Basics
Category: The Nursing Process A client has the following ABGs: -pH: 7.30 -PaO2: 89 mmHg -PaCO2: 50 mmHg -HCO3: 26 mEq/L Based on these values, the nurse should suspect which condition? A) respiratory acidosis B) respiratory alkalosis C) metabolic acidosis D) metabolic alkalosis
Correct Answer: A Reason: an acidic pH value and a high partial pressure of PaCO2 is associated with respiratory acidosis Key Strategy: respiratory alkalosis include a pH above normal and a PaCO2 below normal. metabolic acidosis is a pH and HCO3 below normal. metabolic alkalosis is a pH and HCO3 above normal
Category: The Nursing Process A nurse is caring for a client with a diagnosis of impaired gas exchange. Based upon this nursing diagnosis, which outcome is most appropriate? A) the client maintains a reduced cough effort to lessen fatigue B) the client restricts fluid intake to prevent over-hydration C) the client reduced daily activities to a minimum D) the client has normal breath sounds in all lung fields
Correct Answer: D Reason: interventions around impaired gas exchanged are effective if the patient has normal breath sounds after Key Strategy: impaired gas exchange can be identified if a patient has adventitious breath sounds (either caused by an obstruction, exposure to a chemical/allergy, inflammation, infection) A, reduced cough effort isn't associated with gas being exchanged in the lungs, while coughing can help remove blockages, the outcome is associated with lessening fatigue B, fluids help thin secretions to be able to move them out of the lungs and improve gas exchanges, so its encouraged C, activity should be as tolerated (can help improve impaired gas exchanged, but not the main priority)
Category: Basic Physical Care A client with burns on his groin has developed blisters. As the client is bathing, a few blisters break. The best action for the nurse to take is to: A) remove the raised skin because the blister has already broken B) wash the area with soap and water to disinfect it C) apply a weakened alcohol solution to clean the area D) clean the area with normal saline solution and cover is with a protective dressing
Correct Answer: D Reason: it's best to use a mild solution that doesn't cause skin damage (like a harsh solution, ie soap and alcohol), and to cover the wound with a dressing to prevent introducing bacteria Key Strategy: when cleaning open blisters, its important to prevent introducing infection, and preventing skin/tissue breakdown by using mild solutions A, removing the skin can enlarge the amount of open wound area, which can post a risk for infection B/C, both are hard solutions that can cause tissue damage
Category: The Nursing Process The nurse is serving on the hospital ethics committee which is considering the ethics of a proposal for the nursing staff to search the room of a client diagnosed with substance abuse while he is off the unit without his knowledge. Which of the following should be considered concerning the relationship of ethical and legal standards of behavior? A) ethical standards are generally higher than those required by law B) ethical standards are equal to those required by law C) ethical standards bear no relationship to legal standards for behavior D) ethical standards are irrelevant when the health of a client is at risk
Correct Answer: A Reason: behavior that may be legally accepted can violate ethical standards. Legal and ethical standards are often linked, and ethical standards should never be ignored. Even if the patient's safety is at risk, it is important to abide by ethical standards. *for this questions specifically, it would not be advisable to search the pts room without their permission because its an invasion of their privacy Key Strategy: important to remember that even if an action is legal, its important to act ethically and they always go hand in hand
Category: Basic Physical Care A nurse takes informed consent from a client scheduled for abdominal surgery. Which of the following is the most appropriate principle behind informed consent? A) protects the client's right to self-determination in health care decision-making B) helps the client refuse treatment that he or she does not wish to undergo C) helps the client to make a living will regarding future health care required D) provides the client with in-depth knowledge about the treatment options available
Correct Answer: A Reason: the principle of informed consent is to be able to preserve patient autonomy, by allowing them to make and revoke decisions at any time. informed consent also allows the HCP to educate the client about the treatment, and help them make an educated and shared decision. Key Strategy: B and D are part of what informed consent is, but is not the KEY and most APPROPRIATE principle of informed consent. C is not the right answer because making a living will is not associated with informed consent
Category: The Nursing Process A client is scheduled for surgery under general anesthesia. The night before surgery, the client tells the nurse, "I can't wait to have breakfast tomorrow". Based on this statement, which nursing diagnosis should be the nurse's priority? A) deficient knowledge related to food restrictions associated with anesthesia B) fear related to surgery C) risk for impaired skin integrity related to upcoming surgery D) ineffective coping related to the stress of surgery
