Nur 2101 Final Exam Questions

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data? A. Blood pressure B. Cyanosis C. Nausea D. Petechiae

C. Nausea

A nurse is caring for a client who is unresponsive following a car crash. The clients son states that he does not want any heroic measures performed. Which of the following responses by the nurse is appropriate? A. Let's wait to see if your father's condition improves before we talk about this B. Do you think everyone in the family agrees with you C. If I were you I would let the doctor know about your wishes when she makes rounds today D. Does your father have advanced directives

D. Does your father have advanced directives

What lifestyle changes would the nurse include in a teaching plan for a patient who reports occasional constipation? (Select all that apply) 1. Daily laxative use 2. Increased fluid intake 3. Decreased fluid intake 4. Regular exercise 5. High fiber diet 6. More fruits and vegetables in the diet

2. Increased fluid intake 4. Regular exercise 5. High fiber diet 6. More fruits and vegetables in the diet

You are working on an adolescent unit and know that some minors can legally give consent for their health care. Which of the following minors can legally give consent for a procedure? 1. A 17 year old who is in the armed force 2. A 16 year old whose grandmother has custody of him 3. A 15 year old with a chronic medical condition 4. A 17 year old who is married 5. A 14 year old seeking treatment for a sexually transmitted infection

1. A 17 year old who is in the armed force 4. A 17 year old who is married 5. A 14 year old seeking treatment for a sexually transmitted infection

Which of the following activities reflect a culture of safety within a health care agency? (Select all that apply) 1. A hospital purchases a new bar-code system to check patient identification during medication administration 2. A hospital requires nurse managers to submit an annual safety plan for high-risk patients 3. A nurse commits an error while administering a high-risk medication and is released from her position 4. A hospital enforces routine monthly checks of electrical equipment 5. A nurse is treated unfairly after reporting a medication error

1. A hospital purchases a new bar-code system to check patient identification during medication administration 2. A hospital requires nurse managers to submit an annual safety plan for high-risk patients 4. A hospital enforces routine monthly checks of electrical equipment

Which scenario best describes the first step in the teaching process (Select all that apply) 1. A nurse asks a new mother what she understands about her home care of her cesarean section incision including activity restrictions and incision care 2. A nurse gives a patient who had a stroke a magnet that lists the warning signs of a stroke 3. A nurse provides education regarding a new blood pressure medication to a patient before discharge 4. A nurse gathers information regarding the home and school life of a 10 year old patient who recently had an appendectomy 5. After a patient reads an informational pamphlet the nurse has the patient explain the correct way to take a newly ordered diabetes medication

1. A nurse asks a new mother what she understands about the home care of her cesarean section incision including activity restrictions and incision care 4. A nurse gathers information regarding the home and school life of a 10 year old patient who recently had an appendectomy

Which of the following actions illustrate accountability? (Select all that apply) 1. A patient undergoes a surgical procedure that is new to the agency. The nurse asks the manager to provide an in-service about the procedure 2. A health care provider writes orders for pain management medication even though the patient has been free of pain for 3 days. Out of respect for the health care providers authority, a nurse administers the medications 3. During annual budget preparation at an agency, a nurse advocated for annual pay increases for the staff 4. A patient reports she does not have health insurance and will not be able to pay for her discharge medications. A nurse requests that a social worker meet with this patient to find a way to maximize available health care benefits 5. The policy on a patient care unit requires repositioning of patients every 2 hours. During busy shifts, the nursing staff is unable to keep up with the practice requirement. Whenever this happens, a nurse notifies the manager and discusses possible remedies

1. A patient undergoes a surgical procedure that is new to the agency. The nurse asks the manager to provide an in-service about the procedure 5. The policy on a patient care unit requires repositioning of patients every 2 hours. During busy shifts, the nursing staff is unable to keep up with the practice requirement. Whenever this happens, a nurse notifies the manager and discusses possible remedies

Which of the following patients are at a risk for falls because of intrinsic factors? (Select all that apply) 1. A patient with a tendency to have postural hypotension 2. A patient whose hospital room has a bedside commode and suction machine blocking the path to the bathroom 3. A patient who has bathroom floor mats that are thin and frayed 4. A patient who has dementia and has cataracts 5. A patient whose bed is placed in the highest position

1. A patient with a tendency to have a postural hypotension 4. A patient who has dementia and has cataracts

When caring for a patient with fecal incontinence what is the best way for the nurse to protect the patient's skin? 1. Cleanse the skin with a no-rinse cleanser and apply a barrier cream 2. Scrub the skin with antimicrobial cleanser using a soft washcloth 3. Cleanse skin with soap and water and apply talcum powder 4. Wipe stool away with toilet paper and apply petrolatum ointment

1. Cleanse the skin with a no-rinse cleanser and apply a barrier cream

The nurse is providing care for a patient who reports no bowel movement fo r5 days except for small amounts of liquid stool. Which immediate intervention will most likely be ordered for the patient? 1. Laxatives at bedtime 2. Manual removal of a fecal impaction 3. Instruction in high fiber diet 4. Increase in her ambulation from 1 to 2 times a day

2. Manual removal of a fecal impaction

A nurse is caring for a patient with a history of urinary retention. Which findings indicate the need to use a bladder scanner to measure postvoid residual? (Select all that apply) 1. Dribbling urine while experiencing urgency 2. Absence of voiding in more than 6 hours 3. Reports of pain with palpation of the bladder 4. Swelling over the lower abdomen extending to the umbilicus 5. Visible hematuria noted with the patient's last void

1. Dribbling urine while experiencing urgency 2. Absence of voiding in more than 6 hours 3. Reports of pain with palpation of the bladder 4. Swelling over the lower abdomen extending to the umbilicus

