Practice Questions

The nurse is working in a long-term care facility and overhears a group of unlicensed assistive personnel (UAP) discussing some of the residents of the facility. What statement made by a UAP indicates that education regarding older adult clients is needed? a. "Older adult clients still enjoy sexual relations." b "All old people start to deteriorate mentally." c "Some of the residents still like to look their best." d "Not all people that are elderly live in long-term care facilities"

"All old people start to deteriorate mentally."

A nursing student tells the primary nurse that their patient has not had a bowel movement for 2 days & suggests adding the health problem, "Constipation" to the care plan. How would the nurse best respond a. "Did you assess the patient's usual bowel patterns & appearance of the last stool" b. This condition requires a medical diagnosis c. This early diagnosis will help us manage the problem before it become severe d. have you determined if this is an actual or a possible diagnosis

"Did you assess the patient's usual bowel patterns & appearance of the last stool"

A staff nurse is talking with a clinical nurse leader and asks, "What exactly do you do?" Which statement by the clinical nurse leader would be appropriate? "I'm an advanced practice nurse with a specific specialty area." "I collaborate with health care teams to promote client care." "My position is one of management." "I'm an administrator involved with client care."

"I collaborate with health care teams to promote client care."

A nurse attends a seminar on teaching/learning. Which statement indicates the nurse has a good understanding of teaching/learning? a. "Teaching and learning can be separated." b. "Learning is an interactive process that promotes teaching." c. "Teaching is most effective when it responds to the learner's needs." d. "Learning consists of a conscious, deliberate set of actions designed to help the teacher."

"Teaching is most effective when it responds to the learner's needs."

The patient's son requests to view the documentation in his mother's medical record. What is the nurse's best response to this request? A."I'll be happy to get that for you." B. "You will have to talk to the physician about that." C."You will need your mother's permission." D."You are not allowed to see it.

"You will need your mother's permission." The nurse understands that sharing health information is governed by HIPAA legislation, which defines rights and privileges of patients for protection of privacy. Private health information cannot be shared without the patient's specific permission. The other three responses either are outright false and/or use poor communication techniques.

A nurse demonstrates understanding of Healthy People 2020: Understanding and Improving Health by supporting which statement? a) A client's health is affected by social, economic, and political factors. b) Clinical care supports wellness in the environment. c) Establish a set of nursing skills that focuses on quick resolution to clients' needs. d) Physical therapy supports client safety at home.

A client's health is affected by social, economic, and political factors.

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing? a. A minimum data set b. An admission assessment and acuity level c. A focused assessment/specific body system d. An intake assessment form and auditing phase

A minimum data set

A nurse is determining if teaching is effective. Which finding best indicates learning has occurred? a. A nurse presents information about diabetes. b. A patient demonstrates how to inject insulin. c. A family member listens to a lecture on diabetes. d. A primary care provider hands a diabetes pamphlet to the patient

A patient demonstrates how to inject insulin.

A nurse is providing care to a group of patients. Which patient will the nurse see first? a.A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge incontinence b.A patient with reflex incontinence with elevated blood pressure and pulse rate c.A patient with an indwelling catheter that has stool on the catheter tubing d.A patient who has just voided and needs a postvoid residual test

A patient with reflex incontinence with elevated blood pressure and pulse rate

When conducting an education program for a group preparing for retirement, you would include information about applying for Social Security benefits and Medicare insurance. You would include in your teaching that Medicare is a federally funded insurance program which bases the fee for payment on

A prospective payment plan based on a predetermined fixed cost.

A nurse is caring for a patient recovering from a stroke that paralyzed the dominant arm. The nursing assistant reports that the patient was unable to bathe, comb their hair, or brush their teeth. Which health problem should the nurse add to the care plan? a. Risk for: activities of daily living deficit b. Impaired musculoskeletal system function: paralysis c. ADL deficit: impaired dressing & grooming d. Lack of motivation to complete self care activities

ADL deficit: impaired dressing & grooming

A nurse is discussing quality of life issues with another colleague. Which topic will the nurse acknowledgefor increased attention paid to quality of life concerns? a. Health care disparities b. Aging of the population c. Abilities of disabled persons d. Health care financial reform

Abilities of disabled persons The population of disabled persons in the United States and elsewhere has reshaped the discussion aboutquality of life (QOL). Health care disparities, an aging population, and health care reform are components impactedby personal definitions of quality but are not the underlying reason why QOL discussions have arisen.

