Exam 1 (1, 15, 16, 17, 18, 19, and 20)

4 (Provide the basis for the selection of nursing interventions to achieve outcomes for which the nurse is responsible)

20) A nursing diagnosis: 1. Identifies nursing problems 2. Is not changed during the course of a patient's hospitalization 3. Is derived from the physician's history and physical examination 4. Is a statement of a patient response to a health problem that requires nursing intervention

4 (It is the diagnostic label that describes the essence of a patient's response to health conditions.)

21) The first part of the nursing diagnosis statement: 1. May be stated as a medical diagnosis 2. Identifies the cause of the patient problem 3. Identifies appropriate nursing interventions 4. Identifies an actual or potential health problem

4 (It is associated with the patient's actual or potential response to the health problem.)

22) The second part of the nursing diagnosis statement: 1. Is usually stated as a medical diagnosis 2. Identifies the expected outcomes of nursing care 3. Identifies the probable cause of the patient problem 4. Is connected to the first part of the statement with the phrase "related to"

2 (It is the patient's actual or potential response to the health problem.)

23. Which of the following is the correctly stated nursing diagnosis? 1. Needs to be fed related to broken right arm 2. Impaired skin integrity related to fecal incontinence 3. Abnormal breath sounds caused by weak cough reflex 4. Impaired physical mobility related to rheumatoid arthritis

4 (Prompts patients to describe a situation in more than one or two words)

24) The interview technique that is most effective in strengthening the nurse-patient relationship by demonstrating the nurse's willingness to hear the patient's thoughts is: 1. Direct question 2. Problem solving 3. Problem seeking 4. Open-ended question

1 (Some may be focused, and others may be comprehensive.)

25) While obtaining a health history, the nurse asks Mr. Jones if he has noted any change in his activity tolerance. This is an example of which interview technique? 1. Direct question 2. Problem solving 3. Problem seeking 4. Open-ended question

3 (Takes information provided in the patient's story and then more fully describes and identifies specific problem areas)

26) Mr. Davis tells the nurse that he has been experiencing more frequent episodes of indigestion. The nurse asks if the indigestion is associated with meals or a reclining position and asks what relieves the indigestion. This is an example of which interview technique? 1. Direct question 2. Problem solving 3. Problem seeking 4. Open-ended question

2 (An objective behavior or response that you expect a patient to achieve in a short time, usually less than 1 week)

26) The following statement appears on the nursing care plan for an immunosuppressed patient: "The patient will remain free from infection throughout hospitalization." This statement is an example of a (an): 1. Long-term goal 2. Short-term goal 3. Nursing diagnosis 4. Expected outcome

4 (The measurable change in a patient's condition that you expect to occur in response to the nursing care)

27) The following statements appear on a nursing care plan for a patient after a mastectomy: "Incision site approximated; absence of drainage or prolonged erythema at incision site; and patient remains afebrile." These statements are examples of: 1. Long-term goals 2. Short-term goals 3. Nursing diagnosis 4. Expected outcomes

2 (Asking questions about the normal functioning of each system; the changes are usually subjective data perceived by the patient.)

27) The information obtained in a review of systems (ROS) is: 1. Objective 2. Subjective 3. Based on the nurse's perspective 4. Based on physical examination findings

3 (The nurse sets patient-centered goals and expected outcomes and plans nursing interventions.)

28) The planning step of the nursing process includes which of the following activities? 1. Assessing and diagnosing 2. Evaluating goal achievement 3. Setting goals and selecting interventions 4. Performing nursing actions and documenting them

4 (Involves recognizing an issue exists, analyzing information, evaluating information, and making conclusions)

29) Clinical decision making requires the nurse to: 1. Improve a patient's health 2. Standardize care for the patient 3. Follow the health care provider's orders for patient care 4. Establish and weigh criteria in deciding the best choice of therapy for a patient

A (An actual nursing diagnosis describes a response to a health condition that exists in the patient.)

3. Crystal now has established a nursing diagnosis. This is an example of which of the following types of nursing diagnoses? A. Actual nursing diagnosis B. Risk nursing diagnosis C. Wellness nursing diagnosis D. Health promotional nursing diagnosis

4 (The five steps are assessment, diagnosis, planning, interventions, and evaluation.)

30) Which of the following is not one of the five steps of the nursing process? 1. Planning 2. Evaluation 3. Assessment 4. Hypothesis testing

2

A critical care nurse is using a new research-based intervention to correctly position patients who are on ventilators to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which QSEN competency? 1. Patient-centered care 2. Evidence-based practice 3. Teamwork and collaboration 4. Quality improvement

2 (The ANA's works for the improvement of health standards and the availability of health care services for all, fosters high standards of nursing, and promotes development of nurses.)

