week 2 book questions
A nurse is caring for a patient with type 2 diabetes who has an infected foot ulcer requiring dressing changes. Which nursing action best demonstrates the QSEN competency of patient-centered care? a)Asking the patient if they would like their spouse to be present for a teaching session b)Researching new procedures to care for foot ulcers when developing a care plan for this patient c)Leading a grand rounds or unit-based discussion on complications of diabetes d)Using the electronic medical record to review trends of the patient's blood glucose levels
a
An oncology nurse is analyzing a patient's strengths and finds the patient is well educated, learns quickly, and is resilient. In which phase of the nursing process will the nurse use this information? a)Diagnosing b)Evaluating c)Planning d)Implementing
a
The nursing assessment of a patient with a diagnosis of anorexia nervosa reveals the patient consumes a vegan diet of 700 calories daily and has lost 30 lb in 4 months. The nurse's recommendation to meet with a nutritionist is the outcome of which process? a)Clinical judgment b)Nursing process c)Clinical reasoning d)Critical thinking
a
Nursing students enrolled in a leadership and management course discuss the roles of the nurse manager during post conference. What roles should the students include in the discussion? Select all that apply. a)Developing and overseeing a unit budget for staff and patient care b)Hiring, evaluating, and promoting staff growth c)Performing patient care d)Developing treatment plans to improve care and patient outcomes e)Handling escalating situations between caregivers and patients
a,b,e
During orientation to the critical care unit, a nurse learns that staff follow existing clinical practice guidelines, also called standards, for patient care. Which activities does the nurse expect to be included in these guidelines? Select all that apply. a)Monitoring vital signs and pulse oximetry every hour b)Using intuition to troubleshoot patient problems c)Repositioning a patient on bed rest every 2 hours d)Becoming a nurse mentor to a student nurse e)Administering pain medication prescribed by the health care provider f)Becoming involved in community nursing events
a,c,e
A nurse is developing a clinical outcome for a patient who is an avid runner and is recovering from a stroke resulting in right-sided paresis. Which clinical outcome is most appropriate to include in the care plan? a)After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. b)By 8/15/25, patient will be able to use right arm to dress, comb hair, and feed herself. c)Following physical therapy, patient will begin to gradually participate in walking/running events. d)By 8/15/25, patient will verbalize feeling sufficiently prepared to participate in running events.
b
A nurse manager who is working to institute the SBAR communication process for all health care providers is meeting resistance to the change. How does the manager best approach the resistance? a)Containing the anxiety in a small group and moving forward with the initiative b)Explaining the change and listing the advantages to the person and the organization c)Reprimanding those who oppose the new initiative and praising those who willingly accept the change d)Quickly introducing the change and involving staff in implementation of the change
b
A nurse notices a patient crying after meeting with the health care provider. Prior to formulating a health problem of difficulty coping, the nurse seeks to further support the problem by gathering which data? a)Abnormal vital signs b)Underlying cause of the tears c)Admitting diagnosis d)Patient's support system
b
A nursing student is actively working toward strengthening their leadership skills. What action will best assist the student to meet this goal? a)Being self-reliant in solving problems b)Being self-directed and asking for assistance when needed c)Using written communication instead of face-to-face communication d)Reporting nurses who do not follow policies to the nurse manager
b
During an assessment, the nurse on a neurologic unit finds the patient confused to time and place but able to state their name. How will the nurse best record this in the electronic health record? a)Is more confused than yesterday b)States the year is 1975 and they are at a wedding c)Disoriented to person, time, and place d)Patient's speech is garbled
b
Nurses use the Nursing Interventions Classification (NIC) Taxonomy structure as a resource to plan nursing care for patients. What information is found in this structure? a)Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions b)Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings c)Complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention d)Complete list of reimbursable charges for each nursing intervention
b
The nurse manager of a unit with an excellent safety record meets with staff to present the findings of a recent audit. The manager states, "We're doing well, but I believe we can do better. Who's got an idea to foster increased patient well-being and satisfaction?" This leader has demonstrated they value which process? a)Quality assurance b)Quality improvement c)Process evaluation d)Outcome evaluation
b
To plan the day, a nurse is prioritizing patient diagnoses according to Maslow's hierarchy of human needs. What patient problem will the nurse address first? a)Altered body image perception b)Impaired gas exchange c)Grief d)Situational low self-esteem
b
A nurse has performed an admission assessment on a patient. What step does the nurse perform after clustering the data? a)Developing interventions b)Nursing judgments c)Diagnosing and analyzing d)Concept mapping
c
A nurse in the emergency department is assessing a young adult who has cognitive disability and is reporting severe abdominal pain. The patient is accompanied by the director of the group home where they live. When collecting data from this patient, which action reflects best practice? a)Ask the assessment questions of the director. b)Wait for the young adult's parents to arrive before performing the assessment. c)Ask the young adult questions and validate with the adult present. d)Perform the physical assessment, then the intake interview when the family arrives.