The patient tells the nurse that she is afraid to speak up regarding her desire to end care forfear of upsetting her husband and children. Which principle in the nursing code of ethicsensures that the nurse will promote the patient's cause? A. Responsibility B. Advocacy C. Confidentiality D. Accountability

Advocacy Nurses advocate for patients when they support the patient's cause. A nurse's ability to adequate advocate for a patient is based on the unique relationship that develops and the opportunity to better understand the patient's point of view. Responsibility refers to respectingone's professional obligations and following through on promises. Confidentiality deals with privacy issues, and accountability refers to owning one's actions

Which government policy addresses penalizing hospitals for readmissions of clients with certain diagnoses within 30 days of discharge? a) American Nurses Association By laws b) American Disability Act c) Affordable Care Act d) National Commission for Minorities

Affordable Care Act

A patient has developed a pressure ulcer. Which laboratory data will be important for the nurse to check? a. Vitamin E b. Potassium c. Albumin d. Sodium

Albumin

Four patients arrive at the emergency department at the same time. Which patient will the nurse see first? a. An infant with temperature of 102.2° F and diarrhea for 3 days b. A teenager with a sprained ankle and excessive edema c. A middle-aged adult with abdominal pain who is moaning and holding her stomach d. An older adult with nausea and vomiting for 3 days with blood pressure 112/60

An infant with temperature of 102.2° F and diarrhea for 3 days

The nurse is caring for a new older adult client who states the need to use the restroom. Which safety intervention must the nurse perform first? Apply socks to the client's feet. Arrange furniture securely so that the client has something to hold on to. Apply a lap belt to assist with transfer Assess the need for assistance with ambulation.

Assess the need for assistance with ambulation.

A patient has heart failure and kidney failure. The patient needs teaching about dialysis. Which nursing action is most appropriate for assessing this patient's learning needs? a. Assess the patient's total health care needs. b. Assess the patient's health literacy. c. Assess all sources of patient data. d. Assess the goals of patient care

Assess the patient's health literacy.

A nurse manager informs the staff members during a meeting that unlicensed assistive personnel will no longer be allowed to check clients' blood glucose levels. The nurse manager informs the group that this is a new policy on the unit and that discussions will not change the enforcement of this policy. What type of leadership style is the nurse manager demonstrating? Laissez-faire Transformational Democratic Autocratic

Autocratic

On a medical unit, the nurses complain that they have no voice in the decisions that are made in the operation of the unit. The nurses state they are always told by the nurse manager to perform tasks instead of being asked. Which of these best describes the leadership style of the nurse manager? Laissez-faire Autocratic Nondirectional Democratic

Autocratic

A client is received into the emergency department after getting shot in the chest. The client is hemorrhaging profusely and is in hypovolemic shock. The nurse calls a code blue. What type of leadership style will be most effective during the management of the code? Democratic leadership Autocratic leadership Transactional leadership Laissez-faire leadership

Autocratic leadership

The nurse questions a physician's order to administer a placebo to the patient. The nurse'saction is based on which ethical principle? A. Autonomy B. Beneficence C. Justice D. Fidelity

Autonomy Autonomy refers to the freedom to make decisions free of external control. In this case, the nurse questions the physician's order for a placebo because it supports the patient's autonomy. Although beneficence, taking a positive action for others, has implications here, it is not the primary operating principle. Justice refers to fairness and is most often used in discussions about access to health care resources. Fidelity refers to the agreement to keep promises.

The registered nurse on a busy telemetry floor is delegating tasks to an unlicensed assistive person (UAP). Which task is appropriate for the UAP to complete? Taking an order over the telephone from a health care provider Bathing a combative client Assessing a client's wound Inserting an indwelling urinary catheter

Bathing a combative client

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? a. Gastrointestinal b. Neurological c. Respiratory d. Cardiac

Cardiac

A nurse has recently decided to seek employment in a tertiary health center. Which of the following services should the nurse anticipate would be provided in tertiary care? a) Psychiatric care b) Chronic disease management and education c) Same-day surgery d) Cardiovascular surgery

Cardiovascular surgery

A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take?

Chart on the computer immediately after care is provided.

A nurse is assessing a client admitted to the hospital with reporting left-sided weakness & difficulty speaking. Which documented statement best represents the data that should be collected in a nursing assessment?

Client is unable to communicate basic needs & cannot perform hygiene measures with left hand

A patient learns that a normal adult heartbeat is 60 to 100 beats/min after a teaching session with a nurse. In which domain did learning take place? a. Kinesthetic b. Cognitive c. Affective d. Psychomotor

Cognitive

A nurse manager is trying to resolve a conflict between the day and night shifts. The nurse manager wants to convince the involved persons to set aside their differences, determine a priority common goal having to do with improved client care, and accept mutual responsibility for achieving this goal. The nurse manager is using which type of conflict resolution? Collaborating Competing Avoiding Compromising

Collaborating

A patient is being discharged home. Which information should the nurse include? a. Acuity level b. Community resources c. Standardized care plan d. Signature for verbal order

Community resources

The nurse is caring for a patient with a healing Stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? a. Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results. b.Notify the health care provider by utilizing Situation, Background, Assessment, and Recommendation (SBAR). c. Consult the wound care nurse about the change in status and the potential for infection. d. Check with the charge nurse about the change in status and the potential for infection.