Correct Answer: A Reason: the questions states that the pt is unaware that food is not allowed after surgery because general anesthesia can put the pt at risk for aspiration Key Strategy: anesthesia can make your mouth numb and the pt is unable to protect airways from obstruction *all of the other diagnosis are relevant to pre/post op pts, however the question is asking for a dx related to what the pt said
Category: The Nursing Process A nurse is documenting a variance that has occurred during a shift, and this report will be used for quality improvement to identify high-risk patterns and potentially initiate in-service programs. This is an example of which type of report? A) incident report B) nurse's shift report C) transfer report D) telemedicine report
Correct Answer: A Reason: this type of report deals with anything that happens in the shift that is out of the ordinary, or events that have/can cause harm. these are put in place for quality improvement, and identifying risks Key Strategy: know types of reports B, this type of report is to provide continuity of care in between shift change C, this type of report is a summary of a pts conditions/medical history when they have to move from one institution to another D, when providing remote care, this type of report is to give critical information about the pts condition
Category: The Nursing Process A group of nurses has established a focus group and pilot study to examine the potential application of personal data assistants (PDAs) in bedside care. This study is a tangible application of... A) nursing informatics B) electronic medical records C) telemedicine D) computerized documentation
Correct Answer: A Reason: this speciality integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice
Category: The Nursing Process A nurse has received change of shift report and is briefly reviewing the documentations about a client in the client's medical record. A recent entry reads, "client was upset throughout the morning" How could the charting entry be best improved? A) the entry should include clearer descriptions of the client's mood and behavior B) the entry should avoid mentioning cognitive or psychosocial issues C) the entry should list specific reasons that the client was upset D) the entry should specify the subsequent interventions that were performed
Correct Answer: A Reason: when charting, it should be precise, descriptive, and objective. "upset" is to ambiguous to identify why the client is upset Key Strategy: charting should be specific B, these are valid and should be included but only if they are pertinent to the clients reason for why they are upset C, laying out the reasons why someone is upset doesn't specify why the charting is lack in accuracy (although reasons would be helpful in finding out why the pt is upset) D, charting interventions is necessary but doesn't get at why this is a bad descriptor
Category: Basic Physical Care The nurse-manager of a home health facility includes which item in the capital budget. A) salaries and benefits for her staff B) a 1,200 computer upgrade C) office supplies D) client-education materials costing $300
Correct Answer: B Reason: CAPITAL budgets are associated with items that are valued at more than $500. Salaries and benefits are part of the PERSONNEL budget. Office supplies and client education materials are part of the OPERATING budget Key Strategy: know what a capital budget is
Which scenario complies with Health Insurance Portability and Accountability Act of 1996 (HIPPA) regulations? A) two nurses in the cafeteria are discussing a client's condition B) the health care team is discussing a clients care during a formal care conference C) a nurse checks the computer for the laboratory results of a neighbor who has been admitted to another floor D) a nurse talks with her spouse about a client's condition
Correct Answer: B Reason: HIPPA was instated to protect patient privacy, and mandates that pt information should only be shared in relevant discussion, with only the pertinent people necessary. Sharing information in a formal care conference provides continuity of care for the pt and the health care team. Key Strategy: know what HIPPA is, and why this law was made. A, even if nurses are sharing information for continuity of care, they are sharing in a space where the conversation can be overheard C, the nurse is not allowed to snoop through pt records when she isn't caring for them, even if they have a personal relationship D, the nurse is sharing private pt information with her husband, and he is NOT part of the health care team
Category: Basic Physical Care The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is the most appropriate? A) have the client wear eyeglasses at all times B) lightly tape the eyelid shut C) instill artificial tears once every shift D) clean eyelid with a washcloth every shift
Correct Answer: B Reason: a lack of a blink reflex or close can cause the cornea to become irritated and dry, and can cause a cornea abrasion. taping the eye lids will allow the eyes to stay lubricated Key Strategy: remember that the the eye needs constant lubrication A and D, does not prevent dryness and irritation. D might stop the eye from accumulating bacteria, but not dryness. C, can also be perceived right, if it was more frequent. Once every shift if not enough to keep the eyes lubricated.