c
A nurse is caring for a patient recovering from a stroke that paralyzed the dominant arm. The nursing assistant reports that the patient was unable to bathe, comb their hair, or brush their teeth. Which health problem should the nurse add to the care plan? a)Lack of motivation to complete self-care activities b)Risk for: Activities of Daily Living Deficit c)ADL deficit: impaired dressing and grooming d)Impaired musculoskeletal system function: paralysis
c
A nurse is writing nursing outcomes in the affective domain for a patient who is trying to stop smoking. Which outcome statement will the nurse include in the care plan? a)"The patient will state the relationship between smoking and coronary artery disease." b)"After the teaching session, the patient will redemonstrate the proper application of a nicotine patch." c)"The patient will state they value a healthy body sufficiently to stop smoking prior to discharge." d)"The patient will state that any changes in cough should be reported to the health care provider"
c
A nursing student is assigned to the emergency department (ED) to shadow the triage nurse. What activity will the student expect to perform? a)Acute and emergency interventions b)Daily care and assistance with ADLs c)Assessment and prioritization of care d)Care planning for return to home
c
An RN on a telemetry unit is falling behind while performing assessments and administering medications. Which task can the nurse safely delegate to the AP? a)Assessing a patient who has just arrived on the unit b)Teaching a patient with newly diagnosed diabetes about foot care c)Documenting a patient's I & O in the electronic health record d)Helping a postoperative patient out of bed for the first time
c
Nurses on a hospital unit work to improve staff communication, as outlined in The Joint Commission's National Patient Safety Goals. What process will best provide for continuity of the plan of care? a)Checking two patient identifiers, such as name and date of birth, prior to administering medications b)Ensuring two nurses check doses of high-risk medications such as anticoagulants or insulin c)Giving handoff report in the patients' rooms to update the next nurse on the plan of care d)Obtain a patient sitter for a confused individual who has fallen trying to get out of bed
c
The care plan for a patient just diagnosed with diabetes contains the expected outcome: "the patient will correctly measure the insulin dose and self-administer the injection, using correct technique by 12/12/24." The nurse observes the client fumbled with the syringe and drew up less insulin than prescribed. What action will the nurse take first? a)Document that the plan of care was unsuccessful b)State continuation of the care plan is indicated c)Assess the patient's vision and dexterity and revise the plan d)Designate a family member to administer the insulin
c
A charge nurse on the step-down unit will likely use which leadership style during resuscitation efforts for a cardiac arrest? a)Democratic b)Laissez-faire c)Servant d)Autocratic
d
A nurse working in a long-term care facility reviews the electronic health records of patients who have fallen in the last month to determine if there is a common risk factor. Which QSEN competency is the nurse demonstrating? a)Patient-centered care b)Evidence-based practice c)Teamwork and collaboration d)Informatics
d
A nursery nurse notifies the nurse practitioner (NP) that a newborn has signs of jaundice. The NP performs a brief skin assessment, then orders a blood test for bilirubin levels. Which type of assessment has the NP performed? a)Comprehensive b)Initial c)Time-lapsed d)Quick priority
d
A nursing student is prioritizing interventions for a patient with diabetes who needs diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. The patient states, "I must have my hair washed before I can do anything else; I'm ashamed of the way I look." How will the student best prioritize this patient's care? a)Explain to the patient that there is not enough time to wash their hair today because of the busy schedule b)Schedule the testing and meal planning first and complete hygiene as time permits c)Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last d)Wash the patient's hair and perform hygiene, schedule testing and counseling, then change the dressing
d
A university student works with the student health nurse to develop a weight loss plan that includes increasing activity and avoiding empty calories. At the next session, the student has lost 1 lb instead of the projected 5 lb. What action will the nurse take next? a)Congratulate the student and continue the care plan b)Terminate the care plan since it is not working c)Give the student more time to reach the targeted outcome d)Modify the plan after discussing possible reasons for partial success
d
During shift report, a nurse says that a patient has no integumentary changes or skin care needs. During assessment, the nurse observes reddened areas over bony prominences. What action will the nurse take? a)Correct the initial assessment form b)Redo the initial assessment and document current findings c)Conduct and document an emergency assessment d)Perform and document a focused assessment of skin integrity
d
Nursing students enrolled in a leadership and management course attend clinical on a surgical unit. As they are planning their day, they note one student has a complex patient with multiple medications and the need for frequent turning, pressure injury wound care, and tube feedings. Which action by the group best reflects effective teamwork and coordination? a)Asking patients to prioritize what they want to accomplish each day b)Including a "nice to do" for every "need to do" task on the list c)"Front loading" their schedules with "must do" priorities d)Scheduling times to assist the student with the complex patient
d
When a nurse enters the patient's room to begin a nursing history, the nurse notes the patient's spouse is present. After greeting them, what action will the nurse take? a)Thank the spouse for being present b)Ask the spouse if they want to remain c)Ask the spouse to leave d)Ask the patient if they would like the spouse to stay
d
A nurse works in a long-term care facility where standing orders are in place for influenza vaccines for all residents. What is the nurse's priority, when carrying out the prescriptions? a)Assessing whether the patient previously received the vaccine b)Refusing to give the vaccine without a written prescription c)Determining if the standing orders are inappropriate for their unit d)Calling the nursing supervisor to determine if this is a permitted action
a
A nurse writes the outcome for a patient who is trying to lose weight: "The patient will explain the relationship between weight loss, increased exercise, and decreased calorie intake." This outcome reflects which domain of learning? a)Cognitive b)Psychomotor c)Affective d)Physical changes
a
A nursing student obtains a blood pressure reading of 148/100. To determine the significance of this reading, what action will the nurse take first? a)Comparing this reading to standards and trends in the medical record b)Checking the taxonomy of nursing diagnoses for a pertinent label c)Checking a medical text for the signs and symptoms of high blood pressure d)Consulting with experienced nurse colleagues
a
A nursing student tells the clinical instructor that their patient is fine and has "no complaints." Which question by the faculty coaches the student to provide evidence that supports their assessments? a)"Could you tell me how you validated this?" b)"Do you think your patient feels free to share their concerns?" c)"That's good to hear. Tell me about the care you provided." d)"Please reassess the patient; they were admitted with a serious problem."