Complete the head-to-toe assessment, including current treatment, vital signs, and laboratory results.

Two staff nurses on a unit disagree with one another over certain key aspects of providing client care. The nurse manager of the unit arranges a meeting with the charge nurse and the two staff nurses at a mutually agreed-upon time to discuss this situation. This activity is most accurately described as what? Client protection Delegation Conflict resolution Problem solving

Conflict resolution

A nurse is teaching a patient's family member about permanent tube feedings at home. Which purpose of patient education is the nurse meeting? a. Health promotion b. Illness prevention c. Restoration of health d. Coping with impaired functions

Coping with impaired functions

Care that includes the nurse learning about cultural issues involved in the patients health care belief system and enable patients and families to achieve meaningful and supportive care is known as a. Ethnocentrism. b. Culturally competent care. c. Cultural imposition. d. Culturally congruent care.

Culturally competent care.

According to the Office of Minority Health (OMH) the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups are known as... a. Culture. b. Subculture. c. Ethnicity. d. Cultural backlash.

Culture

The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. Which risk factor will the nurse assess for that predisposes a patient to pressure ulcer development? a.Decreased level of consciousness b.Adequate dietary intake c.Shortness of breath d.Muscular pain

Decreased level of consciousness

The nurse is working to enhance time management skills and has to administer pain medications to several clients, obtain vital signs, and assist clients with bathing. What should the nurse do next? Bathe clients. Administer pain medications. Delegate bathing and vital signs tasks. Obtain vital signs.

Delegate bathing and vital signs tasks.

The nurse has recently been promoted to nurse manager on a pediatric unit and has decided to accept input from staff regarding changes they would like to see on the unit. Which type of leadership style is the nurse embodying? Democratic Laissez-faire Autocratic Quantum

Democratic

The nurse manager who asks staff members to give suggestions on how to improve collaboration between nurses and health care providers is exhibiting what style of leadership? Transactional Laissez-faire Democratic Autocratic

Democratic

The nurse is completing an assessment on an older-adult patient who is having difficulty falling asleep. Which condition will the nurse further assess for in this patient? a. Depression b. Mild fatigue c. Hypertension d. Hypothyroidism

Depression

A nurse is caring for a patient who has been admitted the second time this month for HTN emergency. The care plan contains the health problem: Nonadherence Etiology: lack of knowledge of purpose of medications S/S: BP 220/112 When meeting this patient, which action will the nurse take first? a. Determine the patients knowledge about the medication & their SE b. teach the patient that nonadherence may lead to stroke & heart disease c. Explain that these medications are essential to their health & illness prevention d. Discuss what will motivate the patient to adhere to the mediation regimen

Determine the patients knowledge about the medication & their SE

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking? a. Determining the degree to which standards of care are met by reviewing patients' health records b. Realizing that care not documented in patients' health records still qualifies as care provided c. Basing reimbursement upon the diagnosis-related groups documented in patients' records d. Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment

Determining the degree to which standards of care are met by reviewing patients' health records

A nurse is preparing to teach a patient about smoking cessation. Which factors should the nurse assess to determine a patient's ability to learn? a. Sociocultural background and motivation b. Stage of grieving and overall physical health c. Developmental capabilities and physical capabilities d. Psychosocial adaptation to illness and active participation

Developmental capabilities and physical capabilities

When people work together to solve ethical dilemmas, individuals must examine their ownvalues. This step is crucial to ensure that A. The group identifies the one correct solution. B. Fact is separated from opinion. C. Judgmental attitudes are not provoked. D. Different perspectives are respected

Different perspectives are respected Values are personal beliefs that influence opinions. To be able to negotiate differences in opinions, the nurse must first be clear about personal values, which will influence behaviors, decisions, and actions. Ethical dilemmas are a problem in that no one right solution exists.

The nurse is having a conversation with an adolescent regarding the need for sleep. The adolescent states that it is common to stay up with friends several nights a week. Which action should the nurse take next? a. Talk with the adolescent's parent about staying up with friends and the need for sleep. b. Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness. c. Refer the adolescent for counseling about alcohol abuse problems. d. Take no action for this normal occurrence

Discuss with the adolescent sleep needs and the effects of excessive daytime sleepiness.

A nurse uses evidence-based practice (EBP) to provide nursing care. What is the best rationale for the nurse's behavior? a.EBP is a guide for nurses in making clinical decisions. b.EBP is based on the latest textbook information. c.EBP is easily attained at the bedside. d.EBP is always right for all situations.

EBP is a guide for nurses in making clinical decisions

The nurse manager is concerned about the large number of adolescent mothers being seen in the obstetrics clinic. How can the nurse manager use the transformational leadership style to address the concern? Enlist volunteers to help develop a community outreach project that will educate adolescents on methods to prevent pregnancy. Create a new policy that will limit the number of adolescent mothers the clinic can treat. Conduct community-based research into the number of adolescents who have become parents over the last five years. Talk to each adolescent who comes in to the clinic about ways to not get pregnant again.

