Foundations Exam 1

*Match the concepts for a critical thinker with the application of the term* A. anticipate how a pt might respond to a treatment B. organize assessment on the basis of pt priorities C. be objective in asking questions of a pt D. be tolerant of the pt's views and beliefs 1. Truth seeking 2. Open-mindedness 3. Analyticity 4. Systematicity

*Answer: 1 c, 2 d, 3a, 4b*

*In which of the following examples is a nurse applying critical thinking skills in practice? (select all that apply)* 1. the nurse thinks back about a personal experience before administering a medication subcutaneously 2. the nurse uses a pain-rating scale to measure a pt's pain 3. the nurse explains a procedure step by step for giving an enema to a pt care technician 4. the nurse gathers data on a pt with a mobility limitation to identify a nursing diagnosis 5. a nurse offers support to a colleague who has witnessed a stressful event

*Answer: 1,2,4*

*Which of the following describes a nurse's application of a specific knowledge base during critical thinking? (select all that apply)* 1. initiative in reading current evidence from the literature 2. application of nursing theory 3. reviewing policy and procedure manual 4. considering holistic view of pt needs 5. previous time caring for a specific group of patients

*Answer: 1,2,4*

*An aspect of clinical decision making is knowing the pt. Which of the following is the most critical aspect of developing the ability to know the pt?* 1. working in multiple health care settings 2. learning good communication skills 3. spending time establishing relationships with patients 4. relying on evidence in practice

*Answer: 3*

*A nurse changed a pt's surgical wound dressing the day before and now prepares for another dressing change. The nurse had difficulty removing the gauze from the wound bed yesterday, causing the pt discomfort. Today he gives the pt an analgesic 30 min before the dressing change. Then he added some sterile saline to loosen the gauze for a few minutes before removing it. The pt reports that the procedure was much more comfortable. Which of the following describes the nurse's approach to the dressing change? (select all that apply)* 1. clinical inference 2. basic critical thinking 3. complex critical thinking 4. experience 5. reflection

*Answer: 3,4*

*A nurse enters a 72 yr old patient's home and begins to observe her behaviors and examine her physical condition. The nurse learns that the pt lives alone and notices bruising on the pt's leg. When watching the pt walk, the nurse notes that she has an unsteady gait and leans to one side. The pt admits to having fallen in the past. The nurse identifies the pt as having the nursing dx of Risk for Falls. This scenarios is an example of:* 1. inference 2. basic critical thinking 3. evaluation 4. diagnostic reasoning

*Answer: 4*

*Place the steps of the scientific method in their correct order with number 1 being the first step of the process.* 1. formulate a question or hypothesis 2. evaluate results of the study 3. collect data 4. identify the problem 5. test the question or hypothesis

*Answer: 4, 3, 1, 5, 2*

*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 doctor'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:* A. responsible B. complete C. accurate D. broad

*Answer: A*

*A nurse just started working at a well-baby clinic. One of her recent experiences was to help a mother learn the steps of breast-feeding. During the first clinic visit the mother had difficulty positioning the baby during feeding. After the visit the nurse considers what affected the inability of the mother to breastfeed, including the mother's obesity and inexperience. The nurse's review of the situation is called:* A. reflection B. perseverance C. intuition D. problem solving

*Answer: A*

*A nurse on a busy medicine unit is assigned to 4 patients. It is 10am. Two patients have medications due and one of those has a specimen of urine to be collected. One patient is having complications from surgery and is being prepared to return to the operating room. The fourth pt requires instruction about activity restrictions before going home this afternoon. Which of the following should the nurse use in making clinical decisions appropriate for the pt group? (select all that apply)* A. consider availability of assistive personnel to obtain the specimen B. combine activities to resolve more than one pt problem C. analyze the diagnoses/problems and decide which are most urgent based on patient's need D. plan a family conference for tomorrow to make decisions about resources the pt will need to go home E. Identify the nursing diagnoses for the pt going home

*Answer: A, B, C*

*Two pt deaths have occurred on a medical unit in the last month. The staff notices that everyone feels pressured and team members are getting into more arguments. As a nurse on the unit, what will best help you manage this stress* A. keep a journal B. participate in a unit meeting to discuss feelings about the pt deaths C. ask the nurse manager to assign you to less difficult patients D. review the policy and procedure manual on proper care of patients after death

*Answer: B*

*When a nurse tries to understand a patient's and family caregiver's perspective of why a pt is falling at home, the nurse applies the intellectual standard of ______ to understand all viewpoints*

*Answer: Broad*

*By using known criteria in conducting an assessment such as reviewing with a pt the typical characteristics of pain, a nurse is demonstrating which critical thinking attitude?* A. curiosity B. adequacy C. discipline D. thinking independently

*Answer: C*

*A nurse has seen many cancer patients struggle with pain management bc 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:* A. creativity B. fairness C. clinical reasoning D. applying ethical criteria

*Answer: D*

*A nurse prepares to insert a Foley catheter. The procedure manual calls for the pt to lie in the dorsal recumbent position. The pt complains of having back pain when lying on her back. Despite this, the nurse positions the pt supine with knees flexed as the manual recommends and begins to insert the catheter. This is an example of:* A. accuracy B. reflection C. risk taking D. basic critical thinking

*Answer: D*

A nurse has been caring for a patient over 2 consecutive days. During that time the patient has had an intravenous (IV) catheter in the right forearm. At the end of shift on the second day the nurse inspects the catheter site, observes for redness, and asks if the patient feels tenderness when the site is palpated. This is an example of which indicator reflecting the nurse's ability to perform evaluation: 1. Examining results of clinical data 2. Comparing achieved effects with outcomes 3. Recognizing error 4. Self-reflection

1

A nurse has been caring for a patient over the last 10 hours. The patient's plan of care includes the nursing diagnosis of Nausea related to effects of postoperative anesthesia. The nurse has been asking the patient to rate his nausea over the last several hours after administering antiemetics and using comfort measures such as oral hygiene. The nurse reviews the patient's responses over the past 10 hours and notes how the patient's self-report of nausea has changed. This review an example of: 1. Comparing outcome criteria with actual response. 2. Gathering outcome criteria. 3. Evaluating the patient's actual response. 4. Reprioritizing interventions.

1

A nurse reviews all possible consequences before helping a patient ambulate such as how the patient ambulated last time; how mobile the patient was before admission to the health care facility; or any current clinical factors affecting the patient's ability to stand, remain balanced, or walk. Which of the following is an example of a nurse's review of this situation? 1. Critical thinking 2. Managing an adverse event 3. Exercising self-discipline 4. Time management

1

A patient has been febrile and coughing thick secretions; adventitious lung sounds indicate rales in the left lower lobe of the lungs. The nurse decides to perform nasotracheal suction because the patient is not coughing. The nurse inspects the mucus that is suctioned, which is minimal. The nurse again auscultates for lung sounds. Auscultation and mucus inspection are examples of: 1. Evaluative measures. 2. Expected outcomes. 3. Reassessments. 4. Reflection.