a
A nursing student tells the primary nurse that their patient has not had a bowel movement for 2 days and suggests adding the health problem "Constipation" to the care plan. How would the nurse best respond? a)"Did you assess the patient's usual bowel patterns and appearance of the last stool?" b)"This early diagnosis will help us manage the problem before it becomes severe." c)"Have you determined if this is an actual or a possible diagnosis?" d)"This condition requires a medical diagnosis."
a
A school nurse determines that a student who has lost weight is at risk for an eating disorder and would benefit from a nutritional assessment. What action will the nurse take? a)Perform a focused nutritional assessment b)Seek direction from the student's health care provider c)Suggest the student visit the nurse-run clinic d)Request a consultation with a nutritionist
a
A staff nurse tells a new graduate nurse not to bother studying too hard, since most clinical reasoning becomes second nature and intuitive once they begin practicing. Which response by the student is appropriate? a)Intuitive problem solving comes with years of practice and observation based on nursing knowledge and science. b)For nursing to remain a science, nurses must continue to be vigilant about avoiding intuitive reasoning. c)The emphasis on logical, scientific, evidence-based reasoning has held nursing back; we need intuitive, creative thinkers. d)The nurse's preference dictates whether they are logical, scientific thinkers or intuitive, creative thinkers.
a
A student nurse walks into a patient room, introduces themselves, and begins to complete a full head-to-toe assessment. The clinical faculty member enters the room, introduces themselves, and asks the student to step out of the room for a moment. The student meets the faculty member in the hallway and is asked to identify 15 cues or observations they noted during their initial contact with the patient and the patient's environment. Although the student is unable to reach 15 observations, the faculty guides the student to recognize the linen on the floor, old dinner tray on the windowsill, empty water pitcher, twisted oxygen tubing, the patient's pallor, and several other things requiring action. What is the value of engaging in this kind of activity with students in the clinical setting? a)Developing situational awareness is important to risk prevention, timely implementation of interventions, and prioritizing actions b)Managing cognitive load begins with systematically sorting mental images and immediately addressing pressing concerns c)Nursing best practice requires that an environmental scan be completed and documented in the electronic health record (EHR) d)Designing interventions th
a
Asking the family members to speak to the patient about pain relief A nursing unit has adopted use of a care bundle for insertion of central venous catheters. During the procedure, which action by a nurse requires the charge nurse to intervene? a)They discard the sterile drapes in the insertion kit. b)The primary nurse reminds everyone in the room to wear a mask. c)The team includes every item in the bundle during the procedure. d)The nursing student states using the bundle improves patient outcomes.
a
The charge nurse tells a nursing student to change a surgical dressing while they take care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What action should the student take? a)Tell the charge nurse that they lack the technical competencies to change the dressing independently b)Assemble the equipment for the procedure and follow the steps in the procedure manual c)Ask another student nurse to work collaboratively with them to change the dressing d)Tell the clinical instructor they have not had experience with the delegated task
a
A chief nursing officer with a transformational leadership style is developing a plan for success to obtain Magnet status. What are the most appropriate strategies for the leader to use? Select all that apply. a)Sharing their vision of excellence in patient care and high-level education b)Encouraging nurses to incorporate evidence-based practice through hospital committees and to join nursing organizations c)Promoting compliance by reminding subordinates that they have a good salary and working conditions d)Ensuring employees are kept abreast of new developments in their department and the larger organization e)Writing the Magnet application and supporting documentation with limited input from the nursing staff f)Encouraging nurse managers and nurses to self-schedule as long as proper coverage is maintained
a,b
A nurse is caring for a patient with a painful, non-healing surgical wound. The patient does not request pain medication because they do not want to be a burden. What actions will the nurse implement to improve pain relief? Select all that apply. a)Reestablishing the pain level the patient finds acceptable as the pain management goal b)Obtaining a dry-erase board to remind the patient of the plan of care c)Assessing the patient's pain and offering analgesia during hourly rounding d)Placing the analgesic underneath other medications and quickly handing it to the patient
a,b,c
Nursing programs prepare students for safe clinical practice. As a student nurse, why is a basic understanding of NCSBN's Clinical Judgment Measurement Model (CJMM) important? Select all that apply. a)Successful completion of the NCLEX is required for professional licensure in the United States. b)Nurse educators use the CJMM model and NCLEX test plans to develop exam questions. c)Students should be intimately familiar with theoretical models of education to answer questions. d)Appreciation of the core principles assists students in understanding the structure and intent of nursing exams. e)There is overlap in the core components of clinical judgment models, measurement models, and the nursing process.