To decrease the risk of a urinary tract infection while a patient has a indwelling urinary catheter, what should the nurse do? (Select All that Apply) 1. Encourage fluids before the insertion of the catheter and while the catheter is in place 2. Make sure the catheter and insertion supplies remain sterile throughout the insertion procedure 3. Place the urine collection bag higher than the bladder to maintain patency of drainage tubing 4. Secure the catheter tubing to the patients thigh 5. Assess the patients history of latex allergy

1. Encourage fluids before the insertion of the catheter and while the catheter is in place 2. Make sure the catheter and insertion supplies remain sterile throughout the insertion procedure 4. Secure the catheter tubing to the patients thight

Which statement from a patient indicates and understanding of behaviors that often disrupt sleep? (Select all that apply) 1. I will not watch television in bed 2. I will not drink caffeine later in the day 3. A short nap late in the evening will lead to a more restful night of sleep 4. A glass of wine before bed will help me relax and sleep through the night 5. I will try to develop a regular evening exercise program

1. I will not watch television in bed 2. I will not drink caffeine later in the day 5. I will try to develop a regular evening exercise program

Which of these is a nursing safety consideration before inserting a foley catheter? (Select all that apply) 1. Identify if patient is at risk for a latex allergy 2. Identify if patient has an allergy to povidone-iodine (Betadine) 3. Follow asepsis principles when performing catheter insertion 4. Teach the patient Kegel exercises 5. Discard the first voided specimen

1. Identify if patient is at risk for a latex allergy 2. Identify if patient has an allergy to povidone-iodine (Betadine) 3. Follow asepsis principles when performing catheter insertion

A patient is receiving 5000 units of heparin subcutaneously every 12 hours to prevent venous thromboembolism while on prolonged best rest. Because bleeding is a potential side effect of this medication the nurse should continually assess the patient for which findings? (Select all that apply ) 1. Increased bruising 2. Pale yellow urine 3. Bleeding gums 4. Guaiac positive stools 5. Skin turgor

1. Increased bruising 3. Bleeding gums 4. Guaiac positive stools

Mrs. Wilson is a 70 year old patient who visits the medical clinic for a routine visit. Which nursing interventions would you recommend for this patient? (Select all that apply) 1. Limit fluids 2 -4 hours before sleep 2. Ensure that the room is completely dark 3. Ensure that the room temperature is comfortably cool 4. Provide warm covers 5. Encourage walking an hour before going to bed

1. Limit fluids 2 -4 hours before sleep 3. Ensure that the room temperature is comfortably cool 4. Provide warm covers

A nurse is caring for a 32 year old patient with Down Syndrome, a genetic disorder that includes impaired cognition. The patient's parents are deceased. He lives in a group home and works part time as a bagger at a grocery store. What actions does the nurse take during discharge planning to show respect for the patient's inherent dignity and worth? (Select all that apply) 1. Make sure written materials are written at an appropriate reading level 2. Contact the group home to ensure that a caregiver is involved with discharge plans 3. Allow the patient extra time for return demonstrations of your teaching plan 4. Assume he is unable to understand instruction and focus on needs other than education 5. Let his supervisor at the grocery store know about the patients discharge medications

1. Make sure written materials are written at an appropriate reading level 2. Contact the group home to ensure that a caregiver is involved with discharge plans 3. Allow the patient extra time for return demonstrations of your teaching plan

A nurse is completing a sleep history for a patient being assessed for obstructive sleep apnea (OSA). Which symptoms does the nurse expect the patient to report? (Select all that apply) 1. Nocturia 2. Frightening dreamlike experiences 3. Snoring 4. Fatigue 5. Increased sex drive

1. Nocturia 3. Snoring 4. Fatigue

Which are the most effective ways to prevent transmission of C.difficile between patients? (Select all that apply) 1. Place the patient in contact isolation precautions 2. Clean hands before and after each patient encounter with soap and water 3. Clean hands before and after wearing personal protective equipment such as gloves, gowns, masks and goggles 4. Keep the patient's room door shut at all times 5. Use alcohol disinfectant wipes to clean work surfaces

1. Place the patient in contact isolation precautions 2. Clean hands before and after each patient encounter with soap and water 3. Clean hands before and after wearing personal protective equipment such as gloves, gowns, masks and goggles

You decide to write an editorial to your local newspaper expressing your opinion about disparities in access to health care in your community. Which provisions from the ANA Code of Ethics for Nurses could you use to strengthen your editorial? (Select all that apply) 1. Provision 2: the nurse's primary commitment is to the patient whether an individual, family, group, community or population 2. Provision 6: the nurse through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care 3. Provision 8: the nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy and reduce health disparities 4. Provision 9: the profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession and integrate principles of social justice into nursing and health policy 5. The ANA Code of Ethics for Nurses applies to nursing practice and it is therefore inappropriate to refer to specific provisions when discussing public policy

1. Provision 2: the nurse's primary commitment is to the patient whether an individual, family, group, community or population 3. Provision 8: the nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy and reduce health disparities 4. Provision 9: the profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession and integrate principles of social justice into nursing and health policy

Which of the steps are designed to control the portal of entry of a microorganism? (Select all that apply). 1. Scrub the hub of an IV tubing port before inserting a safety needle 2. Wearing PPE 3. Frequent oral hygiene 4. Daily bathing with chlorhexidine gluconate 5. Keep point of connection between urinary catheter and drainage tube closed

1. Scrub the hub of an IV tubing port before inserting a safety needle 3. Frequent oral hygiene 4. Daily bathing chlorhexidine gluconate 5. Keep point of connection between urinary catheter and drainage tube closed

