NU 270- Exam 2 textbook practice questions

Annie seeks the help of the nurse in the student health clinic because she suspects that her roommate, Angela, suffered date rape. She is concerned because Angela chose not to report the rape and does not seem to be coping well. (1) After talking with Annie, the nurse learns that although Angela blurted out that she had been raped when she first came home, since then she has refused verbalization about the rape ("I don't want to think or talk about it"), has stopped attending all college social activities (a marked change in behavior), and seems to be having nightmares. After analyzing the data, the nurse believes that Angela might be experiencing (2) rape-trauma syndrome: silent reaction. Fortunately, Angela trusts Annie and is willing to come to the student health center for help. A conversation with Angela confirms the nurse's suspicions, and problem identification begins. The nurse talks further with Angela (3) to develop some treatment goals and formulate outcomes. The nurse also begins to think about the types of nursing interventions most likely to yield the desired outcomes. In the initial meeting with Angela, (4) the nurse encourages her expression of feelings and helps her to identify personal coping strategies and strengths. The nurse and Angela decide to meet in 1 week (5) to assess her progress toward achieving targeted outcomes. If she is not making progress, the care plan might need to be modified. (1) _____________________ (2) _____________________ (3) _____________________ (4) _____________________ (5) _____________________

(1) is an illustration of assessing: the collection of patient data. (2) is an illustration of the identification of a nursing diagnosis: a health problem that independent nursing intervention can resolve. (3) is an illustration of planning: outcome identification and related nursing interventions. (4) is an illustration of implementing: carrying out the care plan. (5) is an illustration of evaluating: measuring the extent to which Angela has achieved targeted outcomes.

The nurse obtains a medical history from a patient before beginning drug therapy based on an understanding of which of the following? a. Medical conditions can alter a drug's pharmacokinetics and pharmacodynamics. b. A medical history is a key component of any nursing protocol. c. A baseline of information is necessary to evaluate a drug's effects. d. The medical history is the first step in the nursing process.

a.

A quality-assurance program reveals a higher incidence of falls and other safety violations on a particular unit. A nurse manager states, "We'd better find the people responsible for these errors and see if we can replace them." This is an example of: a. Quality by inspection b. Quality by punishment c. Quality by surveillance d. Quality by opportunity

a. Quality by inspection focuses on finding deficient workers and removing them. Quality as opportunity focuses on finding opportunities for improvement and fosters an environment that thrives on teamwork, with people sharing the skills and lessons they have learned. Quality by punishment and quality by surveillance are not quality-assurance methods used in the health care field.

The nursing care of a patient receiving drug therapy should include measures to decrease the anticipated adverse effects of the drug. Which of the following measures would a nurse consider? Select all that apply a. A positive approach b. Environmental temperature control c. Safety measures d. Skin care e. Refrigeration of the drug f. Involvement of the family

a, b, c, d, f

A nurse is preparing to administer a drug to a client for the first time. What questions should the nurse consider before actually administering the drug? Select all that apply a. Is this the right patient? b. Is this the right drug? c. Is there a generic drug available? d. Is this the right route for this patient? e. Is this the right dose, as ordered? f. Did I record this properly?

a, b, d, e

A client is being started on a laxative regimen. Before administering the medication, the nurse should perform which of the following processes? Select all that apply a. Assessing for allergies b. Evaluating the medication effectiveness c. Evaluating the route of administration d. Diagnosing the patient with ischemic colitis e. Asking the patient for name and birth date record when the medication was dispensed from the pharmacy

a, c, e

A nurse is attempting to improve care on the pediatric ward of a hospital. Which nursing improvements might the nurse employ when following the recommendations of the Institute of Medicine's Committee on Quality of Health Care in America? Select all that apply. a. Basing patient care on continuous healing relationships b. Customizing care to reflect the competencies of the staff c. Using evidence-based decision making d. Having a charge nurse as the source of control e. Using safety as a system priority f. Recognizing the need for secrecy to protect patient privacy

a, c, e. Care should be based on continuous healing relationships and evidence-based decision making. Customization should be based on patient needs and values with the patient as the source of control. Safety should be used as a system priority, and the need for transparency should be recognized.

A new nurse who is being oriented to the subacute care unit is expected to follow existing standards when providing patient care. Which nursing actions are examples of these standards? Select all that apply. a. Monitoring patient status every hour b. Using intuition to troubleshoot patient problems c. Turning a patient on bed rest every 2 hours d. Becoming a nurse mentor to a student nurse e. Administering pain medication ordered by the physician f. Becoming involved in community nursing events

a, c, e. Standards are the levels of performance accepted and expected by the nursing staff or other health care team members. They are established by authority, custom, or consent. Standards would include monitoring patient status every hour, turning a patient on bed rest every 2 hours, and administering pain medication ordered by the physician. Using intuition to troubleshoot patient problems, becoming a nurse mentor to a student nurse, and becoming involved in community nursing events are not patient care standards.

A nurse is using critical pathway methodology for choosing interventions for a patient who is receiving chemotherapy for breast cancer. Which nursing actions are characteristics of this system being used when planning care? Select all that apply. a. The nurse uses a minimal practice standard and is able to alter care to meet the patient's individual needs. b. The nurse uses a binary decision tree for stepwise assessment and intervention. c. The nurse is able to measure the cause-and-effect relationship between pathway and patient outcomes. d. The nurse uses broad, research-based practice recommendations that may or may not have been tested in clinical practice. e. The nurse uses preprinted provider orders used to expedite the order process after a practice standard has been validated through research. f. The nurse uses a decision tree that provides intense specificity and no provider flexibility.

a, c. A critical pathway represents a sequential, interdisciplinary, minimal practice standard for a specific patient population that provides flexibility to alter care to meet individualized patient needs. It also offers the ability to measure a cause-and-effect relationship between pathway and patient outcomes. An algorithm is a binary decision tree that guides stepwise assessment and intervention with intense specificity and no provider flexibility. Guidelines are broad, research-based practice recommendations that may or may not have been tested in clinical practice, and an order set is a preprinted provider order used to expedite the order process after a practice standard has been validated through analytical research.

A nurse researcher keeps current on the trends to watch in health care delivery. What trends are likely included? Select all that apply. a. Globalization of the economy and society b. Slowdown in technology development c. Decreasing diversity d. Increasing complexity of patient care e. Changing demographics f. Shortages of key health care professionals and educators

a, d, e, f. Trends to watch in health care delivery include globalization of the economy and society, increasing complexity of patient care, changing demographics, shortages of key health care professionals and educators, technology explosion, and increasing diversity.