a,b,d,e
A nursing student is committed to providing thoughtful, person-centered care. Which nursing actions demonstrate this type of care? Select all that apply. a)Assisting patients to select meals based on their cultural observances b)Providing nursing care based on patients' needs and preferences c)Documenting nursing interventions in the electronic health record d)Reviewing fingerstick blood glucose levels with the primary nurse e)Listening to a patient's concern for their ill significant other
a,b,e
The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which interventions reflect the use of cognitive skills? Select all that apply. a)Monitoring for side effects of medications b)Safely administering an injectable medication c)Teaching a patient about diabetes and its management d)Acting as witness by signing a surgical consent form e)Helping a patient identify their progress in physical therapy f)Comforting a patient who has received bad news
a,c
The nurse assessing a patient plans to use the OLD CARTS mnemonic to organize their questions. What questions will the nurse include in the assessment? Select all that apply. a)"Can you tell me when the problem began"? b)"Where were you sitting when this started?" c)"Have your symptoms stopped and/or started again?" d)"Would you describe your pain as sharp, dull or burning?" e)"What do you believe has caused this problem?"
a,c,d
The nurse collects subjective and objective data during a patient assessment. When documenting, which data points will the nurse include as subjective data? Select all that apply. a)Feeling nauseated b)Edematous ankles c)Feeling anxious about test results d)Report of left arm tingling e)Pain rated 7 on a scale of 1 to 10 f)Oral temperature of 101°F
a,c,d,e
A nurse is attempting to improve care on the pediatric unit of a hospital. Which improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. a)Basing patient care on continuous healing relationships b)Customizing care to reflect the competencies of the staff c)Using evidence-based decision making d)Having a charge nurse as the source of control e)Using safety as a system priority f)Recognizing the need for secrecy to protect patient privacy
a,c,e
Nurses on an oncology unit plan to adopt use of critical pathways for patients receiving chemotherapy. What positive features of this system will the nurses anticipate? Select all that apply. a)Accessible computerized practice standards, easily individualized for patients b)Binary decision tree for stepwise assessment and intervention c)Ability to measures the cause-and-effect relationship between pathway and patient outcomes d)Research-based practice recommendations that may or may not have been tested in clinical practice e)Preprinted provider prescriptions, using standards validated through research, to streamline care f)Outcomes with suggested time frames for achievement
a,c,f
A nurse is caring for a group of patients. Which actions are appropriate to include in the implementation phase of care? Select all that apply. a)Changing the dressings on a burn victim's arm b)Assessing a patient's nutritional intake c)Formulating a nursing diagnosis for a patient with epilepsy d)Turning a patient in bed every 2 hours to prevent pressure injuries e)Checking a patient's insurance coverage at the initial interview f)Determining availability of community resources for a patient with dementia
a,d,f
A nurse who is considered a servant leader is working in an economically depressed community setting up a free mobile health clinic. Which actions best exemplify a servant leader? Select all that apply. a)Motivating coworkers to solicit funding to set up the clinic b)Setting only realistic goals that are present oriented and easily achieved c)Forming an autocratic governing body to keep the project on track d)Spending time with supporters to help them grow in their roles e)Ensuring that other's lowest priority needs are served f)Prizing leadership because of the need to serve others
a,d,f
The nurse is admitting a pregnant patient to the hospital for treatment of pregnancy-induced hypertension. The patient asks the nurse, "Why are you doing a history and physical exam when the doctor just did one?" What statements will the nurse use to explain the primary purpose of the nursing assessment? Select all that apply. a)"The nursing assessment will allow us to plan and deliver individualized, holistic nursing care that draws on your strengths." b)"It's hospital policy. I know we ask a lot of questions, but I will try to make this quick." c)"As a nursing student, I need to develop assessment skills about your health status and need for nursing care." d)"This validates that your responses with the medical exam are consistent and that all our data are accurate." e)"I will check your health status and see what kind of nursing care you may need." f)"This is to determine the necessity for referring your nursing care needs to a health care provider."
