapist D. The occupational therapist

B. The case manager

Which statement is a primary and historical barrier to effective nurse physician collaboration that has persisted over time? A. The view among the general population that nurses' contributions to patients' care is less important to their health and well-being compared to the contribution of physicians B. The nurses' and physicians' perceptions of inequity in their roles, with nurses assuming a subservient role and physicians assuming leadership and superior role in health-care settings C. A general lack of education provided in schools for health professionals about the benefits on health-care quality linked D. A lack of published evidence about the effectiveness of collaborative efforts among and between nurses and physicians to nurse-physician collaboration

B. The nurses' and physicians' perceptions of inequity in their roles, with nurses assuming a subservient role and physicians assuming leadership and superior role in health-care settings

Handoff communication, the transfer of information during transitions in care such as during change-of-shift report, includes an opportunity to ask questions, clarify, and confirm the information between sender and receiver. Which is the main objective for ensuring effective communication during a patient handoff? A. To avoid lawsuits B. To ensure patient safety C. To facilitate quality improvement D. To make sure all documentation is done

B. To ensure patient safety

A school-age patient is admitted to the pediatric intensive care unit (PICU), unconscious and with multiple traumatic injuries, after a skateboard accident that included a closed head injury. Many health professionals are involved in the patient's care and the scene is chaotic. The parents are extremely anxious and want to know what is happening. The case manager asks for an interdisciplinary team meeting to speak with the patient's parents. Which is the rationale for this meeting? A. To allow for each specialty to practice independently B. To share and evaluate information for care planning and implementation, and prevent priority conflicts, redundancy, and omissions in care C. To all the primary health-care provider to make all the decision regarding the patient's care D. To prevent the parents from trying to change the plan of care

B. To share and evaluate information for care planning and implementation, and prevent priority conflicts, redundancy, and omissions in care

The nurse working in the emergency department (ED) is caring for a patient who experienced deep-thickness burns over 40% of the body and is in shock. Which intravenous (IV) prescription does the nurse anticipate for this patient? A. Nutrient solutions B. Volume expanders C. Electrolyte solutions D. Total parenteral nutrition

B. Volume expanders

The nurse is teaching a group of children and their parents about the prevention of heat-related illness during exercise. Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the teaching session? A. "My child only needs to hydrate at the end of an exercise session." B. "Water is the drink of choice to replenish fluids that are lost during exercise." C. "I will have my child stop every 15-20 minutes during the activity for fluids." D. "It is important for my child to wear dark clothing while exercising in the heat."

C. "I will have my child stop every 15-20 minutes during the activity for fluids."

The nurse is providing care to an older adult patient who has decided to discontinue the prescribed hemodialysis. The patient's family, however, is not supportive of this decision. When using the theory of principles-based reasoning, which statement from the nurse is appropriate? A. "The patient understands the decision and the advanced stage of the disease. If the patient quits treatment, the patient will die." B. "I need to try to help the family understand the patient's decision so they can work through this situation together." C. "This patient is of sound mind and is capable of making independent decisions regarding health care. It really is the patient's decision to make." D. "This patient's health is so deteriorated that the treatment is not saving the patient's life. It is prolonging the ultimate outcome, which is death."

C. "This patient is of sound mind and is capable of making independent decisions regarding health care. It really is the patient's decision to make."

Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypotonic solution? A. 0.9% normal saline B. 5% dextrose in water C. 0.33% sodium chloride D. 5% dextrose in Lactated ringers

C. 0.33% sodium chloride

Which traditional Chinese medical treatment includes the insertion of needles into precise points along the channel system of flow of the qi? A. Cupping B. Moxibustion C. Acupuncture D. Skin pinching

C. Acupuncture

The nurse is caring for several pediatric patients with numerous cultural backgrounds. Which patients would the nurse anticipate will be discouraged to express themselves? Select all that apply. A. An Appalachian adolescent B. A British school-age child C. An Arab school-age child D. An Asian-Indian adolescent E. A Japanese pre-adolescent