Nurses provide care to patients as collaborative members of the health care team. Which roles may be performed by the advanced practice registered nurse? Select all that apply. a. Primary care provider b. Hospitalist c. Physical therapist d. Anesthetist e. Midwife f. Pharmacist

a, d, e. The Advanced Practice Registered Nurse (APRN) is a registered nurse educated at the master's or post-master's level in a specific role and for a specific population. Whether they are nurse practitioners, clinical nurse specialists, nurse anesthetists, or nurse midwives, APRNs play a pivotal role in the future of health care. APRNs are often primary care providers and are at the forefront of providing preventive care to the public. Hospitalists are health care providers who provide care to patients when they visit the emergency department or are admitted to the hospital. A physical therapist completes a specific training program to learn to help patients restore function or to prevent further disability in a patient after an injury or illness. A pharmacist, prepared at the doctoral level, is licensed to formulate and dispense medications.

A nurse is using the implementation step of the nursing process to provide care for patients in a busy hospital setting. Which nursing actions best represent this step? Select all that apply. a. The nurse carefully removes the bandages from a burn victim's arm. b. The nurse assesses a patient to check nutritional status. c. The nurse formulates a nursing diagnosis for a patient with epilepsy. d. The nurse turns a patient in bed every 2 hours to prevent pressure injuries. e. The nurse checks a patient's insurance coverage at the initial interview. f. The nurse checks for community resources for a patient with dementia.

a, d, f. During the implementing step of the nursing process, nursing actions planned in the previous step are carried out. The purpose of implementation is to assist the patient in achieving valued health outcomes: promote health, prevent disease and illness, restore health, and facilitate coping with altered functioning. Assessing a patient for nutritional status or insurance coverage occurs in the assessment step, and formulating nursing diagnoses occurs in the diagnosing step.

The nurse uses blended competencies when caring for patients in a rehabilitation facility. Which examples of interventions involve cognitive skills? Select all that apply. a. The nurse uses critical thinking skills to plan care for a patient. b. The nurse correctly administers IV saline to a patient who is dehydrated. c. The nurse assists a patient to fill out an informed consent form. d. The nurse learns the correct dosages for patient pain medications. e. The nurse comforts a mother whose baby was born with Down syndrome. f. The nurse uses the proper procedure to catheterize a female patient.

a, d. Using critical thinking and learning medication dosages are cognitive competencies. Performing procedures correctly is a technical skill, helping a patient with an informed consent form is a legal/ethical issue, and comforting a patient is an interpersonal skill.

A patient receiving an antihistamine complains of dry mouth and nose. An appropriate comfort measure for this patient would be to a. suggest that the patient use a humidifier. b. encourage voiding before taking the drug. c. have the patient avoid sun exposure. d. give the patient a back rub.

a.

After teaching a patient about digoxin (Lanoxin)—a drug used to increase the effectiveness of the heart's contractions—which statement indicates that the teaching was effective? a. "I need to take my pulse every morning before I take my pill." b. "If I forget my pills, I usually make up the missed dose once I remember." c. "This pill might help my hay fever when it becomes a problem." d. "I don't remember the name of it, but it is the white one."

a.

A nurse is prioritizing the following patient diagnoses according to Maslow's hierarchy of human needs: (1) Disturbed Body Image (2) Ineffective Airway Clearance (3) Spiritual Distress (4) Impaired Social Interaction Which answer choice below lists the problems in order of highest priority to lowest priority based on Maslow's model? 2, 4, 1, 3 3, 1, 4, 2 2, 4, 3, 1 3, 2, 4, 1

a. 2, 4, 1, 3. Because basic needs must be met before a person can focus on higher ones, patient needs may be prioritized according to Maslow's hierarchy: (1) physiologic needs, (2) safety needs, (3) love and belonging needs, (4) self-esteem needs, and (5) self-actualization needs. #2 is an example of a physiologic need, #4 is an example of a love and belonging need, #1 is an example of a self-esteem need, and #3 is an example of a self-actualization need.

A nurse is assessing the following children. Which child would the nurse identify as having the greatest risk for choking and suffocating? a. A toddler playing with his 9-year-old brother's construction set b. A 4-year-old eating yogurt for lunch c. An infant covered with a small blanket and asleep in the crib d. A 3-year-old drinking a glass of juice

a. A young child may place small or loose parts in the mouth; a toy that is safe for a 9-year-old could kill a toddler. An infant sleeping in a crib without a pillow or large blanket and a 3-year-old and a 4-year-old drinking juice and eating yogurt are not particular safety risks.

A nurse is assessing a patient who is diagnosed with anorexia. Following the assessment, the nurse recommends that the patient meet with a nutritionist. This action best exemplifies the use of: a. Clinical judgment b. Clinical reasoning c. Critical thinking d. Blended competencies

a. Although all the options refer to the skills used by nurses in practice, the best choice is clinical judgment as it refers to the result or outcome of critical thinking or clinical reasoning—in this case, the recommendation to meet with a nutritionist. Clinical reasoning usually refers to ways of thinking about patient care issues (determining, preventing, and managing patient problems). Critical thinking is a broad term that includes reasoning both outside and inside of the clinical setting. Blended competencies are the cognitive, technical, interpersonal, and ethical and legal skills combined with the willingness to use them creatively and critically when working with patients.

An experienced nurse tells a beginning nurse not to bother studying too hard, since most clinical reasoning becomes "second nature" and "intuitive" once you start practicing. What thinking below should underlie the beginning nurse's response? a. Intuitive problem solving comes with years of practice and observation, and novice nurses should base their care on scientific problem solving. b. For nursing to remain a science, nurses must continue to be vigilant about stamping out intuitive reasoning. c. The emphasis on logical, scientific, evidence-based reasoning has held nursing back for years; it is time to champion intuitive, creative thinking! d. It is simply a matter of preference; some nurses are logical, scientific thinkers, and some are intuitive, creative thinkers.

a. Beginning nurses must use nursing knowledge and scientific problem solving as the basis of care they give; intuitive problem solving comes with years of practice and observation. If the beginning nurse has an intuition about a patient, that information should be discussed with the faculty member, preceptor, or supervisor. Answer b is incorrect because there is a place for intuitive reasoning in nursing, but it will never replace logical, scientific reasoning. Critical thinking is contextual and changes depending on the circumstances, not on personal preference.

A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. Which information is accurate and should be included in the teaching plan? a. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. b. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. c. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a front-facing safety seat. d. Children older than 6 years may be restrained using a car seat belt in the back seat.

a. Booster seats should be used for children until they are 4′9″ tall and weigh between 80 and 100 lb. All 50 U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to 2 years of age (or up to the maximum height and weight for the seat) should be in a rear-facing safety seat. Many children older than 6 years should still be in a booster seat.

A nurse working in a primary care facility prepares insurance forms in which the provider is given a fixed amount per enrollee of the health plan. What is the term for this type of reimbursement? a. Capitation b. Prospective payment system c. Bundled payment d. Rate setting

a. Capitation plans give providers a fixed amount per enrollee in the health plan in an effort to build a payment plan that consists of the best standards of care at the lowest cost. The prospective payment system groups inpatient hospital services for Medicare patients into DRGs. With bundled payments, providers receive a fixed sum of money to provide a range of services. Rate setting means that the government could set targets or caps for spending on health care services.