You are a new graduate nurse talking to a nursing student about the standards of care on the cardiac unit. The student nurse asks you if the standards of care are set by the State Board of Nursing. Your answer to the student nurse is that the standards of care incorporate which of the following (Select all that Apply) 1. State Nurse Practice Acts 2. Health care providers orders 3. Recommendations from professional nursing organizations 4. Policies and procedures of the health care agency 5. Evidence-based practice recommendations

1. State Nurse Practice Acts 3. Recommendations from professional nursing organizations 4. Policies and procedures of the health care agency 5. Evidence-based practice recommendations

The effects of immobility on the cardiac system include which findings? (Select all that apply) 1. Thrombus formation 2. Increased cardiac workload 3. Weak peripheral pulses 4. Orthostatic hypotension 5. Increased stroke volume

1. Thrombus formation 2. Increased cardiac workload 4. Orthostatic hypotension

A nurse is providing a hand-off report related to a patient leaving the medical-surgical unit for a diagnostic procedure. What should the nurse providing the report include (Select all that apply) 1. Timing and administration of new, STAT, and prn medications 2. Recent laboratory and test results 3. Perceptions of the patient's family situation 4. Discharge planning issues 5. The patient's need for an interpreter

1. Timing and administration of new, STAT, and prn medications 2. Recent laboratory and test results 5. The patient's need for an interpreter

The nurse instructs a female patient how to perform Kegel exercises. Which patient statement indicates she can perform the exercises correctly? 1. I squeeze the anus as if I am holding in gas for 2 or 3 seconds 2. I push like I need to have a bowel movement 3. I squat down and squeeze my thighs together for 5 - 10 secs 4. I contract my abdomen and buttocks for 2 or 3 seconds

1. squeeze the anus as if im holding in gas for 2 - 3 seconds

Which scenario best demonstrated that learning has taken place? (Select all that Apply) 1. A nurse reviews the warning symptoms of a stroke 2. A patient describes how to set up her pill organizer for the week 3. A patient attends a spinal cord injury support group 4. A nurse gives a patient written information regarding a new medication 5. A patient demonstrates how to take his blood pressure at home using his home machine

2. A patient describes how to set up her pill organizer for the week 5. A patient demonstrates how to take his blood pressure at home using his home machine

A nurse is preparing to teach a patient about sleep apnea. Which action is most appropriate for the nurse to perform first? 1. Show the patient how the CPAP machine works 2. Assess what the patient already knows about sleep apnea 3. Evaluate the outcomes of the education session 4. Set mutual goals for the education session

2. Assess what the patient already knows about sleep apnea

A nurse discovers an electrical fire in a patients room. Which action should the nurse take first? 1. Turn off the oxygen to the wall unit 2. Evacuate any patients/visitors in immediate danger 3. Close all doors and windows 4. Use water from the sink in the patient room to extinguish fire

2. Evacuate any patients/visitors in immediate danger

When a patient has an ileostomy the digestive process ends in the terminal ileum. Patient education by the nurse should include the need for the person to ingest more of which dietary component? 1. More food 2. Fluids and salt 3. Less sugar and artificial sweetener 4. Fiber to firm the stool

2. Fluids and salt

A family member angrily tells the nurse "No one told me that my husband was back in his room after surgery. I have been waiting and worrying for 3 hours!" How should the nurse reply?" 1. Well the recovery room nurse is supposed to take care of that before sending the patient back to us. I will bed sure to let her know about your frustration 2. I am sorry we did not notify you more quickly. It sounds like you have been really worried about your husband 3. At least your husbands surgery went well. That is something positive to talk about 4. I would be angry too if no one told me that my husband was back in his room after surgery

2. I am sorry we did not notify you more quickly. It sounds like you have been really worried about your husband

Place the following steps for application of a condom catheter to a male patient in appropriate order 1. Apply clean gloves, provide perineal care, and dry thoroughly 2. Identify patient using at least two identifiers 3. Assess penis for erythema, rashes or open areas 4. Secure condom catheter according to manufacturer directions 5. Apply condom catheter 6. Clip hair at base of penile shaft as necessary 7. Connect drainage tubing to end of condom catheter 8. Perform hand hygiene, prepare condom catheter and help patient to a supine or sitting position

2. Identify patient using at least two identifiers 8. Perform hand hygiene, prepare condom catheter and help patient to a supine or sitting position 1. Apply clean gloves, provide perineal care, and dry thoroughly 3. Assess penis for erythema, rashes or open areas 6. Clip hair at base of penile shaft as necessary 5. Apply condom catheter 4. Secure condom catheter according to manufacturer directions 7. Connect drainage tubing to end of condom catheter

Identify the order in which elastic stockings should be applied. 1. Evaluate skin integrity and circulation 2. Identify patient using at least two identifiers 3. Pull the remainder of the stocking over the patient's heel and on up the leg 4. Turn the stocking inside out holding heel 5. Slide stocking over patient's foot, making sure that toes are covered 6. Assess condition of patient's skin 7. Use tape measure to measure patient's legs to determine proper stocking size

2. Identify patient using at least two identifiers 6. Assess the condition of the patient's skin 7. Use a tape measure to measure the patient's legs to determine proper stocking size 4. Turn the stocking inside out holding the heel 5. Slide stocking over patient's foot, making sure that toes are covered 3. Pull the remainder of the stocking over the patient's heel and on up the leg 1. Evaluate skin integrity and circulation