Enlist volunteers to help develop a community outreach project that will educate adolescents on methods to prevent pregnancy.

A nurse is teaching a culturally diverse patient with a learning disability about nutritional needs. What must the nurse do first before starting the teaching session? a. Obtain pictures of food. b. Get an interpreter. c. Establish a rapport. d. Refer to a dietitian

Establish a rapport.

The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. Which action should the nurse take? a. Turn on the television. b. Explain the procedure. c. Tell the patient "Close your eyes." d. Ask the family to leave the room.

Explain the procedure.

A patient continues to report postsurgical incision pain at a level of 9 out of 10 after pain medicine is given. The next dose of pain medicine is not due for another hour. What should the critically thinking nurse do first? a. Explain to the patient that nothing else has been ordered. b. Explore other options for pain relief. c. Offer to notify the health care provider after morning rounds are completed. d. Discuss the surgical procedure and reason for the pain.

Explore other options for pain relief.

The nurse values autonomy above all other principles. Which patient assignment will thenurse find most difficult to accept? A. Teenager in labor who requests epidural anesthesia B. Middle-aged father of three with an advance directive declining life support C. Elderly patient who requires dialysis D. Family elder who is making the decisions for a 30-year-old female member

Family elder who is making the decisions for a 30-year-old female member Autonomy refers to freedom from external control. A person who values autonomy highly may find it difficult to accept situations where the patient is not the primary decision maker regarding his or her care. A teenager requesting an epidural, a father with an advanced directive, and an elderly patient requiring dialysis all describe a patient or family that can make their own decisions and choices regarding care

Providing culturally congruent care means providing care that a. Fits the patient's valued life patterns and set of meanings. b. Is based on meanings generated by predetermined criteria. c. Is the same as the values of the professional health care system. d. Holds one's own way of life as superior to those of others.

Fits the patient's valued life patterns and set of meanings.

Nurses have an important role in health care reform. The goals of health care reform include which of the following? a) Decreasing health care services to provide all citizens with some access to care, but control escalating costs b) Controlling health care costs through limited services for more consumers of health care. c) Improving quality of care, while limiting access for the uninsured, to control rising costs. d) Focus on cost containment with improved access and quality of services for everyone.

Focus on cost containment with improved access and quality of services for everyone.

The nurse administers an intravenous (IV) hypertonic solution to a patient. In which direction will the fluid shift? a. From intracellular to extracellular b. from extracellular to intracellular c. From intravascular to intracellular d. From intravascular to interstitia

From intracellular to extracellular

The nurse is caring for a patient with a Stage IV pressure ulcer. Which type of healing will the nurse consider when planning care for this patient? a.Partial-thickness wound repair b.Full-thickness wound repair c.Primary intention d.Tertiary intention

Full-thickness wound repair

The nurse is caring for a patient who is experiencing a full-thickness repair. Which type of tissue will the nurse expect to observe when the wound is healing? a. Eschar b. Slough c. Granulation d. Purulent drainage

Granulation

A nurse is working with an older adult population at a local community senior center. Based on information from the Association of Aging, the nurse would anticipate needing to address which condition as most common? a. HTN b. arthritis c. Diabete d. cancer

HTN

The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a Stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How should the nurse document this ulcer in the patient's medical record? a. Stage I pressure ulcer b. Healing Stage II pressure ulcer c. Healing Stage III pressure ulcer d. Stage III pressure ulcer

Healing Stage III pressure ulcer

A nurse incorporates concepts from current models of health when providing health promotion classes for patients. What is a key concept of both the health-illness continuum and the high-level wellness models? - Illness as a fixed point in time - The importance of family - Wellness as a passive state - Health as a dynamic state

Health as a dynamic state

A nursing facility has recently implemented new policies regarding nurse-to-client ratios. The nursing staff seems very resistant to the change. How can the nurse manager help the staff accept the change? -Challenge staff's beliefs and values regarding providing quality client care. -Hold a unit meeting to discuss how the changes will benefit staff. -Institute the changes immediately and collectively to decrease anticipation anxiety. -Use the laissez-faire leadership style to address staff concerns.

Hold a unit meeting to discuss how the changes will benefit staff.