A caregiver asks a nurse to explain respite care. How would the nurse respond? a. "Respite care is a service that allows time away for caregivers." b. "Respite care is a special service for the terminally ill and their family." c. "Respite care is direct care provided to people in a long-term care facility." d. "Respite care provides living units for people without regular shelter."

a. Respite care is provided to enable a primary caregiver time away from the day-to-day responsibilities of homebound patients.

A nurse is preparing a clinical outcome for a patient who is an avid runner and who is recovering from a stroke that caused right-sided paresis. What is an example of this type of outcome? a. After receiving 3 weeks of physical therapy, patient will demonstrate improved movement on the right side of her body. b. By 8/15/20, patient will be able to use right arm to dress, comb hair, and feed herself. c. Following physical therapy, patient will begin to gradually participate in walking/running events. d. By 8/15/20, patient will verbalize feeling sufficiently prepared to participate in running events.

a. Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. Functional outcomes (b) describe the person's ability to function in relation to the desired usual activities. Quality-of-life outcomes (c) focus on key factors that affect someone's ability to enjoy life and achieve personal goals. Affective outcomes (d) describe changes in patient values, beliefs, and attitudes.

A nurse writes the following outcome for a patient who is trying to lose weight: "The patient can explain the relationship between weight loss, increased exercise, and decreased calorie intake." This is an example of what type of outcome? a. Cognitive b. Psychomotor c. Affective d. Physical changes

a. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; affective outcomes pertain to changes in patient values, beliefs, and attitudes; and physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

A nurse caring for patients in a primary care setting submits paperwork for reimbursement from managed care plans for services performed. Which purpose best describes managed care as a framework for health care? a. A design to control the cost of care while maintaining the quality of care b. Care coordination to maximize positive outcomes to contain costs c. The delivery of services from initial contact through ongoing care d. Based on a philosophy of ensuring death in comfort and dignity

a. Managed care is a way of providing care designed to control costs while maintaining the quality of care.

A school nurse notices that a student is losing weight and decides to perform a focused nutritional assessment to rule out an eating disorder. What is the nurse's best action? a. Perform the focused assessment as this is an independent nurse-initiated intervention. b. Request an order from Jill's physician since this is a physician-initiated intervention. c. Request an order from Jill's physician since this is a collaborative intervention. d. Request an order from the nutritionist since this is a collaborative intervention.

a. Performing a focused assessment is an independent nurse-initiated intervention; thus the nurse does not need an order from the physician or the nutritionist.

A student nurse is on a clinical rotation at a busy hospital unit. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student has not changed dressings before and does not feel confident performing the procedure. What would be the student's best response? a. Tell the RN that he or she lacks the technical competencies to change the dressing independently. b. Assemble the equipment for the procedure and follow the steps in the procedure manual. c. Ask another student nurse to work collaboratively with him or her to change the dressing. d. Report the RN to his or her instructor for delegating a task that should not be assigned to student nurses.

a. Student nurses should notify their nursing instructor or nurse mentor if they believe they lack any competencies needed to safely implement the care plan. It is within the realm of a student nurse to change a dressing if he or she is technically prepared to do so.

A nurse is using the SOAP format to document care of a patient who is diagnosed with type 2 diabetes. Which source of information would be the nurse's focus when completing this documentation? a. A patient problem list b. Narrative notes describing the patient's condition c. Overall trends in patient status d. Planned interventions and patient outcomes

a. The SOAP format (Subjective data, Objective data, Assessment, Plan) is used to organize entries in the progress notes of a POMR. When using the SOAP format, the problem list at the front of the chart alerts all caregivers to patient priorities. Narrative notes allow nurses to describe a condition, situation, or response in their own terms. Overall trends in patient status can be seen immediately when using CBE, not SOAP charting. Planned interventions and patient-expected outcomes are the focus of the case management model.

When a fire occurs in a patient's room, what would be the nurse's priority action? a. Rescue the patient. b. Extinguish the fire. c. Sound the alarm. d. Run for help.

a. The patient's safety is always the priority. Sounding the alarm and extinguishing the fire are important after the patient is safe. Calling for help, if possible, rather than running for assistance, allows you to remain with your patient and is more appropriate.

When may a health institution release a PHI for purposes other than treatment, payment, and routine health care operations, without the patient's signed authorization? Select all that apply. a. News media are preparing a report on the condition of a patient who is a public figure. b. Data are needed for the tracking and notification of disease outbreaks. c. Protected health information is needed by a coroner. d. Child abuse and neglect are suspected. e. Protected health information is needed to facilitate organ donation. f. The sister of a patient with Alzheimer's disease wants to help provide care.

b, c, d, e. According to the HIPAA, a health institution is not required to obtain written patient authorization to release PHI for tracking disease outbreaks, infection control, statistics related to dangerous problems with drugs or medical equipment, investigation and prosecution of a crime, identification of victims of crimes or disaster, reporting incidents of child abuse, neglect or domestic violence, medical records released according to a valid subpoena, PHI needed by coroners, medical examiners, and funeral directors, PHI provided to law enforcement in the case of a death from a potential crime, or facilitating organ donations. Under no circumstance can a nurse provide information to a news reporter without the patient's express authorization. An authorization form is still needed to provide PHI for a patient who has Alzheimer's disease.

A nurse is planning care for a patient who was admitted to the hospital for treatment of a drug overdose. Which nursing actions are related to the outcome identification and planning step of the nursing process? Select all that apply. a. The nurse formulates nursing diagnoses. b. The nurse identifies expected patient outcomes. c. The nurse selects evidence-based nursing interventions. d. The nurse explains the nursing care plan to the patient. e. The nurse assesses the patient's mental status. f. The nurse evaluates the patient's outcome achievement.

b, c, d. During the outcome identification and planning step of the nursing process, the nurse works in partnership with the patient and family to establish priorities, identify and write expected patient outcomes, select evidence-based nursing interventions, and communicate the nursing care plan. Although all these steps may overlap, formulating and validating nursing diagnoses occur most frequently during the diagnosing step of the nursing process. Assessing mental status is part of the assessment step, and evaluating patient outcomes occurs during the evaluation step of the nursing process.

An RN working on a busy hospital unit delegates patient care to UAPs. Which patient care could the nurse most likely delegate to a UAP safely? Select all that apply. a. Performing the initial patient assessments b. Making patient beds c. Giving patients bed baths d. Administering patient medications e. Ambulating patients f. Assisting patients with meals

b, c, e, f. Performing the initial patient assessment and administering medications are the responsibility of the RN. In most cases, patient hygiene, bed-making, ambulating patients, and helping to feed patients can be delegated to a UAP.