C. An Arab school-age child D. An Asian-Indian adolescent E. A Japanese pre-adolescent

The nurse is initiating intravenous (IV) therapy for an adult patient who requires IV fluid infusion for 2-3 days and might require blood administration. Which would the nurse choose as the best option for IV catheterization? A. Butterfly B. Huber needle C. Angiocatheter D. Implantable venous access device

C. Angiocatheter

The nurse is setting up an intravenous (IV) infusion on an electronic infusion pump for a patient recently admitted to the unit. After leaving the room, the pump alarms and reads high pressure. Which is the priority action by the nurse? A. Resetting the pump to resume infusion B. Asking the patient if the pump has been tampered with in any way C. Assessing the IV site and the tubing for kinks or closed roller clamps D. Discontinuing the patient's IV access and restarting in a different area

C. Assessing the IV site and the tubing for kinks or closed roller clamps

The nurse is providing care to a patient who is prescribed furosemide as part of the treatment for congestive heart failure (CHF). The patient's serum potassium level is 3.4 mEq/L. Which food should the nurse encourage the patient to eat based on this data? A. Peas B. Iced tea C. Bananas D. Baked fish

C. Bananas

A patient is diagnosed with a sexually transmitted infections (STI) and states to the nurse, "Promise you will not tell anyone about my condition." Which action should the nurse take, when considering the Health Insurance Portability and Accountability Act (HIPAA) of 1996? A. Honor the patient's wishes B. Respect the patient's privacy and confidentiality. C. Communicate only necessary information. D. Not disclosing any information to anyone.

C. Communicate only necessary information.

Which nursing action is appropriate when conducting a cultural assessment for a patient? A. Stereotyping concepts related to the patient's culture B. Evaluating the concepts in isolation from one another C. Determining how each aspect of the patient's culture interacts D. Assuming that the patient believes all aspects of information related to the identified culture

C. Determining how each aspect of the patient's culture interacts

A patient is being fed through a nasogastric tube placed in the stomach. The nurse would carry out which intervention to minimize aspiration risk? A. Add blue dye to the formula. B. Assess the residual every hour. C. Elevate the head of the bed 30 degrees. D. Provide feedings via continuous infusion.

C. Elevate the head of the bed 30 degrees.

The nurse is providing care to a pregnant patient with a history of drug use. The patient refuses testing for human immunodeficiency virus (HIV) despite the recommendation of her nurse-midwife. Which actions by the nurse are appropriate in this situation? Select all that apply. A. Refusing to treat the patient unless she is tested B. Running the test without the patient's knowledge C. Emphasizing the importance of the test to the patient D. Offering counseling regarding the testing E. Encouraging the patient to reconsider the decision to be tested throughout the pregnancy

C. Emphasizing the importance of the test to the patient D. Offering counseling regarding the testing E. Encouraging the patient to reconsider the decision to be tested throughout the pregnancy

Which intervention should the nurse implement for a patient whose serum phosphorus level is 2.0 mg/dL? A. Enforce contact precautions B. Strain all urine for kidney stones C. Encourage consumption of milk and yogurt D. Discourage the consumption of a high-calorie diet

C. Encourage consumption of milk and yogurt

Which component should the nurse anticipate will be prescribed for a patient with an elevated prothrombin time (PT) and international normalized ratio (INR) who is at an increased risk for bleeding? A. Platelets B. Albumin C. Fresh frozen plasma D. Packed red blood cells

C. Fresh frozen plasma

A patient is admitted to the emergency department (ED) for fluid volume deficit. Which body system should the nurse focus to determine the cause of this imbalance when assessing this patient? A. Genitourinary B. Cardiovascular C. Gastrointestinal D. Musculoskeletal

C. Gastrointestinal

A Vietnamese patient with a history of joint and muscle pain presents with large ecchymosis on the hips and legs. Which traditional Vietnamese medical treatment should the nurse inquire about when conducing the assessment? A. Cao gio B. Be bao or bar gio C. Giac D. Xong

C. Giac

The nurse is providing care to an older adult patient who is diagnosed with an ulcer. Which age-related gastrointestinal change is often the cause for this diagnosis? A. Slowed gastric emptying B. Atrophied gastric mucosa C. Increased secretion of gastrin D. Reduced secretion of intrinsic factor