1

Before consulting with a physician about a female patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? 1. Cognitive 2. Interpersonal 3. Psychomotor 4. Consultative

1

The nurse administers a tube feeding via a patient's nasogastric tube. This is an example of which of the following? 1. Physical care technique 2. Activity of daily living 3. Indirect care measure 4. Lifesaving measure

1

Which of the following does a nurse perform when discontinuing a plan of care for a patient? 1. Confirms with the patient that expected outcomes and goals have been met 2. Talks with the patient about reprioritizing interventions in the plan of care 3. Changes the frequency of interventions provided 4. Reassesses how goals were met

1

Which measures does a nurse follow when being asked to perform an unfamiliar procedure? (Select all that apply.) 1. Checks scientific literature or policy and procedure 2. Reassesses the patient's condition 3. Collects all necessary equipment 4. Delegates the procedure to a more experienced nurse 5. Considers all possible consequences of the procedure

1 2 3 5

A nurse is conferring with another nurse about the care of a patient with a stage II pressure ulcer. The two decide to review the clinical practice guideline of the hospital for pressure ulcer management. The use of a standardized guideline achieves which of the following? (Select all that apply.) 1. Makes it quicker and easier for nurses to intervene 2. Sets a level of clinical excellence for practice 3. Eliminates need to create an individualized care plan for the patient 4. Delivers evidence-based interventions for stage II pressure ulcer 5. Summarizes the various approaches used for the practice concern or problem

1 2 4

Purposes of the Nursing Outcomes Classification (NOC) include which of the following? (Select all that apply.) 1. To identify and label nurse-sensitive patient outcomes 2. To test the classification in clinical settings 3. To establish health care reimbursement guidelines 4. To identify nursing interventions for linked nursing diagnoses 5. To define measurement procedures for outcomes

1 2 5

A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.) 1. Data collection. 2. Data clustering. 3. Data interpretation. 4. Making a diagnostic statement. 5. Goal setting.

1 3

Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) 1. Impaired Skin Integrity related to physical immobility 2. Fatigue related to heart disease 3. Nausea related to gastric distention 4. Need for improved Oral Mucosa Integrity related to inflamed mucosa 5. Risk for Infection related to surgery

1 3

A nurse in a community health clinic has been caring for a young teenager with asthma for several months. The nurse's goal of care for this patient is to achieve self-management of asthma medications. Identify appropriate evaluative indicators for self-management for this patient. (Select all that apply.) 1. Quality of life 2. Patient satisfaction 3. Use of clinic services 4. Adherence to use of inhaler 5. Description of side effects of medications

1 3 4

A nurse working on a surgery floor is assigned five patients and has a patient care technician assisting her. Which of the following shows the nurse's understanding and ability to safely delegate to the patient care tech? (Select all that apply.) 1. The nurse considers the time available to gather routine vital signs on one patient before checking on a second patient arriving from a diagnostic test. 2. Determining what is the patient care technician's current workload. 3. The nurse chooses to delegate the measurement of a stable patient's vital signs and not the assessment of the patient arriving from a diagnostic test. 4. The nurse reviews with the NAP, newly hired to the floor, her experience in measuring a blood pressure. 5. The nurse confers with another registered nurse about organizing priorities.

1 3 4

Which of the following statements correctly describes the evaluation process? (Select all that apply.) 1. Evaluation is an ongoing process. 2. Evaluation usually reveals obvious changes in patients. 3. Evaluation involves making clinical decisions. 4. Evaluation requires the use of assessment skills. 5. Evaluation is only done when a patient's condition changes.

1 3 4

A nurse checks an intravenous (IV) solution container for clarity of the solution, noting that it is infusing into the patient's left arm. The IV solution of 9% NS is infusing freely at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room the nurse inspects the condition of the dressing and notes the date on the dressing label. In which ways did the nurse evaluate the condition of the IV site? (Select all that apply.) 1. Checked the IV infusion rate 2. Checked the type of IV solution 3. Confirmed from nurses' notes the time of dressing change 4. Inspected the condition of the IV dressing at the site 5. Checked clarity of IV solution

1 4

In which of the following examples are nurses making diagnostic errors? (Select all that apply.) 1. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data 2. The nurse who measures joint range of motion after the patient reports pain in the left elbow 3. The nurse who considers conflicting cues in deciding which diagnostic label to choose 4. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping 5. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.

1 4 5

The nurse received a hand-off report at the change of shift in the conference room from the night shift nurse. The nursing student assigned to the nurse asks to review the medical records of the 314patients assigned to them. The nurse begins assessing the assigned patients and lists the nursing care information for each patient on each individual patient's message board in the patient rooms. The nurse also lists the patients' medical diagnoses on the message board. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? 1. discussing patient conditions in the nursing report room at the change of shift 2. allowing nursing students to review patient charts before caring for patients to whom they are assigned 3. Posting medical information about the patient on a message board in the patient's room 4. releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

Posting medical information about the patient on a message board in the patient's room

The examination for registered nurse (RN) licensure is exactly the same in every state in the US. This examination: 1. Guarantees safe nursing care for all patients 2. Ensures standard nursing care for all patients 3. Ensures that honest and ethical care is provided 4. Provides a minimal standard of knowledge for an RN in practice

Provides a minimal standard of knowledge for an RN in practice

A nurse is planning care for a patient going to surgery. Who is responsible for informing the patient about the surgery along with possible risks, complications, and benefits? 1. family member 2. surgeon 3. nurse 4. nurse manager

Surgeon

Which of the following actions, if performed by a registered nurse, would result in both criminal and administrative law sanctions against the nurse? (Select all that apply.) 1. Taking or selling controlled substances 2. refusing to provide health care information to a patient's child 3. reporting suspected abuse and neglect of children 4. applying physical restraints without a written physician's order 5. completing an occurrence report on the unit

Taking or selling controlled substances Applying physical restraints without a written physician's order

A nurse stops to help in an emergency at the scene of an accident. The injured party files a suit, and the nurse's employing institution insurance does not cover the nurse. What would probably cover the nurse in this situation? 1. the nurse's automobile insurance 2. the nurse's homeowner's insurance 3. The Good Samaritan law, which grants immunity from suit if there is no gross negligence 4. the Patient Care Partnership, which may grant immunity from suit if the injured party consents

The Good Samaritan law, which grants immunity from suit if there is no gross negligence

A nurse is sued for negligence due to failure to monitor a patient appropriately after a procedure. Which of the following statements are correct about this lawsuit? (Select all that apply.) 1. the nurse does not need any representation 2. the patient must prove injury, damage, or loss occurred 3. the person filing the lawsuit has to show a compensable damage, such as lost wages, occurred 4. The patient must prove that a breach in the prevailing standard of care caused an injury. 5. the burden of proof is always the responsibility of the nurse

The patient must prove injury, damage, or loss occurred. The person filing the lawsuit has to show a compensable damage, such as lost wages, occurred. The patient must prove that a breach in the prevailing standard of care caused an injury.