A group that lobbies at the state and federal levels for advancement of nurses' role, economic interests, and health care is the: 1. State Boards of Nursing 2. American Nurses Association 3. American Hospital Association 4. National Student Nurses Association

Risk for fall

A home health nurse completes a home safety assessment. The data reveal that the patient is 71 years old with bilateral cataracts that are causing blurred vision and sensitivity to bright lights. The patient is recovering from a stroke that has caused left-sided weakness of the leg, with an unsteady gait. When talking with the patient, the nurse learns the patient lives alone and fell in the bathroom 4 months ago. Rooms in the home are in disrepair. The nurse identifies nursing diagnoses of Impaired Vision, Impaired Mobility, and Risk for Fall. Which diagnosis is the nurse's priority?

2, 4, 6, 7

A home health nurse is visiting a 62-year-old Hispanic woman diagnosed with type 2 adult-onset diabetes mellitus following a 2-day stay at a local hospital. The physician ordered home health with placement of the patient on a diabetic protocol for education about diabetes mellitus and a new medication and diet counseling. The patient lives with her 73-year-old husband, who has progressive dementia. Their daughter checks on her parents daily, buys groceries, and helps with home maintenance. The nurse conducts an initial history to gather information about the patient's condition. Which of the following data cues combine to reveal a possible health problem? (Select all that apply.) 1. First time hospitalized 2. Unable to describe diabetes 3. Takes antiinflammatory for arthritis 4. Has limited health literacy 5. Husband is able to perform self-bathing 6. Patient unable to identify food sources on prescribed diet 7. Patient has reduced vision and wears glasses 8. Patient prescribed an oral hypoglycemic drug

3

A nursing student is providing a hand-off report to the RN assuming the patient's care. The nursing student explains, "I ambulated him twice during the shift; he tolerated walking to end of hall and back each time with no shortness of breath. Heart rate was 88 and regular after exercise. The patient said he slept better last night after I closed his door and gave him a chance to have some uninterrupted sleep. I changed the dressing over his intravenous (IV) site and started a new bag of D5½NS." Which intervention is a dependent intervention? 1. Providing hand-off report at change of shift 2. Enhancing the patient's sleep hygiene 3. Administering IV fluids 4. Taking vital signs

2

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment to the abdomen, has liquid stool, and the skin is clean and intact. The student selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? 1. Incorrect clustering of data 2. Wrong diagnosis 3. Condition is a collaborative problem 4. Premature ending assessment

b

If Ming decides to choose a career as a critical care CNS, then his specialty is ID'd by which means a. population b. setting c. disease speciality d. type of care e. type of problem

5

In preparing to collect a nursing history for a patient admitted for elective surgery, which of the following data are part of the review of present illness in the nursing health history? 1. Current medications 2. Patient expectations of planned surgery 3. Review of patient's family support system 4. History of allergies 5. Patient's explanation for what might be the cause of symptoms that require surgery

D (The ANA Standards of Practice describe competent levels of nursing practice. The implementation standard defines that the registered nurse implements the identified plan of care)

Joan gives Mr. Owens his prescribed medications, changes his dressing, and helps him with his bath. Which standard of care is Joan performing? A. Assessment B. Planning C. Diagnosis D. Implementation E. Evaluation

D (Asking for help when uncertain about a problem is an example of responsibility and authority.)

John Walsh is a nursing student who has clinical rotation on the postsurgical unit. His assignment for the day is Rebecca Taylor, a 40-year-old patient who had gastric bypass surgery yesterday. She has been complaining of pain in the incision. John is completing an assessment of Mrs. Taylor and notices that she has a rash that he has never seen before. He reports the rash to the nurse and asks her to assess it with him. What type of critical thinking attitude is John applying? A. Humility B. Thinking independently C. Curiosity D. Responsibility and authority

C (Experience is using what has been gained in practice from one patient and applying it to a new patient.)

John had a patient last week on clinical who had an infiltrated peripheral IV. Why is John now more prepared to observe for problems with Mrs. Taylor's IV? A. Reflection B. Curiosity C. Experience D. Knowledge

B D C A (To ensure a successful phone consultation, perform the following: have all of the necessary information available before making the call; assess the patient yourself before making the call; think through some of the possible solutions to the problem; and summarize the problem.)

Lalani needs to call the county hospital free clinic to arrange an interpreter for Ms. Lam for her mammogram. Rank in order the steps Lalani should take for ensuring a successful phone consultation. A. Summarize the problem. B. Have all of the necessary information available. C. Think through possible solutions to the problem. D. Assess the patient.

B (The main purpose of clinical pathways is to deliver timely care at each phase of the care process for a specific type of patient.)

Lalani reviews Ms. Lam's care plan to ensure accuracy. The main purpose of clinical pathways is to present an overview of the patient's care goals. A. True B. False

community, home, and family (Planning care for patients in community-based settings involves using the same principles of nursing practice. However, in these settings a more comprehensive assessment of the patient's community, home, and family is required.)

Lalani updates Ms. Lam's care plan. Care plans for community-based settings require a thorough assessment of ___________, _______, and _______.