A nurse is caring for a patient who had surgery 2 days ago and has not yet had a bowel movement. Upon assessment, the nurse finds bowel sounds are present in all 4 quadrants, abdomen is slightly distended, and patient reports feeling uncomfortably full. The patient has been scheduled for discharge tomorrow. The nursing history on admission noted that the patient had a history of constipation and takes stool softeners. The nurse prepares to call the health care provider to request a medication for constipation. Place the following in the correct order for an SBAR communication related to this concern. 1. Would you prescribe a medication for relief of constipation? 2. Mr. John Smith had surgery 3 days ago and he has not yet had a bowel movement. He is slated for discharge tomorrow. 3. Mr. Smith reports that he has a history of constipation and often takes stool softeners at home 4. Mr. Smith has bowel sounds in all four quadrants and has passed flatus today. His abdomen is slightly distended, and he reports feeling uncomfortably full

2. Mr. John Smith had surgery 3 days ago and he has not yet had a bowel movement. He is slated for discharge tomorrow. 3. Mr. Smith reports that he has a history of constipation and often takes stool softeners at home 4. Mr. Smith has bowel sounds in all four quadrants and has passed flatus today. His abdomen is slightly distended, and he reports feeling uncomfortably full 1. Would you prescribe a medication for relief of constipation?

The nurse observes the NAP apply and monitor a patient's sequential compression device (SCD) appropriately when the following is observed 1. Initial patient measurement is made around the calves 2. NAP verifies fit of SCD by placing two fingers between patient's leg and SCD sleeve 3. Sleeves are wrapped directly over the leg from the ankle to the knee 4. NAP removes SCD sleeves every 2 hours during placement

2. NAP verifies fit of SCD by placing two fingers between patient's leg and SCD sleeve

In what order would you prepare to enter the room of a patient in contact and droplet isolation precautions for MRSA? 1. Put on eyewear 2. Perform hand hygiene 3. Put on gloves 4. Put on mask 5. Put on gown

2. Perform hand hygiene 5. Put on gown 4. Put on mask 1. Put on eyewear 3. Put on gloves

Which nursing interventions are appropriate to include in a plan of care to promote sleep for patients who are hospitalized? (Select all that apply) 1. Give patients a cup of coffee 1 hour before bedtime 2. Plan vital signs to be taken before patients are asleep 3. Turn television on 15 min before bedtime 4. Have patients follow at-home bedtime schedule 5. Close the door to patient's rooms at bedtime

2. Plan vital signs to be taken before patients are asleep 4. Have patients follow at-home bedtime schedule 5. Close the door to patient's rooms at bedtime

A nurse is caring for a 36 year old patient with a brain tumor who is dying. The patient has undergone surgery and chemotherapy but nothing has worked so far to stop the growth of the tumor. The physician offered the patient one further treatment plan that could prolong life for a few weeks but the treatment has painful side effects. The patient tells his nurse that he is at peace with the prognosis and wants to stop all further treatment. The nurse is troubled by the patient's response. She feels confident that the side effects could be managed and for her refusing treatment violates a belief in the sanctity of life. Which of the following accurately describes ethical principles at stake in this situation? (Select all that apply) 1. Even though the patient does not want it making sure that the patient gets all possible treatments including experimental treatments will show a commitment to justice for this patient 2. Respect for the patient's autonomy is a fundamental ethical commitment and needs to be taken into consideration when making clinical decisions with a patient 3. The principle of beneficence implies that the providers need to ensure the patient receives the treatment because it could possibly work to the patient's benefit 4. The nurse will remain committed to advocacy for this patient speaking for the patient's point of view even though it conflicts with her own beliefs. Her commitment reflects a professional commitment to fidelity 5. The nurse's concern about managing difficult side effects represents the practice of nonmaleficence, the commitment to do no harm

2. Respect for the patient's autonomy is a fundamental ethical commitment and needs to be taken into consideration when making clinical decisions with a patient 4. The nurse will remain committed to advocacy for this patient speaking for the patient's point of view even though it conflicts with her own beliefs. Her commitment reflects a professional commitment to fidelity 5. The nurse's concern about managing difficult side effects represents the practice of nonmaleficence, the commitment to do no harm

Place the following steps for applying wrist restraint in the correct order. 1. Pad the skin overlying the wrist 2. Insert two fingers under secured restraint to be sure that it is not too tight 3. Be sure that the patient is comfortable and in correct anatomical alignment 4. Secure restraint straps to bed frame with quick-release buckle 5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly

3. Be sure that the patient is comfortable and in correct anatomical alignment 1. Pad the skin overlying the wrist 5. Wrap limb restraint around wrist or ankle with soft part toward skin and secure snugly 2. Insert two fingers under secured restraint to be sure that it is not too tight 4. Secure restraint straps to bed frame with quick release buckle

Which statement made by the patient indicates an understanding of sleep hygiene practices? 1. "I drink a cup of warm milk in the evening about 30 minutes before bedtime 2. If I exercise right before bedtime I will be tired and fall asleep faster 3. I know that it is best for me to go to bed when I feel tired 4. Long term use of hypnotics will cure my insomnia

3. I know that it is best for me to go to bed when I feel tired

The ANA Code of Ethics for Nurses articulates that the nurse "promotes, advocates for and strives to protect the health, safety, and rights of the patient." This promise to protect includes a promise to protect patient privacy. On the basis of this principle, if you participate in a public online social network such as Facebook, could you post images of a patient's x-ray film if you obscured or deleted all patient identifiers? Indicate the right answer with the best rationale. 1. Yes. Patient privacy would not be violated because patient identifiers were removed 2. Yes. Respect for Autonomy implies that you have the autonomy to decide what constitutes privacy 3. No. A viewer might identify the patient based on other comments that you make online about the patient's condition and your place of work 4. No. The principle of justice requires you to allocate resources fairly

3. No. A viewer might identify the patient based on other comments that you make online about the patient's condition and your place of work

Your patient has a discharge order. You check his blood pressure before he gets dressed and find that his blood pressure has decreased significantly from that morning. You call the provider and leave a message about the blood pressure, but no one returns your call. What should you do next? 1. Recheck the patient's blood pressure and complete the discharge process if his blood pressure has returned to normal 2. Complete the discharge process because the provider would have returned your call if the discharge was canceled 3. Notify the nursing supervisor of the need for the patient's discharge to be delayed until the provider returns the call. 4. Complete the discharge process but tell the patient to check his blood pressure in the morning and notify the provider of his results

3. Notify the nursing supervisor of the need for the patient's discharge to be delayed until the provider returns the call.