C. Increased secretion of gastrin

The nurse is providing care to a patient who is exhibiting clinical manifestations of a fluid and electrolyte deficit. Based on this data, which health-care provider prescriptions does the nurse prepare to implement? Select all that apply. A. Administer diuretics B. Administer antibiotics C. Initiate hypodermoclysis D. Closely monitor patient's I&O's E. Initiate intravenous therapy

C. Initiate hypodermoclysis D. Closely monitor patient's I&O's E. Initiate intravenous therapy

The case manager assembles a team of health-care professionals, including the patient's primary health-care provider, physical therapist, and social worker, for the purpose of collaborative discharge planning and decision making. Which type of team did the case manager assemble? Select all that apply. A. Management B. Intradisciplinary C. Interdisciplinary D. Interprofessional E. Primary nursing care

C. Interdisciplinary D. Interprofessional

Which action is appropriate when dealing with an ethical dilemma in practice? A. Relying on nursing judgment B. Examining all conflicts in the situation C. Investigating all aspects of the situation D. Making a decision based on the policy of the agency

C. Investigating all aspects of the situation

The nurse is caring for a patient who is to have a peripherally inserted central catheter (PICC) line inserted tomorrow afternoon. The patient's current peripheral access line is infiltrated, and needs to be restarted. Which site would the nurse avoid using? A. Radial vein B. Cephalic vein C. Median cubital vein D. Dorsal metacarpal veins

C. Median cubital vein

The nurse is providing care to a patient who is diagnosed with multisystem fluid volume deficit. The patient is currently experiencing tachycardia and decreased urine output along with skin that is pale and cool to the touch. The patient has a decreased urine output. Which probable cause to the patient's symptoms should the nurse include when educating the family? A. Congestive heart failure B. Rapidly infused intravenous fluids C. Natural compensatory mechanisms D. Pharmacological effects of a diuretic

C. Natural compensatory mechanisms

A patient has been admitted to the critical care unit after a stroke. After "failing" a swallow study, the patient is placed on enteral feedings. Following placement of a nasogastric tube for tube feeding, what is the next critical step? A. Administer medications. B. Cap off and wait 24 hours before starting feedings. C. Obtain a chest radiograph. D. Start the tube feeding.

C. Obtain a chest radiograph.

The nurse is caring for a Chinese patient who is one day postoperative for abdominal surgery. The patient's nonverbal cues indicate pain, but the patient denies the need for pain medication. Which action by the nurse is appropriate? A. Seeking out a family member to convince the patient to take the medication B. Consulting the health-care provider about administering medication without the patient's knowledge C. Offering the medication again stating that providing comfort is a priority D. Allowing the patient to suffer in silence

C. Offering the medication again stating that providing comfort is a priority

The nurse is providing care to an older adult patient who is experiencing bradycardia. When educating the patient about this disorder, which age-related cardiovascular change should the nurse include? A. Stiffened artery walls B. Increased size of the left atrium C. Reduced number of pacemaker cells in the SA node D. Decreased cardiac responsiveness to beta-adrenergic stimuli

C. Reduced number of pacemaker cells in the SA node

Which aspect of intravenous (IV) therapy could the nurse safely delegate to the unlicensed assistive personnel (UAP)? A. Changing the IV site dressing on the patient's left hand B. Watching the IV insertion site of the patient who complained of pain at the site C. Reporting patient's complaints of pain or leakage from the IV site when bathing the patient D. Replacing patient's IV solution when bag runs dry if it is only D5W, without medications added

C. Reporting patient's complaints of pain or leakage from the IV site when bathing the patient

Which senescence term should the nurse use to describe the hardening of tissue due to fibrous tissue overgrowth that occurs with the aging process? A. Atrophy B. Stenosis C. Sclerosis D. Calcification

C. Sclerosis

The nurse is providing care to a patient who states, "My doctor is refusing to treat me because I am noncompliant with his recommendations." Which is the priority nursing action in this situation? A. Have the patient contact a consumer agency. B. Advise the patient to sue the health-care provider. C. Take the patient's issue to the hospital ethics committee. D. Notify the health-care provider of the patient's complaints.