Which nursing practice is part of the tertiary health care system? a) Hospice care nursing b) Community clinic nursing c) Emergency room nursing d) Oncology nursing

Hospice care nursing

The nurse observes edema in a patient who has venous congestion from right heart failure. Which type of pressure facilitated the formation of the patient's edema? a. Osmotic b. Oncotic c. Hydrostatic d. Concentration

Hydrostatic

The nurse is caring for a patient with a Stage IV pressure ulcer. Which nursing diagnosis does the nurse add to the care plan? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain

Impaired skin integrity

A patient has dehydration. While planning care, the nurse considers that the majority of the patient's total water volume exists in with compartment? a. Intracellular b. Extracellular c. Intravascular d. Transcellular

Intracellular

The nurse is reviewing a research article on a patient care topic. Which area should entice the nurse to read the article? a.Literature review b.Introduction c.Methods d.Results

Introduction

The nurse is caring for a patient who is known as a "frequent Flyer" and who has been labeled as "noncompliant" by most of the staff because she does not follow her prescribed regimen for diabetes management. As a prescriber to Orem's theory, the nurse interviews the patient in an attempt to identify the cause of the patient's "noncompliance" This is because Orem's theory: A. Is useful in designing interventions to promote self-care. B. Does not allow for environmental influences on care. C. Allows for development of a plan of care that the patient must follow. D. Is not useful in promoting self-care regimens.

Is useful in designing interventions to promote self-care.

Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle is compromised when only one nurse anesthetist is on call? A. Justice B. Nonmaleficence C. Beneficence D. Fidelity

Justice Justice refers to fairness and is used frequently in discussion regarding access to health care resources. Here the just distribution of resources, in this case pain management, cannot be justly apportioned. Nonmaleficence means "do no harm," beneficence means "to do good," and fidelity means "to be true to, or honest." Each of these principles is partially expressed in the question; however, justice is most comprised because not all laboring patients have equal access to pain management owing to lack of personnel resources

Two nurses have requested that the nurse manager allow them to plan in-service education with creative, new education techniques. Which leadership style would be best for the nurse manager to use to get the new project completed? Democratic Laissez-faire Autocratic Authoritarian

Laissez-faire

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

Left-sided heart failure

The nurse is caring for a patient who is actively bleeding. Dr. orders blood transfusion, but patient is Jehovah's Witness. The patient tell doctors that the patient cannot receive blood and request alternative treatment. The nurse contacts the physician to tell him that blood cannot be given to the patient and requests alternative treatment. In doing so, the nurse is operating within which of the following theories?

Leininger's culture care diversity and underiversality theory

A charge nurse meets with staff to outline a plan to provide transcultural nursing care for patients in their health care facility. The charge nurse explains that transcultural care as the central theme of nursing care, knowledge, and practice was promoted by which theorist? a. Madeline Leininger b. Jean Watson c. Dorothy E. Johnson d. Betty Newman

Madeline Leininger Madeline Leininger's theory provides the foundations of transcultural nursing care by making caring the central theme of nursing. Jean Watson stated that nursing is concerned with promoting and restoring health, preventing illness, and caring for the sick. The central theme of Dorothy E. Johnson's theory is that problems arise because of disturbances in the system or subsystem or functioning below optimal level. Betty Newman proposed that humans are in constant relationship with stressors in the environment and the major concern for nursing is keeping the patient system stable through accurate assessment of these stressors.

The implementation of diagnosis-related groups (DRGs) by Medicare in 1983 affected hospitals in which of the following ways?

Medicare pays only the amount of money preassigned to a treatment for a diagnosis.

A patient is admitted for a bowel obstruction and has had a nasogastric tube set to low intermittent suction for the past 3 days. Which arterial blood gas values will the nurse expect to observe? a. Respiratory alkalosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory acidosis

Metabolic alkalosis The patient is losing acid from the nasogastric tube so the patient will have metabolic alkalosis. Lung problems will produce respiratory alkalosis or acidosis. Metabolic acidosis will occur when too much acid is in the body like kidney failure.

A public health nurse is planning interventions for a community and plans to determine the frequency of diseases in the area. What information will best guide the nurse? Morbidity table (Morbidity, how frequently a disease occurs) Disease eradication statistics Mortality rates Annual hospital admissions

Morbidity table

Which issue has increased the attention paid to quality of life concerns in recent history? A. Health care disparities B. National movement regarding disabled persons C. Aging of the population D. Health care financial reform

National movement regarding disabled persons Quality of life (QOL) is often at the center of ethical dilemmas, including futile care and DNRdiscussions, and has been reshaped in the United States. The national effort to better respect the abilities of the disabled has forced Americans to reconsider the definition of QOL. Health care disparities, an aging population, and health care reform are components impacted by personal definitions of quality but are not the underlying reason why QOL discussions have arisen in the United States

A young woman who is pregnant with a fetus exposed to multiple teratogens consents to haveher fetus undergo serial PUBS (percutaneous umbilical blood sampling) to examine howexposure affects the fetus over time. Although these tests will not improve the fetus' outcomesand will expose it to some risks, the information gathered may help infants in the future.Which ethical principle is at greatest risk? A. Autonomy B. Fidelity C. Nonmaleficence D. Beneficence

Nonmaleficence Nonmaleficence is the ethical principle that focuses on avoidance of harm or hurt. The nurse must balance risks and benefits of care. Repeated PUBS may place the mother and fetus at risk for infection and increased pain, and may place the mother at risk for increased emotional health stress. Fidelity refers to the agreement to keep promises. Autonomy refers to freedom from external control, and beneficence refers to taking positive actions to help others.