A nurse finds a 68 year old woman wandering in the hallway and exhibiting confused behavior. The patient says that she is looking for the bathroom. Which interventions are appropriate to ensure the safety of the patient? (Select all that apply). 1. Ask the physician or health care provider to order a restraint 2. Insert a urinary catheter 3. Provide scheduled toileting rounds every 2 to 3 hours 4. Consult with the health care provider about ordering an anti-anxiety medication 5. Keep the bed in low position with the side rails down 6. Keep the pathway from the bed to the bathroom clear

3. Provide scheduled toileting rounds every 2-3 hours 5. Keep the bed in low position with the side rails down 6. Keep the pathway from the bed to the bathroom clear

A patient recovering from a surgery that has a decreased ability to speak has activated her nurse call system. How should the nurse respond? 1. Use the intercom and ask the patient "what do you need?" 2. Respond in person and speak loudly and carefully 3. Respond in person and ask simple questions that can be answered with a gesture 4. Use the intercom and use simple sentences

3. Respond in person and ask simple questions that can be answered with a gesture

The nurse is assessing intake and output for an alert patient at the end of shift and notes red-colored urine. Which nursing action is appropriate? 1. Immediately call the health care provider 2. Collect a clean-catch urine specimen 3. Review the patients dietary history for the past 24 hr 4. Review the patient's most recent urinalysis lab report

3. Review the patients dietary history for the past 24 hr

A nurse is teaching an older adult patient about post-stroke seizures. Which teaching technique is most appropriate to use? 1. A pamphlet with large font in green ink 2. Speaking in a high pitched voice 3. Short sessions during which the nurse provides the most important information at the beginning and end of the education session 4. An hour-long lecture including symptoms of a seizure, safety during a seizure, type of seizures, and information regarding medications used to treat seizures

3. Short sessions during which the nurse provides the most important information at the beginning and end of the education session

A nurse is being uncivil by speaking poorly about a new nurse in front of a patient. What should the charge nurse who overhears this do? 1. Promptly counter the negative statement by the uncivil nurse with a positive statement 2. Immediately correct the uncivil nurse's poor judgment in speaking about the new nurse in front of the patient 3. Speak privately with the uncivil nurse about not providing evaluative judgments about others especially in front of patients 4. Immediately write up the uncivil nurse for inappropriate communication skills

3. Speak privately with the uncivil nurse about not providing evaluative judgments about others especially in front of patients

A 3 year old child is diagnosed with type 1 diabetes. The provider starts the patient on injections of insulin at her endocrinology appointment. How does the nurse best explain the injection to the child? 1. The nurse speaks only to the parents because a 3 year old child cannot comprehend what is being said regarding medication 2. The nurse verbally reviews information with both the patient and the parents 3. The nurse uses a doll to show the child how the injection works 4. The nurse demonstrates the injection on the child

3. The nurse uses a doll to show the child how the injection works

You are a new graduate nurse working on a medical/surgical unit. One morning, you are floated to the labor and delivery unit for the day because it is very short staffed. You tell your charge nurse that you are uncomfortable working on a unit so different from your own. The charge nurse tells you that the labor and delivery charge nurse will make sure you have easy patients and will help you with anything you need. What should you do? 1. Refuse to accept the assignment and go home for the day 2. Obtain hand-off report on the new patients and determine whether you can safely care for them 3. Notify the charge nurse on the labor and delivery unit of your concerns so that all the nurses can help you 4. Call the nursing supervisor about your concerns and take the assignment only if your concerns are documented in writing

4. Call the nursing supervisor about your concerns and take the assignment only if your concerns are documented in writing

A patient has a new ileostomy and needs to be taught hoe to care for the ileostomy. The nurse is seeing the patient on the first postoperative day. The patient has abdominal pain that is rated as 7 out of 10 and about 150 mL of dark green effluent in the ileostomy pouch. What skill would be best for the nurse to teach the patient at this time? 1. Care of the peristomal skin 2. Cutting and fitting the ostomy pouch 3. Placing a new ostomy pouch 4. Emptying the pouch

4. Emptying the pouch

A patient has just returned from surgery and has an order for insulin, but the patient does not have diabetes. When you ask the nurse, the nurse tells you that the surgeon who ordered it must have felt that the patient needed the medication and to give the insulin. What should you do in this situation? 1. Give the insulin but document that the patient's nurse was consulted 2. Give the insulin but only if the patient's nurse was consulted 3. Hold the insulin until the patient is able to eat 4. Hold the insulin until someone clarifies the order with the surgeon

4. Hold the insulin until someone clarifies the order with the surgeon

A patient diagnosed with a multidrug-resistant organism in a surgical wound asks the nurse what it means to be placed on isolation. What is the nurse's best response? 1. The patient must remain in the room at all times so the contact with other patients is avoided 2. The organism is easily spread so family and visitors must be limited to one at a time 3. The patient needs to remain in the room at all times and wear gloves when using the restroom 4. The patient must remain in the room most of the time to control for transmission of the infection but with proper precautions can leave the room for procedures

