Ch 17, 18, 19, 25, 26

11. A nurse working in a clinic is planning to conduct vision screenings for a group of low-income women. What equipment would be needed to test vision? A) Snellen chart B) Stethoscope C) Ophthalmoscope D) Otoscope

Ans: A Feedback: A Snellen chart is used as a screening test for distant vision. It consists of characters in 11 lines of different-sized type, with the largest characters at the top of the chart and the smallest characters at the bottom. Vision is recorded as a score; for example, 20/20 is normal vision. A stethoscope is used to auscultate body sounds. An ophthalmoscope is used to assess the inner eye. An otoscope is used to inspect the nasal passages.

1. A client being prepared for discharge to his home will require several interventions in the home environment. The nurse informs the discharge planning team, consisting of a home health care nurse, physical therapist, and speech therapist, of the client's discharge needs. This interaction is an example of which professional nursing relationship? A) Nurse-health care team B) Nurse-patient C) Nurse-patient-family D) Nurse-nurse

Ans: A Feedback: A nurse-health care team professional relationship occurs when the nurse coordinates the input of the multidisciplinary team into a comprehensive plan of care. The nurse may also serve as a liaison between the client and family and the health care team, as necessary.

12. A student is reading the medical record of an assigned client and notes the client has been afebrile for the past 12 hours. What does the term "afebrile" indicate? A) Normal body temperature B) Decreased body temperature C) Increased body temperature D) Fluctuating body temperature

Ans: A Feedback: A person with normal body temperature is referred to as afebrile.

22. Which activity is a possible solution for inadequate nursing staffing? A) Identify the kind and amount of nursing services required. B) Learn to give quality care during designated work period. C) Use a team conference to develop a consistent plan of care. D) Educate the client to become an assertive health care consumer.

Ans: A Feedback: A possible solution for inadequate staffing is to identify the kind and amount of nursing services required. Using a team conference to develop a consistent plan of care is a possible solution for the client who refused to cooperate with the therapeutic regimen. Educating the client to become an assertive health care consumer is a possible solution for the client who quietly accepts whatever care is delivered or not delivered. A possible solution for the nurse who is a candidate for burnout is to learn to give quality care during the designated work period.

29. The nurse is preparing to mail a client satisfaction questionnaire to a client who was discharged from the hospital four days ago. Which type of evaluation is the nurse conducting? A) Retrospective evaluation B) Peer review C) Nursing audit D) Concurrent evaluation

Ans: A Feedback: A retrospective audit uses post-discharge questionnaires to collect data. A nursing audit is a method of evaluating nursing care that involves reviewing client records to assess the outcomes of nursing care (or the process by which these outcomes were achieved). Concurrent evaluation involves direct observations of nursing care, client interviews, and chart review to determine whether the specified evaluative criteria are met. Peer review involves the evaluation of one staff member by another staff member on the same level in the hierarchy of the organization. This is done for the purpose of professional performance improvement.

2. The nurses who provide care in a large, long-term care facility utilize charting by exception (CBE) as the preferred method of documentation. This documentation method may have which of the following drawbacks? A) Vulnerability to legal liability since nurse's safe, routine care is not recorded B) Increased workload for nurses in order to complete necessary documentation C) Failure to identify and record client problems and associated interventions D) Significant differences in the charting between nurses due to lack of standardization

Ans: A Feedback: A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing. CBE is generally less time-consuming than alternate methods of documentation, and both standardization of charting and identification of client-specific problems are possible within this documentation framework.

13. A school nurse is preparing to test the auditory function of grade school students. What equipment will be needed for this examination? A) Tuning fork B) Percussion hammer C) Speculum D) Ophthalmoscope

Ans: A Feedback: A tuning fork is a two-pronged metal instrument used to test auditory function and vibratory perception. The fork is activated to vibrate by holding the base and gently tapping the prongs against the palm of the examiner's hand. Once vibrating, the fork is held at the base to avoid diminishing the vibration.

20. A nurse uses informatics to plan nursing care for a client. Which three terms best describes this science as it is applied to nursing? A) Data, information, knowledge B) Process, documentation, analysis C) Research, controls, variables D) Hypothesis, nursing, practice

Ans: A Feedback: According to the ANA Scope and Standards of Nursing Informatics Practice, nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support clients, nurses, and other providers in their decision making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology (ANA, 2001, p. vii).

6. The nurse witnessed a more senior nurse make six unsuccessful attempts at starting an intravenous (IV) line on a client. The senior nurse persisted, stating, "I refuse to admit defeat." This resulted in unnecessary pain for the client. How should the first nurse best respond to this colleague's incompetent practice? A) Report the nurse's practice and have the nurse manager address the matter. B) Encourage the nurse to attend an in-service on IV starts. C) Reassure the nurse that this is a difficult skill and give her feedback on her performance. D) Document an unmet outcome in the client's plan of care.

Ans: A Feedback: According to the study Silence Kills: The Seven Crucial Conversations for Healthcare (Maxfield, Grenny, Patterson, McMillan, & Switzler, 2005), an appropriate response to incompetence is to report the matter and enlist the manager to conduct follow-up. Reassuring the nurse and encouraging education are not sufficient responses to incompetence. This action does not constitute an unmet outcome on the part of the client.

11. A nurse in a community health center has been having regular meetings with a woman who wants to stop smoking. Which of the following outcome decision options would the nurse document if the woman has not smoked for three months? A) Outcome met B) Outcome partially met C) Outcome not met D) Outcome inappropriate

Ans: A Feedback: After data have been collected and interpreted to determine client outcome achievement, the nurse makes and documents a judgment summarizing the findings. The three decision options are met, partially met, and not met. In this case, the nurse's judgment is that the client has met the expected outcome of smoking cessation.

1. A client's diagnosis of pneumonia requires treatment with antibiotics. The corresponding order in the client's chart should be written as ... A) Avelox (moxifloxacin) 400 mg daily B) Avelox (moxifloxacin) 400 mg Q.D. C) Avelox (moxifloxacin) 400 mg qd D) Avelox (moxifloxacin) 400 mg OD

Ans: A Feedback: Among the JCAHO's list of "do not use" abbreviations are Q.D., qd, and OD when denoting a once-per-day drug administration. Because of the potential for misinterpretation and consequent drug errors, the JCAHO recommends writing "daily" in the order.

31. The client reports participating in water aerobics for 60 minutes three times each week. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

Ans: A Feedback: An affective outcome involves changes in the client's values, beliefs, and attitude, such as participating in water aerobics. Cognitive outcomes demonstrate increases in client knowledge. Physiologic outcomes are physical changes in the client. Psychomotor outcomes describe the client's achievement of new skills.

5. Nurses have identified the following outcome in the care of a client who is recovering from a stroke: "Client will ambulate 100 feet without the use of mobility aids by 12/12/2011." Several nurses have evaluated the client's progression towards this outcome at various points during her care. Which of the following evaluative statements is most appropriate? A) "12/12/2011 - Outcome partially met. Patient ambulated 75 feet without the use of mobility aids" B) "12/12/2011 - Outcome unmet. Patient's ambulation remains inadequate." C) "12/10/2011 Outcome met, but with the use of a quad cane to assist ambulation." D) "12/14/2011 Outcome met."