A nurse is caring for a client with pneumonia. Which task is most appropriate for the nurse to delegate to an experienced unlicensed assistive personnel (UAP)? Assessing for shortness of breath Obtaining vital signs every 4 hours Instructing the client about the need to alternate activity with rest Administering nebulizer treatments as needed

Obtaining vital signs every 4 hours

A clinic nurse works with a population experiencing health disparities. Which patient does the nurse identify as having the highest risk for postponing annual breast examinations and mammograms? - Patient whose best friend had a benign breast lump removed - Patient who lives in a low-income neighborhood - Patient who has a family history of breast cancer - Patient whose family encourages regular physical examinations

Patient who lives in a low-income neighborhood

A nursing student is assisting with nursing care for patients in a primary care center. Based on the setting, what activities will the student expect to perform? - Assisting with major surgery - Performing health assessments - Maintaining patients' function and independence - Maintaining immunization records

Performing health assessments

The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Peripheral edema b. Basilar crackles c. Chest pain d. Cyanosis

Peripheral edema Right-sided heart failure results from inability of the right side of the heart to pump effectively, l eading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion

Ethical dilemmas are common occurrences when caring for patients. The nurse understandsthat dilemmas are a result of.. A. Presence of conflicting values. B. Hierarchical systems. C. Judgmental perceptions of patients. D. Poor communication with the patient.

Presence of conflicting values. Poor communication and the hierarchical systems that exist in health care, such as reporting structures within the hospital or the historically unequal relationship between physicians and nurses, may complicate dilemmas. The primary, underlying reason that ethical dilemmas occur is that there are no clear cut, universally accepted solutions to a problem when participating individuals do not share the same values. Without clarification of values, the nurse may not be able to distinguish fact from opinion or value, and this can lead to judgmental attitudes

The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer? a. Resistance b. Pressure c. Weight d. Stress

Pressure

A nurse has volunteered to give influenza immunizations at a local health clinic. In which level of health promotion and illness prevention is the nurse participating? a. Tertiary b. Secondary c. Primary d. Promotive

Primary

The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan? a. Partial-thickness repair b. Secondary intention c. Tertiary intention d. Primary intention

Primary intention

A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which type of patient education is the nurse providing? a. Health analogies b. Restoration of health c. Coping with impaired functions d. Promotion of health and illness prevention

Promotion of health and illness prevention

The nurse is collaborating with the dietitian about a patient with a Stage III pressure ulcer. Which nutrient will the nurse most likely increase after collaboration with the dietitian? a. Fat b. Protein c. Vitamin E d. Carbohydrate

Protein

The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first? a. Offer calcium-rich foods. b. Administer diuretic. c. Raise head of bed. d. Increase fluids.

Raise head of bed.

The nurse is providing diabetic diet teaching to a Hispanic man and his wife. When the nurse is discussing foods that are acceptable, the wife continues to interrupt with statements like, "Oh, he doesn't eat that," or, "All he eats is rice and beans." What should the nurse do? a. Ask the wife to leave so he/she can focus on teaching the patient. b. Explain how "rice and beans" are not acceptable foods on a diabetic diet. c. Provide a diet plan with only food alternatives selected by the patient. d. Refer the patient and his wife to a dietitian familiar with Spanish food choices.

Refer the patient and his wife to a dietitian familiar with Spanish food choices.

A patient is experiencing respiratory acidosis. Which organ system is responsible for compensation in this patient? Endocrine Respiratory Renal Gastrointenstinal

Renal

A nurse is caring for a postoperative patient. Which finding will alert the nurse to a potential wound dehiscence? a. Protrusion of visceral organs through a wound opening b. Chronic drainage of fluid through the incision site c. Report by patient that something has given way d. Drainage that is odorous and purulent

Report by patient that something has given way

2-year-old child is brought into the emergency department after ingesting a medication that causes respiratory depression. For which acid-base imbalance will the nurse most closely monitor this child? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis

Respiratory acidosis Respiratory depression leads to hypoventilation. Hypoventilation results in retention of CO2 and respiratory acidosis. Respiratory alkalosis would result from hyperventilation, causing a decrease inCO2 levels. Metabolic acid-base imbalance would be a result of kidney dysfunction, vomiting, diarrhea, or other conditions that affect metabolic acids.

During a home care visit to a home-bound elderly patient, the husband/caregiver verbalizes anger, fatigue, and sleeplessness. Which of the following recommendations by the nurse will be most effective in relieving caregiver role strain?