A nurse is caring for a group of clients on a medical-surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (type all that apply) A. A client who has terminal cancer requests hospice care in her home. B. A client asks about community resources available for older adults. C. A client states that she wants her child baptized before surgery. D. A client requests an electric wheelchair for use after discharge. E. A client states that he does not understand how to use a nebulizer.

a b d

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.) 1. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs 2. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves 239 3. Helps nurses focus on the scope of nursing practice 4. Creates practice guidelines for collaborative health care activities 5. Builds and expands nursing knowledge

1, 3, 5 Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs Helps nurses focus on the scope of nursing practice Builds and expands nursing knowledge

A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.) 1. How is your diabetic diet affecting you and your family? 2. You seem to not want to follow health guidelines. Can you explain why? 3. What worries you the most about having diabetes? 4. What do you expect from us when you do not take your insulin as instructed? 5. What do you believe will help you control your blood sugar?

1, 3, 5 How is your diabetic diet affecting you and your family? What worries you the most about having diabetes? What do you believe will help you control your blood sugar?

The nurse is speaking in front of a group of ninth grade students about nursing as a profession. One student states that she does not want to be a nurse because all nurses do is take care of sick people and play politics. The most appropriate response that the nurse could give and expand on is that a. Nursing is ideal for the person who hates politics. b. Nursing focuses on curing the person's disease. c. Nursing is not political because it has its own knowledge base. d. An area of nursing exists for every interest.

an area of nursing exists for every interest

A nurse assesses a 78-year-old patient who weighs 108.9 kg (240 lbs) 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 2 days. The nurse identifies the nursing diagnosis of Risk for Impaired Skin Integrity. Which of the following outcomes is appropriate for the patient? a. Patient will be turned every 2 hours within 24 hours b. Patient will have normal bowel function within 72 hours c. Patient's skin integrity will remain intact through discharge d. Erythema of skin will be mild to none within 48 hours

d

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 impt. Which of the following best describes this code? 1. improves self-health care 2. protects patients confidentiality 3. ensures identical care to all patients 4. defines the principles of right and wrong to provide patient care

defines the principles of right and wrong to provide patient care

A critical care nurse is using a computerized decision support system to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which QSEN competency? 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Informatics

informatics

Which of the following statements indicate that the new nursing graduate understands ways to remain involved professionally? (Select all that apply.) 1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing." 4. "Nurses do not have very much voice in legislation in Washington, D.C., because of the nursing shortage" 5. "I will go back to school as soon as I finish orientation"

1. "I am thinking about joining the health committee at my church." 2. "I need to read newspapers, watch news broadcasts, and search the Internet for information related to health." 3. "I will join nursing committees at the hospital after I have completed orientation and better understand the issues affecting nursing."

Match the category of direct care on the left with the specific direct care activity on the right. 1. Counseling ___ 2. Lifesaving measure ____ 3. Physical care technique ___ 4. Activity of daily living ____ a. Assisting patient with oral care b. Discussing a patient's options in choosing palliative care c. Protecting a violent patient from injury d. Using safe patient handling during positioning of a patient

1b, 2c, 3d, 4a

A nurse caring for a patient with heart failure instructs the patient on foods to eat for a low-sodium diet. The nurse will perform which of the following evaluation measures to determine success of her instruction? 1. Patient weight 2. Asking patient to identify three low-sodium foods to eat for lunch 3. A calorie count of food 4. Patient description of how food selections are made

2

A patient is being discharged after treatment for colitis (inflammation of the colon). The patient has had no episodes of diarrhea or abdominal pain for 24 hours. Following instruction, the patient identified correctly the need to follow a low-residue diet and the types of food to include if a bout of diarrhea develops at home. These behaviors are examples of: 1. Evaluative measures. 2. Expected outcomes. 3. Reassessments. 4. Standards of care.

2

The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): 1. Risk nursing diagnosis. 2. Problem-focused nursing diagnosis. 3. Health promotion nursing diagnosis. 4. Wellness nursing diagnosis.

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 and has had liquid stool and the skin is clean and intact; therefore she 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 2. Wrong diagnostic label 3. Condition is a collaborative problem. 4. Premature closure of clusters

2 Wrong diagnostic label

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) 1. The application of the skin barrier is a dependent care measure. 2. The call to the ostomy and wound care specialist is an indirect care measure. 3. The cleansing of the skin is a direct care measure. 4. The application of the skin barrier is an instrumental activity of daily living. 5. Inspecting the skin is a direct care activity.

2 3

A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order, beginning with the first step. 1. Considers context of patient's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label

2 3 4

A faculty member is reviewing a nursing student's plan of care, including the interventions the student provided for a patient with dementia. The student reviewed clinical guidelines on a professional website to identify interventions successful in reducing wandering in patients with dementia. The faculty member should evaluate which of the following? (Select all that apply.) 1. Number of interventions 2. Appropriateness of the intervention for the patient 3. The prior use of interventions by other nursing staff 4. Correct application of the intervention for the patient care setting 5. The time it takes to provide interventions

2 4

A nurse is caring for a complicated patient 3 days in a row. The nurse attends an interdisciplinary conference to discuss the 268patient's plan of care. In which ways can the nurse develop trust with members of the conference team? (Select all that apply.) 1. Is willing to challenge other members' ideas because the nurse disagrees with their rationale 2. Shows competence in how to monitor patients' clinical status and inform the physician of critical changes 3. Asks a more experienced nurse to attend the conference 4. Listens to opinions of members of interdisciplinary team and expresses recommendations for care clearly 5. During the meeting focus on similar problems the nurse has had in delivering care to other patients.