A nurse uses critical thinking skills to focus on the care plan of an older adult who has dementia and needs placement in a long-term care facility. Which statements describe characteristics of this type of critical thinking applied to clinical reasoning? Select all that apply. a. It functions independently of nursing standards, ethics, and state practice acts. b. It is based on the principles of the nursing process, problem solving, and the scientific method. c. It is driven by patient, family, and community needs as well as nurses' needs to give competent, efficient care. d. It is not designed to compensate for problems created by human nature, such as medication errors. e. It is constantly re-evaluating, self-correcting, and striving for improvement. f. It focuses on the big picture rather than identifying the key problems, issues, and risks involved with patient care.

b, c, e. Critical thinking applied to clinical reasoning and judgment in nursing practice is guided by standards, policies and procedures, and ethics codes. It is based on principles of nursing process, problem solving, and the scientific method. It carefully identifies the key problems, issues, and risks involved, and is driven by patient, family, and community needs, as well as nurses' needs to give competent, efficient care. It also calls for strategies that make the most of human potential and compensate for problems created by human nature. It is constantly re-evaluating, self-correcting, and striving to improve

A nurse is providing health care to patients in a health care facility. Which of these patients are receiving secondary health care? Select all that apply. a. A patient enters a community clinic with signs of strep throat. b. A patient is admitted to the hospital following a myocardial infarction. c. A mother brings her son to the emergency department following a seizure. d. A patient with osteogenesis imperfecta is being treated in a medical center. e. A mother brings her son to a specialist to correct a congenital heart defect. f. A woman has a hernia repair in an ambulatory care center.

b, c, f. Secondary health care treats problems that require specialized clinical expertise, such as an MI, a seizure, and a hernia repair. Treating strep throat is primary health care. Tertiary health care involves management of rare and complex disorders, such as osteogenesis imperfecta and congenital heart malformations.

A nurse on a busy surgical unit relies on informal planning to provide appropriate nursing responses to patients in a timely manner. What are examples of this type of planning? Select all that apply. a. A nurse sits down with a patient and prioritizes existing diagnoses. b. A nurse assesses a woman for postpartum depression during routine care. c. A nurse plans interventions for a patient who is diagnosed with epilepsy. d. A busy nurse takes time to speak to a patient who received bad news. e. A nurse reassesses a patient whose PRN pain medication is not working. f. A nurse coordinates the home care of a patient being discharged.

b, d, e. Informal planning is a link between identifying a patient's strength or problem and providing an appropriate nursing response. This occurs, for example, when a busy nurse first recognizes postpartum depression in a patient, takes time to assess a patient who received bad news about tests, or reassesses a patient for pain. Formal planning involves prioritizing diagnoses, formally planning interventions, and coordinating the home care of a patient being discharged.

The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply. a. A patient who is older than 50 b. A patient who has already fallen twice c. A patient who is taking antibiotics d. A patient who experiences postural hypotension e. A patient who is experiencing nausea from chemotherapy f. A 70-year-old patient who is transferred to long-term care

b, d, f. Risk factors for falls include age over 65 years, documented history of falls, postural hypotension, and unfamiliar environment. A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy or antibiotics.

A nurse is collecting more patient data to confirm a patient diagnosis of emphysema. This is an example of formulating what type of diagnosis? a. Actual b. Possible c. Risk d. Collaborative

b. An intervention for a possible diagnosis is to collect more patient data to confirm or rule out the problem. An intervention for an actual diagnosis is to reduce or eliminate contributing factors to the diagnosis. Interventions for a risk diagnosis focus on reducing or eliminating risk factors, and interventions for collaborative problems focus on monitoring for changes in status and managing these changes with nurse- and physician-prescribed interventions.

A nurse is about to perform pin site care for a patient who has a halo traction device installed. What is the FIRST nursing action that should be taken prior to performing this care? a. Administer pain medication. b. Reassess the patient. c. Prepare the equipment. d. Explain the procedure to the patient.

b. Before implementing any nursing action, the nurse should reassess the patient to determine whether the action is still needed. Then the nurse may collect the equipment, explain the procedure, and, if necessary, administer pain medications.

The nursing process ensures that nurses are person centered rather than task centered. Rather than simply approaching a patient to take vital signs, the nurse thinks, "How is Mrs. Barclay today? Are our nursing actions helping her to achieve her goals? How can we better help her?" This demonstrates which characteristic of the nursing process? a. Systematic b. Interpersonal c. Dynamic d. Universally applicable in nursing situations

b. Interpersonal. All of the other options are characteristics of the nursing process, but the conversation and thinking quoted best illustrates the interpersonal dimension of the nursing process.

A nurse is caring for patients in a primary care center. What is the most likely role of this nurse based on the setting? a. Assisting with major surgery b. Performing a health assessment c. Maintaining patients' function and independence d. Keeping student immunization records up to date

b. Performing patient health assessments is a common role of the nurse in a primary care center. Assisting with major surgery is a role of the nurse in the hospital setting. Maintaining patients' function and independence is a role of the nurse in an extended-care facility, and keeping student immunization records up to date is a role of the school nurse.

Nurses use the NIC Taxonomy structure as a resource when planning nursing care for patients. What information is found in this structure? a. Case studies illustrating a complete set of activities that a nurse performs to carry out nursing interventions b. Nursing interventions, each with a label, a definition, and a set of activities that a nurse performs to carry it out, with a short list of background readings c. A complete list of nursing diagnoses, outcomes, and related nursing activities for each nursing intervention d. A complete list of reimbursable charges for each nursing intervention

b. The NIC Taxonomy lists nursing interventions, each with a label, a definition, a set of activities that a nurse performs to carry it out, and a short list of background readings. It does not contain case studies, diagnoses, or charges.

A nurse working in a pediatric clinic provides codes for a patient's services to a third-party payer who pays all or most of the care. This is an example of what mode of health care payment? a. Out-of-pocket payment b. Individual private insurance c. Employer-based group private insurance d. Government financing

b. The four basic modes of paying for health care are out-of-pocket payment, individual private insurance, employer-based group private insurance, and government financing. With individual private insurance, members pay monthly premiums either by themselves or in combination with employer payments. These plans are called third-party payers because the insurance company pays all or most of the cost of care. Out-of-pocket payment is paying for health care with cash payments. Employer-based private insurance is employer-sponsored coverage and government financing is provided through Medicare and Medicaid, and other federally funded programs.

The Joint Commission issues guidelines regarding the use of restraints. In which case is a restraint properly used? a. The nurse positions a patient in a supine position prior to applying wrist restraints. b. The nurse ensures that two fingers can be inserted between the restraint and patient's ankle. c. The nurse applies a cloth restraint to the left hand of a patient with an IV catheter in the right wrist. d. The nurse ties an elbow restraint to the raised side rail of a patient's bed.

b. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. The patient should not be put in a supine position with restraints due to risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered.