Ans: A Feedback: An evaluative statement should include both the decision about how well the outcome was met along with data that support this decision. Characterizing the client's ambulation as "inadequate" is not sufficiently precise. Stating that this outcome was met with the use of a cane contradicts the original terms of the outcome.

18. What is the primary purpose of an incident report? A) Means of identifying risks B) Basis for staff evaluation C) Basis for disciplinary action D) Format for audiotaped report

Ans: A Feedback: An incident report, also termed a variance or occurrence report, is a tool used by health care agencies to document the occurrence of anything out of the ordinary that results in, or has the potential to result in, harm to a client, employee, or visitor. Incident reports should not be used for disciplinary action against staff members.

2. The nurse notes a difference in systolic blood pressure readings between the client's arms. How will the nurse approach subsequent readings based upon this difference in blood pressures? A) The nurse will use the arm with the highest reading. B) The nurse will use the arm with the lowest reading. C) The nurse will average the two blood pressures and document this average. D) The nurse will obtain a blood pressure on the client's leg.

Ans: A Feedback: An initial nursing assessment should include blood pressure assessments on both arms. It is normal to have a 5- to 10-mm Hg difference in the systolic reading between arms. Use the arm with the higher reading for subsequent pressures.

1. Upon auscultation of a client's heart rate, the nurse notes the rate to have an irregular pattern of 72 beats/minute. The nurse notifies the physician because the client is exhibiting signs of which of the following? A) A dysrhythmia B) Tachycardia C) Bradycardia D) Hypertension

Ans: A Feedback: An irregular pattern of heartbeats is called a dysrhythmia. Tachycardia is an increased heart rate of 100 to 180 beats/minute. Bradycardia is a pulse rate below 60 beats/minute. The normal pulse rate ranges from 60 to 100 beats per minute. Hypertension is a blood pressure that is above normal for a sustained period.

1. Upon entering the client's room at the beginning of a shift and throughout the shift, the nurse assesses the client. The nurse considers the client's plan of care and response to nursing interventions during the assessments. What type of assessment is the nurse performing? A) Ongoing partial assessment B) Comprehensive assessment C) Focused assessment D) Emergency assessment

Ans: A Feedback: An ongoing partial assessment is conducted at regular intervals during care of the client and concentrates on identified health problems and the effectiveness of interventions. A comprehensive assessment includes a health history and complete physical examination and is usually conducted when a client first enters a health care setting. A focused assessment is conducted to assess a specific problem. An emergency assessment is a type of rapid focused assessment conducted to determine a potentially fatal situation.

33. The nurse is giving a shift report to the oncoming nurse who will be caring for a client with a portacath access device. The oncoming nurse states, I have never taken care of a client with a portacath. Would you give me the basics, so I know what to do? Which standard for establishing and sustaining healthy work environments is the oncoming nurse breaching? A) Appropriate staffing B) Effective decision making C) True collaboration D) Skilled communication

Ans: A Feedback: Appropriate staffing ensures that client needs are effectively matched with nurse competencies. In this scenario, the nurse is ill-prepared to care for the client. The nurse needs structured training to learn about the nursing care of portacaths. Skilled communication requires health team members to communicate in a respectful, non-intimidating manner with colleagues. True collaboration involves skilled communication, mutual respect, shared responsibility, and decision making among nurses, and between nurses and other health team members. Effective decision making ensures nurses are valued and active partners in making policy, directing and evaluating clinical care, and leading organizational operations.

4. When assessing a client's vital signs, a nursing student has explained each of her next actions prior to assessing the client's temperature, pulse, and blood pressure. However, the nurse has not announced her intention to assess the client's respiratory rate prior to measuring it. Which of the following is a plausible rationale for the nurse's decision? A) Respirations have both autonomic and voluntary control. B) The nurse likely assessed the client's respiratory rate simultaneous to heart rate. C) Temperature, pulse, and blood pressure are more volatile than respiratory rate. D) Tachypnea is an expected finding among hospitalized individuals.

Ans: A Feedback: Because respiratory rate is under both autonomic and voluntary control, making the client conscious of his or her respiratory rate prior to assessment has the potential to affect that accuracy of the assessment. It is not possible to simultaneously assess pulse and respirations. Temperature, pulse, and blood pressure are not necessarily more volatile than respiratory rate. Tachypnea is not an expected finding.

4. The nurse is conducting an assessment on the integumentary system of a client age 74 years. Which of the following findings should the nurse document as an anomaly that may warrant follow-up? A) The client states that a mole on his forehead has become larger in recent months. B) Decreased skin turgor is evident when the skin is folded and then released. C) Small, round, red spots are present on the client's forearms bilaterally. D) There are some raised, brown areas on the backs of the client's hands.

Ans: A Feedback: Changes in the size or appearance of a mole always require further assessment and follow-up due to their association with skin cancer. Decreased skin turgor is an expected finding in older adults, as are diffuse red spots (cherry angioma) and raised, dark areas (senile lentigines).

32. The nurse is assessing a client with a diagnosis of hypertension. The client's blood pressure is 178/88, an increase from 134/78 at the previous clinic visit. The nurse asks the client what has changed from the previous visit. Which client statement identifies a potential factor interfering with the plan of care? A) My husband has been ill and I don't have anyone to help me care for him. B) I have learned to prepare foods differently so they are low in fat. C) My neighbor walks with me around the neighborhood every morning. D) I have been taking my hydrochlorothiazide (HydroDIURIL) every day.

Ans: A Feedback: Common factors that contribute to a client not following the plan of care include lack of family support, inability to afford treatment, limited access to treatment, and adverse physical or emotional effects of treatment. The burden of caring for her husband may be placing stress on the client, and causing her blood pressure to be elevated despite engaging in health promotion and blood pressure-lowering activities.

33. A nurse has an order to take the core temperature of a client. At which of the following sites would a core body temperature be measured? A) Rectal B) Oral C) Skin surface D) Axillary

Ans: A Feedback: Core temperatures are measured by nurses rectally. Surface body temperatures are measured at oral (sublingual), axillary, and skin surface sites.

12. A nurse is interested in improving client care on the unit through performance improvement. What is the first step in this process? A) Discover the problem. B) Plan a strategy. C) Implement a change. D) Assess the change.

Ans: A Feedback: Each nurse must decide how to respond when he or she perceives that client care is being compromised. The four steps listed are all components of the process of performance improvement, with discovering the problem being the first step.

5. A male client 30 years of age is postoperative day 2 following a nephrectomy (kidney removal) but has not yet mobilized or dangled at the bedside. Which of the following is the nurse's best intervention in this client's care? A) Educate the client about the benefits of early mobilization and offer to assist him. B) Respect the client's wishes to remain in his bed and ask him when he would like to begin mobilizing. C) Show the client the expected outcomes on his clinical pathway that relate to mobilization. D) Document the client's noncompliance and reiterate the consequences of delaying mobilization.