2 4

A nurse is visiting a patient in the home and is assessing the patient's adherence to medications. While talking with the family caregiver, the nurse learns that the patient has been missing doses. The nurse wants to perform interventions to improve the patient's adherence. Which of the following will affect how this nurse will make clinical decisions about how to implement care for this patient? (Select all that apply.) 1. Reviewing the family caregiver's availability during medication administration times 2. Making a judgment of the value of improved adherence for the patient 3. Reviewing the number of medications and time each is to be taken 4. Determining all consequences associated with the patient missing specific medicines 5. Reviewing the therapeutic actions of the medications

2 4

Which of the following nursing diagnoses is stated correctly? (Select all that apply.) 1. Fluid Volume Excess related to heart failure 2. Sleep Deprivation related to sustained noisy environment 3. Impaired Bed Mobility related to postcardiac catheterization 4. Ineffective Protection related to inadequate nutrition 5. Diarrhea related to frequent, small, watery stools.

2, 4 Sleep deprivation related to sustained noisy environment Ineffective protection related to inadequate nutrition

For the nursing diagnosis of Deficient Knowledge a nurse selects an outcome from the Nursing Outcome Classification (NOC) of patient knowledge of arthritis treatment. Which of the following are examples of an outcome indicator for this outcome? (Select all that apply.) 1. Nurse provides four teaching sessions before discharge. 2. Patient denies joint pain following heat application. 3. Patient describes correct schedule for taking antiarthritic medications. 4. Patient explains situations for using heat application on inflamed joints. 5. Patient explains role family caregiver plays in applying heat to inflamed joint.

3 4

During the implementation step of the nursing process, a nurse reviews and revises a patient's plan of care. Place the following steps of review and revision in the correct order. 1. Modify care plan as needed. 2. Decide if the nursing interventions remain appropriate. 3. Reassess the patient. 4. Compare assessment findings to validate existing nursing diagnoses.

3 4 2 1

A nurse collects equipment needed to administer an enema to a patient. Previously the nurse reviewed the procedure in the policy manual. The nurse raises the patient's bed and adjusts the room lighting to illuminate the work area. A patient care technician 269comes into the room to assist. Which aspect of organizing resources and care delivery did the nurse omit? 1. Environment 2. Personnel 3. Equipment 4. Patient

4

A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: 1. Collaborative data set. 2. Diagnostic label. 3. Related factors. 4. Data cluster.

4

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? 1. Identifying the clinical sign instead of an etiology 2. Identifying a diagnosis on the basis of prejudicial judgment 3. Identifying the diagnostic study rather than a problem caused by the diagnostic study 4. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

4

After caring for a young man newly diagnosed with diabetes, a nurse is reviewing what was completed in his plan of care following discharge. She considers how she related to the patient and whether she selected interventions best suited to his educational level. It was the nurse's first time caring for a new patient with 278 diabetes. The nurse's behavior is an example of which of the following? 1. Reflection-in-action 2. Reassessment 3. Reprioritizing 4. Reflection-on-action

4

A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? 1. Disturbed Sleep Pattern evidenced by frequent awakening 2. Disturbed Sleep Pattern related to family caregiving responsibilities 3. Disturbed Sleep Pattern related to need to improve sleep habits 4. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

4 Disturbed sleep pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

2. A newly licensed nurse is reporting to the charge nurse about the care she gave to the client. She states, "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hours ago. The prescription reads every 4 hours prn for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with client 40 minutes later,and he said his pain is going away." The charge nurse should inform the newly licensed nurse that she left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A

5. The nurse is discussing the nursing process with a newly hired nurse. Which of the following statements by the newly hired nurse should the nurse identify as appropriate for the planning step of the nursing process. A. I will determine the most important client problems that we should address. B. I will review the PMH on the clients record to get more information C. I will go carry out the new prescriptions from the provider. D. I will ask the client if his nausea has resolved.

A

A nurse is caring for a client who has a new prescription for antihypertensive medication. Prior to administering the medication, the nurse uses an electronic database to gather information about the medication and the effects it might have on this client. Which of the following components of critical thinking is the nurse using when he reviews the medication information? A.Knowledge B. Experience C. Intuition D. Competence

A

A nurse is caring for a client who is 24 hr postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking? A. Basic B. Commitment C. Complex D. Intergrity

A

A nursing student knows that all patients should be ambulated regularly. The patient to which she is assigned has had reduced activity tolerance. She followed orders to ambulate the patient twice during the shift of care. In what way can the nursing student make the goal of improving the patient's activity tolerance a patient-centered effort? a. Engage the patient in setting mutual outcomes for distance he is able to walk b. Confirm with the patient's health care provider about ambulation goals c. Have physical therapy assist with ambulation d. Refer to medical record regarding nature of patient's physical problem

A

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid remaining in the intravenous (IV) line, and the patient asking questions about whether his doctor is coming. Which of the following does the nurse perform first? a. Reconnect the drainage tubing b. Inspect the condition of the IV dressing c. Obtain the next IV fluid bag from the medication room d. Explain when the health care provider is likely to visit

A

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 Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals with the appropriate outcome statements: Patient walks 20 feet using a walker in 24 hrs a. Patient will ambulate independently in 3 days b. Patient will be injury free for 1 month c. Patient will achieve 5-lb weight gain in 1 month d. Patient will achieve pain relief by discharge

A

By the 2nd postoperative day, a client has not achieved satisfactory pain relief. Based on the evaluation, which of the following actions should the nurse take, according to the nursing process? A. Reassess the client to determine the reason s for inadequate pain relief B. Wait to see whether the pain lessens during the next 24 hours. C. Change the plan of care to provide different pain relief medications. D. Teach the client about the plan of care for managing the pain.

A

A newly licensed nurse is considering strategies to improve critical thinking. Which of the following actions should the nurse take? (SATA) A. Find a mentor B. Use a journal to write about the outcomes of clinical judgments C. Review articles about evidence-based practice D. Limit consultations with other professionals involved in a client's care D. Make quick decisions when unsure about a client's needs

A B C

A nurse begins the night shift being assigned to five patients. She learns that the floor will be a registered nurse (RN) short as a result of a call in. A patient care technician from another area is coming to the nursing unit to assist. The nurse is required to do hourly rounds on all patients, so she begins rounds on the patient who has recently asked for a pain medication. As the nurse begins to approach the patient's room, a nurse stops her in the hallway to ask about another patient. Which factors in this nurse's unit environment will affect her ability to set priorities? (Select all that apply) a. Policy for conducting hourly rounds b. Staffing level c. Interruption by staff nurse colleague d. RN's years of experience e. Competency of patient care technician

A B C

A nurse is acquainting a group of newly licensed nurses with the roles of various members of the health care team they will encounter o a medical-surgical unit. When she gives examples of the types of tasks certified nursing assistants (CNAs) may perform, which of the following client activities should she include? (type all that apply) A. Bathing B. Ambulating C. Toileting D. Determining pain level E. Measuring vital signs