1b, 2d, 3c, 4a

Match the advanced practice nurse specialty with the statement about the role. 1. Clinical nurse specialist 2. Nurse anesthetist 3. Nurse practitioner 4. Nurse-midwife a. Provides independent care, including pregnancy and gynecological services b. Expert clinician in a specialized area of practice such as adult diabetes care c. Provides comprehensive care, usually in a primary care setting, directly managing the medical care of patients who are healthy or have chronic conditions d. Plans and delivers anesthesia and pain management to patients across the life span

1A, 2A, 3B, 4B

Match the assessment activity with the type of assessment ___1. Assessment conducted at beginning of a nurse's shift ___2. Review of a patient's chief complaint ___3. Completion of admitting history at time of patient admission to a hospital ___4. Completion of the Long Term Care Minimum Data Set during an older adult's admission to a nursing home A. Problem focused B. Comprehensive

1c, 2d, 3a, 4b

Match the concepts for a critical thinker with the application of the term ___ 1. Truth seeking ___ 2. Open-mindedness ___ 3. Analyticity ___ 4. Systematicity a. Anticipate how a patient might respond to a treatment. b. Organize assessment on the basis of patient priorities. c. Be objective in asking patient questions. d. Be tolerant of the patient's views and beliefs.

1c, 2e, 3a, 4b, 5d

Match the elements for correct identification of outcome statements with the SMART acronym terms below. ___1. Specific ___ 2. Measurable ___ 3. Attainable ___ 4. Realistic ___ 5. Timed a. Mutually set an outcome a patient agrees to meet. b. Set an outcome that a patient can meet based upon physiological, emotional, economic, and sociocultural resources. c. Be sure an outcome addresses only one patient behavior or response. d. Include when an outcome is to be met. e. Use a term in an outcome statement that allows for observation as to whether a change takes place in a patient's status.

A, B, C, E (The medical diagnosis is developed by the physician; the other choices are all goals of the nurse during the initial assessment.)

Mr. Chuck Rhodes is admitted to the medical-surgical unit for unrelenting abdominal pain. Mr. Rhodes is a 37-year-old fireman. He has been intermittently vomiting for the past 2 days. His wife has accompanied him to the hospital. Mr. Rhodes has never been hospitalized. Crystal is the student nurse who has been assigned to admit Mr. Rhodes. Crystal is in her first clinical rotation. Crystal goes into Mr. Rhodes' room, introduces herself, and explains that she will be collecting information that is needed for his admission. Mr. Rhodes is agreeable and asks Crystal to call him Chuck.1. Crystal starts the data collection. What would she want to accomplish during the interview? (Select all that apply.) A. Establish a caring, therapeutic relationship with Chuck and his wife. B. Determine what Chuck's goals and expectations are regarding hospitalization. C. Gain insight about Chuck's concerns and worries. D. Determine Chuck's medical diagnosis. E. Obtain cues about which parts of the interview may require further investigation.

A (An expected outcome is an objective criterion for a goal that is observable, measureable, and time limited.)

Mr. Rhodes, the patient who was being cared for by Crystal in the previous case study, is diagnosed with appendicitis. The surgeon schedules his surgery for that afternoon at 1300. Crystal continues to develop his care plan. Mr. Rhodes has never had surgery and tells Crystal that the thought of surgery makes him very nervous.1. Crystal wants to add information to his care plan now that the surgery has been scheduled. Which one of the following is an important expected outcome for Mr. Rhodes regarding surgery? A. Is able to describe the importance of postoperative exercises before going to surgery B. Demonstrates use of the call bell if he needs something after surgery C. Will not vomit after surgery D. Learns about postoperative exercises to prevent blood clots

A (Using basic critical thinking is using the principle that the experts have the right answers for a problem. It is based on a set of rules or guidelines)

Mrs. Taylor has difficulty voiding after surgery, so John is to insert a Foley catheter. He has not inserted a Foley catheter into a patient before. John reviews the procedure manual before carrying out the procedure. What level of critical thinking is John using? A. Basic critical thinking B. Complex critical thinking C. Nursing process D. Scientific method

Risk

Nigel develops nursing diagnoses for Mr. Hannigan's care plan. Impaired gas exchange is a ______ nursing diagnosis for pneumonia.

A, B, D (Data cluster is a set of signs and symptoms gathered during the assessment that are grouped together in a logical way. Pain and hematuria do not fit with the respiratory data in this scenario.)

Nigel is a nursing student assigned to Mr. Hannigan, a 72-year- old Caucasian with a diagnosis of pneumonia who is admitted to the medical-surgical unit. Mr. Hannigan is a one-pack-per-day smoker who experiences chronic problems with bronchitis and pneumonia as a result of his smoking. Nigel's immediate tasks are to complete an admission history and physical examination and design a care plan for Mr. Hannigan. Which of the following of Mr. Hannigan's assessment findings can Nigel group together to formulate a data cluster? (Select all that apply.) A. Respirations 32 breaths/min B. Crackles in right and left lung bases C. Pain at incision site D. Shortness of breath with ambulation E. Hematuria

problem, etiology, symptoms

Nigel wishes to use the PES format for Mr. Hannigan's nursing diagnoses. The acronym PES stands for _________ ______________ ___________________.