Category: Basic Physical Care A primiparous woman has recently delivered a term infant. Priority teaching for the patient includes information on: A) sudden infant death syndrome (SIDS) B) breastfeeding C) infant bathing D) infant sleep-wake cycles
Correct Answer: B Reason: breastfeeding is the most immediate action because babies need to eat within the first hour of life, and every 2-3 hours after. Key Strategy: since this is a first time mom, it is important to guide her on the immediate things, like breastfeeding (since there is a time constriction for this). all of the other answers, while important, can be taught before discharge.
Category: The Nursing Process A client complains of severe abdominal pain. To elicit as much information as possible about the pain, the nurse should ask... A) "do you have pain all the time?" B) "can you describe the pain?" C) "where does it hurt the most?" D) "is the pain stabbing like a knife?"
Correct Answer: B Reason: don't assume that you know what the pain is like, rather inquire and ask the pt to describe. open-ended questions encourage the client to describe all aspects of the pain Key Strategy: when asking pts about their condition, its best to ask open-ended questions A, this isn't specific to what the pain feels like C, this is close ended, and while location is important, they won't most likely describe anything else D, this is assuming a pain sensation for the pt (might not be accurate)
Category: Basic Physical Care As a nurse helps a client, the client says "I had trouble sleeping last night." Which action should the nurse take first? A) recommending warm milk or warm shower at bedtime B) gathering more information about the client's sleep problem C) determining whether the client is worried about something D) finding about whether the client is taking medication that may impede sleep
Correct Answer: B Reason: its important to inquire first about the situation and gather information about why the patient is having trouble sleeping, before pursing any other intervention Key Strategy: DON'T assume! if a patient has a complaint, do not intervene right away! there isn't any sufficient information about why the pt has a hard time sleeping, and interventions can't be directed towards the problem and might make it worse A, can't assume that this is what helps them fall asleep C, this would require the nurse asking more information D, if you change meds, without first asking the patient about why he isn't sleeping well, it can disrupt the pts medication regimen
Category: The Nursing Process A parent brings a 5 y/o child to a vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. To determine the current evidence for best practice for scheduling missed vaccinations the nurse should: A) ask the primary care provider B) check the website at the CDC C) read the vaccine manufacturer's insert D) contact the pharmacist
Correct Answer: B Reason: the CDC is responsible for vaccination recommendations for adults and children via the Advisory Committee on Immunization Practices Key Strategy: refer to your resources! this questions is also asking for best practices when it comes to missing vaccinations. the schedule for vaccinations should be on the CDC website A, if the child is missing vaccines, this probably indicates that the child doesn't have a PCP C, this is a time consuming process and can lead to errors. also if you have the internet, giving you information ASAP, why use this method? D, the pharmacist will most likely redirect you to the CDC's website
Category: Basic Physical Care The nurse walks into a client's room to administer the 9AM medication and notices that the client is in an awkward position in bed. What is the nurse's first action? A) ask the client his name B) check the client's name band C) straighten the client's pillow behind his back D) give the client his medication
Correct Answer: C Reason: C is attending to the client's basic care needs, and is necessary to attend to FIRST Key Strategy: although the purpose wasn't to reposition the client, it's important to attend the fact that the patient is probably uncomfortable. also, this awkward position might not be the best position to take their medication A,B, D, are not good options. This is a PRIORITIZATION question, therefore its important to notice what's wrong FIRST, and to fix it if it's important
Category: The Nursing Process A nurse is developing a nursing diagnosis for a client. Which information should she include? A) actions to achieve goals B) expected outcomes C) factors influencing the client's problem D) nursing history
Correct Answer: C Reason: a nursing diagnosis entails the pts health problem and the factors affecting it (ex: "secondary to..."), in addition to signs and symptoms that the pt might be having (ex; "AEB...") Key Strategy: this question is asking what's in a nursing diagnosis (problem, secondary to, AEB) A, this is part of Planning/Intervention B, in ADPIE, this is the last step and not part of the Dx step D, this can be included in the Assessment portion of ADPIE