Ans: A Feedback: Educating the client about the benefits of mobilizing, and offering to assist combines teaching with the promotion of self-care. It is likely premature to label the client as noncompliant, and showing him the expected outcomes on his clinical pathway is unlikely to motivate him if he is reluctant. It is appropriate for the nurse to educate and encourage the client rather than simply accepting his refusal and providing no other interventions.

5. As a component of a head to toe assessment, the nurse is preparing to assess convergence of the client's eyes. How should the nurse conduct this assessment? A) Ask the client to follow her finger as she slowly moves it towards the client's nose. B) Ask the client to look ahead while slowly bringing a pen light in from the side and to the client's pupil. C) Ask the client to hold his head stationary while following a pencil from left to right. D) Ask the client to read a Snellen chart from a distance of 20 feet.

Ans: A Feedback: Eye convergence is assessed by holding your finger 6″ to 8″ from the patient's nose and asking the patient to follow it as it moves closer. A pen light is used to assess pupillary reaction. Visual acuity is assessed with the use of a Snellen chart. Following a pencil from side to side is a test for extraocular movements.

6. A nurse is conducting a health assessment. How will the information collected from the client be used? A) As a basis for the nursing process B) To illustrate nursing competence C) To facilitate nurse-client caring D) As one component of medical care

Ans: A Feedback: Health assessment is an integral component of nursing care and is the basis of the nursing process. Health assessments by nurses are used to plan, implement, and evaluate education and care. Nursing assessment is different from other types of health care provider assessments, as it is a holistic collection of information about a client's level of health.

20. A nurse is taking a client's temperature and wants the most accurate measurement, based on core body temperature. What site should be used? A) Rectal B) Oral C) Axillary D) Forehead

Ans: A Feedback: Heat is generated by metabolic processes in the core tissues of the body, transferred to the skin surface by the circulating blood, and then dissipated to the environment. Core body temperatures may be measured at rectal or tympanic sites.

16. A middle-aged, overweight adult man has had hypertension for 15 years. What pathologic event is he most at risk for? A) Stroke B) Anemia C) Cancer D) Infection

Ans: A Feedback: Hypertension is the most important risk factor associated with stroke.

36. The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment, Recommendation, Read Back) during which of the following clinical situations? A) When communicating a client's change in condition to the client's physician B) When providing a change-of-shift report to a colleague C) When documenting the care that was provided to a client whose condition recently deteriorated D) When reporting to a client's family member or significant other

Ans: A Feedback: ISBARR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members. ISBARR is considered a framework for communication rather than a format for documentation.

28. An African American client with jaundice has been admitted to the health care facility. Which of the following body areas is the best place to assess jaundice? A) Sclera B) Nailbeds C) Lips D) Palm

Ans: A Feedback: In African American clients, the sclera is the best place to assess the yellowish discoloration of jaundice. Jaundice assessment cannot be done on the nailbeds, lips, or palm due to hyperpigmentation.

8. What is the unique focus of nursing implementation? A) Client response to health and illness B) Client response to nursing diagnosis C) Client compliance with treatment regimen D) Client interview and physical assessment

Ans: A Feedback: In all nurse-client interactions, the nurse is concerned with the client's response to health and illness and the nurse's ability to meet basic human needs. Whereas other health care professionals focus on selected aspects of the client's treatment regimen, nurses are concerned with how the client is responding to the plan of care in general.

29. A nurse is assessing the spine of a client with kyphosis. Which of the following would the nurse expect to observe about the client's posture? A) The shoulder and upper back curves forward B) The lumbar region tends to curve inward C) The sacral region tends to turn outward D) A portion of the spine is curved to the side laterally

Ans: A Feedback: In kyphosis, the shoulder and upper back tend to curve forward. In lordosis, the lumbar region curves inward and the sacral region curves outward. Scoliosis is a curvature of a portion of the spine to the side, laterally.

3. The nurse is performing an assessment on an infant. Which finding is considered an abnormal cardiovascular assessment that should be documented and reported to the physician? A) Decreased heart rate B) Visible pulsation through a thin chest wall C) Sinus dysrhythmia that increases with inspiration and decreases with expiration D) Presence of an S heart sound

Ans: A Feedback: Infants and children should have a more rapid heart rate, instead of a decreased heart rate, until about age 8 years. Common cardiovascular findings include visible pulsation if the chest wall is thin, sinus dysrhythmia (the rate increases with inspiration and decreases with expiration), and the presence of an S heart sound.

7. The manager of a medical unit regularly reviews the incident reports that result from errors and near misses that occur on the unit. How should the manager best respond to these incident reports? A) Use them to inform improvements and education on the unit. B) Use them to identify deficient workers for removal or demotion. C) Cross-reference them with client satisfaction reports from the unit. D) Use them to identify individuals who would benefit from probationary measures.

Ans: A Feedback: It is most beneficial for the manager to frame incident reports as sources of improvement, which can improve both client care and the work environment. Punitive follow-up by demotion, probation, or removal is likely to create reluctance among staff to complete incident reports. Cross-referencing incident reports with client satisfaction reports is unlikely to result in substantial improvements to the unit's care and culture.

3. The American Nurses Association recommends adherence to defined principles when delegating care tasks to unlicensed assistive personnel. According to these principles, who is responsible and accountable for nursing practice? A) The registered nurse B) The American Nurses Association C) The nurse manager D) The unit's medical director

Ans: A Feedback: It is the registered nurse who is responsible and accountable for nursing practice.

29. A home health care nurse notices that his assigned client uses a mercury thermometer. He asks the nurse what to do if it breaks. Which of the following is not correct? A) "Just flush the glass and mercury down the toilet." B) "Do not vacuum the area where it breaks." C) "Open the windows and close off the room for an hour." D) "Throw away any clothing exposed to the mercury."

Ans: A Feedback: Mercury should never be flushed down the toilet. Mercury is not only hazardous to people but it also pollutes the environment, especially if it gets into water. The other responses are correct.

34. The nurse at the beginning of the shift plans to see which client first, based on the following vital signs? A) The client age 2 years whose respiratory rate is 16 breaths/minute B) The newborn whose axillary temperature is 98.2 ºF (36.8 ºC) C) The client age 7 years whose pulse is 120 beats/minute D) The client age 10 years whose blood pressure is 102/62 mmHg

Ans: A Feedback: Normal respiratory rate for a child 1 to 3 years of age is 20 to 40 breaths/minute. Therefore, the nurse should assess the 2-year-old with a respiratory rate of 16 first, as the other clients' vital signs are within normal limits.

2. A graduate nurse recently attended a conference on acute coronary syndrome. In preparing a plan of care for a client admitted with acute coronary syndrome, the nurse considers the information she learned at the conference. Which nursing variable is the nurse utilizing in the development of the plan of care? A) Research findings B) Resources C) Current standards of care D) Ethical and legal guides to practice

Ans: A Feedback: Nurses concerned about improving the quality of nursing care use research findings to enhance their nursing practice. Reading professional journals and attending continuing education workshops and conferences are excellent ways to learn about new nursing strategies that have proved effective.