4. The patient must remain in the room most of the time to control for transmission of the infection but with proper precautions` can leave the room for procedures

A nurse is caring for a patient who is postoperative following a n appendectomy. The surgeon initially prescribes a clear liquid diet. Which of the following items should the nurse offer the patient? (Select All That Apply) A. Broth B. Grape Juice C. Nonfat milk D. Custard E. Lemon Gelatin

A. Broth B. Grape Juice E. Lemon Gelatin

Which of the following illnesses are considered a chronic illness? A. Diabetes mellitus B. Influenza C. Hypertension D. Asthma E. Pneumonia

A. Diabetes mellitus C. Hypertension D. Asthma

A nurse is orienting a newly licensed nurse about documentation of a patients information in the electronic health record. Which of the following statements by the newly licensed nurse indicates an understanding of the purpose of documentation? A. Documentation is a communication tool for the inter-professional health care team B. Documentation provides information to the patient about financial charges for care provided C. Documentation provides information for a patient audit D. Documentation allows providers to monitor the nurse's activities

A. Documentation is a communication tool for the inter- professional health care team

A nurse is caring for a group of patients on a medical surgical unit. Which of the following situations requires that the nurse wear gloves (Select All That Apply.) A. Emptying urine from an indwelling urine collection bag B. Providing oral care C. Changing an ostomy pouch D. Delivering a food tray to a patient who has AIDS E. Placing oral medication tablets into a patient's hand

A. Emptying urine from an indwelling urine collection bag B. Providing oral care C. Changing an ostomy pouch

Which of the following statements correctly describes the evaluation process (Select all that apply). A. Evaluation is an ongoing process B. Evaluation usually reveals obvious changes in a patient C. Evaluation involves making clinical decisions D. Evaluation requires the use of assessment skills E. Evaluation is performed only when the patients condition changes

A. Evaluation is an ongoing process C. Evaluation involves making clinical decisions D. Evaluation requires the use of assessment skills

A nurse is teaching a patient who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select All That Apply) A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake D. Increased fiber in the diet E. Increased activity

A. Excessive laxative use B. Ignoring the urge to defecate C. Inadequate fluid intake

Which signs and symptoms do you expect to assess in a patient who is in the alarm stage of the general adaptation syndrome (GAS)? (Select All That Apply ). A. Increased heart rate B. Return of Vital signs towards baseline C. Dilated pupils D. Decreased hormone levels E. Increased respirations F. An irregular pulse and atrial fibrillation

A. Increased heart rate C. Dilated pupils E. Increased respirations

A nurse is reviewing information about the health insurance portability and accountability act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching? A. Information about a patient can be disclosed to a family member at any time B. HIPAA established regulations of individually identifiable health information in verbal, electronic, or written form C. A patients address would be an example of personally identifiable information D. HIPAA is a federal law not a state law

A. Information about a patient can be disclosed to a family member at any time

The nurse suspects that a patient is being abused by the spouse based on the presence of many unexplained bruises and the nonverbal behavior of the patient. Which critical thinking technique was used by the nurse?

A. Intuition

At the end of a shift a nurse is giving a hand-off report about a patient named Mrs. Bean to another nurse who pieces of information are appropriate to include in the hand-off report (Select ALL That Apply) A. Mrs. Bean is 45 years old, she was admitted yesterday after an open cholecystectomy B. Mrs. Bean has really been difficult today. She has been using her call bell constantly and nothing I've done has pleased her C. Mrs. Bean is allergic to strawberries, fentanyl and sulfa medications D. Mrs. Bean has a catheter in place that has drained 450 mL of clear light yellow urine E. Mrs. Bean has received tramadol 100mg PO every 8 hours for pain and has constantly rated her pain from 5-6 on a 1-10 scale this shift F. Mrs. Bean has a dressing over her right upper quadrant incision that has a moderate amount of old dark red drainage I was not able to change dressing this shift because of inadequate staffing

A. Mrs. Bean is 45 years old, she was admitted yesterday after an open cholecystectomy C. Mrs. Bean is allergic to strawberries, fentanyl and sulfa medications D. Mrs. Bean has a catheter in place that has drained 450 mL of clear light yellow urine E. Mrs. Bean has received tramadol 100mg PO every 8 hours for pain and has constantly rated her pain from 5-6 on a 1-10 scale this shift F. Mrs. Bean has a dressing over her right upper quadrant incision that has a moderate amount of old dark red drainage I was not able to change dressing this shift because of inadequate staffing

A nurse is completing discharge teaching with a patient of the following barriers to learning. The nurse identifies with this patient which should the nurse interpret as a need to postpone the session? A. Pain B. Hearing loss C. The patients culture D. Motor impairment

A. Pain

A nurse working on a cardiac unit is assigned an 84 year old patient who was just admitted with symptoms of lung infection. When the nurse enters the room, the nurse notices that the patient is short of breath. The patient continues to cough and has a respiratory rate of 36 breaths/min. The patient is anxious and states "I am scared." The nurse does an initial preliminary assessment and follows up 30 minutes later. The nurse's knowledge about the patient results in which of the following assessment approaches? (Select All That Apply) A. Problem-focused approach B. Structured comprehensive approach C. Emotion-focused approach D. Using multiple visits to gather a complete patient database E. Focusing on the functional health pattern of role-relationship

A. Problem-focused approach D. Using multiple visits to gather a complete patient database

What is the purpose of documenting patient teaching. (Select All That Apply) A. Provides a legal record B. Communicated topics taught C. Provides a chart audit D. Identifies additional teaching needed E. Releases nurses from legal responsibility