Category: Basic Physical Care A man of Chinese descent is admitted to the hospital with multiple injuries after a motor vehicle accident. His pain is not under control. The client states, "If I could be with my people, I could receive acupuncture for this pain." The nurse should understand that acupuncture in the Asian culture is based on the theory that it: A) purges evil spirits B) promotes tranquility C) restores the balance of energy D) blocks nerve pathways to the brain
Correct Answer: C Reason: acupuncture is a practice common in Asian cultures, and is thought of to restore energy balance when needles are applied to energy pathways throughout the body Key Strategy: I guess, know what acupuncture is? Another possible answer might have also been B, but even is pain relief can cause tranquility, it is not the goal of acupuncture
Category: The Nursing Process When developing a care plan for a client with a DNR order, a nurse should... A) withhold food and fluids B) discontinue pain medication C) ensure access to spiritual care providers upon the client's request D) always make the DNR client the last prioritization of clients
Correct Answer: C Reason: ensuring that the patient has access to spiritual care to be able to have guidance with dealing with death is important! Key Strategy: its important to remember the emotional effects of death. this can increase anxiety, and its important to provide support. A, this intervention is not acceptable unless it has been identified as an intervention in their living will B, part of comfort care is assuring comfort and this include managing pain with pain medication D, this is a misunderstanding; even people with a DNR order have specific nursing needs and should be prioritized along with other patients
Category: The Nursing Process An 18 y/o high school senior wishes to obtain birth control though her parents' insurance but does not want the information disclosed. The nurse tells the client that under HIPPA, parents... A) have the right to review a minor's medical records until high school graduation B) have the right to review a minor's medical record if they are responsible for the payment C) may not view the medical record but may learn the visit through the insurance bill D) may not view the minor's medical record or the insurance bill
Correct Answer: C Reason: if someone is above 18 y/o, they have the right to medical privacy and their medical records may not be disclosed without their permission. but the parents can find out if an insurance bill is sent to them
Category: Basic Physical Care A physician has ordered penicillin G potassium (Pfizerpen), I.V, for a client with a severe streptococcal infection. A nurse determines that the client may be allergic to penicillin. When considering best practice, what should the nurse's priority intervention be? A) holding the penicillin G potassium and charting that is was held because the client is allergic B) administering the penicillin G potassium and staying alert for any reaction C) holding the penicillin G potassium and notifying the physician that the client may have an allergy to penicillin D) administering the penicillin G potassium but notifying the pharmacist that the client might experience an allergic reaction
Correct Answer: C Reason: its important to hold the medication if there is a SUSPECTED allergy. its better to hold the med and prevent a reaction, rather than cause a life threatening allergic reaction Key Strategy: with meds, its especially important to do a med reconciliation, 6 rights/3 checks, check for allergies! A, this is a good intervention, but its important to let the physician know so he can prescribe a different antibiotic B, best to not administer medication to prevent life threatening reaction D, again don't administer it. also if the pt has a suspected allergy, best to notify physician FIRST, and then pharmacist second to be able to label the pts chart apporpriately
Category: The Nursing Process During the health history interview, which of the following strategies is the most effective for the nurse to use to help clients take an active role in their health care? A) ask clients to complete a questionnaire B) provide clients with written instructions C) ask the clients for their descriptions of events and for their views concerning past medical care D) ask clients if they have any questions
Correct Answer: C Reason: one of the best strategies to help the client feel in control is to ask them about their perspective is on their situation and to let them guide their care. this helps the client feel heard about what they think their condition is like, helps them feel motivated to take over their care Key Strategy: motivational interviewing. this helps the pt feel acknowledge and that your are hearing their concerns, and motivating them about taking responsibility about their care *all of their
Category: The Nursing Process During rounds, a nurse finds that a client with hemiplegia has fallen from the bed because the nursing assistant has failed to raise the side rails after giving a back massage. The nurse assists the client to the bed and assesses for injury. As per agency policies, the nurse fills our an incident report. Which of the following activities should the nurse perform after finishing the incident report? A) attach a copy to the client's report B) highlight the mistake in the client's record C) include the time and date of the incident D) mention the name of the nursing assistant in the clients record