4. An older adult client is receiving care on a rehabilitative medicine unit during her recovery from a stroke. She complains that the physical therapist, occupational therapist, neurologist, primary care physician, and speech language pathologist "don't seem to be on the same page" and that "everyone has their own plan for me." How can the nurse best respond to the client's frustration? A) Facilitate communication between the different professionals and attempt to coordinate care. B) Educate the client about the unique scope and focus of each member of the healthvcare team. C) Modify the client's plan of care to better reflect the commonalities between the different disciplines. D) Arrange for each professional to perform bedside assessments and interventions simultaneously rather than individually.

Ans: A Feedback: Nurses play a pivotal role in the coordination of care and often need to facilitate communication between members of different disciplines. Educating the client about the role of each professional may be useful, but it does not achieve coordination of care. Similarly, amending the client's plan of care will not create unity and collaboration. It is unrealistic to expect each member of the care team to always visit simultaneously.

3. An older adult client has lost significant muscle mass during her recovery from a systemic infection. As a result, she has not yet met the outcomes for mobility and activities of daily living that are specified in her nursing plan of care. How should her nurses best respond to this situation? A) Continue the plan of care with the aim of helping the client achieve the outcomes. B) Terminate the plan of care since it does not accurately reflect the client's abilities. C) Modify the plan of care to better reflect the client's current functional ability. D) Replace the client's individualized plan of care with a clinical pathway.

Ans: A Feedback: Nurses regularly evaluate clients' progression toward the achievement of outcomes that are specified in plans of care. When clients need more time to achieve desired outcomes, it is appropriate to continue with the existing plan of care. It is not necessary to terminate the plan of care and modification may be premature. Abandoning the plan and replacing it with a clinical pathway is counterproductive to the continuity of care.

30. During a nurse's visit to the client's home, the client states, "I have pain in my right knee." The nurse assesses the client's right knee. What kind of assessment is this? A) Focused assessment B) Spiritual assessment C) Social assessment D) Comprehensive assessment

Ans: A Feedback: Often, nurses must select the most important interviewing questions or assessment techniques to use, and perform a focused health assessment based on the client's problem.

3. The nurse managers of a home health care office wish to maximize nurses' freedom to characterize and record client conditions and situations in the nurses' own terms. Which of the following documentation formats is most likely to promote this goal? A) Narrative notes B) SOAP notes C) Focus charting D) Charting by exception

Ans: A Feedback: One of the advantages of a narrative notes model of documentation is that it allows nurses to describe clinical encounters in their own terms, as they understand them. Other documentation formats, such as SOAP notes, focus charting, and charting by exception, are more rigidly delineated and allow nurses less latitude in their documentation.

18. A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client complains of dizziness and faintness. The client's blood pressure is 90/50. What is the name for this condition? A) Orthostatic hypotension B) Orthostatic hypertension C) Ambulatory bradycardia D) Ambulatory tachycardia

Ans: A Feedback: Orthostatic hypotension (postural hypotension) is a low blood pressure associated with weakness or fainting when one rises to an erect position (from supine to sitting, supine to standing, or sitting to standing). It is the result of peripheral vasodilation without a compensatory rise in cardiac output.

7. A female client 89 years of age has been admitted to the hospital with a diagnosis of failure to thrive. She has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. She admits to her nurse that the problem is rooted in the fact that she feels mortified to attempt a bowel movement on a commode at her bedside where staff and other clients can hear her. The nurse should respond by modifying which of the following resources? A) Environment B) Personnel C) Equipment D) Patient and visitors

Ans: A Feedback: Providing an environment for the client that is more conducive to privacy and, ultimately, to her elimination needs is necessary in this case. The equipment itself (i.e., the commode) is not the problem, but rather its proximity to others. The staff and the client herself are not central to the client's new problem.

6. Many of the homeless clients who are supposed to receive care for HIV/AIDS miss their appointments at a clinic because it is located in a high-rise building on a university campus. Several of the clients state that the clinic is difficult to find and in an intimidating environment. This demonstrates that which of the following variables influencing outcome achievement is being inadequately addressed? A) Psychosocial background of clients B) Developmental stage of clients C) Ethical and legal considerations D) Resources

Ans: A Feedback: Requiring clients to attend a clinic that is difficult to access, and located in a daunting environment, shows a lack of consideration for clients' psychosocial backgrounds. Resources, development, and ethics are not central to this lapse in care.

2. Nursing care and client outcomes may be evaluated by use of a retrospective evaluation process. Which of the following is an example of a retrospective evaluation process? A) Postdischarge questionnaire. B) Direct observation of nursing care. C) Client interview during hospitalization. D) Review of client's chart during hospitalization.

Ans: A Feedback: Retrospective evaluation may use postdischarge questionnaires and client interviews, or chart reviews after the client has been discharged. Concurrent evaluation occurs while the client is receiving care and may include the following: direct observation of nursing care and client interviews; and direct observation of chart reviews during hospitalization.

2. An older adult asks the nurse about the appearance of flat brown age spots on the hands. After examining the client's hands, the nurse recognizes these skin characteristics as a common skin variation in the older adult and documents the variations as which of the following? A) Senile lentigines B) Lanugo C) Senile keratosis D) Cherry angiomas

Ans: A Feedback: Senile lentigines are flat, brown age spots, senile keratosis are raised, dark areas, and cherry angiomas are small, round red spots. All are common skin variations in the older adult. Lanugo is a fine downy hair that appears on the newborn for the first two weeks of life.

24. A nurse caring for a client who is being treated by three physicians uses the source-oriented format for documentation. What are the benefits of using this format of documentation? A) Information is documented in separate forms by each health care personnel. B) It is a unified, cooperative approach for resolving the client's problems. C) It is organized at one location according to the client's health problems. D) It is compiled to facilitate communication among health care professionals.

Ans: A Feedback: Source-oriented documentation is a record organized according to the source of documented information. This type of record contains separate forms on which health care personnel make written entries about their own specific activities in relation to the client's care. The problem-oriented method of recording demonstrates a unified, cooperative approach to resolving the client's problems. Source-oriented records are organized at numerous locations; there is not one location for information. The problem-oriented record is compiled to facilitate communication among health care professionals.

9. A student has reviewed a client's chart before beginning assigned care. Which of the following actions violates client confidentiality? A) Writing the client's name on the student care plan B) Providing the instructor with plans for care C) Discussing the medications with a unit nurse D) Providing information to the physician about laboratory data

Ans: A Feedback: Students using client records are bound professionally and ethically to keep in strict confidence all the information they learn from those records. The student may discuss care with the instructor, medications with a staff nurse, and laboratory data with the physician. The student should not use actual client names or other identifiers in written assignments or oral reports.

19. A nurse on duty finds that a client is anxious about the results of laboratory testing. Which intervention by the nurse reflects a supportive intervention? A) Sitting with the client to encourage her to talk B) Telling the laboratory technician to speed up the results C) Calling the physician for an order for an anxiolytic D) Educating the client about reducing risk factors

Ans: A Feedback: Supportive interventions include recognizing the need for encouragement, unconditional acceptance of behaviors, and the positive effects of being present for clients during stress or crisis. To support the anxious client, the nurse should sit with her and encourage her to talk. Telling the laboratory technician to speed up the results, or calling the physician and taking orders for anxiolytics are inappropriate supportive interventions. Educating the client about reducing risk factors is an educational intervention.