C. Take the patient's issue to the hospital ethics committee.

Which should the nurse be aware of when preparing to act as a patient advocate in the hospital setting? Select all that apply. A. The rights of a patient in a long-term care facility B. The health department's patient rights statement C. The hospital's patient rights statement D. State and federal patient rights legislation E. The unit policy manual

C. The hospital's patient rights statement D. State and federal patient rights legislation

A patient's feeding tube has been successfully placed in the small intestine with continuous flow tube feeding. The nurse knows that this approach was chosen because of what physiological process? A. Intermittent feedings cause increased nausea and vomiting. B. The increased filling of the stomach increases absorption. C. The intestinal mucosa normally receives nutrients from the stomach in peristaltic waves. D. This will prevent malabsorption syndrome.

C. The intestinal mucosa normally receives nutrients from the stomach in peristaltic waves.

The nurse is providing care to a 3-year-old child whose parents decide to decline further treatment for cancer, which has metastasized. There is a conflict between the child's parents and the rest of the family. Which should the nurse consider when determining the appropriate action for this patient? A. The age of the child B. The beliefs of the child C. The values of the parents D. The values of the rest of the family

C. The values of the parents

The nurse is analyzing the intake and output record for a patient being treated for dehydration. The patient weighs 176 lbs. and had a 24-hour intake of 2,000 mL and urine output of 1,200 mL. Based on this data, which conclusion by the nurse is the most appropriate? A. Treatment has not been effective. B. Treatment needs to include a diuretic. C. Treatment is effective and should continue. D. Treatment has been effective and should end.

C. Treatment is effective and should continue.

The nurse educates the older adult patient to increase activity, lose weight, and limit dietary intake of fats and calories. Which disease process is the patient at risk for based on the teaching? A. Fecal impaction B. Diabetes insipidus C. Type 2 diabetes mellitus (DM) D. Gastroesophageal reflux disorder (GERD)

C. Type 2 diabetes mellitus (DM)

The nurse is providing care to a Muslim patient who presents to the emergency department (ED) with abdominal pain and vaginal bleeding. The patient's spouse asks that only a female examines the patient. Which is the most culturally appropriate statement by the nurse in response to this request? A. "Your spouse will be covered so it will not matter what the gender of the examiner is." B. "The male and female providers here both respect privacy." C. "Your request is unreasonable and cannot be honored at this time." D. "Every attempt will be made to honor your request regarding the care of your spouse."

D. "Every attempt will be made to honor your request regarding the care of your spouse."

The nurse is caring for a patient who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this patient is at risk for fluid volume excess. The family asks why the patient is at risk for this condition. Which response by the nurse is the most appropriate? A. "Fluid volume excess is caused by inactivity." B. "Fluid volume excess is caused by the intravenous fluids." C. "Fluid volume excess is caused by new onset liver failure caused by the surgery." D. "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery."

D. "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery."

The nurse is discussing follow-up care with a patient who is being discharged. The patient and family cross their arms and state angrily that the team's suggestions are not acceptable. Which response by the nurse is appropriate? A. "We only want what's best for you." B. "We will leave you alone to discuss your options." C. "Perhaps you did not understand the recommendations." D. "Let's discuss other options that might work well for you and your family."

D. "Let's discuss other options that might work well for you and your family."

A patient who is recovering from coronary bypass surgery is placed on a critical pathway for extended care. Which patient statement indicates appropriate understanding of the plan of care? A. "I cannot alter the critical pathway plan." B. "I must be able to meet goals that are set for me." C. "My insurance plan can deny payment if I do not meet goals." D. "The chosen critical pathway can be altered to meet my needs."

D. "The chosen critical pathway can be altered to meet my needs."

The nurse is caring for a patient with a potassium level of 5.9 mEq/L. The health-care provider prescribes both glucose and insulin for the patient. The patient's spouse asks, "Why is insulin needed?" Which response by the nurse is the most appropriate? A. "The insulin will help his kidneys excrete the extra potassium." B. "The insulin is safer than other medications that can lower potassium levels." C. "The insulin lowers his blood sugar levels and this is how the extra potassium is excreted." D. "The insulin will cause his extra potassium to move into his cells, which will lower potassium in the blood."