Respite care

The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In doing so, the nurse is applying for a position in:

Restorative Care

A nurse is trying to help a patient begin to accept the chronic nature of diabetes. Which teaching technique should the nurse use to enhance learning? a. Lecture b. Role play c. Demonstration d. Question and answer sessions

Role play

A community health nurse cares for vulnerable populations. What problem will the nurse prioritize for a patient who is homeless? - Love and belonging - Safety - Self-esteem - Self-actualization

Safety

The nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to find resolution in this assignment? A. Call for an ethical committee consult. B. Decline the assignment on religious grounds. C. Scrutinize her own personal values. D. Convince the family to challenge the directive

Scrutinize her own personal values. Values develop over time and are influenced by family, schools, religious traditions, and life experiences. The nurse must recognize that no two humans have the same set of experiences, and so differences in values are more likely the norm than the exception. Closer inspection of one's values may be a step in gaining understanding of another person's perspective. Calling for a consult, declining the assignment, and convincing the family to challenge the patient's directive are not ideal resolutions because they do not address the reason for the nurse's discomfort, which is the conflict between the nurse's values and those of the patient.

The nurse is a member of the multidisciplinary team in a large primary healthcare setting. The nurse understands that which healthcare team member is responsible for a client's swallow evaluation following a CVA (cerebral vascular accident)? a) Physical therapist b) Speech pathologist/therapist c) Physician's assistant d) Occupational therapist

Speech pathologist/therapist

The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open reddish, pink ulcer without slough on the right heel of the patient. How will the nurse stage this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV

Stage II

Care designed to prevent further progression of a disease is termed a. Primary prevention. b. Secondary prevention. c. Tertiary prevention. d. Health promotion.

Tertiary prevention.

A charge nurse on a medical-surgical unit is asked by the nurse manager to serve as a mentor to another staff nurse who is less experienced. Which of these would best describe this role? The staff nurse is learning about all the hospital policies from the charge nurse. The charge nurse is being paid to supervise the staff nurse. The charge nurse is providing support for the staff nurse in new responsibilities. The staff nurse is orienting to the unit as a newly hired nurse.

The charge nurse is providing support for the staff nurse in new responsibilities.

The nurse is advising a client about health problems related to being overweight. The client acknowledges the need to lose weight. The nurse provides education on how to count calories in food and the importance of daily exercise. The client states an intention to begin counting calories with the next meal. The client also states an intention to begin an exercise program with friends. Which statement associated with this scenario illustrates Lewin's stage of unfreezing? The nurse provides education on how to count calories in food and the importance of daily exercise. The client also states an intention to begin an exercise program with friends. The client acknowledges the need to lose weight. The client states an intention to begin counting calories with the next meal.

The client acknowledges the need to lose weight.

The new nurse is having difficulty managing the time required to care for a group of complex clients and is several hours behind in completing nursing interventions. Which intervention should the nurse complete first? Obtain discharge orders for a client who is ready to be transferred to a long-term nursing facility. Complete a medication reconciliation form on a client who has recently been admitted to the hospital. Perform a dressing change to an abdominal abscess that is three hours behind schedule. Administer a dose of digoxin that is two hours behind schedule.

The first step in time management is to determine which tasks are priority. Digoxin is a critical client medication and therefore takes priority over the other options. Dressing changes, discharge orders, and completing facility forms can be delayed until critical tasks are complete.

Two new nurses are requesting the same preceptor for unit orientation. Both new nurses have been very vocal about being unhappy if they do not receive their choice of preceptor. Which illustrates the nurses using a compromise approach to conflict resolution? The nurses agree to allow the preceptor to decide which nurse to precept. The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end. The nurses ignore each other's request for the preceptor. The nurses agree that one nurse will obtain the preceptor for orientation in exchange for that nurse working each weekend.

The nurses agree to have the preceptor precept one nurse at the beginning of the orientation and the other at the end.

Which nursing observation will indicate the patient is at risk for pressure ulcer formation? a. The patient has fecal incontinence. b. The patient ate two thirds of breakfast. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds.

The patient has fecal incontinence.

Public health nursing differs from community health nursing in that public health nursing A. Focuses on individuals and families. B. Understands the needs of a population. C. Ignores political processes. D. Considers the individual as one member of a group

Understands the needs of a population.

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient? a. Upon admission b. Right before discharge c. After the congestion is treated d. When the primary care provider writes the order

Upon admission

The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial actions should the nurse take to decrease this risk? a. Use gentle cleansers, and thoroughly dry the skin. b. Use therapeutic bed and mattress. c. Use absorbent pads and garments. d. Use products that hold moisture to the skin.

Use gentle cleansers, and thoroughly dry the skin.

Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions?

Using the nursing process

Determinations regarding quality of life are A. Based on a person's ability to act according to ethical principles. B. Based on a patient's self-determination. C. Value judgments that can vary from person to person. D. Consistent and stable over the course of one's lifetime

Value judgments that can vary from person to person. Determinations regarding quality of life are value judgments. This means that they are judgments based on what individuals believe is desirable. Beliefs about what people find desirable vary from person to person

The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? a. Assess the patients for edema in extremities. b. Ask the patients to record their intake and output. c. Weigh the patients every morning before breakfast. d. Measure the patients' blood pressures every 4 hours.