a,e,f
A nurse enters the patient's room to perform pin-site care for a patient wearing a halo vest to stabilize the cervical spine. What action will the nurse take first? a)Administer pain medication b)Reassess the patient c)Prepare the equipment d)Explain the procedure to the patient
b
A nurse erroneously administered two tablets of acetaminophen totaling 650 mg to their patient. When reporting this to the nurse manager, the nurse states, "there are two tablets in a package labeled '325 mg. acetaminophen.' The prescription reads 'administer 325 mg of acetaminophen;' therefore, I administered what was in the package." Based on a philosophy of just culture, what should happen next? a)The nurse should be found at fault for not clarifying the order. b)The package labeling should be reviewed with the pharmacy. c)The nurse should be disciplined. d)No follow-up is needed as the medication is over the counter.
b
A nurse is caring for a patient with dehydration who has a prescription to encourage oral fluids. Which outcome statement will best direct nursing interventions? a)Offer patient 60 mL of fluid every 2 hours while awake. b)During the next 24-hour period, patient's fluid intake will total at least 2,000 mL. c)Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/25. d)At the next visit on 12/23/24, patient will know to drink at least 3 L of water per day.
b
A nurse is performing an initial comprehensive assessment of a patient admitted to a long-term care facility. The nurse begins the assessment by asking the patient, "How would you describe your health status and well-being?" and, "What do you do to keep yourself healthy?" These questions reflect what model for organizing data? a)Maslow's hierarchy of needs b)Gordon's functional health patterns c)Human response patterns d)Body system model
b
A nurse is updating the plan of care with nurse-initiated interventions. Which intervention is appropriate to include? a)Administering acetaminophen for a headache b)Offering emotional support to a patient c)Consulting with a physical therapist d)Attending a team meeting for care planning
b
A nurse is writing outcomes for a patient admitted with a cardiac condition causing fluid overload and edema. Which reflects an appropriately worded outcome? a)Offer to elevate the patient's legs on a stool while out of bed b)Patient will restrict fluids to 1,500 mL per 24-hour period c)Monitor the patient's intake and output d)Weigh the patient each morning prior to breakfast
b
A nursing program uses Tanner's Clinical Judgment Model, a research-based model that accounts for differences in the patient, environment, and individual student nurse. What makes Tanner's reflection step unique? a)The emphasis is on noticing, interpreting, and responding; reflection is less important. b)Reflection occurs both in-action (in the moment) and on-action (after the situation). c)Reflection occurs first in the model that is focused on rapid decision making and patient outcomes. d)Reflection is the last step in a linear model and is designed to minimize bias in the student nurse.
b
A nursing student is performing a nursing history for the first time. The student asks the primary nurse how anyone learns all the questions needed to get complete baseline data. What would be the nurse's best reply? a)"There's a lot to learn at first, but once it becomes part of you, you just ask the same questions over and over in each situation until you can do it in your sleep!" b)"You make the basic questions a part of you and apply critical thinking to modify them, to help you plan quality care." c)"It is really hard to learn how to do this well, as each history is different. I often feel like I'm starting fresh with each new patient." d)"Don't worry about learning all of the questions to ask. Every facility has its own assessment form you must use."
b
A nursing student on the surgical unit is assigned to perform a review of systems using the head-to-toe format on a patient admitted for a fractured femur. Using this format, what system will the student assess first? a)Genitourinary b)Neurologic c)Respiratory d)Musculoskeletal
b
A visiting nurse is following up with a patient who was given a prescription for a diuretic and told to chart her weight daily. The patient's weight has increased 5 lb since the nurse's last visit. What actions will the nurse take first? a)Explain to the patient that it is clear she is not adhering to her prescription and the health care provider will be notified b)Document the 5-lb weight gain and ask the patient about sodium intake and medication side effects c)Terminate the plan of care while determining the cause for the weight gain d)Encourage the patient to continue the prescription and return in 1 week
b
After assessing a patient recovering from a stroke in a rehabilitation facility, the nurse's initial analysis suggests a potential health problem of situational low self-esteem. How will the nurse record the problem when they believe more data are needed? a)No problem b)Possible problem c)Actual nursing diagnosis d)Clinical problem other than nursing
b
As part of a hospital-wide quality-assurance program, an electronic medical record review for the last 6 months reveals a higher incidence of falls on a specific unit. The nurse authoring the study refers to the review as what type of evaluation? a)Quality by inspection b)Retrospective evaluation c)Concurrent study d)Quality by indicator
b
During a change-of-shift report, a nurse receives information that a patient admitted with hypertensive emergency has prescriptions for antihypertensive medications given at 8 AM and due at 8 PM. During the 8:00 PM assessment, the patient's blood pressure is 90/60, and they report slight dizziness upon standing. After returning the patient to bed, what action will the nurse take? Exhibit: Electronic health record, vital signs 8:00 AM 182/100 12:00 PM 168/98 4:00 PM 160/88 a)Record the BP in the electronic health record b)Notify the health care provider c)Administer the 8:00 PM medications d)Place the patient flat in bed