A friend of a nurse calls and tells the nurse that his girlfriend's father was just admitted to the hospital as a patient, and he wants the nurse to provide information about the man's condition. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make? a. "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information." b. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks." c. "Because of HIPAA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!" d. "Why do you think Sue isn't talking about her worries?"

b. The nurse should immediately clarify what he or she can and cannot do. Since the primary reason for refusing to help is linked to the responsibility to protect patient privacy and confidentiality, the nurse should not begin by mentioning the real penalties linked to abuses of privacy. Finally, it is appropriate to ask about Sue and her worries, but this should be done after the nurse clarifies what he or she is able to do.

A nurse is documenting the care given to a patient diagnosed with an osteosarcoma, whose right leg was amputated. The nurse accidentally documents that a dressing changed was performed on the left leg. What would be the best action of the nurse to correct this documentation? a. Erase or use correcting fluid to completely delete the error. b. Mark the entry "mistaken entry"; add correct information; date and initial. c. Use a permanent marker to block out the mistaken entry and rewrite it. d. Remove the page with the error and rewrite the data on that page correctly.

b. The nurse should not use dittos, erasures, or correcting fluids when correcting documentation; block out a mistake with a permanent marker; or remove a page with an error and rewrite the data on a new page. To correct an error after it has been entered, the nurse should mark the entry "mistaken entry," add the correct information, and date and initial the entry. If the nurse records information in the wrong chart, the nurse should write "mistaken entry—wrong chart" and sign off. The nurse should follow similar guidelines in electronic records.

A nurse is caring for a patient who is receiving fluids for dehydration. Which outcome for this patient is correctly written? a. Offer the patient 60-mL fluid every 2 hours while awake. b. During the next 24-hour period, the patient's fluid intake will total at least 2,000 mL. c. Teach the patient the importance of drinking enough fluids to prevent dehydration by 1/15/20. d. At the next visit on 12/23/20, the patient will know that he should drink at least 3 L of water per day.

b. The outcomes in (a) and (c) make the error of expressing the patient goal as a nursing intervention. Incorrect: "Offer the patient 60-mL fluid every 2 hours while awake." Correct: "The patient will drink 60-mL fluid every 2 hours while awake, beginning 1/3/20." The outcome in (d) makes the error of using verbs that are not observable and measurable. Verbs to be avoided when writing outcomes include "know," "understand," "learn," and "become aware."

After one nursing unit with an excellent safety record meets to review the findings of the audit, the nurse manager states, "We're doing well, but we can do better! Who's got an idea to foster increased patient well-being and satisfaction?" This is an example of leadership that values: a. Quality assurance b. Quality improvement c. Process evaluation d. Outcome evaluation

b. Unlike quality assurance, quality improvement is internally driven, focuses on patient care rather than organizational structure, focuses on processes rather than people, and has no end points. Its goal is improving quality rather than assuring quality. Process evaluation and outcome evaluation are types of quality-assurance programs.

A patient reports that she has a drug allergy. In exploring the allergic reaction with the patient, which of the following might indicate an allergic response? a. Increased urination b. Dry mouth c. Rash d. Drowsiness

c

A school nurse is teaching parents about home safety and fires. What information would be accurate to include in the teaching plan? Select all that apply. a. Sixty percent of U.S. fire deaths occur in the home. b. Most fatal fires occur when people are cooking. c. Most people who die in fires die of smoke inhalation. d. Fire-related injury and death have declined due to the availability and use of smoke alarms. e. Fires are more likely to occur in homes without electricity or gas. f. Fires are less likely to spread if bedroom doors are kept open when sleeping.

c, d, e. Of all fire deaths in the United States, 80% occur in the home. Most fatal home fires occur while people are sleeping, and most people who die in house fires die of smoke inhalation rather than burns. The widespread availability and use of home smoke alarms is considered the primary reason for the significant decline in fire-related injury and death. People with limited financial resources should be asked about how they heat their house because the electricity or gas may have been turned off and space or kerosene heaters, wood stoves, or a fireplace may be the sole source of heat. Bedroom doors should be kept closed when sleeping and monitors used to listen for children.

A nurse performs nurse-initiated nursing actions when caring for patients in a skilled nursing facility. Which are examples of these types of interventions? Select all that apply. a. A nurse administers 500 mg of ciprofloxacin to a patient with pneumonia. b. A nurse consults with a psychiatrist for a patient who abuses pain killers. c. A nurse checks the skin of bedridden patients for skin breakdown. d. A nurse orders a kosher meal for an orthodox Jewish patient. e. A nurse records the I&O of a patient as prescribed by his health care provider. f. A nurse prepares a patient for minor surgery according to facility protocol.

c, d, f. Nurse-initiated interventions, or independent nursing actions, involve carrying out nurse-prescribed interventions resulting from their assessment of patient needs written on the nursing care plan, as well as any other actions that nurses initiate without the direction or supervision of another health care professional. Protocols and standard orders empower the nurse to initiate actions that ordinarily require the order or supervision of a health care provider. Consulting with a psychiatrist is a collaborative intervention.

A nurse is documenting patient data in the medical record of a patient admitted to the hospital with appendicitis. The health care provider has ordered 10-mg morphine IV every 3 to 4 hours. Which examples of documentation of care for this patient follow recommended guidelines? Select all that apply. a. 6/12/20 0945 Morphine 10 mg administered IV. Patient's response to pain appears to be exaggerated. M. Patrick, RN b. 6/12/20 0945 Morphine 10 mg administered IV. Patient seems to be comfortable. M. Patrick, RN c. 6/12/20 0945 30 minutes following administration of morphine 10 mg IV, patient reports pain as 2 on a scale of 1 to 10. M. Patrick, RN d. 6/12/20 0945 Patient reports severe pain in right lower quadrant. M. Patrick, RN e. 6/12/20 0945 Morphine IV 10 mg will be administered to patient every 3 to 4 hours. M. Patrick, RN f. 6/12/20 0945 Patient states she does not want pain medication despite return of pain. After discussing situation, patient agrees to medication administration. M. Patrick, RN

c, d, f. The nurse should enter information in a complete, accurate, concise, current, and factual manner and indicate in each entry the date and both the time the entry was written and the time of pertinent observations and interventions. When charting, the nurse should avoid the use of stereotypes or derogatory terms as well as generalizations such as "patient's response to pain appears to be exaggerated" or "seems to be comfortable." The nurse should never document an intervention before carrying it out.

The nurse is helping a patient turn in bed and notices the patient's heels are red. The nurse places the patient on precautions for skin breakdown. This is an example of what type of planning? a. Initial planning b. Standardized planning c. Ongoing planning d. Discharge planning

c. Ongoing planning is problem oriented and has as its purpose keeping the plan up to date as new actual or potential problems are identified. Initial planning addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care. Standardized care plans are prepared care plans that identify the nursing diagnoses, outcomes, and related nursing interventions common to a specific population or health problem. During discharge planning, the nurse uses teaching and counseling skills effectively to help the patient and family develop sufficient knowledge of the health problem and the therapeutic regimen to carry out necessary self-care behaviors competently at home.