B

Nursing is defined as a profession because nurses: a. perform specific skills b. practice autonomy c. utilize knowledge from the medical discipline d. charge a fee for services rendered

1, 3, 4, 5

One element of clinical decision making is knowing the patient. Which of the following activities affect a nurse's ability to know patients better? (Select all that apply.) 1. Caring for similar groups of patients over time 2. Reading the evidence-based practices appropriate to patients 3. Learning how patients typically respond to their clinical situations 4. Observing patients 5. Engaging with patients experiencing illness

D

Professional nursing speciality organizations seek to: a. improve standards of practice b. expand nursing roles c. improve the welfare of nurses in specialty areas d. all of the above

2, 4

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) 1. Offer frequent skin care because of Impaired Skin Integrity 2. Risk for Infection 3. Chronic Pain related to osteoarthritis evidenced by reduced hip range of motion 4. Activity Intolerance related to physical deconditioning evidenced by exertional dyspnea 5. Lack of Knowledge related to laser surgery

1, 3

Setting priorities for a patient's nursing diagnoses or health problems is an important step in planning patient care. Which of the following statements describe elements to consider in planning care? (Select all that apply.) 1. Priority setting establishes a preferential order for nursing interventions. 2. In most cases wellness problems take priority over problem-focused problems. 3. Recognition of symptom patterns helps in understanding when to plan interventions. 4. Longer-term chronic needs require priority over short-term problems. 5. Priority setting involves creating a list of care tasks.

3, 1, 6, 2, 5, 7, 4

The REFLECT model can improve learning after providing patient care. Place the steps of this model in the correct order: 1. Think about your thoughts and actions at the time of a situation. 2. Review the knowledge you gained from the experience. 3. Review the facts of the situation. 4. Set a schedule for completing your plan of action. 5. Consider options for handling a similar situation in the future. 6. Recall any feelings you had at the time of the situation. 7. Create a plan for future situations.

3

The examination for RN licensure is the same in every state in the United States. This examination: 1. Guarantees safe nursing care for all patients 2. Ensures standard nursing care for all patients 3. Provides the minimal standard of knowledge for an RN in practice 4. Guarantees standardized education across all prelicensure programs

3 (Nurse educators are revising practice and school curricula to meet the ever-changing needs of society.)

The factor that best advanced the practice of nursing in the twentieth-first century was: 1. the growth of cities 2. the teachings of Christianity 3. better education of nurses 4. improved conditions for women

2

The nurse asks a patient the following series of questions: "Describe for me how much you exercise each day." "How do you tolerate the exercise?" "Is the amount of exercise you get each day the same, less, or more than what you did a year ago?" This series of questions would likely occur during which phase of a patient-centered interview? 1. Orientation 2. Working phase 3. Data interpretation 4. Termination

4

The nurse manager meets with the registered nursing staff about an increase in urinary tract infections in patients with a Foley catheter. The staff work together to review the literature on catheter-associated urinary tract infections (CAUTIs), identifies at-risk patients, and establishes new catheter care practices. This is an example of which QSEN competency? 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Quality improvement

1

The nurse spends time with a patient and family reviewing a dressing change procedure for the patient's wound. The patient's spouse demonstrates how to change the dressing. The nurse is acting in which professional role? 1. Educator 2. Advocate 3. Caregiver 4. Communicator

4

The nurses on an acute care medical floor notice an increase in pressure injury formation in their patients. A nurse consultant decides to compare two types of treatment. The first is the procedure currently used to assess for pressure injury risk. The second uses a new assessment instrument to identify at-risk patients. Given this information, the nurse consultant exemplifies which career? 1. Clinical nurse specialist 2. Nurse administrator 3. Nurse educator 4. Nurse researcher

D

The nursing process organized your approach while delivering nursing care. To provide the best professional care to patients, nurses need to incorporate nursing process and: A) decision making B) problem solving C) intellectual standards D) critical thinking skills

B

The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done : A) logically B) haphazardly C) independently D) systematically

C

the nursing process organizes your approach to delivering nursing care. To provide care to your patients, you will need to incorporate nursing process and: a. decision making b. problem solving c. interview process d. intellectual standards

situation

which part of SBAR: -ID self and patient name -state what is going on with patient that is cause for concern -provide concise statement of the problem

assessment

which part of SBAR: -provide results of your clinical assessment -what are the clinician's findings -what is the analysis -what is the consideration of options -is the problem severe or life threatening

background

which part of SBAR: -what is the clinical background that is pertinent to the situation? -diagnoses, meds, recent vital signs, lab results, med history, recent clinical findings

e

Concept mapping is one way to: a) connect concepts to a central subject b)relate ideas to patient health problems c) challenge a nurse's thinking about patient needs and problems d) graphically display ideas by organizing data e) all of the above

1, 2, 3, 4

Contemporary nursing requires that the nurse have knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples of these roles and responsibilities? (Select all that apply.) 1. Caregiver 2. Autonomy 3. Patient advocate 4. Health promotion 5. Genetic counselor

B (The statement describes the actual response to a health problem that a nurse is licensed to treat.)