b
Nurses note that allowing patients to choose the time of their breakfast to improve patient satisfaction has resulted in medication delays for patients who have prescriptions for medications taken on an empty stomach. Which action will direct the nurses to the best outcome? a)Asking the pharmacy to dispense the medication at bedtime b)Suggesting a quality improvement project piloting a 6:00 AM administration c)Requesting that the health care provider prescribe the medication for midnight d)Telling the nurse manager that patients are getting their medications late n
b
The nurses at an acute care hospital participate in a committee focused on achieving Magnet status. Which action do the nurses suggest to help achieve this goal? a)Centralizing the decision-making and scheduling process b)Promoting self-governance at the unit level c)Deterring professional autonomy to promote teamwork d)Promoting evidence-based practice over innovative nursing practice
b
The nursing philosophy in an acute care hospital includes a commitment to deliver thoughtful, person-centered care. Which description of the nursing process best supports this commitment? a)Systematic b)Interpersonal c)Dynamic d)Universally applicable in nursing situations
b
When caring for a patient who sustained a spinal cord injury, the nurse formulates the health problem: Impaired Tissue Integrity Etiology: sensory and motor deficit Signs and symptoms: difficulty turning, reddened areas on heels and sacrum Which phrase gives direction to the underlying cause of the problem? a)Impaired Tissue Integrity b)Sensory and motor deficit c)Signs and symptoms d)Reddened areas of skin on the heels and back
b
When developing the admission care plan for a patient with multiple sclerosis and quadriplegia, the nurse formulates the patient problem: Impaired Tissue Integrity: Impaired Skin Integrity. What action will the nurse take next? a)Elevate the patient's heels off the bed using a pillow b)Develop a goal that the patient will consume protein at each meal c)Delegate assessment of the skin on the patient's back to the AP d)Teach the patient to turn themselves in bed every hour
b
A nurse is planning care for a patient admitted to the hospital for treatment of a drug overdose. What actions will the nurse take during the outcome identification and planning step of the nursing process? Select all that apply. a)Formulating nursing diagnoses b)Identifying expected patient outcomes c)Selecting evidence-based nursing interventions d)Explaining the nursing care plan to the patient e)Assessing the patient's mental status f)Evaluating the patient's outcome achievement
b,c,d
Identifying community resources to help the family cope A nurse is caring for a patient who presents with dyspnea, tachypnea, productive cough, fever, and low oxygen saturation. When developing the nursing care plan, which health problems might the nurse identify for this patient? Select all that apply. a)Bronchial pneumonia b)Impaired gas exchange c)Impaired Respiratory System Function d)Altered breathing pattern e)Impaired Thermoregulation
b,c,d,e
A nurse uses critical-thinking skills to develop the care plan for an older adult with dementia awaiting placement in a long-term care facility. Which statements describe characteristics of the critical thinking used by nurses engaged in clinical reasoning? Select all that apply. a)Functions independently of nursing standards, ethics, and state practice acts b)Based on the principles of the nursing process, problem solving, and the scientific method c)Driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care d)Avoids designs to compensate for problems created by human nature, such as medication errors e)Constantly reevaluating, self-correcting, and striving for improvement f)Focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care
b,c,e
An RN working on a hospital unit frequently delegates patient care to assistive personnel (AP). Which activities are appropriate for the nurse to safely delegate? Select all that apply. a)Performing patient assessments b)Making patient beds c)Giving patients bed baths d)Administering oral medications e)Ambulating patients f)Assisting patients with meals
b,c,e,f
A nurse on a mother-baby unit engages in informal planning while providing ongoing nursing care. What actions are included in this type of planning? Select all that apply. a)Sitting down with a patient and prioritizing existing diagnoses b)Assessing a woman for postpartum depression during patient education c)Planning interventions for a patient with a risk for bleeding d)Taking time to speak with a new mother who just received bad news e)Reassessing a patient who reports their pain medication is not working f)Coordinating home care for a patient being discharged later today
b,d,e
A registered nurse is formulating nursing diagnoses for a patient with multiple fractures. Which actions does the nurse take during this step of the nursing process? Select all that apply. a)Conducting a nursing interview to collect patient data b)Analyzing data collected in the nursing assessment c)Developing a care plan for the patient d)Pointing out the patient's strengths e)Assessing the patient's mental status
b,d,f
A nurse manager is planning to update a health care provider's office from paper to electronic health records (EHR) by using the eight-step process for planned change. Place the following actions in the order in which they should be initiated: a)The nurse devises a plan to switch to EHR. b)The nurse records the time spent on written records versus EHR. c)The nurse attains approval from management for new computers. d)The nurse analyzes all options for converting to EHR. e)The nurse installs new computers and provides an in-service for the staff. f)The nurse explores possible barriers to changing to EHR. g)The nurse follows up with the staff to check compliance with the new system. h)The nurse evaluates the effects of changing to EHR.