Nursing students are reviewing information about health care delivery systems in preparation for a quiz the next day. Which statements describe current U.S. health care delivery practices? Select all that apply. a. Access to care depends only on the ability to pay, not the availability of services. b. The Patient Protection and Affordable Care Act provides private health care insurance to underserved populations. c. Every health insurance plan in the Health Insurance Marketplace offers comprehensive coverage, from doctors to medications to hospital visits. d. The uninsured pay for more than one third of their care out of pocket and are usually charged lower amounts for their care than the insured pay. e. Fifty years ago, half of the doctors in the United States practiced primary care, but today fewer than one in three do. f. Quality of care can be defined as the right care for the right person at the right time.

c, e, f. The Health Insurance Marketplace is designed to help people more easily find health insurance that fits their budget. Every health insurance plan in the Marketplace offers comprehensive coverage, from doctors to medications to hospital visits. Fifty years ago, half of the doctors in the United States practiced primary care, but today fewer than one in three do. Quality is the right care for the right person at the right time. Access to care depends on both the ability to pay and the availability of services. The Patient Protection and Affordable Care Act provides Medicaid or subsidized coverage to qualifying people with incomes up to 400% of poverty. The uninsured pay for more than one third of their care out of pocket and are often charged higher amounts for their care than the insured pay.

The evaluation step of the nursing process a. is often used as a last resort. b. is important primarily in the acute setting. c. is a continuous process. d. includes making nursing diagnoses.

c.

The nurse writes a nursing diagnosis for which reason? a. Direct medical care b. Help to increase patient compliance c. Identify actual or potential alteration in patient function d. Determine insurance reimbursement in most cases

c.

A nurse is using a concept map care plan to devise interventions for a patient with sickle cell anemia. What is the BEST description of the "concepts" that are being diagrammed in this plan? a. Protocols for treating the patient problem b. Standardized treatment guidelines c. The nurse's ideas about the patient problem and treatment d. Clinical pathways for the treatment of sickle cell anemia

c. A concept map care plan is a diagram of patient problems and interventions. The nurse's ideas about patient problems and treatments are the "concepts" that are diagrammed. These maps are used to organize patient data, analyze relationships in the data, and enable the nurse to take a holistic view of the patient's situation. Answers (a) and (b) are incomplete because the concepts being diagrammed may include protocols and standardized treatment guidelines but the patient problems are also diagrammed concepts. Clinical pathways are tools used in case management to communicate the standardized, interdisciplinary care plan for patients.

A nurse writes the following outcome for a patient who is trying to stop smoking: "The patient values a healthy body sufficiently to stop smoking." This is an example of what type of outcome? a. Cognitive b. Psychomotor c. Affective d. Physical changes

c. Affective outcomes pertain to changes in patient values, beliefs, and attitudes. Cognitive outcomes involve increases in patient knowledge; psychomotor outcomes describe the patient's achievement of new skills; physical changes are actual bodily changes in the patient (e.g., weight loss, increased muscle tone).

While discussing home safety with the nurse, a patient admits that she always smokes a cigarette in bed before falling asleep at night. Which nursing diagnosis would be the priority for this patient? a. Impaired gas exchange related to cigarette smoking b. Anxiety related to inability to stop smoking c. Risk for suffocation related to unfamiliarity with fire prevention guidelines d. Deficient knowledge related to lack of follow-through of recommendation to stop smoking

c. Because the patient is not aware that smoking in bed is extremely dangerous, she is at risk for suffocation from fire. The other three nursing diagnoses are correctly stated but are not a priority in this situation.

The nurse practices using critical thinking indicators (CTIs) when caring for patients in the hospital setting. The best description of CTIs is: a. Evidence-based descriptions of behaviors that demonstrate the knowledge that promotes critical thinking in clinical practice b. Evidence-based descriptions of behaviors that demonstrate the knowledge and skills that promote critical thinking in clinical practice c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice d. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, standards, and skills that promote critical thinking in clinical practice

c. Evidence-based descriptions of behaviors that demonstrate the knowledge, characteristics, and skills that promote critical thinking in clinical practice.

A resident who is called to see a patient in the middle of the night is leaving the unit but then remembers that he forgot to write a new order for a pain medication a nurse had requested for another patient. Tired and already being paged to another unit, he verbally tells the nurse the order and asks the nurse to document it on the health care provider's order sheet. What is the nurse's BEST response? a. State: "Thank you for taking care of this! I'll be happy to document the order on the health care provider's order sheet." b. Get a second nurse to listen to the order, and after writing the order on the health care provider order sheet, have both nurses sign it. c. State: "I am sorry, but VOs can only be given in an emergency situation that prevents us from writing them out. I'll bring the chart and we can do this quickly." d. Try calling another resident for the order or wait until the next shift.

c. In most facilities, the only circumstance in which an attending physician, nurse practitioner, or house officer may issue orders verbally is in a medical emergency, when the physician or nurse practitioner is present but finds it impossible, due to the emergency situation, to write the order. Trying to call another resident for the order or waiting until the next shift would be inappropriate; the patient should not have to wait for the pain medication, and a resident is available who can immediately write the order.

A nurse is caring for a patient who has complications related to type 2 diabetes mellitus. The nurse researches new procedures to care for foot ulcers when developing a care plan for this patient. Which QSEN competency does this action represent? a. Patient-centered care b. Evidence-based practice c. Quality improvement d. Informatics

c. Quality improvement involves routinely updating nursing policies and procedures. Providing patient-centered care involves listening to the patient and demonstrating respect and compassion. Evidence-based practice is used when adhering to internal policies and standardized skills. The nurse is employing informatics by using information and technology to communicate, manage knowledge, and support decision making.

A female patient who is receiving chemotherapy for breast cancer tells the nurse, "The treatment for this cancer is worse than the disease itself. I'm not going to come for my therapy anymore." The nurse responds by using critical thinking skills to address this patient problem. Which action is the first step the nurse would take in this process? a. The nurse judges whether the patient database is adequate to address the problem. b. The nurse considers whether or not to suggest a counseling session for the patient. c. The nurse reassesses the patient and decides how best to intervene in her care. d. The nurse identifies several options for intervening in the patient's care and critiques the merit of each option.

c. The first step when thinking critically about a situation is to identify the purpose or goal of your thinking. Reassessing the patient helps to discipline thinking by directing all thoughts toward the goal. Once the problem is addressed, it is important for the nurse to judge the adequacy of the knowledge, identify potential problems, use helpful resources, and critique the decision.