A. Provides a legal record B. Communicates topics taught D. Identifies additional teaching needed

An older adult has limited mobility as a result of a surgical repair of a fractured hip. During assessment, you note that the patient cannot tolerate lying flat. Which of the following assessment data supports a possible pulmonary problem related to impaired mobility? (Select all that apply.) A) B/P = 128/84 B) Respirations 26 per minute on room air C) HR 114 D) Crackles heard on auscultation E) Pain reported as 3 on scale of 0 to 10 after medication

B) Respirations 26 per minute on room air C) HR 114 D) Crackles heard on auscultation

If a nurse decides to withhold a medication because it might further lower the patients blood pressure. The nurse will be practicing the principle of? A. Responsibility B. Accountability C. Competency D. Moral Behavior

B. Accountability Because she has to answer to her decision

A nurse is caring for a patient who has a mental health disorder. The patient asks about his medications and their effects. The nurse asks the patient why he needs to know this. Which of the following non therapeutic communication techniques is the nurse using? A. Changing the subject B. Asking for an explanation C. Behaving defensively D. Arguing

B. Asking for an explanation

A nurse is receiving change of shift report for a group of assigned patients. The nurse anticipates which of the following activities first in delivering patient care using the nursing process? A. Critically analyze patient data to determine priorities B. Collect and organize patient data C. Set patient centered measurable and realistic goals D. Determine effectiveness of interventions

B. Collect and organize patient data

Which is the best tool that the nurse can use to make sense of the patient's multiple medical diagnoses, assessment findings and medications? A. Plan of care B. Concept map C. Reflective journal D. Intellectual standards

B. Concept map

A patient is in what stage of behavior change if they state "I have a problem with smoking and I really think I need to work on it". A. Pre-contemplation B. Contemplation C. Preparation D. Action E. Maintenance

B. Contemplation

A nurse in a dialysis center is caring for a patient who has a new diagnosis of end-stage kidney disease. When he arrives for his first dialysis treatment, he tells the nurse, " I decided to come today, but i am not sure if i will need to come back again this week. I am feeling much better since my discharge from the hospital and i think my kidneys are working again." The nurse should identify that this patient is demonstrating which of the following Kubler Ross Stages of Grieving. A. Bargaining B. Denial C. Depression D. Anger

B. Denial

Which of the following foods will a patient on a vegan diet eat? (Select All That Apply) A. Eggs B. Fruit C. Dairy D. Veggies E. Meat

B. Fruit D. Veggies

A nurse is planning care for a patient who has anorexia nervosa. The nurse should make which of the following patient goals a priority? A. Attain a weight that is greater than the 75th percentile for age and height B. Make positive statements about improvements in body image C. Feel in control of her behavior D. Identify changes within the family unit that promote the patients autonomy

B. Make positive statements about improvements in body image

A patient has a pressure injury resulting from urinary incontinence and sustained pressure over the coccyx. The nursing plan of care includes a goal of "pressure injury heals in 3 weeks." Which of the following is an evaluation measure for this goal? (Select All That Apply) A. Turn patient every 90 mins B. Measure the diameter of the pressure injury C. Measure urine output D. Monitor patients report of discomfort E. Measure depth of pressure injury

B. Measure the diameter of the pressure injury E. Measure the depth of pressure injury

A nurse has completed an informed consent form with the patient. The patient then states I have changed my mind and do not wish to have the procedure done. Which of the following actions should the nurse take? A. Remind the patient that a signed informed consent form is a legally binding document B. Notify the surgeon that the patient wishes to withdraw informed consent for the procedure C. Inform the surgical team to cancel the patient's surgery D. Proceed with the preparation of the patient for the surgical procedure

B. Notify the surgeon that the patient wishes to withdraw informed consent for the procedure

A nurse in a long-term care facility is planning care for several patients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)? A. Admission assessment of a new patient B. Scheduling a diagnostic study for a patient C. Evaluating changes to a patients pressure ulcer D. Teaching a patient insulin injection

B. Scheduling a diagnostic procedure

A nurse is documenting information in a computerized health record. Which of the following nursing actions jeopardizes patient confidentiality? A. Logging out of the computer before leaving a terminal B. Sharing computer passwords with co workers C. Using a computer terminal in a non public area D. Preventing an unidentified health care worker from viewing a health record on the computer screen

B. Sharing computer passwords with co workers

A nurse is caring for a client who is 36 weeks of gestation and is on the antepartum unit for close monitoring. The client confides to the nurse that she doesn't think she will even be a good mother and begins to cry. Which of the following responses should the nurse make? A. Reassure the client that the provider will use advanced medical technology to detect any problems with her pregnancy B. Sit quietly with the client and follow her cues C. Suggest that the client discuss her fears with her provider D. Gently change the subject to something more positive

B. Sit quietly with the client and follow her cues

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select All That Apply.) A. Keep the clients room dark at night B. Teach the client to use the call light C. Keep the clients bed in the lowest position D. Place a fall risk identification band on the client's wrist E. Assess the client every 4 hours

B. Teach the client to use the call light C. Keep the clients bed in the lowest position D. Place a fall risk identification band on the clients wrist

A nurse is filling out an incident report after finding a patient lying on the floor. Which of the following information should the nurse include? A. The client attempted to climb over the side rails and fell B. The client was lying on the floor next to his bed C. The client was restless and trying to get out of bed all evening D. The presence of a bed alarm could have prevented the client from falling

B. The client was lying on the floor next to his bed

A nurse is observing a patients nonverbal behavior when evaluating this behavior the nurse should factor in which of the following principles influencing nonverbal communication? A. Nonverbal communication conveys less truth than what the patient states verbally B. The patients sociocultural background influences nonverbal communication C. Nonverbal communication is a poor reflection of what the patient feels. D. The patient enacts nonverbal communication consciously