A B C E

Which of the following factors does a nurse consider for a patient with the nursing diagnosis of Disturbed Sleep Pattern related to noisy home environment in choosing an intervention for enhancing the patient's sleep? (Select all that apply) a. The intervention should be directed at reducing noise b. The intervention should be one shown to be effective in promoting sleep on the basis of research c. The intervention should be one commonly used by the patient's sleep partner d. The intervention should be one acceptable to the patient e. The intervention should be one you used with other patients in the past

A B D

A 62-year-old patient had a portion of the large colon removed and a colostomy created for drainage of stool. The nurse has had repeated problems with the patient's colostomy bag not adhering to the skin and thus leaking. The nurse wants to consult with the wound care nurse specialist. Which of the following should the nurse do? (Select all that apply) a. Assess condition of skin before making the call b. Rely on the nurse specialist to know the type of surgery the patient likely had c. Explain the patient's response emotionally to the repeated leaking of stool d. Describe the type of bag being used and how long it lasts before leaking e. Order extra colostomy bags currently being used

A C D

A client who is postoperative following knee arthroplasty is concerned about the adverse effects of the medication he is receiving for pain management. Which of the following members of the inter professional care team can assist the client in understanding the medication's effects? (type all that apply) A. Provider B. Certified nursing assistant C. Pharmacist D. Registered nurse E. Respiratory therapist

A C D

3. A charge nurse is reviewing the steps of the nursing process with a group of nurse. Which of the following data should the charge nurse identify as objective data? SATA A. Respiratory rate is 22/min with even, unlabored respiration's. B. The clients partner states, "He said he hurts after walking about 10 minutes. C. Pain rating is a 3 on a scale of 0 to 10. D. Skin is pink, warm and dry. E. The AP reports the client walked with a limp

A D E

It is time for a nurse hand-off between the night nurse and nurse starting the day shift. The night nurse checks the most recent laboratory results for the patient and then begins to discuss the patient's plan of care to the day nurse using the standard checklist for reporting essential information. The patient has been seriously ill, and his wife is at the bedside. The nurse asks the wife to leave the room for just a few minutes. The night nurse completes the summary of care before the day nurse is able to ask a question. Which of the following activities are strategies for an effective hand-off? (Select all that apply) a. Using a standardized checklist for essential information b. Asking the wife to briefly leave the room c. Completing the hand-off without inviting questions d. Doing prework such as checking laboratory results before giving a report e. Including the wife in the hand-off discussion

A D E

A nurse notes that an advance directive is on a patient's medical record. Which statement represents the best description of an advance directive guideline that the nurse will follow? 1. a living will allows an appointed person to make health care decisions when the patient is in an incapacitated state 2. A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state. 3. the patient cannot make changes in the advance directive once admitted to the hospital 4. a durable power of attorney for health care is invoked only when the patient has a terminal condition or is in a persistent vegetative state

A living will is invoked only when the patient has a terminal condition or is in a persistent vegetative state.

The physician is planning to take the patient to surgery in the morning and leaves an order for the nurse to get the patient to sign the surgical permit. The physician's note indicates that the patient has been educated on the procedure. However, the patient tells the nurse, "I have no idea what he's going to do. He rushed in and rushed out so fast, I couldn't ask any questions." The nurse does not allow the patient to sign the permit and calls the physician to inform him of the patient's statement. This is an example of the nurse acting as a. Patient advocate. b. Patient educator. c. Manager. d. Clinical nurse specialist.

patient advocate

The nurse is caring for her patients and is focused on managing their care as opposed to managing and performing skills. This nurse demonstrates which level of proficiency according to Benner? a. Novice b. Competent c. Proficient d. Expert

proficient

The patient requires routine gynecological services after giving birth to her son, and while seeing the nurse midwife, she asks for a referral to a pediatrician for the newborn. The nurse midwife should a. Provide the referral as requested. b. Offer to provide the newborn care. c. Refer the patient to the supervising physician. d. Tell the patient that she cannot make referrals.

provide the referral

The major difference between a baccalaureate degree nursing program and an associate's degree nursing program is that the baccalaureate program includes studies in a. Basic sciences and theoretical courses. b. Social sciences and humanities. c. Theoretical and clinical courses. d. Basic sciences and clinical courses.

social sciences and humanities

A nurse meets with the registered dietician and physical therapist to develop a plan of care that focuses on improving nutrition and mobility for a patient. This is an example of which Quality and Safety in the Eduction of Nurses (QSEN) competency? 1. Patient-centered care 2. Safety 3. Teamwork and collaboration 4. Informatics

teamwork and collaboration

In 1923, the Goldmark Report was an important study that a. Formed formal nurse midwifery programs. b. Established the Center for Ethics and Human Rights. c. Revised the ANA code of ethics. d. Led to the development of the Yale School of Nursing.

the Yale School of Nursing was developed

The student nurse has a goal of becoming a certified registered nurse anesthetist (CRNA). It is important for the student to understand that the CRNA a. Works under the guidance of an anesthesiologist. b. Manages acute medical conditions. c. Manages gynecological services such as PAP smears. d. Must have a PhD degree in anesthesiology.

works under the guidance of an anesthesiologist

The nurse in the twenty-first century is facing an extremely complex profession with multiple external forces affecting the nursing profession. Factors influencing the nursing profession include which of the following? (Select all that apply.) a. Demography b. Women's health care c. Human rights d. The threat of bioterrorism e. The medically underserved

ANS: A, B, C, D, E

The nurse manager from the oncology unit has had two callouts; the orthopedic unit has had multiple discharges and probably will have to cancel one or two of its nurses. The orthopedic unit has agreed to "float" two of its nurses to the oncology unit if oncology can "float" a nursing assistant to the orthopedic unit to help with obtaining vital signs. This is an example of (Select all that apply.) a. Autonomy. b. Accountability. c. Political activism. d. Politics.

ANS: A, B, D

Which of the following is (are) an example of an advanced practice nurse? (Select all that apply.) a. Nurse practitioner b. Clinical nurse specialist c. Patient advocate d. Certified registered nurse anesthetist e. Nurse midwife

ANS: A, B, D, E

After licensure, the practicing nurse is required to update his or her knowledge about the latest research and practice developments. The most common way nurses do this is through _____ programs. (Select all that apply.) a. Continuing education b. Master's degree c. In-service education d. DNP

ANS: A, C

Which concept means that the nurse is responsible, professionally and legally, for the type and quality of nursing care provided? a. Autonomy b. Accountability c. Patient advocacy d. Patient education

Accountability

Fill in the Blank. A nurse administered an antibiotic 30 minutes ago and returns to the patient's room to determine if the patient is having any unexpected symptoms. This is an example of assessing for a(n) ___________________.