b,f,d,c,a,e,h,g
A nurse develops a care plan for an adolescent patient who gave birth to a premature infant. When presented with the collaborative care plan, including home health care visits, the patient states, "We will be fine on our own. I don't need any more care." What is the nurse's best response? a)"You know your personal situation better than I do; I will respect your wishes." b)"If you don't accept these services, your baby's health will suffer." c)"Let's take a look at the plan again and see if we can adjust it to fit your needs." d)"I'm going to assign your case to a social worker who can explain the services better."
c
A nursing student is presenting their concept map care plan for a patient with sickle cell anemia in post-conference. How does the student best describe the "concepts" that are being diagrammed in the plan? a)Protocols for treating the patient's medical problem b)Evidence-based treatment guidelines c)Synthesis of the patient's problems and treatment d)Clinical pathways reflecting evidence-based treatment for sickle cell anemia
c
A patient who is receiving cancer chemotherapy tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm stopping treatment." Which nursing action best promotes a patient-centered, therapeutic relationship? a)Determining if the patient database is adequate to address the problem b)Considering whether to suggest a counseling session for the patient c)Reassessing the patient and determining how to best support them d)Identifying possible interventions and critiquing the merit of each option
c
Nursing students and those studying other health sciences (medicine, pharmacy, physical therapy, etc.) are often engaged in competency-based education. What is the value of competency-based education? a)It provides comprehensive skills checklists for students to check their progress and move on to other elements. b)It allows for student individualization based on their unique experience and preferences. c)It provides specific guidance on the expected level of performance that integrates knowledge, skills, abilities, and judgment. d)Like most other education models, it is a high-level way of thinking that is not related to clinical judgment.
c
The development of clinical judgment requires intentional focus and a willingness to grow and change both personally and professionally. How can a nursing student best foster the development of clinical judgment? a)Engaging in learning that only appeals to their preferred learning style b)Focusing on knowledge acquisition that is straightforward and clear c)Developing a model for learning that integrates feedback and reflection d)Focusing inward to develop emotional intelligence and communication skills
c
The nurse is formulating a care plan for a patient in a long-term care facility who has lost 12 lb in the last 2 months. To arrive at a patient-centered nursing judgment, what will the nurse do first? a)Ensure the patient is receiving foods they like, including favorites. b)Make sure the patient's dentures are clean and inserted at mealtimes. c)Assess the patient's food intake and hydration over the last 1 to 3 days. d)Request that the nursing assistant feed the client at mealtime.
c
The nurse notes a temperature of 102°F in a patient scheduled for surgery in 30 minutes. As the patient has been afebrile and asymptomatic until now, what action will the nurse take next? a)Inform the charge nurse b)Notify the surgeon c)Reassess the temperature d)Document the finding in the electronic health record
c
The nurse on a medical-surgical unit attends a class on the seven crucial conversations in health care. After observing a colleague administer an incorrect dose of medication without reporting it, which action will the nurse take? a)Speak to the nurse privately and tell her if she does not complete an event report, you will report her to the unit manager b)Tell the nurse you overheard her discussing giving too much medication, and she must complete an event report or you will c)Explain that you are aware of the medication incident, and you can assist her in notifying the health care provider for patient safety d)Give the nurse a copy of the handout from the class and explain that this class in crucial conversations was very helpful
c
When implementing a thoughtful, patient-centered care plan, which action does the nurse prioritize? a)The patient's loved ones are considered part of the team. b)A caring relationship with mutual trust is established. c)Measures for safety are visibly incorporated. d)Transparent communication is observed.