4. The nurse has responded to a client's request to view her medical chart by arranging a meeting between the client, the clinical nurse leader, and her primary care physician. The nurse is exemplifying which of the following characteristics of quality health care? A) Information B) Science C) Cooperation D) Individualization

Ans: A Feedback: The Institute of Medicine's Committee on Quality Health Care in America has identified aspects of care that clients can reasonably expect. One of these expectations is information, which is manifested by allowing clients access to their medical records. Other characteristics that clients can expect are knowledge-based care (science), coordination between professionals (cooperation), and respect for client choices and preferences (individualization).

12. Which one of the following methods of documentation is organized around client diagnoses rather than around patient information? A) Problem-oriented medical record (POMR) B) Source-oriented record C) PIE charting system D) focus charting

Ans: A Feedback: The POMR is organized around a client's problems rather than around sources of information. With POMRs, all health care professionals record information on the same forms. The advantages of this type of record are that the entire health care team works together in identifying a master list of client problems and contributes collaboratively to the plan of care.

13. A nurse organizes client data using the SOAP format. Which of the following would be recorded under "S" of this acronym? A) Client complaints of pain B) Client history C) Client's chief complaint D) Client interventions

Ans: A Feedback: The SOAP format (subjective data, objective data, Assessment [the caregiver's judgment about the situation], plan) is used to organize data entries in the progress notes of the POMR. A client complaint of pain is subjective data (S).

4. A hospital utilizes the SOAP method of charting. Within this model, which of the nurse's following statements would appear at the beginning of a charting entry? A) "Client complaining of abdominal pain rated at 8/10." B) "Client is guarding her abdomen and occasionally moaning." C) "Client has a history of recent abdominal pain." D) "2 mg Dilaudid PO administered with good effect"

Ans: A Feedback: The SOAP method of charting (Subjective data, Objective data, Assessment, Plan) begins with the information provided by the client, such as a complaint of pain. The nurse's objective observations and assessments follow, with interventions, actions, and plans later in the charting entry.

3. An male client 86 years of age with a diagnosis of vascular dementia and cardiomyopathy is exhibiting signs and symptoms of pneumonia. The nurse has attempted to assess his temperature using an oral thermometer, but the client is unable to follow directions to close his mouth and secure the thermometer sublingually. Additionally, he repeatedly withdraws his head when the nurse attempts to use a tympanic thermometer. How should the nurse proceed with this assessment? A) Assess the client's temperature by axilla. B) Assess the client's skin tone and the presence or absence of sweating to determine whether the client is febrile. C) Use a disposable mercury thermometer to take the client's temperature. D) Take the client's temperature rectally.

Ans: A Feedback: The axillary site is an accurate and acceptable alternative when other sites are impractical or contraindicated. Rectal temperatures are contraindicated in cardiac clients; mercury thermometers are not commonly used. It is unacceptable for the nurse to rely solely on subjective assessments to determine whether the client is febrile.

24. A nurse is assessing the blood pressure on an obese woman. What error might occur if the cuff used is too narrow? A) Reading is erroneously high B) Reading is erroneously low C) Pressure on the cuff with be painful D) It will be difficult to pump up the bladder

Ans: A Feedback: The bladder of the cuff should enclose at least two-thirds of the adult limb. If the cuff is too narrow, the reading could be erroneously high because the pressure is not being transmitted evenly to the artery.

34. The correct sequence of steps for performance improvement is: 1. Discover a problem. 2. Plan a strategy using indicators. 3. Implement a change. 4. Assess the change. A) 1, 2, 3, 4 B) 1, 4, 2, 3 C) 4, 1, 2, 3 D) 1, 2, 4, 3 E) 1, 3, 2, 4

Ans: A Feedback: The correct sequence of steps for performance improvement is (1) discover a problem; (2) plan a strategy using indicators; (3) implement a change; and (4) assess the change; if the change is not met, plan a new strategy.

25. Various sounds are heard when assessing a blood pressure. What does the first sound heard through the stethoscope represent? A) Systolic pressure B) Diastolic pressure C) Auscultatory gap D) Pulse pressure

Ans: A Feedback: The first sound heard through the stethoscope, which is the onset of phase I of Korotkoff sounds, represents the systolic pressure.

18 A nurse is performing a general survey of a client admitted to the hospital. Which of the following actions is an element of this procedure? A) Taking vital signs B) Palpating the integument C) Identifying risk factors for altered health D) Assessing the head and neck

Ans: A Feedback: The general survey is the first component of the physical assessment. It includes observing the client's overall appearance and behavior, taking vital signs, and measuring height and weight. Information from the general survey provides clues to the client's overall health. Palpating the integument and assessing the head and neck are part of the physical assessment. Identifying risk factors for altered health occurs in the health history.

8. An adolescent comes to a community health clinic with complaints of vaginal itching and discharge. She believes it is from having sex with her boyfriend. Which response should the nurse use during the health history to elicit information? A) "Tell me about the sexual activity with your boyfriend." B) "Why did you ever have sex with someone you don't know?" C) "You are old enough to know to use condoms." D) "I don't understand how you could be so careless."

Ans: A Feedback: The health history is used to collect subjective data about the client's health status. Nurses use therapeutic communication skills, including open-ended statements and questions that are not threatening or negative, to establish an effective nurse-client relationship that facilitates communication.

35. The nurse is reviewing a client's chart. When reading the history, physical, and physician progress notes, the nurse anticipates finding which of the following? A) The physician's assessment and treatment B) Results of laboratory and diagnostic studies C) Nursing documentation and plan of care D) Information from other members of the health care team

Ans: A Feedback: The medical history, physical examination, and progress notes record the findings of physicians as they assess and treat the client. They focus on identifying pathologic conditions and their causes, as well as determining the medical regimen for treatment.

8. Which of the following is an average normal temperature in Centigrade for a healthy adult? A) oral: 37.0°C B) rectal: 36.5°C C) axillary: 37.5°C D) tympanic: 34.4°C

Ans: A Feedback: The normal range for an oral temperature is 37.0°C, a rectal temperature is 37.5°C, an axillary temperature is 36.5°C, and a tympanic temperature is 37.5°C.

14. A nurse is evaluating and revising a plan of care for a client with cardiac catheterization. Which of the following actions should the nurse perform before revising a plan of care? A) Discuss any lack of progress with the client. B) Collect information on abnormal functions. C) Identify the client's health-related problems. D) Select appropriate nursing interventions.

Ans: A Feedback: The nurse should discuss any lack of progress with the client so that both the client and the nurse can speculate on what activities need to be discontinued, added, or changed. Collecting information on abnormal functions and risk factors is done during the assessment. Identification of the client's health-related problems is done during diagnosis. Nurses select appropriate nursing interventions and document the plan of care in the planning stage of the nursing process, not during evaluation.

35. The nurse preparing to perform an abdominal assessment on a client places the client in which of the following positions? A) Supine B) Sims C) Prone D) Lithotomy

Ans: A Feedback: The nurse should place the client in the supine position when performing an abdominal assessment.