Adverse reaction

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 surgery to the family and discuss the patient's wishes with them. The nurse is acting as the patients: 1. Education 2. Advocate 3. Caregiver 4. Case Manager

Advocate

Which of the following examples are steps of nursing assessment? (Select all that apply.) 1. Collection of information from patient's family members 2. Recognition that further observations are needed to clarify information 3. Comparison of data with another source to determine data accuracy 4. Complete documentation of observational information 5. Determining which medications to administer based on a patient's assessment data

Answer: 1, 2, 3.

The nurse enters the room of an 82-year-old patient for whom she has not cared previously. The nurse notices that the patient wears a hearing aid. The patient looks up as the nurse approaches the bedside. Which of the following approaches are likely to be effective with an older adult? (Select all that apply.) 1. Listen attentively to the patient's story. 2. Use gestures that reinforce your questions or comments. 3. Stand back away from the bedside. 4. Maintain direct eye contact. 5. Ask questions quickly to reduce the patient's fatigue.

Answer: 1, 2, 4.

When a nurse conducts an assessment, data about a patient often comes from which of the following sources? (Select all that apply.) 1. An observation of how a patient turns and moves in bed 2. The unit policy and procedure manual 3. The care recommendations of a physical therapist 4. The results of a diagnostic x-ray film 5. Your experiences in caring for other patients with similar problems

Answer: 1, 3, 4.

A nurse gathers the following assessment data. Which of the fol- lowing cues together form(s) a pattern suggesting a problem? (Select all that apply.) 1. The skin around the wound is tender to touch. 2. Fluid intake for 8 hours is 800 mL. 3. Patient has a heart rate of 78 beats/min and regular. 4. Patient has drainage from surgical wound. 5. Body temperature is 38.3° C (101° F). 6. Patient states, "I'm worried that I won't be able to return to work when I planned."

Answer: 1, 4, 5.

A nurse makes the following statement during a change-of-shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, and he moves slowly as he transfers to a chair." What can the nurse who is begin- ning a shift do to validate the previous nurse's assessment findings when she conducts rounds on the patient? (Select all that apply.) 1. The nurse asks the patient to rate his pain on a scale of 0 to 10. 2. The nurse asks the patient what caused his fall. 3. The nurse asks the patient if he has had pain in his back in the past. 4. The nurse assesses the patient's lower-limb strength. 5. The nurse asks the patient what pain medication is most effec- tive in managing his pain.

Answer: 1, 4.

A nurse is checking a patient's intravenous line and, while doing so, notices how the patient bathes himself and then sits on the side of the bed independently to put on a new gown. This observation is an example of assessing: 1. Patient's level of function. 2. Patient's willingness to perform self-care. 3. Patient's level of consciousness. 4. Patient's health management values.

Answer: 1.

A nurse is conducting a patient-centered interview. Place the state- ments 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 last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." "So, to summarize, you've lost about 6 lbs in the last month, and your appetite has been poor correct?"

Answer: 2, 4, 1, 5, 3.

The nurse asks a patient, "Describe for me a typical night's sleep. What do you do to fall asleep? Do you have difficulty falling or staying asleep? This series of questions would likely occur during which phase of a patient-centered interview? 1. Orientation 2. Working phase 3. Data validation 4. Termination

Answer: 2.

Which type of interview question does the nurse first use when assessing the reason for a patient seeking health care? 1. Probing 2. Open-ended 3. Problem-oriented 4. Confirmation

Answer: 2.

A nurse is assigned to a 42-year-old mother of 4 who weighs 136.2 kg (300 lbs), has diabetes, and works part time in the kitchen of a restaurant. The patient is facing surgery for gallbladder disease. Which of the following approaches demonstrates the nurse's cultural competence in assessing the patient's health care problems? 1. "I can tell that your eating habits have led to your diabetes. Is that right?" 2. "It's been difficult for people to find jobs. Is that why you work part time?" 3. "You have four children; do you have any concerns about going home and caring for them?" 4. "I wish patients understood how overeating affects their health."

Answer: 3.

During a visit to the clinic, a patient tells the nurse that he has been having headaches on and off for a week. The headaches sometimes make him feel nauseated. Which of the following responses by the nurse is an example of probing? 1. So you've had headaches periodically in the last week and sometimes they cause you to feel nauseated—correct? 2. Have you taken anything for your headaches? 3. Tell me what makes your headaches begin. 4. Uh huh, tell me more.

Answer: 3.

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

Answer: 3.

A 72-year-old male patient comes to the health clinic for an annual follow-up. The nurse enters the patient's room and notices him to be diaphoretic, holding his chest and breathing with difficulty. The nurse immediately checks the patient's heart rate and blood pres- sure and asks him, "Tell me where your pain is." Which of the following assessment approaches does this scenario describe? 1. Review of systems approach 2. Use of a structured database format 3. Back channeling 4. A problem-oriented approach

Answer: 4.

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been here, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you've been in following his plan?" The nurse's assessment covers which of Gordon's func- tional health patterns? 1. Value-belief pattern 2. Cognitive-perceptual pattern 3. Coping-stress-tolerance pattern 4. Health perception-health management pattern

Answer: 4.

A patient who visits the surgery clinic 4 weeks after a traumatic amputation of his right leg tells the nurse practitioner that he is worried about his ability to continue to support his family. He tells the nurse he feels that he has let his family down after having an auto accident that led to the loss of his left leg. The nurse listens and then asks the patient, "How do you see yourself now?" On the basis of Gordon's functional health patterns, which pattern does the nurse assess? 1. Health perception-health management pattern 2. Value-belief pattern 3. Cognitive-perceptual pattern 4. Self-perception-self-concept pattern

Answer: 4.

An 18 yr. old woman in the emergency department with fever and cough. The nurse obtains her vital signs, listens to her lung and heart sounds, determines her level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed? 1. Diagnosis 2. Evaluation 3. Assessment 4. Implementation

Assessment

The nurse is caring for the patient who has had major abdominal surgery and also has a large sacral pressure sore. The nurse implements coughing and deep breathing exercises and consults the wound care specialist to evaluate and prescribe care for the pressure sore, even though no physician order has provided instructions to do so. In doing this, the nurse is implementing the element of a. Autonomy. b. Accountability. c. Advanced practice. d. Nurse practitioner.