c
A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which reflect these types of actions? Select all that apply. a)Administering an antibiotic to a patient with pneumonia b)Consulting with a psychiatrist for a patient who misuses opiates c)Checking the skin of bedridden patients for skin breakdown d)Ordering a kosher meal for an orthodox Jewish patient e)Recording a patient's intake and output f)Preparing a patient for surgery according to facility protocol
c,d,f
A new graduate nurse phones the surgeon to report their patient is having severe incisional pain. The surgeon asks about vital signs and appearance of the wound, causing the nurse to return to the bedside for additional assessments. Upon reflection with the preceptor, which characteristic of the nursing process should the nurse have remembered? a)Centric b)Dynamic c)Interpersonal d)Systematic
d
A nurse in the psychiatric clinic is developing a problem list for a patient. What statement best reflects a correctly written, two-part problem? a)Difficulty Coping: Impaired Family Coping Etiology: inability to maintain marriage b)Difficulty Coping: Impaired Acceptance of Health Status Etiology: anger management issues c)Impaired Cognition: Distorted Thought Process Etiology: psychosis as evidence by hallucinations d)Impaired Cognition: Decisional Conflict Etiology: placement of parent in a long-term care facility
d
A nurse is asked to act as a mentor to a new nurse. What action will the mentor expect to perform? a)Accepting payment to introduce the new nurse to their responsibilities b)Hiring the new nurse and assigning duties related to the position c)Enabling the new nurse to participate in professional organizations d)Advising and assisting the new nurse to adjust to the work environment of a busy emergency department
d
A nurse is caring for a patient who had abdominal surgery yesterday. The nurse observes the patient guarding the area with hands and a pillow, refusing to move, and grimacing. What information does the nurse use to formulate the health problem statement? a)Symptoms b)Diagnostic statement c)Etiology d)Cue
d
A nurse is caring for a patient who has been admitted the second time this month for hypertensive emergency. The care plan contains the health problem: Nonadherence Etiology: lack of knowledge of purpose of medications Signs and symptoms: BP, 220/112; readmitted for hypertensive crisis after 2 weeks When meeting the patient, which action will the nurse take first? a)Teach the patient that nonadherence may lead to stroke and heart disease b)Discuss what will motivate the patient to adhere to the medication regimen c)Explain that these medications are essential to their health and illness prevention d)Determine the patient's knowledge about the medications and their side effects
d
A nurse is caring for a patient who refuses to look at or care for a new colostomy. The patient states, "I don't care what I look like anymore. I'm not washing up, let alone touching or changing this bag!" The nurse formulates the health problem: Difficulty Coping: Impaired Acceptance of Health Status, reflecting which type of health problem? a)Collaborative b)Interdisciplinary c)Medical d)Nursing
d
A nurse is developing a problem list for a care plan. Which reflects a correctly written three-part problem statement? Select all that apply. a)Difficulty Coping: Impaired Family Coping: Etiology: lack of knowledge about tube feeding Signs and symptoms: child needing tube feeding discharged to home b)Impaired Nutritional Status: Impaired Nutritional Intake Etiology: striving for perfect weight, wishes to excel in gymnastics Signs and symptoms: 20-lb weight loss in 1 month c)Need to learn how to care for child on ventilator at home Etiology: discharge of child after 3-month hospital stay Signs and symptoms: repeated comments, "I know I'll harm her because I'm not a nurse." and "I can't do medical things." d)Impaired Spiritual Status Etiology: inability to accept diagnosis of terminal illness Signs and symptoms: comments such as, "I don't deserve this"; "I've tried to live my life well"; and "How could God make me suffer this way?" e)Impaired Tissue Integrity: Impaired Skin Integrity Etiology: failure of home health aides to turn patient every 2 hours Signs and symptoms: stage 3 pressure wound on sacrum.
d
A nurse is developing outcomes in the affective domain for a patient with a foot ulcer related to diabetes. Which outcome best addresses this domain? a)Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to foot ulcer after discharge. b)By 6/12/25, the patient will correctly demonstrate application of wet-to-dry dressing on the foot ulcer. c)By 6/19/25, the patient's pressure ulcer will decrease in size from 3 to 2.5 inches. d)By 6/12/25, the patient will verbalize they value their health sufficiently to control diabetes and prevent recurrence of diabetic ulcers.
d
A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is most correctly written? a)"Outcome met." b)"1/21/25—Patient reports no change in diet." c)"Outcome not met. Patient reports no change in diet or activity level." d)"1/21/25—Outcome met. Cholesterol level has decreased 10 mg."
d
After observing conflicts between nurses about scheduling, a nurse manager compliments the nurses for achieving the monthly goal of no patient falls. What strategy for conflict resolution did the manager display? a)Collaborating b)Competing c)Compromising d)Smoothing
d
After reviewing the admission SBAR and plan of care, the nurse begins to evaluate patient outcomes. Which statement reflects a clear evaluation of the patient's primary problem? Electronic health record (EHR) 8:00 AM Admission note S. Patient with profound wheezing, tachycardia, and anxiety B. Patient has history of asthma, for which she regularly uses inhalers and carries a rescue inhaler A. Pulse oximetry 89%, cyanosis of lips, dyspnea with increased work of breathing R. Admit to telemetry unit, add IV corticosteroids and mini-nebulizer treatments a)The patient states they were terrified when they were fighting to breathe and the wheezing would not stop. b)The nurse determines the patient's strengths include adherence to their medication regimen. c)The care plan includes the health problem of impaired gas exchange, etiology, bronchospasm. d)At 10:00 AM, no wheezing on auscultation, pulse oximetry is 94%, the patient reports no anxiety; the outcome has been met.
d
The nurse is assigned to care for a group of patients. Which patient will the nurse assess first? a)Postoperative patient reporting pain 4/10 b)Individual with pneumonia whose WBCs are now 7,000 c)Adolescent with a burn to the face who is going home tomorrow d)Patient's pulse oximetry reading 89%, as reported by AP
d
A nurse is using the classic elements of evaluation when caring for patients. Place the steps of evaluation in the proper order they are carried out. a)Interpreting and summarizing findings b)Collecting data to determine whether evaluative criteria and standards are met c)Documenting your judgment d)Terminating, continuing, or modifying the plan e)Identifying evaluative criteria and standards (i.e., expected patient outcomes)
e,b,a,c,d