Correct Answer: C Reason: when documenting an incident report, it needs to be specific. include: -date/time -events leading up to it -pts response -full nursing assessment Key Strategy: think about what an incident report is and what is absolutely NECESSARY to include A, for legal issues the nurse shouldn't attach a copy of the report to the pts file B, to prevent litigation, the mistake shouldn't be highlighted in the pts records D, for legal reasons, the name of the NA shouldn't be included
Category: The Nursing Process Which of the following should be included in the plan of care for a client with a surgical wound that requires a wet-to-dry dressing? A) place a dry dressing in the wound B) use Burrow's solution to wet the dressing C) pack the wet dressing tightly into the wound D) cover the wet packing with a sterile dressing
Correct Answer: D Reason: a wet to dry dressing should be able to dry out between dressing changes. the dressing should be moist not dry when applied and when the moist dressing dries, the necrotic tissue will be debrided. Key Strategy: the idea behind a wet-dry dressing is debridement of necrotic tissues A, placing a dry dressing doesn't allow the necrotic tissue to adhere to the dressing B, this solution will irritate the wound C, packing a dressing tightly will cut circulation from the site
Category: The Nursing Process A 57 y/o Hispanic woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do? A) as the client's daughter to serve as an interpreter B) as one of the Hispanic nursing assistants to serve as an interpreter C) use the limited Spanish she remembers from high school along with nonverbal communication D) obtain a trained medical interpreter
Correct Answer: D Reason: getting a trained professional is important in order to ensure safety, accuracy of history of data, and pt confidentiality. the other strategies violates pt confidentiality, and accuracy of interpretation Key Strategy: don't be lazy, just get the interpreter to able to ensure that communication with the pt is accurate. also medical interpreters are aware of the pts right and can assure accuracy and privacy
Category: Basic Physical Care A nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess for a pneumothorax resolution, the nurse can anticipate that the client will require. A) monitoring of arterial oxygen saturation B) ABG studies C) chest auscultation D) a chest x ray
Correct Answer: D Reason: its important to first confirm that the patient has a pneumothorax first, and a chest x ray will reveal if the pt has air in their lungs. Key Strategy: remember that pneumothorax is a COLLAPSED LUNG, due to the air accumulating in the lung that causes pressure that makes the lungs collapsed. A, can decrease SaO2, but within 24 hours it returned to normal. B, can show hypoxemia but is associated with respiratory acidosis and hypercapnia, not pneumothorax C, okay to do and will give you an idea of lung status, but its hard to tell if the chest has expanded sufficiently Basically, its FIRST necessary to be able to get a visual of how much air is in the lungs and confirm the PNEUMOTHORAX
Category: The Nursing Process The nurse is assigning tasks to unlicensed assistive personnel (UAP) for a client with an abdominal hysterectomy on the first postoperative day. Which of the following can NOT be delegated to the UAP? A) taking vital signs B) recording intake/output C) giving perineal care D) assessing incision site
Correct Answer: D Reason: our responsibility as nurses post op is to prevention infection by checking the incision site for s/s and the status of the incision Key Strategy: know your scope of practice A, B, C are all tasks that can be delegated to an UAP
Category: Basic Physical Care Communicating with parents and children about health care has become increasingly significant because: A) consumers of health care cannot keep up with rapid advances in science B) the influence of the media and specialization have increased the complexity of managing health C) nurse educators have recognized the value of communication D) clients are more demanding that their rights be respected
Correct Answer: D Reason: with the growing influence of media, more information is disseminated into the public and can be hard to grasp, explain, or comprehend from parents to their children. Nurses have the opportunity to be able to educate their patients about health concerns and advances. It's also a nurse's responsibility to make sure the patient is aware of all possible opportunities and to clarify misunderstandings Key Strategy: in this questions, its asking why communication about health care has increased more so now, than before. the difference between now and before is technology. therefore, more information about debunking and explaining advanced in medicine is important to ensure health promotion
