Nurs 299 test #1

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

1. Call the nursing supervisor to discuss the situation

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

1. Recognize normal changes associated with aging. 3. Lean forward and smile as you pose questions. 4. Allow for pauses as patient tells his story.

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

2. Advocate

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

2. Surgeon

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

3. Contact a child abuse hotline

A nurse initiates a brief interview with a patient who has come to the medical clinic because of self-reported hoarseness, sore throat, and chest congestion. The nurse observes that the patient has a slumped posture and is using intercostal muscles to breathe. The nurse auscultates the patient's lungs and hears crackles in the left lower lobe. The patient's respiratory rate is 20 per minute compared with an average of 16 per minute during previous clinic visits. The patient tells the nurse, "It is hard for me to get a breath." Which of the following data sets are examples of subjective data? (Select all that apply.) 1. Heart rate of 20 per minute and chest congestion 2. Lung sounds revealing crackles and use of intercostal muscles to breathe 3. Patient statement, "It's hard for me to get a breath" 4. Slumped posture and previous respiratory rate of 16 per minute 5. Patient report of sore throat and hoarseness

3. Patient statement, "It's hard for me to get a breath" 5. Patient report of sore throat and hoarseness

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

3. Provided a minimal standard of knowledge for an RN in practice

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

3. Teamwork and collaboration

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

4. A question about perspective

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

4. Data Cluster

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

4. Defines the principles of right and wrong to provide patient care.

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

5. Patient's explanation for what might be the cause of symptoms that require surgery

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

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

A nurse is conferring with another nurse about the care of a patient with a stage II pressure injury. The two decide to review the clinical practice guideline of the hospital for pressure injury care. The use of a clinical practice guideline achieves which of the following? (Select all that apply.) 1. Allows nurses to act more quickly and appropriately 2. Sets a level of clinical excellence for practice 3. Eliminates need to create an individualized care plan for the patient 4. Incorporates evidence-based interventions for stage II pressure injury 5. Provides for access to patient care information within the electronic health record

1. Allows nurses to act more quickly and appropriately 2. Sets a level of clinical excellence for practice 4. Incorporates evidence-based interventions for stage II pressure injury

Which of the following best describe a collaborative health problem? (Select all that apply.) 1. An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status 2. The language medical practitioners use to communicate a patient's health problem and associated treatments and response 3. A diagnostic label that classifies a patient's response to illness so that all nurses can be familiar with a specific patient's health care needs 4. A language used by health care providers to communicate and consider each other's unique perspective, so they can better manage the multiple factors that influence the health of individuals 5. A diagnosis that provides clear direction as to the type of nursing interventions nurses are licensed to provide independently

1. An actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status 4. A language used by health care providers to communicate and consider each other's unique perspective, so they can better manage the multiple factors that influence the health of individuals

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

1. Caregiver 2. Autonomy 3. Patient advocate 4. Health promotion

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

1. Caring for similar groups of patients over time 3. Learning how patients typically respond to their clinical situations 4. Observing patients 5. Engaging with patients experiencing illness

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

1. Checks scientific literature or policy and procedure 2. Determines whether additional assistance is needed 3. Collects all necessary equipment 5. Considers all possible consequences of the procedure

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

1. Educator

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

1. Failure to document a change in assessment data 5. Failure to notify a health care provider about a change in the patient's condition

Which of the following describes a nurse's application of a specific knowledge base during critical thinking? (Select all that apply.) 1. Initiative in reading current evidence from the literature 2. Application of nursing theory 3. Reviewing policy and procedure manual 4. Considering a colleague's view of a patient's needs 5. Previous time caring for a specific group of patients

1. Initiative in reading current evidence from the literature 2. Application of nursing theory

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

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

Which of the following is a diagnostic error involving identification of a goal of care rather than a patient need? 1. Patient obtains social support care related to caregiver stress 2. Fear related to open-heart surgery 3. Acute Pain related to splinting of incision 4. Impaired Family Coping related to insufficient caregiver support

1. Patient obtains social support care related to caregiver stress

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

1. Physical care technique

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

1. Priority setting establishes a preferential order for nursing interventions 3. Recognition of symptom patterns helps in understanding when to plan interventions.