34. The nurse notes that the blood glucose level of a client has increased and is planning to notify the health care provider by telephone. Which of the following techniques would be most appropriate for the nurse to use when communicating with the health care provider? A) ISBAR B) EMAR C) SOAP D) CBE

Ans: A Feedback: The nurse should use ISBAR to communicate verbally to the health care provider. Identify/Introduction, Situation, Background, Assessment, and Recommendation (ISBAR) is the communication tool to provide critical client information to the health care provider. EMAR is Electronic Medication Administration Record, which documents medication administration. SOAP is Subjective, Objective, Assessment, and Plan, which is a progress note that relates to only one health problem. CBE is Charting by Exception and permits the nurse to document only those findings that fall outside the standard of care and norms that have been developed by the institution.

1. Upon evaluation of the client's plan of care, the nurse determines that the expected outcomes have been achieved. Based upon this response, the nurse will do what? A) Terminate the plan of care. B) Modify the plan of care. C) Continue the plan of care. D) Re-evaluate the plan of care.

Ans: A Feedback: The nurse will terminate the plan of care when each expected outcome has been achieved. Modifying the plan of care is necessary if there are difficulties in achieving the outcomes. Re-evaluating each step of the nursing process is a step in the modification of a plan of care. Continuing the plan of care occurs if more time is needed to achieve the outcomes.

34. Each time a nurse administers an insulin injection to a client with diabetes, she tells the client what she is doing and demonstrates each step of preparing and giving the injection. What is the nurse promoting in the client? A) Self-care B) Dependence C) Competence D) Discipline

Ans: A Feedback: The plan of nursing care should include specific instructions for education/learning needs of the client to promote self-care and independence. Competency pertains to the nurse's ability (knowledge, skills, and attitudes) to provide safe and effective care. The nurse's role includes education, counseling, and advocating, but not providing discipline to clients.

25. The nurse is caring for a client with a diagnosis of end-stage renal disease. The client has expressed the desire to be kept comfortable and to not continue further treatment. The daughter arrives from out of town and is demanding to have further testing done to determine the best treatment option for the client. What is the best action for the nurse to take at this time? A) Explain to the daughter the wishes of the client. B) Arrange a meeting between the physician and daughter. C) Contact the imaging center to schedule the testing. D) Persuade the client to agree to the daughter's request.

Ans: A Feedback: The priority is for the nurse to explain to the daughter the wishes of the client and support the client's decision. As an advocate, the nurse implements actions to protect the rights of the client. The other options do not support the client's decision.

32. The nurse is preparing to assess a client's cranial nerves. Which of the following techniques should you use to assess cranial nerve III? A) Shine a bright light in the client's eye and observe for bilateral pupillary response. B) Ask the client to close the eyes, occlude a nostril, then identify the smell of different substances. C) Determine visual acuity using a Snellen chart D) Occlude the patient's right ear, whisper a word into the left ear, and ask the patient to repeat it.

Ans: A Feedback: This technique is used to assess CN VIII (Optic).

28. The nurse is delegating to the unlicensed assistive personnel (UAP). What is the best instruction by the nurse? A) Notify me right away if the client's systolic blood pressure is 170 or greater. B) Let me know if the client's blood pressure becomes elevated. C) If the client's blood pressure falls outside normal limits, come get me. D) I need to know if the client's blood pressure changes from his normal baseline.

Ans: A Feedback: When delegating tasks, it is essential for the nurse to give clear instructions to the person to whom the task is being delegated. The statement, which includes specific parameters for the systolic blood pressure, clearly identifies what the UAP should be alerted to and the subsequent action to take. The other three options are vague and do not provide adequate direction for the UAP.

21. Which client outcome is a physiologic outcome? Select all that apply. A) The client's HA1c is 7.4%. B) The client's blood pressure is 118/74. C) The client rates his or her pain rating as 6. D) The client self-administers insulin subcutaneously. E) The client describes manifestations of wound infection.

Ans: A, B, C Feedback: Physiologic outcomes are physical changes in the client, such as pain ratings and blood pressure and HA1c measurements. Psychomotor outcomes describe the client's achievement of new skills, such as insulin administration. Cognitive outcomes demonstrate gains in client knowledge, such as manifestations of infection.

20. Which activity does the nurse engage in during evaluation? Select all that apply. A) Collect data to determine whether desired outcomes are met. B) Assess the effectiveness of planned strategies. C) Adjust the time frame to achieve the desired outcomes. D) Involve the client and family in formulating desired outcomes. E) Initiate activities to achieve the desired outcomes.

Ans: A, B, C Feedback: The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage. During the evaluation stage, the nurse collects data to determine whether desired outcomes are met, assesses the effectiveness of planned strategies, and adjusts the time frame to achieve the desired outcomes.

31. Which of the following are examples of breaches of client confidentiality? Select all that apply. A) A nurse discusses a client with a coworker in the elevator. B) A nurse shares her computer password with a relative of a client. C) A nurse checks the medical record of a client to see who should be called in an emergency. D) A nurse updates the employer of a client regarding the client's return to work. E) A nurse uses a computer to document a client's response to pain medication.

Ans: A, B, D Feedback: Nurses may use computers to document client data as long as they are not in a public area, and as long as the computer is shut down following the entries. A nurse can also check the medical record for a relative to call in case of an emergency. All the other examples are violations of client confidentiality.

30. Which of the following are examples of incidental disclosures of client health information that are permitted? Select all that apply. A) A nurse working in a physician's office puts out a sign-in sheet for incoming clients. B) Two nurses are overheard talking about a client through the door of an empty client room. C) A nurse places a client chart in a holder on the examining room door with the name facing out. D) A nurse leaves an x-ray on a light board in the hallway that leads to the examining rooms. E) A nurse calls out the name of a client who is seated in the waiting room.

Ans: A, B, E Feedback: Permitted incidental disclosures of PHI include using sign-in sheets without the reason for visit; the possibility of a conversation being overheard if measures are taken to be private; placing a client chart on the door with the face pages facing inward; placing an x-ray on a light board as long as it is not unattended; calling the name of a waiting patient; and leaving appointment reminders on answering machines (provided only a minimal amount of information is given).

29. Which of the following abbreviations is on the list of the Joint Commission do not use abbreviations? Select all that apply. A) U (unit) B) QD (daily) C) NPO (nothing per os) D) mL (milliliters) E) > (greater than)

Ans: A, B, E Feedback: The words "unit", "daily", "greater than" and "less than" should be spelled out. NPO, mL, and mcg are acceptable abbreviations.

24. The nurse is trying to determine factors influencing a client who is not following the plan of care. Which client statement identifies a potential factor interfering with following the plan of care? Select all that apply. A) I don't drive so I was unable to fill my prescription. B) I consult the list of low sodium foods when preparing meals. C) My social security check does not come until next week. D) I dropped the strips for my finger-stick blood glucose testing in the bath water. E) "My daughter helps me with my range of motion exercises every morning and afternoon."

Ans: A, C, D Feedback: Common factors that contribute to a client not following the plan of care include inability to afford treatment (social security check) and limited access to treatment (doesn't drive; damaged testing strips).