Crystal establishes the following nursing diagnoses for Mr. Rhodes. Which one of these nursing diagnoses is best reflective of her assessments? A. Nausea related to unknown cause of stomach pain B. Imbalanced nutrition: less than body requirements related to decreased ability to ingest food as a result of vomiting

B (The priority in this case would be knowledge deficit because Mr. Rhodes needs this information before going to surgery.)

Crystal has two nursing diagnoses on Mr. Rhodes' care plan. Which of these is the priority for Crystal? A. Imbalanced nutrition: less than body requirements related to decreased ability to ingest food as a result of vomiting B. Deficient knowledge regarding postoperative care related to lack of exposure to information

structured database format (A structured database format is based on an accepted theoretical framework or practice standards and allows for a more comprehensive assessment.)

Crystal is assessing Chuck using Gordon's functional health patterns. This is an example of which approach to comprehensive assessment?

2, 4, 7

A nurse assesses a 42-year-old woman at a health clinic. The woman is married and lives in a condo with her husband. She reports having frequent voiding and pain when she urinates. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes, usually twice or more." The patient had an episode of diarrhea 1 week ago. She weighs 136 kg (300 lb) and reports having difficulty cleansing herself after voiding or passing stool. Which of the following demonstrate assessment findings that cluster to indicate the nursing diagnosis Impaired Urination. (Select all that apply.) 1. Age 42 2. Dysuria 3. Difficulty performing perineal hygiene 4. Nocturia 5. Episode of diarrhea 6. Weighs 136 kg (300 lb) 7. Frequent voiding

4

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lb) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last two days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? 1. Patient will be turned every two hours within 24 hours. 2. Patient will have normal formed stool within 48 hours. 3. Patient's ability to turn self in bed improves. 4. Erythema of skin will be mild to none within 48 hours.

2, 3, 4, 5, 6, 8

A nurse conducts an assessment of a 42-year-old woman at a health clinic. The woman is married and lives in an apartment with her husband. She reports having frequent voiding and pain when she passes urine. The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes." The patient had an episode of diarrhea 1 week ago. She weighs 136 kg (300 lb). The nurse documents the assessment findings listed below. Which of the assessment findings require priority follow-up by the nurse? (Select all that apply.) 1. The patient has no history of chronic disease. 2. Patient urinates at night. 3. Patient reports having difficulty cleansing herself after voiding or passing stool. 4. Body temperature 38°C (100.4°F) 5. Recent history of weight gain 6. Knowledge of perineal care 7. Last normal bowel movement 2 days ago 8. Frequency of diarrhea

2, 4, 5

A nurse enters a patient's room at the beginning of a shift to assess his condition following a blood transfusion. The nurse cared for the patient on the previous day as well. The patient has several issues he wishes to share with the nurse, who takes time to explore each issue. The nurse also assesses the patient and finds no signs or symptoms of a reaction to the blood product. The nurse observed the patient the prior day and sees a change in his behavior—a reluctance to get out of bed and ambulate. Which of the following actions improve the nurse's ability to make clinical decisions about this patient? (Select all that apply.) 1. Working the same shift each day 2. Spending time during the patient assessment 3. Knowing the early mobility protocol guidelines 4. Caring for the patient on consecutive days 5. Knowing the pattern of patient behavior about ambulation

3, 4, 5

A nurse has been caring for a patient with a chronic wound that has not been healing. The nurse talks with a nurse specialist in wound care to find alternative approaches from what the health care provider ordered for dressing the wound. The two decide that because of the patient's allergy to tape, a nonallergenic dressing will be used. The nurse obtains an order from the health care provider for the new dressing. After 2 days there is improvement in the wound. This is an example of which critical thinking standards? (Select all that apply.) 1. Clarity 2. Broadness 3. Relevance 4. Risk taking 5. Creativity

4

A nurse has seen many cancer patients struggle with pain management because they are afraid of becoming addicted to the medicine. Pain control is a priority for cancer care. By helping patients focus on their values and beliefs about pain control, a nurse can best make clinical decisions. This is an example of: 1. Creativity 2. Fairness 3. Clinical reasoning 4. Applying ethical criteria

3, 5

A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient's lungs and hears crackles in the left lower lobe. The patient's respiratory rate is 22 breaths/min compared with an average of 16 breaths/min during previous clinic visits. The patient tells the nurse, "It's hard for me to get a breath." Which of the following data sets are examples of subjective data? (Select all that apply.) 1. Heart rate of 22 breaths/min and chest congestion 2. Lung sounds revealing crackles and use of intercostal muscles to breathe 3. Patient statement, "It's hard for me to get a breath" 4. Slumped posture and previous respiratory rate of 16 breaths/min 5. Patient report of sore throat and hoarseness

4

A nurse interviews and conducts a physical examination of a patient that includes the following findings: reduced range of motion of lower hip, reduced strength in left leg, and difficulty turning in bed without assistance. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster. 5. Validated data set

4, 2, 3, 6, 1, 5

A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. 1. Consider the context of patient's health problem and select a related factor. 2. Review assessment findings, noting objective and subjective clinical cues. 3. Cluster cues that form a pattern. 4. Gather thorough patient data about the patient's health problem. 5. Identify the nursing diagnosis. 6. Consider whether data are expected or unexpected based on the patient's problem.