A nurse is preparing medications for a patient. The nurse checks the name of the medication on the label with the name of the medication on the doctor's order. At the bedside the nurse checks the patient's name against the medication order as well. The nurse is following which critical thinking attitude: 1. Responsible 2. Humility 3. Accurate 4. Fairness

1. Responsible

Which of the following actions, if performed by a registered nurse, could result in both criminal and administrative law sanctions against the nurse? (Select all that apply). 1. Reviewing the electronic health record of a family member who is a patient in the same hospital on a different unit. 2. Refusing to provide health care information to a patient's child 3. Reporting suspected abuse and neglect of children 4. Applying physical restraints without a written order 5. Completing an occurrence report on the unit

1. Reviewing the electronic health record of a family member who is a patient in the same hospital on a different unit 4. Applying physical restraints without a written order

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, three others are stable and resting, and one has requested a pain medication. The patient in pain has two analgesics ordered prn for pain and has been using cold applications on his surgical site for pain relief. The last time an analgesic was given was 4 hours ago. The patient is scheduled for a physical therapy visit in 2 hours. Which of the following demonstrate good clinical decision making during intervention? (Select all that apply.) 1. The nurse reviews the options for pain relief for the patient. 2. The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed. 3. The nurse reviews the policy and procedure for the cold application. 4. The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy. 5. The nurse delegates vital sign assessment of the patient returning from surgery to the assistive personnel.

1. The nurse reviews the options for pain relief for the patient. 2. The nurse assesses whether the prn medication, ordered every 4 to 6 hours and last given 4 hours ago, is effective and whether a new type of medication is needed. 4. The nurse considers how the patient might react if the pain medication is held until an hour before physical therapy.

A nurse completes the following steps during her shift of care. Which are the steps of nursing assessment? (Select all that apply) 1. The review of patient data in the medical record 2. Confirming a patient's self- report of abdominal pain by inspecting the abdomen 3. Reporting results of an ongoing assessment to a nurse working the next scheduled shift 4. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of mobility alteration 5. Conducting an interview of a family caregiver

1. The review of patient data in the medical record 2. Confirming a patient's self- report of abdominal pain by inspecting the abdomen 4. Analyzing a set of signs revealing lower leg weakness and unsteady gait with a pattern of mobility alteration 5. Conducting an interview of a family caregiver

Which of the following factors should be considered when choosing an intervention for a patient's plan of care? (Select all that apply.) 1. The specific patient outcome against which to judge effectiveness of interventions 2. The timing of care activities routinely conducted on the care unit 3. The scientific evidence available in support of an intervention 4. The amount of time required for implementation in consideration of patient's condition 5. The patient's values and beliefs regarding the intervention

1. The specific patient outcome against which to judge effectiveness of interventions 3. The scientific evidence available in support of an intervention 4. The amount of time required for implementation in consideration of patient's condition 5. The patient's values and beliefs regarding the intervention

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

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

Match the assessment activity on the left with the type of assessment on the right. 1. Assessment conducted at beginning of a nurse's shift 2. Review of a patient's chief complaint 3. Completion of admitting history at time of patient admission to a hospital 4. Completing of the Long Term Care Minimum Data Set during an elderly patient admission to a nursing home. A. Problem focused B. Comprehensive

1A 2A 3B 4B

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: Risk for Fall, Impaired Physical Mobility related to pain, and Imbalanced Nutrition: Less Than Body Requirements related to reduced ability to feed self. The nursing staff identified several goals of care. Match the goals with the appropriate outcome statements. Goals 1. _____ Patient will ambulate independently in 3 days. 2. _____ Patient will be injury free for 1 month. 3. _____ Patient will achieve 5-pound weight gain in 1 month. 4. _____ Patient will achieve pain relief by discharge. Outcomes a. Patient expresses fewer nonverbal signs of discomfort within 24 hours. b. Patient increases caloric intake to 2500 calories daily. c. Patient walks 20 feet using a walker in 24 hours. d. Patient identifies barriers to remove in the home within 1 week.