Autonomy

A home health nurse visits a 42-year-old woman with diabetes who has a recurrent foot ulcer. The ulcer has prevented the woman from working for over 2 weeks. The patient has had diabetes for 10 years. The ulcer has not been healing; it has drainage with a foul-smelling odor. As the nurse examines the patient, she learns that the patient is not following the ordered diabetic diet. Which of the following is considered a low-priority goal for this patient? a. Achieving wound healing of the foot ulcer b. Enhancing patient knowledge about the effects of diabetes c. Providing a dietitian consultation for diet retraining d. Improving patient adherence to diabetic diet

B

A nurse receives a prescription for an antibiotic for a client who has cellulitis. The nurse checks the client's medical record, discovers that the client is allergic to the antibiotic, and calls the provider to request a prescription for a different antibiotic. Which of the following critical thinking attitudes did the nurse demonstrate? A. Fairness B. Responsibility C. Risk-taking D. Creativity

B

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 Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals with the appropriate outcome statements: Patient identifies barriers to remove in the home within 1 week a. Patient will ambulate independently in 3 days b. Patient will be injury free for 1 month c. Patient will achieve 5-lb weight gain in 1 month d. Patient will achieve pain relief by discharge

B

Nurses working in the Henry Street Settlement in 1893 were among the first nurses to demonstrate autonomy in practice. This was because those nurses a. Had no ability to work in the hospital setting. b. Were required to use critical thinking skills. c. Focused solely on healing the very ill. d. Planned their care around research findings.

B

Which of the following resources guides faculty on structure and evaluation of the nursing curriculum? a. ANA's Standards of Nursing Practice b. Essentials of Baccalaureate Education c. NLNAC Interpretive Guidelines d. Standards of Professional Performance

B

Which of the following factors does a nurse consider in setting priorities for a patient's nursing diagnoses? (Select all that apply) a. Numbered order of diagnosis on the basis of severity b. Notion of urgency for nursing action c. Symptom pattern recognition suggesting a problem d. Mutually agreed on priorities set with patient e. Time when a specific diagnosis was identified

B C D

A patient has the nursing diagnosis of Nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? (Select all that apply) a. Providing mouth care every 4 hours b. Maintaining intravenous (IV) infusion at 100 mL/hr c. Administering prochlorperazine (Compazine) via rectal suppository d. Consulting with dietitian on initial foods to offer patient e. Controlling aversive odors or unpleasant visual stimulation that triggers nausea

B D

The nurse has been working in the clinical setting for several years as an advanced practice nurse and has earned her master's degree as a family nurse practitioner. However, she seems unfulfilled and has a strong desire to do research. To fulfill her desire, the nurse most likely would apply to attend a program that would lead to a a. Doctor of Nursing Science degree (DNSc). b. Doctor of Philosophy degree (PhD). c. Doctor of Nursing Practice degree (DNP). d. Doctor in the Science of Nursing degree (DSN).

B. PhD

A bill has been submitted to the State House of Representatives that is designed to reduce the cost of health care by increasing the patient-to-nurse ratio from a maximum of 2:1 in intensive care units to 3:1. The nurse realizes that a. Legislation is politics beyond the nurse's control. b. National programs have no bearing on state politics. c. The individual nurse can influence legislative decisions. d. Focusing on nursing care provides the best patient benefit.

C

A nurse enters the room of a 32-year-old patient newly diagnosed with cancer at the beginning of the 0700 evening/night shift. The nurse noted in the patient's nursing history that this is her first hospitalization. She is scheduled for surgery in the morning to remove a tumor and has questions about what to expect after surgery. She is observed talking with her mother and is crying. The patient says, "This is so unfair." An order has been written for an enema to be given this evening in preparation for the surgery. The nurse establishes priorities for which of the following situations first? a. Giving the enema on time b. Talking with the patient about her past experiences with illness c. Talking with the patient about her concerns and acknowledging her sense of unfairness d. Beginning instruction on postoperative procedures

C

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 Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals with the appropriate outcome statements: Patient increases calorie intake to 2500 daily a. Patient will ambulate independently in 3 days b. Patient will be injury free for 1 month c. Patient will achieve 5-lb weight gain in 1 month d. Patient will achieve pain relief by discharge

C

Graduates of baccalaureate degree or associate's degree nursing programs are eligible to take which of the following to become registered nurses in the state in which they will practice? a. Continuing education credits b. In-service education programs c. National Council Licensure Examination d. Graduate education

C

A nursing student is reporting during hand-off to the registered nurse (RN) assuming her patient's care. The student states, "Mr. Roarke had a good day, his intravenous (IV) fluid is infusing at 124 mL/hr with D5 ½ NS infusing in right forearm. The IV site is intact, and no complaints of tenderness. I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. He still uses his cane without difficulty. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. If the nurse's goal for Mr. Roarke was to improve activity tolerance, which expected outcomes were shared in the hand-off? (Select all that apply) a. IV site not tender b. Uses cane to walk c. Walked to end of hall d. No shortness of breath e. Slept better during night

C D

4. A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a providers prescription. Which of the following interventions should the charge nurse include? (SATA) A. Writing a prescription for morphine sulfate as needed for pain. B. Inserting a NG tube to relieve gastric gastric detention C. Showing a client how to use progressive relaxation. D. Performing a daily bath after the evening meal. E. Repositioning a client every 2 hours to reduce pressure ulcer risk.

C D E

You are floated to work on a nursing unit where you are given an assignment that is beyond your capability. Which is the best nursing action to take first? 1. Call the nursing supervisor to discuss the situation 2. discuss the problem with a colleague 3. leave the nursing unit and go home 4. say nothing and begin your work

Call the nursing supervisor to discuss the situation

The American Red Cross was founded by a. Florence Nightingale. b. Harriet Tubman. c. Clara Barton. d. Mary Mahoney.

Clara Barton

A home health nurse notices significant bruising on a 2-year-old patient's head, arms, abdomen, and legs. The patient's mother describes the patient's frequent falls. What is the best nursing action for the home health nurse to take? 1. document her findings and treat the patient 2. instruct the mother on safe handling of a 2 year old child 3. contact a child abuse hotline 4. discuss this story with a colleague

Contact a child abuse hotline

A client who has had a cerebrovascular accident has persistent problems with dysphagia (difficulty swallowing). The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team? A. Social worker B. Certified nursing assistant C. Occupational therapist D. Speech-language pathologist

D

A goal for a client who has difficulty with self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral to which of the following members of the inter professional care team? A. Social worker B. Certified nursing assistant C. Registered dietician D. Occupational therapist

D

A nurse uses a head-to-toe approach to conduct a physical assessment of a client who will undergo surgery the following week. Which of the following critical thinking attitudes did the nurse demonstrate? A. Confidence B. Perserverance C. Intergrity D. Discipline

D

A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention? a. Reporting hand-off at change of shift b. Ambulating patient down hallway c. Sleep hygiene Incorrect d. IV fluid administration