2, 4

A nurse is assigned to care for a woman who is expecting her first child. The nurse organizes herself and plans to gather data about the patient by applying Pender's health promotion model, including the patient's characteristics and experiences and situational influences. She plans to observe patient behavior and consider the patient's psychosocial issues. Such data will offer a clear understanding to help the nurse identify the patient's needs. This is an example of which of the following concepts? (Select all that apply.) 1. Diagnostic reasoning 2. Deductive reasoning 3. Inductive reasoning 4. Assessment 5. Problem solving

2, 3, 5

A nurse is assigned to care for six patients at the beginning of the night shift. The nurse learns that the floor will be short by one registered nurse (RN) because one of the nurses called in sick. Assistive personnel (AP) from another area is coming to the nursing unit to assist. Because the unit requires hourly rounds on all patients, the nurse begins to make rounds on a patient who recently asked for a pain medication. The nurse is interrupted by another registered nurse who asks about another patient. Which factors in this nurse's unit environment will affect the ability to set priorities? (Select all that apply.) 1. Policy for conducting hourly rounds 2. Staffing level 3. Interruption by staff nurse colleague 4. Type of hospital unit 5. Competency of assistive personnel (AP)

4

A nurse is caring for a patient who has poor pain control. The patient has a history of opioid abuse. During the day, the patient made frequent requests for a pain medication. To make an effective clinical decision about this patient, the nurse needs to ask questions about the data available on the patient to make a thorough and thoughtful decision. The nurse asks herself, "How does my view about the patient's pain tolerance compare with the patient's, and does that pose a problem?" This is an example of: 1. A question about assumptions 2. A question about evidence 3. A question about procedure 4. A question about perspective

2

A nurse is caring for a patient with end-stage lung disease. The patient wants to go home on oxygen and be comfortable. The family wants the patient to have a new surgical procedure. The nurse explains the risk and benefits of the operation to the family and discusses the patient's wishes with them. The nurse is acting as the patient's: 1. Educator 2. Advocate 3. Caregiver 4. Communicator

2, 4, 1, 5, 3

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order, beginning with the first statement a nurse would ask. 1. "You say you've lost weight. Tell me how much weight you've lost in the past month." 2. "My name is Terry. I'll be the nurse taking care of you today." 3. "I have no further questions. Is there anything else you wish to ask me?" 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the past month, and your appetite has been poor—correct?"

2, 3, 4

A nurse is giving a patient a medication and notices the dosage. From the nurse's experience, the dosage is higher than what is normally given. Which of the following steps should the nurse take to ensure a safe outcome for the patient? (Select all that apply.) 1. Wait until end of shift when there is time to check dosage with pharmacy reference. 2. Recognize how the nursing team communicates problems, and consult with charge nurse. 3. Hold the dose and confer with the ordering health care provider now. 4. Assess patient knowledge of what has been the routine dose for this medication. 5. Administer the medication and closely monitor patient response.

1

A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the health care provider's order. At the bedside, the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude? 1. Responsibility 2. Humility 3. Accuracy 4. Fairness

2

A nurse observes a patient walking down the hall with a shuffling gait. When the patient returns to bed, the nurse checks the strength in both of the patient's legs. The nurse applies the information gained to suspect that the patient has a mobility problem. This conclusion is an example of: 1. Reflection 2. Clinical inference 3. Cue 4. Validation

1A, 2A, 3A, 4B, 5B, 6A

A nurse on a hospital unit is preparing to hand off care of a patient being discharged to a home health nurse. Match the activities with the hand-off report categories ___ 1. Use a standard checklist for the report. ___ 2. Encourage questions and clarification. ___ 3. Offer specific information on how to reduce patient's risks. ___ 4. Give report at time when shift has ended and other nurses are requesting information. ___ 5. Explain how patient's discharge was delayed by insufficient numbers of staff. ___ 6. Organize time by preparing in advance what to report. a. Strategy for Effective Hand-off b. Strategy for Ineffective Hand-off

2, 3, 4

A nurse reviews data gathered regarding a patient's response to a diagnosis of cancer. The nurse notes that the patient is restless, avoids eye contact, has increased blood pressure, and expresses a sense of helplessness. The nurse compares the pattern of assessment findings for Anxiety with those of Fear and selects Anxiety as the correct diagnosis. This is an example of the nurse avoiding an error in which of the following? (Select all that apply.) 1. Data collection 2. Data clustering 3. Data interpretation 4. Making a diagnostic statement 5. Outcome setting