1C 2D 3B 4A

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

1b 2c 3d 4a

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

1b 2d 3c 4a

Match the following: a. Anticipate how a patient might respond to treatment b. Organize assessment on the basis of patient priorities c. Be objective in asking questions of a patient d. Be tolerant of the patients views and beliefs 1. Truth seeking 2. Open-mindedness 3. Analyticity 4. Systematicity

1c 2d 3a 4b

Match the elements for correct identification of outcome statements with the SMART acronym terms below. 1. Specific 2. Measurable 3. Attainable 4. Realistic 5. Timed a. Mutually set an outcome that a patient agrees to meet b. Set an outcome that a patient can meet based upon his or her physiological, emotional, economic, and sociocultural resources c. Be sure an outcome addresses only one patient behavior or response. d. Include when an outcome is to be met. e. Use a term in an outcome statement that allows for observation as to whether a change takes place in a patients status

1c 2e 3a 4b 5d

A nurse is assigned to a new patient admitted to the medical unit. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. 1. Consider the context of patient's health problem and select a related factor. 2. Review assessment data, noting objective and subjective clinical information. 3. Cluster clinical data elements that form a pattern. 4. Identify appropriate assessment findings for diagnosis. 5. Identify a nursing diagnosis

2. 3. 5. 1. 4.

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

2. 4. 1. 5. 3.

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

2. Clinical inference

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

2. Data clustering 3. Data interpretation 4. Making a diagnostic statement

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

2. Deductive reasoning 4. Assessment

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

2. Determining the value the patient places on taking medications 4. Determining all consequences associated with the patient missing specific medicines

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

2. Dysuria 4. Nocturia

A critical care nurse is using a new research-based intervention to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? 1. Patient-centered care 2. Evidence Based practice 3. Teamwork and collaboration 4. Quality improvement

2. Evidence based practice

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

2. Risk of Infection 4. Activity Intolerance related to physical deconditioning

A patient diagnosed with colon cancer has been receiving chemotherapy for 6 weeks. The patient visits the outpatient infusion center twice a week for infusions. The nurse assigned to the patient is having difficulty accessing the patient's intravenous (IV) port used to administer the chemotherapy. Despite attempts to flush the port, it is obstructed. This also occurred 2 weeks earlier. What steps should the nurse follow to make a consultation with a member of the IV infusion team? (Select all that apply.) 1. Ask the IV nurse to come to the infusion center at a time when the nurse starts care for a second patient. 2. Specifically identify the problem of port obstruction, and attempt to flush the port to resolve the problem. 3. Explain to the IV nurse the frequency in which this port has obstructed in the past. 4. Tell the IV nurse the problem is probably related to the physician who inserted the port. 5. Describe to the IV nurse the type and condition of the port currently in use.

2. Specifically identify the problem of port obstruction, and attempt to flush the port to resolve the problem. 3. Explain to the IV nurse the frequency in which this port has obstructed in the past. 5. Describe to the IV nurse the type and condition of the port currently in use.

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

2. Spending time during the patient assessment 4. Caring for the patient on consecutive days 5. Knowing the pattern of patient behavior about ambulation

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

2. Staffing level 3. Interruption by staff nurse colleague 5. Competency of patient care technician

A nurse sends a text message to the oncoming nurse to report that a patient refuses to take medication as ordered. What should the oncoming nurse do? (Select all that apply). 1. Add this information to the board hanging at that patient's bedside. 2.Tell the nurse who sent the text that the text is a HIPAA violation. 3. Inform the nursing supervisor. 4. Forward the text to the change nurse. 5. Thank the nurse for sending information.