23. Which example reflects client variables that influence outcome achievement? Select all that apply. A) The client was born with cystic fibrosis. B) The nurse works at a hospital in a diverse community. C) Nursing interventions are consistent with standards of care. D) The client is a college graduate and is employed. E) The client engages in activities associated with Ramadan.

Ans: A, D, E Feedback: Important client variables that influence outcome achievement include the physical health of the client, level of education attained, and cultural practices that impact life and health practices. Nurse variables, such as working in a diverse community, and standards of practice also influence client outcome achievement.

17. A nurse working in a hospital setting discovers problems with the delivery of nursing care on the pediatric unit. Which of the following suggestions from the Institute of Medicine's Committee on Quality of Health Care in America (Kohn, Corrigan, & Donaldson, 2000) could help redesign and improve care? Select all that apply. A) Base care on continuous healing relationships. B) Customize care based on available resources. C) Keep the nurse as the source of control. D) Share knowledge and allow for free flow of information. E) Practice evidence-based decision making.

Ans: A, D, E Feedback: The Institute of Medicine's Committee on Quality of Health Care in America (Kohn, Corrigan, & Donaldson, 2000) suggests 10 new rules to redesign and improve care: (1) care based on continuous healing relationships, (2) customization based on client needs and values, (3) the client as the source of control, (4) shared knowledge and the free flow of information, (5) evidence-based decision making, (6) safety as a system property, (7) the need for transparency, (8) anticipation of needs, (9) continuous decrease in waste, and (10) cooperation among clinicians.

11. In what type of documentation method would a nurse document narrative notes in a nursing section? A) Problem-oriented medical record B) Source-oriented record C) PIE charting system D) Focus charting

Ans: B Feedback: A source-oriented record is one in which each health care group keeps data on its own separate form (e.g., physicians, nurses, and laboratory). Progress notes written by nurses using this method are narrative notes.

21. A hospital unit has a policy that rectal temperatures may not be taken on clients who have had cardiac surgery. What rationale supports this policy? A) It is an embarrassing and painful assessment. B) Thermometer insertion stimulates the vagus nerve. C) It is less expensive to take oral temperatures. D) It is to avoid perforating the wall of the rectum.

Ans: B Feedback: Because inserting the thermometer into the rectum can slow the heart rate by stimulating the vagus nerve, assessing a rectal temperature may not be allowed for clients after cardiac surgery.

22. While conducting a physical examination of the thorax, a nurse notes and documents breath sounds as moderate "blowing" sounds with equal inspiration and expiration. What type of breath sounds are these? A) Bronchial B) Bronchovesicular C) Vesicular D) Adventitious

Ans: B Feedback: Bronchial breath sounds are high pitched, with expiration longer than inspiration. Bronchovesicular sounds are moderate "blowing" sounds with equal inspiration and expiration. Vesicular sounds are soft and low-pitched, with longer inspiration than expiration. Adventitious sounds are not normally heard in the lungs.

14. Which of the following methods of documenting client data is least likely to hold up in court if a case of negligence is brought against a nurse? A) Problem-oriented medical record B) Charting by exception C) PIE charting system D) Focus charting

Ans: B Feedback: Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in narrative notes. A significant drawback to charting by exception is its limited usefulness when trying to prove high-quality safe care in response to a negligence claim made against nursing.

19. When inspecting the skin of a client, the nurse notes a bluish tinge to the skin. What condition would the nurse document? A) Jaundice B) Cyanosis C) Erythema D) Pallor

Ans: B Feedback: Cyanosis is a bluish or grayish discoloration of the skin in response to inadequate oxygenation. Jaundice is a yellow color of the skin resulting from liver and gallbladder disease, some types of anemia, and excessive hemolysis. Erythema is redness of the skin associated with sunburn, inflammation, fever, trauma, and allergic reactions. Pallor is paleness of the skin, which often results from a decrease in the amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues.

8. What cognitive processes must the nurse use to measure client achievement of outcomes during evaluation? A) Intuitive thinking B) Critical thinking C) Traditional knowing D) Rote memory

Ans: B Feedback: Each element of evaluation requires the nurse to use critical thinking about how best to evaluate the client's progress toward valued outcomes.

8. Alice Jones, a registered nurse, is documenting assessments at the beginning of her shift. How should she sign the entry? A) Alice J, RN B) A. Jones, RN C) Alice Jones D) AJRN

Ans: B Feedback: Each entry is signed with the first initial, last name, and title. In this case, A. Jones, RN, is correct.

14. A nurse is preparing to insert an intravenous line and begin administering intravenous fluids. The client has visitors in the room. What should the nurse do? A) Ask the visitors to leave the room. B) Ask the client if visitors should remain in the room. C) Tell the client to ask the visitors to leave the room. D) Wait until the visitors leave to begin the procedure.

Ans: B Feedback: If visitors are in the client's room, check with the client to see whether she or he wants the visitors to stay during the procedure.

26. A nurse is documenting client information using PIE charting. Which information would the nurse expect to document? A) Client assessment B) Intervention carried out C) Written plan of care D) Multidisciplinary interventions

Ans: B Feedback: In the PIE notes, the nurse documents the problem, intervention and evaluation. Thus the nurse would document the intervention carried out. Client assessment is not a part of the PIE notes, because this information is recorded on flow sheets for each shift. Although the PIE system uses a nursing plan-of-care format, there is no written plan of care. The PIE system is not multidisciplinary; it provides a documentation system for nursing only.

17. A nurse is documenting information about a client in a long-term care facility. What is used in a Medicare-certified facility as a comprehensive assessment and as the foundation for the Resident Assessment Instrument (RAI)? A) PIE system B) Minimum data set C) OASIS D) Charting by exception

Ans: B Feedback: Long-term care documentation is specified by the RAI with the minimum data set forming the foundation for the assessment. This is required in all facilities certified to participate in Medicare or Medicaid. OASIS is used in the home health care industry.

16. Which of the following can a nurse assess by palpation? A) Heart sounds, lung sounds, blood pressure B) Temperature, turgor, moisture C) Vision, hearing, cranial nerves D) Tissue density, gait, reflexes

Ans: B Feedback: Palpation is an assessment technique that uses the sense of touch. The hands and fingers can assess temperature, turgor, texture, moisture, vibrations, and shape.

10. A nurse is educating a client on how to administer insulin, with the expected outcome that the client will be able to self-administer the insulin injection. How would this outcome be evaluated? A) Asking the client to verbally repeat the steps of the injection B) Asking the client to demonstrate self-injection of insulin C) Asking family members how much trouble the client is having with injections D) Asking the client how comfortable he or she is with injections

Ans: B Feedback: Psychomotor outcomes describe the client's achievement of new skills and are evaluated by asking the client to demonstrate the new skill.

32. A nurse palpates the pulse of a client and documents the following: 6/6/12 pulse 85 and regular, 3+, and equal in radial, popliteal, and dorsalis pedis. What does the number 3+ represent? A) Pulse rate B) Pulse quality (amplitude) C) Pulse rhythm D) Pulse deficit

Ans: B Feedback: Pulse quality/amplitude describes the quality of the pulse in terms of its fullness, ranging from absent (0) to bounding (4+). Pulse rates are measured in beats per minute. Pulse rhythm is the pattern of the pulsations and the pauses between them. The pulse deficit is the difference between the apical and radial pulse rates.