D

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 Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals with the appropriate outcome statements: Patient expresses fewer nonverbal signs of discomfort within 24 hrs a. Patient will ambulate independently in 3 days b. Patient will be injury free for 1 month c. Patient will achieve 5-lb weight gain in 1 month d. Patient will achieve pain relief by discharge

D

The nurse writes an expected outcome statement in measurable terms. An example is: a. Patient will have normal stool evacuation b. Patient will have fewer bowel movements c. Patient will take stool softener every 4 hours d. Patient will report stool soft and formed with each defecation

D

You are the night shift nurse caring for a newly admitted patient who appears to be confused. The family asks to see the patient's medical record. What is the priority nursing action? 1. give the family the record 2. discuss the issues that concern the family with them 3. call the nursing supervisor 4. Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

Determine from the medical record if the family has been granted permission by the patient to access his or her medical information

The nurse spends time with the patient and family receiving the 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. Case Manager

Educator

A homeless man enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? 1. health insurance portability and accountability act (HIPAA) 2. americans with disabilities act (ADA) 3. Patient Self-Determination Act (PSDA) 4. Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

Emergency Medical Treatment and Active Labor Act (EMTALA) without triage completed

A patient has a fractured femur that is placed in skeletal traction with a fresh plaster cast applied. The patient experiences decreased sensation and a cold feeling in the toes of the affected leg. The nurse observes that the patient's toes have become pale and cold but forgets to document this because one of the nurse's other patients experienced cardiac arrest at the same time. Two days later the patient in skeletal traction has an elevated temperature, and he is prepared for surgery to amputate the leg below the knee. Which of the following statements regarding a breach of duty apply to this situation? (Select all that apply.) 1. Failure to document a change in assessment data 2. failure to provide discharge instructions 3. failure to follow the six rights of medication administration 4. failure to use proper medical equipment ordered for patient monitoring 5. Failure to notify a health care provider about a change in the patient's condition

Failure to document a change in assessment data Failure to notify a health care provider about a change in the patient's condition

How does knowledge of genomics affect patient treatment decisions?

Genomics describes the study of all the genes in a person, as well as interactions of those genes with each other and with that person's environment. Genomic information allows health care providers to determine how genomic changes contribute to patient conditions and influence treatment decisions.

During the American Civil War, which of the following women was active in the Underground Railroad movement and assisted in leading more than 300 slaves to freedom? a. Harriet Tubman b. Clara Barton c. Dorothea Dix d. Mary Ann Ball (Mother Bickerdyke)

Harriet Tubman

Which of the following internet resources can help consumers compare quality care measures? (select all that apply) 1. WebMD 2. Hospital compare 3. Magnet Recognition Program 4. Hospital consumer assessment of healthcare 5. The American Hospital Association's webpage

Hospital compare Hospital consumer assessment of healthcare

A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hrs. Which standard of practice is performed? 1. Planning 2. Evaluation 3. Assessment 4. Implementation

Implementation

Nurses in an acute care hospital care attending a unit-based eduction program to learn how to use a new pressure-relieving device for patients at risk for pressure ulcers. This is which type of eduction? 1. Continuing eduction 2. Graduate eduction 3. In-service education 4. Professional Registered Nurse education

In-service education

A woman has severe life-threatening injuries and is hemorrhaging following a car accident. The health care provider ordered 2 units of packed red blood cells to treat the woman's anemia. The woman's husband refuses to allow the nurse to give his wife the blood for religious reasons. What is the nurse's responsibility? 1. obtain a court order to give blood 2. coerce the husband into giving the blood 3. call security and have the husband removed from the hospital 4. More information is needed about the wife's preference and if the husband has her medical power of attorney

More information is needed about the wife's preference and if the husband has her medical power of attorney

Health care reform will bring changes in the emphasis of care. Which of the following 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 an acute illness to a disease management model 4. Moving from a chronic care to an illness prevention model

Moving from an acute illness to a health promotion, illness prevention model

The first practicing nurse epidemiologist was a. Florence Nightingale. b. Mildred Montag. c. Clara Barton. d. Mary Agnes Snively.

Nightingale

The nurses on an acute care medical floor notice an increase in pressure ulcer 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 ulcer 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

Nurse researcher

A nurse is caring for a patient who recently had coronary bypass surgery and now is on the postoperative unit. Which are legal sources of standards of care that the nurse uses to deliver safe health care? (Select all that apply.) 1. Information provided by the head nurse 2. policies and procedures of the employing hospital 3. State Nurse Practice Act 4. Regulations identified in the Joint Commission manual 5. The American Nurses Association standards of nursing practice

Policies and procedures of the employing hospital State Nurse Practice Act Regulations identified in The Joint Commission manual The American Nurses Association standards of nursing practice

What is the importance of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey? 1. Measures a nurse's competency in interdisciplinary care 2. Measures the number of adverse events in a hospital 3. Measures quality of care within hospitals 4. Measures referrals to a health care agency

3

Which principle is most important for a nurse to follow when using a clinical practice guideline for an assigned patient? 1. Knowing the source of the guideline 2. Reviewing the evidence used to develop the guideline 3. Individualizing how to apply the clinical guideline for a patient 4. Explaining to a patient the purpose of the guideline

3

Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples? (select all that apply) 1. Caregiver 2. Autonomy and Accountability 3. Patient advocate 4. Health Promotion 5. Lobbyist

1. Caregiver 2. Autonomy and Accountability 3. Patient advocate 4. Health Promotion

A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? 1. Insufficient cluster of cues 2. Disorganization 3. Insufficient number of cues 4. Evidence that another diagnosis is more likely

3

A nurse enters a patient's room and begins a conversation. During this time the nurse evaluates how a patient is tolerating a new diet plan. The nurse decides to also evaluate the patient's expectations of care. Which statement is appropriate for evaluating a patient's expectations of care? 1. On a scale of 0 to 10 rate your level of nausea. 2. The nurse weighs the patient. 3. The nurse asks, "Did you believe that you received the information you needed to follow your diet?" 4. The nurse states, "Tell me four different foods included in your diet."

3

A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? 1. Infant crying at breast 2. Infant unable to latch on to breast correctly 3. Mother's deficient knowledge 4. Lack of infant weight gain

3

A nurse notes that the health care unit keeps a listing of the patient names at the front desk in easy view for health care providers to more efficiently locate the patient. The nurse talks with the nurse manager because this action is a violation of which act? 1. Patient Protection and Affordable Care Act (PPACA) 2. Patient Self-Determination Act (PSDA) 3. Health Insurance Portability and Accountability Act (HIPAA) 4. Emergency Medical Treatment and Active Labor Act

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