2. Tell the nurse who sent the text that the text is a HIPAA violation. 3. Inform the nursing supervisor.

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

2. The call to the ostomy and wound care specialist is an indirect care measure. 3. The cleansing of the skin is a direct care measure.

A nurse is assigned to five patients, including one who was recently admitted and one returning from a diagnostic procedure. It is currently mealtime. The other three patients are stable, but one has just requested a pain medication. The nurse is working with an assistive personnel. Which of the following are appropriate delegation actions on the part of the nurse? (Select all that apply.) 1. The nurse directs the assistive personnel to obtain a set of vital signs on the patient returning from the diagnostic procedure. 2. The nurse directs the patient care technician to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient. 3. The nurse directs the patient care technician to set up meal trays for patients. 4. The nurse directs the patient care technician to gather a history from the newly admitted patient about his medications. 5. The nurse directs the patient care technician to assist one of the stable patients up in a chair for his meal.

2. The nurse directs the patient care technician to go to the patient in pain and to reposition and offer comfort measures until the nurse can bring an ordered analgesic to the patient. 3. The nurse directs the patient care technician to set up meal trays for patients. 5. The nurse directs the patient care technician to assist one of the stable patients up in a chair for his meal.

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

2. Working phase

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

2. Wrong diagnosis

A nursing student is reporting during hand-off to the RN assuming her patient's care. She explains, "I ambulated him twice during the shift; he tolerated well walking to end of hall and back with no shortness of breath. Mr. Roarke said he slept better last night after I closed his door and gave him a chance to be uninterrupted. I changed the dressing over his intravenous (IV) site and started a new bag of D5 ½ NS. Which intervention is a dependent intervention? 1. Providing hand-off report at change of shift 2. Enhancing the patients sleep hygiene 3. Administering IV fluids 4. Taking vital signs

3. Administering IV fluids

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

3. Individualizing how to apply the clinical guideline for a patient

Place the following steps of the assessment process in the correct order. 1. Compare data with another source to determine data accuracy. 2. As a pattern forms, probe and frame further questions. 3. Interview a patient, observe behavior, and gather physical assessment findings. 4. Cluster cues that relate together, make inferences, and identify emerging patterns. 5. Differentiate important data from the total data you collect.

3. Interview a patient, observe behavior, and gather physical assessment findings. 5. Differentiate important data from the total data you collect. 4. Cluster cues that relate together, make inferences, and identify emerging patterns. 2. As a pattern forms, probe and frame further questions. 1. Compare data with another source to determine data accuracy.

A young male patient enters the emergency department with fever and signs of a possible sexually transmitted infection. The nurse enters the patient's cubicle and begins to enter a history on the computer screen. Before beginning the nurse introduces himself and tells the patient all information will be held confidentially. The nurse starts data collection by establishing eye contact with the patient and then looks at the computer prompts to select a series of questions. As the nurse fills out questions on the computer, the patient asks a question about his treatment. The nurse states, "Let me get through these questions first." Which action interferes with the nurse's ability to use connection as a communication skill. 1. Introducing self to patient 2. Using the computer as a prompt for questions 3. Making the nurse's questions a priority 4. Assuring the patient all information is confidential

3. Making the nurse's questions a priority

A nurse working the evening shift has five patients and is teamed up with an assistive personnel. One of the assigned patients has just returned from surgery, one is newly admitted, and one has requested a pain medication. The patient who has returned from surgery just minutes ago has a large abdominal dressing, is still on oxygen by nasal cannula, and has an intravenous line. One of the other patients has just called out for assistance in setting up a meal tray. Another patient is stable and resting comfortably. Which patient is the nurse's current greatest priority? 1. Patient in pain 2. Patient newly admitted 3. Patient who returned from surgery 4. Patient requesting assistance with meal tray