D. "The insulin will cause his extra potassium to move into his cells, which will lower potassium in the blood."

The novice nurse working in an inner-city hospital that serves a diverse patient population states, "I want to learn everything possible about all of the patients." Which response by the seasoned nurse is appropriate? A. "I will give you a great book that describes all of the critical factors." B. "You should always be nonjudgmental." C. "This will come with time as you get to know clients and then encounter problems." D. "You need to first understand who you are."

D. "You need to first understand who you are."

A patient is admitted to the emergency department (ED) for dehydration. The patient is 154 lbs. Which urine output indicate the rehydration efforts for this patient have been effective? A. 20 mL/hr B. 25 mL/hr C. 30 mL/hr D. 35 mL/hr

D. 35 mL/hr

The nurse is assessing the older adult patient using the Get-Up-and-Go test. The patient is unable to stand without assistance. Which score should the nurse document? A. 0 B. 1 C. 3 D. 4

D. 4

Which intravenous (IV) fluid should the nurse prepare when a patient requires a hypertonic solution? A. 0.9% normal saline B. 2.5% dextrose in water C. 0.33% sodium chloride D. 5% dextrose in Lactated ringers

D. 5% dextrose in Lactated ringers

Which senescence term should the nurse use to describe deposits of calcium salt in the blood vessels that often occurs with aging? A. Atrophy B. Stenosis C. Sclerosis D. Calcification

D. Calcification

A nurse is working as the designated leader of a group of health-care providers in a community clinic setting. The team members are working to decrease the number of adolescent pregnancies in the community. They have defined the problem and are now focusing on objectives and considering various viewpoints presented by the group. The nurse is tasked with helping the team to stay focused in order to address the defined problem. Which competency of collaboration does this describe? A. Trust B. Mutual respect C. Communication D. Decision making

D. Decision making

The nurse is providing care to an older adult patient who is diagnosed with atrial fibrillation. When educating the patient about this disorder, which age-related cardiovascular change should the nurse include? A. Stiffened artery walls B. Increased size of the left atrium C. Reduced number of pacemaker cells in the SA node D. Decreased cardiac responsiveness to beta-adrenergic stimuli

D. Decreased cardiac responsiveness to beta-adrenergic stimuli

When preparing an in-service for staff nurses regarding health disparity, which definition should the nurse include in the presentation? A. Factors that help explain why some people experience poorer health than others. B. Describes the health of a person or community along with the many measures that contribute to this health. C. Achieved when every person has the opportunity to attain his or her health potential and no one is disadvantaged. D. Differences in the incidence, prevalence, mortality rate, and burden of diseases that exist among specific populations.

D. Differences in the incidence, prevalence, mortality rate, and burden of diseases that exist among specific populations.

The nurse is preparing a patient for discharge who will be requiring physical therapy (PT) to rehabilitate after a total knee replacement. After reading the health-care provider's order for PT, which would be the nurse's initial action? A. Teach the family the exercises needed for the patient. B. Call home health and schedule a therapist to visit the home for therapy. C. Set up appointments according to the order with the hospital PT department. D. Discuss the various types of settings for therapy and have the patient choose the venue.

D. Discuss the various types of settings for therapy and have the patient choose the venue

A male nurse enters the room of a female patient to obtain the patient's vital signs. The patient's spouse appears uncomfortable with the nurse and moves closer to the patient. Which action by the nurse is most appropriate? A. Ask a female staff member to obtain the patient's vital signs. B. Ask the spouse to leave the patient's room to obtain the vital signs. C. Perform the intervention without discussion with the patient or spouse. D. Explain the procedure to both the patient and the spouse.