2

A nurse's assessment reveals a patient having frequent voiding and pain when she urinates. Her body temperature is 38°C (100.4°F). The nurse asks whether she has to go to the bathroom at night, and the patient responds, "Yes." When asked how often, the patient replies, "About three times a night." The nurse asks if having to urinate at night is recent or normal for the patient. The patient explains, "I usually go once a night but that is all." The nurse then asks, "When you feel the need to go, can you reach the toilet in time?" The patient says, "Oh, yes, I can." The nurse asks, "And have you had any leaking of urine?" The patient denies leaking. When asked if she is having any back or abdominal pain, the patient denies discomfort. The nurse then gathers a urine specimen from the patient and inspects its character, noting it is cloudy and foul smelling. Which of the following nursing diagnoses are indicated by cues in this patient's assessment? 1. Impaired Kidney Function 2. Impaired Urination 3. Urge Incontinence of Urine 4. Total Urinary Incontinence

4, 5, 8

A nursing student is providing a hand-off report to a registered nurse (RN) who is assuming the patient's care at the end of the clinical day. The student states, "The patient had a good day. His intravenous (IV) fluid is infusing at 124 mL/hr with D5½NS infusing in left forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he walked to the visitors lounge and back with no shortness of breath, respirations 14, heart rate 88 after returning to chair. He uses his walker without difficulty, gait normal. The patient ate ¾ of his dinner with no gastrointestinal complaints." Which expected outcomes aimed at improving the patient's activity tolerance were discussed in the hand-off? (Select all that apply.) 1. IV site not tender 2. Ambulated twice during shift 3. Uses walker to walk 4. Walked to visitors lounge 5. No shortness of breath 6. Tolerated dinner meal 7. Patient had a good day 8. Vital signs after ambulation

2, 3, 5

A patient diagnosed with colon cancer has been receiving chemotherapy for six weeks. The patient visits the outpatient infusion center twice a week for infusions. The nurse assigned to the patient is having difficulty accessing the patient's intravenous port used to administer the chemotherapy. Despite attempts to flush the port, it is obstructed. This occurred two weeks earlier as well. What steps should the nurse follow to make a consultation with a member of the IV infusion team? (Select all that apply.) 1. Ask the IV nurse to come to the infusion center at a time when the nurse starts care for a second patient. 2. Specifically identify the problem of port obstruction and attempt to flush the port to resolve the problem. 3. Explain to the IV nurse the frequency in which this port has obstructed in the past. 4. Tell the IV nurse the problem is probably related to the physician who inserted the port. 5. Describe to the IV nurse the type and condition of the port currently in use.

B

A patient is suffering from shortness of breath. The correct goal statement would be written as: a) the patient will be comfortable by the morning b) the patient will breath unlabored at 14 to 18 breaths per minute by the end of the shift c) the patient will not complain of breathing problems within the next 8 hours d) the patient will have a respiratory rate of 14 to 18 breaths per minute

4

A student is participating in a postclinical conference with the other students in the clinical group and an instructor. The student states, "My patient has two nursing diagnoses I chose to focus on, Risk for Impaired Skin Integrity and Lack of Knowledge regarding diabetic diet restrictions. I observed no pressure areas this morning. Because of her weight (100 kg; 220 lb), I turned her every two hours, and we put her on a pressure-relieving surface. We discussed how diabetes mellitus affects her circulation. During the day she had a glucose tolerance test that was normal. We discussed her diet during lunchtime. She completed a menu for a day with food choices that fit her diet. Before the shift was over, I talked with her physician about the patient's medication plan; her blood glucose levels have been higher than desired." Which of the following taken from the student's summary is a nurse-sensitive outcome? 1. Normal glucose tolerance test 2. Discussion of diet restrictions 3. Use of turning and pressure relief 4. Menu completion with food choices fitting diet 5. Blood glucose level elevated 6. Discussion of influence diabetes has on circulation

1d, 2a, 2c, 3b

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Impaired Nutritional Intake related to reduced ability to feed self. The nursing staff identified several outcomes of care. Match the diagnoses with the appropriate outcome statements ___ 1. Risk for Fall ___ 2. Impaired Physical Mobility related to pain ___ 3. Impaired Nutritional Intake related to reduced ability to feed self a. Patient expresses fewer nonverbal signs of discomfort when walking within 24 hours. b. Patient increases calorie intake to 2500 calories daily. c. Patient walks 20 feet using a walker in 24 hours. d. Patient identifies barriers to remove in the home within 1 week.

B, C, D (A nursing diagnosis is a standardized statement about the health of a patient (who can be an individual, a family, or a community) for the purpose of providing nursing care.)

Crystal, a student nurse, is caring for Mr. Chuck Rhodes, a 37-year-old firefighter who was admitted to the medical-surgical unit for unrelenting abdominal pain. He has been intermittently vomiting for the last 2 days and has been unable to eat any solid food. His wife has accompanied him. Mr. Rhodes has never been hospitalized. During her assessment, Mr. Rhodes rated his pain as a 9 on a scale of 0 to 10. Crystal is developing the nursing diagnosis. She reviews her assessments.1. Which of the following statements are true about nursing diagnosis? (Select all that apply.) A. Nursing diagnoses are always based on a physiological problem. B. Nursing diagnoses have two parts, which include the diagnostic label and the related factor. C. Errors in nursing diagnosing can occur from inadequate assessment. D. Nursing diagnoses are focused on the scope of nursing practice.