3. Patient who returned from surgery

A nurse received bedside report at the change of shift with the night-shift nurse and the patient. The nursing student assigned to the patient asks to review the patient's medical record. The nurse lists patient's medical diagnoses on the message boards in the patient's rooms. Later in the day the nurse discusses the plan of care for a patient who is dying with the patient's family. Which of these actions describes a violation of the Health Insurance Portability and Accountability Act (HIPAA)? 1. Discussing patient conditions at the bedside at the change of shift 2. Allowing the nursing student to review the assigned patient's chart before providing care during the clinical experience 3. Posting medical information about the patient on a message board in the patient's room 4. Releasing patient information regarding terminal illness to family when the patient has given permission for information to be shared

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

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

3. Relevant 4. Risk taking 5. Creativity

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

3. Review the facts of the situation. 1. Think about your thoughts and actions at the time of a situation. 6. Recall any feeling you had at the time of the situation. 2. Review the knowledge you gained from the experience. 5. Consider options for handling a similar situation in the future. 7. Create a plan for future situations. 4. Set a schedule for completing your plan of action.

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

3. Walked to visitors lounge 4. No shortness of breath

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

4. Applying ethical criteria

A man who is homeless enters the emergency department seeking health care. The health care provider indicates that the patient needs to be transferred to the City Hospital for care. This action is most likely a violation of which of the following laws? 1. Health Insurance Portability and Accountability Act (HIPAA) 2. Americans with Disabilities Act (ADA) 3. Patient Self-Determination Act (PSDA) 4. Emergency Medical Treatment and Active Labor Act (EMTALA)

4. Emergency Medical Treatment and Active Labor Act (EMTALA)

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

4. Erythema of skin will be mild to none within 48 hours

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

4. Gather more information about the wife's preferences and determine whether the husband is her power of attorney for health care.

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

4. Nurse researcher

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

A Knowledge

A nurse is discussing the nursing process with a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process? A. "I will determine the most important client problems that we should address" B. "I will review the past medical history on the client's record to get more information" C. "I will carry out the new prescriptions from the provider." D. "I will ask the client if their nausea has resolved."

A. "I will determine the most important client problems that we should address"

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

A. A client who has terminal cancer requests hospice care in their home B. A client asks about community resources available for older adults D. A client requests an electric wheelchair for use after discharge

A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client's MAR and noted the last dose of pain medication was 6hr ago. The prescription reads every 4hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process? A. Assessment B. Planning C. Intervention D. Evaluation

A. Assessment

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

A. Basic

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

A. Bathing B. Ambulating C. Toileting E. Measuring vital signs

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

A. Find a mentor B. Use a journal to write about the outcomes of clinical judgements. C. Review articles about evidence-based practice

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

A. Provider C. Pharmacist D. Registered nurse

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

A. Reassess the client to determine the reasons for inadequate pain relief.

A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply). A. Respiratory rate is 22/min with even, unlabored respirations. B. The client's partner states, "They said they hurt after walking about 10 minutes" C. The client's pain rating is 3 on a scale of 0 to 10 D. The client's skin is pink, warm, and dry E. The assistive personnel reports that the client walked with a limp.

A. Respiratory rate is 22/min with even, unlabored respirations. D. The client's skin is pink, warm, and dry E. The assistive personnel reports that the client walked with a limp.

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

B. Responsibility

A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider's prescription. Which of the following interventions should the charge nurse include? (Select all that apply) A. Writing a prescription for morphine sulfate as needed for pain B. Inserting a nasogastric (NG) tube to relieve gastric distention C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2hr to reduce pressure injury risk

C. Showing a client how to use progressive muscle relaxation D. Performing a daily bath after the evening meal E. Repositioning a client every 2hr to reduce pressure injury risk

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

D. Discipline

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

D. Occupational therapist

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

D. Speech-language pathologist

A (n) ----------- diagnosis is one that applies when there is an increased potential or vulnerability for a patient to develop a problem.

risk diagnosis