D. Explain the procedure to both the patient and the spouse.

Which ethical principle requires the nurse to be accountable for commitments made to self or others? A. Beneficence B. Autonomy C. Justice D. Fidelity

D. Fidelity

The nurse is providing care to an adult patient admitted with dehydration and hyponatremia. Which medical condition supports the current nursing diagnosis of Electrolyte Imbalance? A. Osmotic pressure B. Hydrostatic pressure C. Isotonic dehydration D. Hypotonic dehydration

D. Hypotonic dehydration

The patient's case manager, diabetes educator, and dietician meet to discuss the patient's needs in preparation for discharge to home. The patient's primary health-care provider arrives and states, "I will be making all decisions regarding the patient's discharge care." With the primary health-care provider's decision to lead the team, the dynamic has shifted between which two types of teams? A. Intradisciplinary to interdisciplinary team B. Multidisciplinary to intradisciplinary team C. Interprofessional to interdisciplinary team D. Interdisciplinary to multidisciplinary team

D. Interdisciplinary to multidisciplinary team

A patient is prescribed 20 mEq of potassium chloride due to excessive vomiting. Which is the rationale for this drug the nurse should provide to the patient? A. It controls and regulates water balance in the body. B. It is used in the body to synthesize ingested protein. C. It is vital in regulating muscle contraction and relaxation. D. It is needed to maintain skeletal, cardiac, and neuromuscular activity.

D. It is needed to maintain skeletal, cardiac, and neuromuscular activity.

Which component should the nurse anticipate will be prescribed for a patient with acute blood loss? A. Platelets B. Albumin C. Fresh frozen plasma D. Packed red blood cells

D. Packed red blood cells

A patient is receiving enteral tube feedings and has developed drug-nutrient interactions. The nurse recognizes which drug as having the potential for causing drug-nutrient reactions? A. Aspirin B. Enoxaparin C. Ibuprofen D. Phenytoin

D. Phenytoin

The nurse is planning care for the patient with acute renal failure. The nurse plans the patient's care based on the nursing diagnosis of Excess Fluid Volume. Which assessment data supports this nursing diagnosis? A. Wheezing in the lungs B. Generalized weakness C. Bowel sounds positive in four quadrants D. Pitting edema in the lower extremities

D. Pitting edema in the lower extremities

The nurse is caring for a patient with rheumatoid arthritis who expresses the desire to remain active as long as possible. In order for the patient to meet this goal, what should the nurse prepare to do? A. Tell the patient there is no hope. B. Ask the patient the reason for the decision. C. Teach the patient nutrition and joint exercises. D. Refer the patient to the appropriate professionals.

D. Refer the patient to the appropriate professionals.

The nurse is caring for a patient with a medical diagnosis of increased intracranial pressure (ICP). Which intravenous (IV) fluid order would the nurse accept without questioning? A. Run normal saline at 125 mL/hour. B. Run half-normal saline at 200 mL/hour. C. Run 5% dextrose in water at 80 mL/hour. D. Run 5% dextrose in 0.45% NaCl at 75 mL/hour.

D. Run 5% dextrose in 0.45% NaCl at 75 mL/hour.

Which traditional Vietnamese medical treatment is used to treat a headache or sore throat? A. Cupping B. Moxibustion C. Acupuncture D. Skin pinching

D. Skin pinching

Which clinical manifestation does the nurse anticipate when providing care to an older adult patient diagnosed with failure to thrive (FTT)? A. An increased appetite B. A high cholesterol level C. A weight loss of five pounds D. Skin that loses elasticity with poor turgor

D. Skin that loses elasticity with poor turgor

Which professional value is the nurse demonstrating by volunteering time to work in a local free clinic? A. Human dignity B. Integrity C. Altruism D. Social justice

D. Social justice

The nurse is administering a blood transfusion to an adult patient. The patient reports feeling cold and is shivering 15 minutes after the initiation of the transfusion. The patient's blood pressure has decreased since the last assessment. Which is the nurse's priority action? A. Notify the health-care provider. B. Monitor the blood pressure every five minutes. C. Stop the blood infusion, and run the normal saline on the other side of the Y tubing. D. Stop the blood infusion, and remove the tubing from the IV catheter, replacing it with normal saline.

D. Stop the blood infusion, and remove the tubing from the IV catheter, replacing it with normal saline.

The patient is to start total parenteral nutrition (TPN). The nurse knows to prepare which site for catheter insertion? A. Basilic vein B. Femoral artery C. Radial artery D. Subclavian vein

D. Subclavian vein

Which acculturation behavior will the nurse observe in a patient who has emigrated from Mexico to the United States? A. The client buys all needed products from the local store owned by people from Mexico. B. The client lives in a neighborhood that is populated predominantly with people from Mexico. C. The client speaks Spanish only. D. The client attends a church service in the neighboring community to meet new people.