C (Whereas open-ended questions encourage the patient to describe a situation using more than one word, closed-ended questions require just a yes or no answer.)

During the initial interview, Crystal notices that Chuck is grimacing and will not make eye contact with her. She wants to get more information. Which question is most appropriate to help Crystal in her assessment? A. Do you hurt? B. Do you feel like you are going to vomit? C. How are you feeling now? D. Do you need pain medicine?

a. assessment activity, b. cue, c. cue, d. assessment activity, e. cue, f. assessment activity, g. assessment activity, g. assessment activity

Fill in the spaces below to identify the following concepts: assessment activity or cue. The nurse inspects (a. _____) a patient's sacral pressure injury and notices that the wound is 6 cm (2.4 inches) in diameter (b. _____) with inflammation (c. _____). The nurse gently applies pressure (d. ____) around the wound, with the patient acknowledging pain (e. _____). The nurse asks the patient to rate the level of pain on a scale (f. _____) from 0 to 10. A final assessment includes reviewing the electronic record (g. _____) for how frequently the patient was turned in the last 12 hours.

a

For a student to avoid a data collection error, the student should: a) assess the patient and, if unsure of the finding, ask a faculty member to assess the patient b) review his or her own comfort level and competency with assessment skills c) ask another student to perform the assessment d) consider whether the diagnosis should be actual, potential, or risk

1 (Candidates are eligible to take the NCLEX-RN to become registered nurses in the state in which they will practice.)

Graduate nurses must pass a licensure examination administered by the: 1. State Boards of Nursing 2. National League for Nursing 3. Accredited School of Nursing 4. American Nurses Association

1

Health care reform will bring changes in the emphasis of care. Which of these models is expected from health care reform? 1. Moving from an acute illness to a health promotion, illness prevention model 2. Moving from an illness prevention to a health promotion model 3. Moving from hospital-based to community-based care 4. Moving from an acute illness to a disease management model

A, B, C, D, E (All of the above are characteristics that define what constitutes a profession.)

Tim Owens is a 66-year-old man who is in the hospital for a total knee repair. He had surgery the day before. He has an intravenous line infusing at 125 mL/hr and a patient-controlled analgesia pump for pain control. His wife Linda is in the room with him. Joan Black is the nursing student assigned to Mr. Owens for her clinical experience. Joan is in her second clinical nursing course. In preconference, Joan's instructor asks her if she thinks that nursing is a profession, and Joan responds that she does. What are some characteristics that identify nursing as a profession? (Select all that apply.) A. Nursing provides a specific service. B. Nursing requires an extended education. C. Nursing has a code of ethics for practice. D. Nursing has a theoretical body of knowledge. E. Nurses have autonomy in decision making and practice

situation, background, assessment, recommendation

What does SBAR stand for?

c

When caring for a patient who has multiple health problems and related medical diagnoses, nurses can best perform nursing diagnoses and nursing interventions by developing a: a) critical pathway b) nursing care plan c) concept map d) diagnostic label

1, 3, 4

Which of the following approaches are recommended when gathering assessment data from an 82-year-old male patient entering a primary care clinic for the first time? (Select all that apply.) 1. Recognize normal changes associated with aging. 2. Avoid direct eye contact. 3. Lean forward and smile as you pose questions. 4. Allow for pauses as patient tells his story. 5. Use the list of questions from the clinic assessment form to complete all data.

D (A nursing intervention includes action, frequency, quantity, method, and person to perform the activity.)

Which of the following interventions is written correctly for Crystal to add to Mr. Rhodes' care plan? A. Provide frequent mouth care B. Keep NPO C. Reposition in bed every 2 hours D. Offer 30 ml of water hourly while awake

A (A CNS is one type of advanced practice nurse who works with a specialty population and functions as an expert clinician, educator, consultant, or researcher.)

While Joan is in with Mr. Owens, Judy Collins, the clinical nurse specialist (CNS), enters the room to check on Mr. Owens. After Judy leaves, Mr. Owens asks Joan what the difference is between a CNS and a regular nurse. What is the best response for Joan to give to Mr. Owens? A. A CNS is an advanced practice nurse who is an expert in a specialized area of nursing. B. She has a higher degree, that's all. C. She is considered the manager of the unit. D. A CNS does the same things as a physician.

4

You are preparing a presentation for your classmates regarding the clinical care coordination conference for a patient with terminal cancer. As part of the preparation, you have your classmates read the Nursing Code of Ethics for Professional Registered Nurses. Your instructor asks the class why this document is important. Which statement best describes this code? 1. Improves self-health care 2. Protects the patient's confidentiality 3. Ensures identical care to all patients 4. Defines the principles of right and wrong to provide patient care

b

a patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient, the nurse is using the process of: a. evaluation b. data collection c. problem identification d. testing a hypothesis