B. The patients sociocultural background influences nonverbal communication

A nurse accidentally administers the wrong medication to a patient, which results in a severe allergic reaction and prolongs the patients hospitalization. The patient could rightfully sue the nurse for which of the following? A. Battery B. Assault C. Malpractice D. Abuse

C. Malpractice

A nurse is caring for a patient who is 1 day postoperative following gynecologic surgery and reports incisional pain. Which of the following action should the nurse take first? A. Determine the time the patient last received pain medication B. Measure the patients vital signs, including temperature C. Ask the patient to rate her pain on a scale from 0-10 D. Reposition the patient and offer her a back rub

C. Ask the patient to rate her pain on a scale from 0-10

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process? A. Planning B. Evaluation C. Assessment D. Implementation

C. Assessment

When reviewing the admitting prescription for a patient the nurse notes that the dose of one medication is a higher dose than the usual dose of this medication. Which of the following actions should the nurse take? A. Contact the pharmacy and confirm that the dosage is safe to administer B. Ask another nurse to verify that the dosage is appropriate for the patient C. Contact the provider to question the dosage D. Inform the charge nurse and administer the dose of the medication the provider prescribed

C. Contact the provider and question the dosage

What type of grief occurs when an individual cant openly acknowledge a loss or receive support from others? A. Normal B. Anticipatory C. Disenfranchised D. Complicated

C. Disenfranchised

Which type of family unit consisting of aunts, uncles, grandparents, and cousins? A. Nuclear B. Blended C. Extended D. Single-parent

C. Extended

Provides services for patients who are at the end of life and generally have less than 6 months to live? A. Acute care B. Palliative care C. Hospice care D. Restorative care

C. Hospice care

A nurse is caring for an older adult patient who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? A. Limit the patient's fluid intake in the evening B. Obtain a bedside commode for the patient's use C. Leave a nightlight on in the patient's room D. Put the side rails up and tell the patient to call the nurse before voiding

C. Leave a nightlight on in the patient's room

A nurse is caring for a patient who has an infection. The nurse should use which of the following strategies to prevent the transmission of the patients infection? A. Changing the patients bed lines each day B. Encouraging the patient to consume a high protein diet C. Performing hand hygiene before, during and after direct contact with the patient D. Placing the patient in a room with positive pressure airflow

C. Performing hand hygiene before, during, and after direct contact with he patient

During the implementation step of the nursing process, a nurse reviews and revises the nursing plan of care. Place the following steps of review and revision in correct order. A. Review the care plan B. Decide if the nursing interventions remain appropriate C. Reassess the patient D. Compare assessment findings to validate existing nursing diagnoses

C. Reassess the patient -> D. Compare assessment findings to validate existing nursing diagnoses ->A. Review the care plan -> B. Decide if the nursing interventions remain appropriate

A nurse is developing the plan of care for a patient that does not speak the same language as the nurse. Which of the following interventions should the nurse include? A. Make sure a family member is present to interpret for the staff B. Determine the patient's level of fluency in his primary language C. Speak directly to the interpreter when teaching the patient D. Encourage the patient to nod to indicate understanding

C. Speak directly to the interpreter when teaching the patient

Which patients needs constitutes the highest priority for the nurse? A. The patient who is waiting for discharge teaching in order to go home B. The constipated patient that has not had a bowel movement in 3 days C. The patient with sudden onset of slurred speech and right-sided weakness D. The patient who requires linen changes after being incontinent of urine and stool

C. The patient with sudden onset of slurred speech and right sided weakness

A nurse is instructing a young adult patient about helpful sleep habits. Which of the following statements should the nurse identify as an indication that the patient needs further teaching? A. I dont take naps throughout the day B. I go to bed and get up routinely at the same time each day C. I have a small snack and take a bath before going to bed each day D. I watch television until i fall asleep at night

D. I watch television until I fall asleep at night

Your patient is about to undergo a controversial orthopedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patients only treatment choice. This example describe the ethical principle of? A. Autonomy B. Fidelity C. Justice D. Nonmaleficence

D. Nonmaleficence

A nurse completes a respiratory assessment on a patient who had abdominal surgery 1 day ago. During the assessment the nurse auscultates crackles in both lower lobes, and the patient coughs, producing light yellow sputum. The patients body temperature is 37 degrees Celsius (98.6 F), pulse is 110 beats/min, respiratory rate is 28 breaths/min and blood pressure is 118/82 mm Hg. Pulse oximetry was 99% and is now 93%. The nurse identifies a nursing diagnosis of Impaired Gas Exchange. Which of the following goals is appropriate for this patient? A. Patients pulse oximetry will be greater than 95% B. Instruct patient to deep breathe and cough every 2 hours C. Patients lungs will be clear to auscultation D. Patient will be able to sleep through the night

D. Patient will be able to sleep through the night

A patient newly diagnosed with diabetes needs to learn how to use the glucometer. Use of a glucometer constitutes? A. Affective Learning B. Cognitive Learning C. Motivational Learning D. Psychomotor Learning

D. Psychomotor Learning

A nurse is giving a presentation about patient confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality? A. Discussing a patients surgical procedure with the nurse manager B. Notifying the provider of physical examination findings C. Identifying the patient by name when making a referral for home health services D. Reporting laboratory findings to a member of the patient's family

D. Reporting laboratory findings to a member of the patient's family

Which is an example of Tertiary Care? A. The patient has annual mammograms to screen for breast cancer B. The patient sees the podiatrist monthly to precent diabetic foot ulcers C. The patient is seen at an urgent care clinic to treat a badly sprained wrist D. The patient is referred to a Cardiac rehab program following a myocardial infarction

D. The patient is referred to a cardiac rehab program following a myocardial infarction