Weigh the patients every morning before breakfast.

A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic? a. abdominal distention b.constipation c. pain medication d. decreased GI motility

abdominal distention Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation (problem or NANDA-1 diagnosis) is the identified problem derived from the defining characteristics.

Which actions should the nurse take to best develop critical thinking skills? a. study three hours more each night b. interview staff nurses about the nursing experiences c. activitley participate in clinical experience d. attend all in-service opportunities

activitley participate in clinical experience

The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? a. provide privacy & check on the patient 30 min later b. set a box of tissues at the patients bedside before leaving the room c. limit visitors while the patient is upset d. ask the patient about the crying

ask the patient about the crying

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which intial action will the nurse take next to revise the plan of care

assess the patient

After a nurse manager implements a solution to the problem of delays in obtaining supplies, the first task for the manager is to: ask the staff members for other solutions. assess whether the desired results have occurred. plan to monitor the supply cabinets. make an appointment with the chief nursing officer.

assess whether the desired results have occurred.

A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? a. 0.225% sodium chloride (1/4 NS) b. 0.45% sodium chloride (1/2 NS) c. 0.9% sodium chloride (NS) d. 3% sodium chloride (3% NaCl)

c. 0.9% sodium chloride (NS)

A nursing student obtains a BP reading of 148/100. To determine the significance of this reading, what action will the nurse take first? a. comparing this reading to standards & trends in the medical record b. checking a medical text for S/S of high BP c. consulting with experienced nursing colleagues

comparing this reading to standards & trends in the medical record

The development of clinical judgement requires intentional focus & a willingness to grow & change both personally & professionally. How can a nursing student best foster the development of clinical judgement? a. focusining on knowledge acquisition that is straightforward & clear b. engaging in learning that only appeals to their preferred learning style c. developing a model for learning that integrates feedback & reflection d. focusing inward to develop emotional intelligence & communication skills

developing a model for learning that integrates feedback & reflection

A new nurse is confused about using evaluative measures when caring for patients & asks the charge nurse for an explanation. Which response by the CN is most accurate? a. Evaluative measures are multiple page documents used to evaluate nurse performace b. evaluative measures are objectives for completion of nursing interventions c. evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse d. evaluative measures including assessment data used to determine whether patient's have met their expected outcome & goals

evaluative measures including assessment data used to determine whether patient's have met their expected outcome & goals

A nurse has decided to specialize in the care of the aging individuals in both illness and health. What is the term for this nursing specialty? a. geriatrics b. hospice nursing c. gerontologic nursing d. long term care

gerontologic nursing

A registered nurse is delegating activities to unlicensed assistive personnel (UAP) on a hospital unit. Which activity(ies) could this nurse normally delegate? Select all that apply. taking routine vital signs giving a bed bath to a client administering medications to a client planning education for a client with a colostomy determining a nursing concern for care planning for a client with breast cancer transferring a client to another floor

giving a bed bath to a client taking routine vital signs transferring a client to another floor

A nurse is assessing an older adult with impaired thinking, mood and communication. The nurse would expect to find that the client is most likely experiencing problems with which activity initially? Select all that apply. a. managing finances b. ambulating c. shopping d. bathing e. cooking

managing finances shopping cooking losing IADLs before ADLs

During shift report, a nurse says that a patient has no integumentary changes or skin care needs. During assessment, the nurse observes reddened areas over bony prominences. What action will the nurse take

perform & document a focused assessment of skin integrity

A nurse is assessing a patient. Which assessment finding should cause the nurse to further assess for extracellular fluid volume deficit? supple skin tugor pitting edema postural hypotension moist mucous membranes

postural hypotension

When caring for a patient who sustained a spinal cord injury, the nurse formulates the health problem: Impaired Tissue Integritty Etiology: sensory & motor deficit S/S: difficulty turning, reddened areas on heels & sacrum Which phrase gives direction to the underlying cause of the problem? a. reddened areas of skin on the heels and back b. s/s c. impaired tissue integrity d. sensory & motor deficit

sensory & motor deficit

Which action indicates a registered nurse is being responsible for making clinical decisions?

takes immediate action when a patients condition worsens

A student nurse is on a clinical rotation at a hospital. The RN in charge tells the student to change a surgical dressing on a patient while she takes care of other patients. The student had not changed dressings before and does not feel confident with the procedure. What would be the students best response? a. tell the CN they lack the technical competencies to change the dressing independently b. tell the clinical instructor they have not had experience with the delegated task c. assemble the equipment for the procedure & follow the steps in the procedure manual d. ask another student nurse to work collaboratively with them to change the dressing

tell the CN they lack the technical competencies to change the dressing independently

The nurse completes a health history & physical assessment on a client who has been admitted to the hospital for surgery. What is the purpose of this initial assessment?

to establish a database to identify problems & strengths