A nurse uses the classic elements of evaluation when caring for patients: (1) Interpreting and summarizing findings (2) Collecting data to determine whether evaluative criteria and standards are met (3) Documenting your judgment (4) Terminating, continuing, or modifying the plan (5) Identifying evaluative criteria and standards (what you are looking for when you evaluate—i.e., expected patient outcomes) Which item below places them in their correct sequence? 1, 2, 3, 4, 5 3, 2, 1, 4, 5 5, 2, 1, 3, 4 2, 3, 1, 4, 5

c. The five classic elements of evaluation in order are (1) identifying evaluative criteria and standards (what you are looking for when you evaluate—i.e., expected patient outcomes); (2) collecting data to determine whether these criteria and standards are met; (3) interpreting and summarizing findings; (4) documenting your judgment; and (5) terminating, continuing, or modifying the plan.

A nurse cares for dying patients by providing physical, psychological, social, and spiritual care for the patients, their families, and other loved ones. What type of care is the nurse providing? a. Respite care b. Palliative care c. Hospice care d. Extended care

c. The hospice nurse combines the skills of the home care nurse with the ability to provide daily emotional support to dying patients and their families. Respite care is a type of care provided for caregivers of homebound ill, disabled, or older adults. Palliative care, which can be used in conjunction with medical treatment and in all types of health care settings, is focused on the relief of physical, mental, and spiritual distress. Extended-care facilities include transitional subacute care, assisted-living facilities, intermediate and long-term care, homes for medically fragile children, retirement centers, and residential institutions for mentally and developmentally or physically disabled patients of all ages.

A new RN is being oriented to a nursing unit that is currently understaffed and is told that the UAPs have been trained to obtain the initial nursing assessment. What is the best response of the new RN? a. Allow the UAPs to do the admission assessment and report the findings to the RN. b. Do his or her own admission assessments but don't interfere with the practice if other professional RNs seem comfortable with the practice. c. Tell the charge nurse that he or she chooses not to delegate the admission assessment until further clarification is received from administration. d. Contact his or her labor representative to report this practice to the state board of nursing.

c. The nurse should not delegate this nursing admission assessment because only nurses can perform this intervention. The nurse should seek clarification for this policy from the nursing administration.

A nurse develops a detailed care plan for a 16-year-old patient who is a new single mother of a premature infant. The plan includes collaborative care measures and home health care visits. When presented with the plan, the patient states, "We will be fine on our own. I don't need any more care." What would be the nurse's best response? a. "You know your personal situation better than I do, so I will respect your wishes." b. "If you don't accept these services, your baby's health will suffer." c. "Let's take a look at the plan again and see if we can adjust it to fit your needs." d. "I'm going to assign your case to a social worker who can explain the services better."

c. When a patient does not follow the care plan despite your best efforts, it is time to reassess strategy. The first objective is to identify why the patient is not following the therapy. If the nurse determines, however, that the care plan is adequate, the nurse must identify and remedy the factors contributing to the patient's noncompliance.

A nurse is using the ISBARR physician reporting system to report the deteriorating mental status of Mr. Sanchez, a patient who has been prescribed morphine via a patient-controlled analgesia pump (PCA) for pain related to pancreatic cancer. Place the following nursing statements related to this call in the correct ISBARR order. a. "I am calling about Mr. Sanchez in Room 202 who is receiving morphine via a PCA pump for pancreatic cancer." b. "Mr. Sanchez has been difficult to arouse and his mental status has changed over the past 12 hours since using the pump." c. "You want me to discontinue the PCA pump until you see him tonight at patient rounds." d. "I am Rosa Clark, an RN working on the second floor of South Street Hospital." e. "Mr. Sanchez was admitted 2 days ago following a diagnosis of pancreatic cancer." f. "I think the dosage of morphine in Mr. Sanchez's PCA pump needs to be lowered."

d, a, e, b, f, c. The order for ISBARR is: Identity/Introduction, Situation, Background, Assessment, Recommendation, and Read-back.

When establishing the nursing interventions appropriate for a given patient a. the patient should not be actively involved. b. the patient support systems should be included only at discharge. c. teaching should be done when the patient states he or she is ready to learn. d. an evaluation of all of the data accumulated should be incorporated to achieve an effective care plan.

d.

A nurse is filing a safety event report for a confused patient who fell when getting out of bed. What action is performed appropriately? a. The nurse includes suggestions on how to prevent the incident from recurring. b. The nurse provides minimal information about the incident. c. The nurse discusses the details with the patient before documenting them. d. The nurse records the circumstances and effect on the patient in the medical record.

d. A safety event report objectively describes the circumstances of the accident or incident. The report also details the patient's response and the examination and treatment of the patient after the incident. The nurse completes the event report immediately after the incident, and is responsible for recording the circumstances and the effect on the patient in the medical record. The safety event report is not a part of the medical record and should not be mentioned in the documentation. Because laws vary in different states, nurses must know their own state law regarding safety event reports.

A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response? a. "I'm sorry, but patients are not allowed to copy their medical records." b. "I can make a copy of your record for you right now." c. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules." d. "I will need to check with our records department to get you a copy."

d. According to HIPAA, patients have a right to see and copy their health record; update their health record; get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of facility policies regarding the patient's right to access and copy records.

A nurse is identifying outcomes for a patient who has a leg ulcer related to diabetes. What is an example of an affective outcome for this patient? a. Within 1 day after teaching, the patient will list three benefits of continuing to apply moist compresses to leg ulcer after discharge. b. By 6/12/20, the patient will correctly demonstrate application of wet-to-dry dressing on leg ulcer. c. By 6/19/20, the patient's ulcer will begin to show signs of healing (e.g., size shrinks from 3 to 2.5 in). d. By 6/12/20, the patient will verbalize valuing health sufficiently to practice new health behaviors to prevent recurrence of leg ulcer.

d. Affective outcomes describe changes in patient values, beliefs, and attitudes. Cognitive outcomes (a) describe increases in patient knowledge or intellectual behaviors; psychomotor outcomes (b) describe the patient's achievement of new skills; and (c) is an outcome describing a physical change in the patient.

A student nurse is organizing clinical responsibilities for a patient who is diabetic and is being treated for foot ulcers. The patient tells the student, "I need to have my hair washed before I can do anything else today; I'm ashamed of the way I look." The patient's needs include diagnostic testing, dressing changes, meal planning and counseling, and assistance with hygiene. How would the nurse best prioritize this patient's care? a. Explain to the patient that there is not enough time to wash her hair today because of her busy schedule. b. Schedule the testing and meal planning first and complete hygiene as time permits. c. Perform the dressing changes first, schedule the testing and counseling, and complete hygiene last. d. Arrange to wash the patient's hair first, perform hygiene, and schedule diagnostic testing and counseling.

d. As long as time constraints permit, the most important priorities when scheduling nursing care are priorities identified by the patient as being most important. In this case, washing the patient's hair and assisting with hygiene puts the patient first and sets the tone for an effective nurse-patient partnership.