D. The client attends a church service in the neighboring community to meet new people.

The nurse is preparing to document care provided to the patient during the day shift. The nurse documents that the patient experienced an increased pain level while ambulating which required an extra dose of pain medication; took a shower; visited with family; and ate a small lunch. Which information is important to include during the oral end-of-shift reporting? Select all that apply. A. The last antibiotics given B. The patient's taking a shower C. The patient's visit with family D. The extra dose of pain medication E. The patient's response to ambulation

D. The extra dose of pain medication E. The patient's response to ambulation

The nurse is providing care to a patient diagnosed with end-stage renal disease. When planning a care plan conference for this patient, who does the nurse invite to participate? A. The oncologist B. The psychiatrist C. The hospital CEO D. The family members

D. The family members

The nurse is providing care to an older adult patient who is scheduled for surgery. During the preoperative assessment, the nurse discovers that the patient does not have an adequate understanding of the procedure. Which is the reason for the nurse to take action in this situation? A. The patient is very old and has multiple health problems. B. The family needs to agree to the surgery. C. The nurse witnessed the consent. D. The patient has a right to informed consent.

D. The patient has a right to informed consent.

A patient is being ventilated and has been started on enteral feedings with a nasogastric small- bore feeding tube. What is the primary reason the nurse must frequently assess tube placement? A. To assess for paralytic ileus B. To maintain the patency of the feeding tube C. To monitor for skin breakdown on the nose D. To prevent aspiration of the feedings

D. To prevent aspiration of the feedings

The case manager interviews an older adult patient hospitalized after hip replacement surgery. The patient requires in-patient rehabilitation prior to being discharged home. The case manager works with the hospital nursing staff, the rehabilitation center, the patient's family members, and other care providers to assist with a smooth transition. Which is the primary goal of the care management model described here? A. To provide greater peace of mind for the patient and his or her family members B. To track a patient's progress to ensure that appropriate care is provided until discharge C. To manage concerns that are related to the patient's medical care and treatment regimen only D. To provide a continuum of clinical services in order to help contain costs and improve patient outcomes

D. To provide a continuum of clinical services in order to help contain costs and improve patient outcomes

During a sexual history the patient states, "I have always felt like a man trapped in a woman's body." Which conclusion about the patient is potentially accurate? A. Bisexuality B. Heterosexuality C. Homosexuality D. Transgender

D. Transgender

A patient who is receiving continuous enteral feedings has just vomited 250 mL of milky green fluid. What is the most likely cause of the vomiting? A. A bowel obstruction B. Developed an ileus C. Gastrointestinal bleeding D. Tube feeding intolerance

D. Tube feeding intolerance

Which health-care practices are anticipated when providing care to an Alaskan Native patient? Select all that apply. A. Traditional practices as the first line of defense B. Self-medicating with over-the-counter drugs C. Use of liberal pain medication D. Use of medications ordered from other countries E. Mental health issues hold a stigma and are hidden

D. Use of medications ordered from other countries E. Mental health issues hold a stigma and are hidden

Which patient population should the nurse plan care based on collectivistic cultural attributes? A. British B. Swedish C. Norwegian D. Vietnamese

D. Vietnamese

Which data collected by the nurse during the assessment process places the older adult patient at risk for dehydration? A. Poor skin turgor B. Body mass index of 20.5 C. Blood pressure of 140/98 mmHg D. Water intake of 2 glasses per day

D. Water intake of 2 glasses per day

What objective data is used to determine whether nutrition goals are not being met? A. Hyperglycemia, normovolemia, and increased protein level B. Overhydration, hypoglycemia, and weight gain C. Weight gain, inconsistent glucose, and normovolemia D. Weight loss, elevated glucose, and dehydration

D. Weight loss, elevated glucose, and dehydration

Which classification should the nurse use when providing care to an adult patient who is 70 years of age? A. Old B. Old-old C. Oldest old D. Young-old

D. Young-old