When discussing emergency preparedness with a group of first responders, what information would be important to include about preparation for a terrorist attack? a. Posttraumatic stress disorders can be expected in most survivors of a terrorist attack. b. The FDA has collaborated with drug companies to create stockpiles of emergency drugs. c. Even small doses of radiation result in bone marrow depression and cancer. d. BLI is a serious consequence following detonation of an explosive device.

d. BLI is a recognized consequence following exposure to an explosive device. The CDC is the federal facility that has collaborated with the pharmaceutical companies to stockpile drugs for an emergency. A high dose of radiation exposure can result in bone marrow depression and cancer. Most survivors of a terrorist event will experience stress and some (possibly one third of survivors) may exhibit posttraumatic stress disorder.

Based on the statistics for the leading cause of hospital admission for trauma in older adults, what would be the nurse's priority intervention to prevent trauma when caring for older adults in a nursing home? a. Checking to make sure fire alarms are working properly. b. Preventing exposure to temperature extremes. c. Screening for partner or elder abuse. d. Making sure patient rooms are decluttered.

d. Falls among older adults are the most common cause of hospital admissions for trauma, therefore rooms should be free of clutter. Elder abuse, fires, and temperature extremes are also significant hazards for older adults but are not the most common cause of trauma admissions. IPV occurs more frequently in adults as opposed to older adults.

A nurse orients an older adult to the safety features in her hospital room. What is a priority component of this admission routine? a. Explain how to use the telephone. b. Introduce the patient to her roommate. c. Review the hospital policy on visiting hours. d. Explain how to operate the call bell.

d. Knowing how to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury.

A patient has an order for an analgesic medication to be given PRN. When would the nurse administer this medication? a. Every 3 hours b. Every 4 hours c. Daily d. As needed

d. PRN means "as needed"—not every 3 hours, every 4 hours, or once daily.

A student health nurse is counseling a college student who wants to lose 20 lb. The nurse develops a plan to increase the student's activity level and decrease her consumption of the wrong types of foods and excess calories. The nurse plans to evaluate the student's weight loss monthly. When the student arrives for her first "weigh-in," the nurse discovers that instead of the projected weight loss of 5 lb, the student has lost only 1 lb. Which is the BEST nursing response? a. Congratulate the student and continue the care plan. b. Terminate the care plan since it is not working. c. Try giving the student more time to reach the targeted outcome. d. Modify the care plan after discussing possible reasons for the student's partial success.

d. Since the student has only partially met her outcome, the nurse should first explore the factors making it difficult for her to reach her outcome and then modify the care plan. It would not be appropriate to continue the plan as it is since it is not working, and it is premature to terminate the care plan since the student has not met her targeted outcome. The student may need more than just additional time to reach her outcome.

What consideration should the nurse keep in mind regarding the use of side rails for a patient who is confused? a. They prevent confused patients from wandering. b. A history of a previous fall from a bed with raised side rails is insignificant. c. Alternative measures are ineffective to prevent wandering. d. A person of small stature is at increased risk for injury from entrapment.

d. Studies of restraint-related deaths have shown that people of small stature are more likely to slip through or between the side rails. The desire to prevent a patient from wandering is not sufficient reason for the use of side rails. Creative use of alternative measures indicates respect for the patient's dignity and may in fact prevent more serious fall-related injuries. A history of falls from a bed with raised side rails carries a significant risk for a future serious incident.

A nurse working in a long-term care facility bases patient care on five caring processes: knowing, being with, doing for, enabling, and maintaining belief. This approach to patient care best describes whose theory? a. Travelbee's b. Watson's c. Benner's d. Swanson's

d. Swanson (1991) identifies five caring processes and defines caring as "a nurturing way of relating to a valued other toward whom one feels a personal sense of commitment and responsibility." Travelbee (1971), an early nurse theorist, developed the Human-to-Human Relationship Model, and defined nursing as an interpersonal process whereby the professional nurse practitioner assists an individual, family, or community to prevent or cope with the experience of illness and suffering, and if necessary to find meaning in these experiences. Benner and Wrubel (1989) wrote that caring is a basic way of being in the world, and that caring is central to human expertise, curing, and healing. Watson's theory is based on the belief that all humans are to be valued, cared for, respected, nurtured, understood, and assisted.

A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which evaluative statement is written correctly? a. "Outcome not met." 2. "1/21/20—Patient reports no change in diet." 3. "Outcome not met. Patient reports no change in diet or activity level." 4. "1/21/20—Outcome not met. Patient reports no change in diet or activity level."

d. The evaluative statement must contain a date; the words "outcome met," "outcome partially met," or "outcome not met"; and the patient data or behaviors that support this decision. The other answer choices are incomplete statements.

A nurse is collecting evaluative data for a patient who is finished receiving chemotherapy for an osteosarcoma. Which nursing action represents this step of the nursing process? a. The nurse collects data to identify health problems. b. The nurse collects data to identify patient strengths. c. The nurse collects data to justify terminating the care plan. d. The nurse collects data to measure outcome achievement.

d. The nurse collects evaluative data to measure outcome achievement. While this may justify terminating the care plan, that is not necessarily so. Data to assess health problems and patient variables are collected during the first step of the nursing process.

A nurse working in a pediatrician's office receives calls from parents whose children have ingested toxins. What would be the nurse's best response? a. Administer activated charcoal in tablet form and take child to the ED. b. Administer syrup of ipecac and take child to the ED. c. Bring the child in to the primary care provider for gastric lavage. d. Call the PCC immediately before attempting any home remedy.

d. The nurse should tell the parents to call the PCC immediately, before attempting any home remedy. Parents may be instructed to bring the child immediately to an emergency facility for treatment. Activated charcoal is considered the most effective agent for preventing absorption of the ingested toxin. It is not recommended for storage or use at home. Activated charcoal can be administered through a nasogastric tube in the ED for serious poisonings after the risks and benefits have been determined. Syrup of ipecac is no longer recommended because vomiting may be dangerous. A toxic substance may prove more hazardous coming up rather than when it was swallowed. Gastric lavage is no longer prescribed routinely for the treatment of ingestion of a toxic substance because it may propel the poison into the small intestine, where absorption will occur. The amount of toxin removed by gastric lavage is relatively small.

An older resident who is disoriented likes to wander the halls of his long-term care facility. Which action would be most appropriate for the nurse to use as an alternative to restraints? a. Sitting him in a geriatric chair near the nurses' station b. Using the sheets to secure him snugly in his bed c. Keeping the bed in the high position d. Identifying his door with his picture and a balloon

d. This allows the resident to be on the move and be more likely to find his room when he wants to return. The alternative would be to not allow him to wander. Many facilities use this kind of approach. Identifying his door with his picture and a balloon may work as an alternative to restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would probably result in a fall.

A nurse is looking for trends in a postoperative patient's vital signs. Which documents would the nurse consult first? a. Admission sheet b. Admission nursing assessment c. Flow sheet d. Graphic record

d. While one recording of vital signs should appear on the admission nursing assessment, the best place to find sequential recordings that show a pattern or trend is the graphic record. The admission sheet does not include vital sign documentation, and neither does the flow sheet.