15. When a charge nurse evaluates the need for additional staff nurses and additional monitoring equipment to meet the client's needs, the charge nurse is performing an evaluation termed ... A) process evaluation B) structure evaluation C) outcome evaluation D) summary evaluation

Ans: B Feedback: Structure evaluation focuses on the attributes of the setting or surroundings where health care is provided.

26. An adult client is assessed as having an apical pulse of 140. How would the nurse document this finding? A) Bradycardia B) Tachycardia C) Dysrhythmia D) Normal pulse

Ans: B Feedback: Tachycardia is a rapid pulse (heart) rate. An adult has tachycardia when the pulse rate is 100 to 180 beats/min. The nurse would document a rate of 140 as tachycardia. Bradycardia is a slower than normal pulse rate. Dysrhythmia is an irregular pulse rate.

10. A physician's order reads "up ad lib." What does this mean in terms of client activity? A) May walk twice a day B) May be up as desired C) May only go to the bathroom D) Must remain on bed rest

Ans: B Feedback: The abbreviation "up ad lib" means the client may be up as desired.

20. Educating clients on their diabetic regimen of administering insulin is the implementation of which skill? A) Intrinsic B) Technical C) Interpersonal D) Visual

Ans: B Feedback: The administration of insulin is a technical skill. Technical competence means being able to use equipment, machines, and supplies in a particular specialty.

13. A nurse forgets to raise the bed railings of a client who is confused after taking pain medications. The client attempts to get out of bed, and suffers a minor fall. The nurse asks a colleague who witnessed the fall not to mention it to anyone because the client only had minor bruises. What would be the appropriate action of the colleague? A) No other steps need to be taken, since the client was not seriously injured. B) The colleague should inform the nurse that a full report of the incident needs to be made. C) The colleague should monitor the client closely for any adverse effects of the fall. D) The colleague should report the incident in a peer review of the nurse.

Ans: B Feedback: The colleague should tell the nurse that a full report needs to be made. If appropriate, the colleague could help the nurse identify what contributed to her not raising the bed railings in an effort to prevent it from happening in the future.

10. What would a nurse ensure before beginning a health assessment? A) That the time needed for the assessment fits into the nurse's work schedule B) That the room is private, quiet, warm, and has adequate light C) That family members are present to answer specific questions D) That there is a written physician's order for the assessment

Ans: B Feedback: The nurse and client should agree on a time for the assessment. The room (or area) should be private, quiet, and warm enough to prevent chilling, and it should have adequate lighting, either by sunlight or overhead fixtures. Family members may remain, especially if they are needed to explain activities to the client. A nursing assessment does not require a physician's order.

27. What is one purpose of documentation of the health assessment? A) To identify the nurse's role in health care B) To identify actual and potential health problems C) To expand nursing knowledge and skills D) To provide a basis for evidence-based nursing

Ans: B Feedback: The nurse organizes and documents assessment data to identify actual and potential health problems, to make nursing diagnoses, to plan appropriate care, and to evaluate the client's response to treatment.

21. A client complains to the nurse-in-charge about another nurse on night shift. The client says that he kept calling the nurse but she never responded. Further, when he questioned the nurse, she said that she had other patients to take care of. The nurse-in-charge is aware that the client can be very demanding. What is an appropriate response for the nurse? A) "I am sorry that you had to suffer this way. The nurse on night duty should be fired." B) "It's hard to be in bed and ask for help. You ring for a nurse who never seems to help." C) "You seem to be impatient. The nurses work very hard and they do whatever they can." D) "I can see that you are angry. What the nurse did is wrong, and it won't happen again."

Ans: B Feedback: The nurse should empathize with the client to perceive how the client is feeling. The nurse shares his or her perception with the client, which makes him comfortable to share his anxieties, fear, and concerns. The first response conveys pity on the client, which is inappropriate. In the third response, the nurse is taking the side of the nursing staff and the client may not like it. The fourth response is nontherapeutic.

21. A nurse assesses a client's eyes by testing the cardinal fields of vision for coordination and alignment. What eye characteristic is being assessed by this process? A) Visual acuity B) Extraocular movements C) Peripheral vision D) Existence of cataracts

Ans: B Feedback: The nurse tests for extraocular movements by assessing the cardinal fields of vision for coordination and alignment. Normally both eyes move together, are coordinated, and are parallel. Visual acuity is assessed with the Snellen chart. Tests for peripheral vision (or visual fields) are used to assess retinal function and optic nerve function. Full peripheral vision is normal. Cataracts are noted by inspection (cloudiness of the lens).

6. Which is the primary source of heat in the body? A) Hormones B) Metabolism C) Blood circulation D) Muscles

Ans: B Feedback: The primary source of heat in the body is metabolism, with heat produced as a byproduct of metabolic activities that generate energy for cellular functions. Various mechanisms increase body metabolism, including hormones and exercise.

9. What anatomic site regulates the pulse rate and force? A) Thermoregulatory center B) Cardiac sinoatrial node C) Cardiac atria and valves D) Peripheral chemoreceptors

Ans: B Feedback: The pulse is regulated by the autonomic nervous system through the cardiac sinoatrial node. The other anatomic sites may affect, but do not regulate, the pulse rate and force.

13. A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would be likely? A) Bradycardia B) Tachycardia C) Dysrhythmia D) Bigeminal

Ans: B Feedback: The pulse rate increases (tachycardia) and decreases in response to a variety of physiologic mechanisms. Tachycardia is a response to an elevated body temperature and pain.

9. The researchers developing classifications for interventions are also committed to developing a classification of which of the following? A) Diagnoses B) Outcomes C) Goals D) Data clusters

Ans: B Feedback: The researchers involved in the development of NICs are also committed to developing a classification of client outcomes for nursing interventions, called Nursing Outcomes Classifications (NOCs). This research aims to identify, label, validate, and classify nursing-sensitive client outcomes and indicators, evaluate the validity and usefulness of the classification in clinical field-testing, and define and test measurement procedures for the outcomes and indicators.

5. Which of the following clients should the nurse monitor vital signs every four hours? A) A client in a critical care unit B) A client hospitalized for high blood pressure C) a resident in a long-term care facility D) a long-term care resident on Medicare A

Ans: B Feedback: Vital signs are assessed at least every four hours in hospitalized clients with elevated temperatures, with high or low blood pressures, with changes in pulse rate or rhythm, or with respiratory difficulty. In critical care settings, technologically advanced devices are used to continually monitor clients' vital signs. Regulations require monthly vital sign measurements in long-term care residents, but if the resident is classified as Medicare A (meaning discharged from the hospital and Medicare is paying for the stay to receive skilled nursing care) vital signs are taken daily.

24. When conducting a physical assessment, what should the nurse assess and document about size and shape of body parts? A) Actual measurements in centimeters B) Symmetry (comparison of bilateral body parts) C) Indications of general health status D) Vital signs of all extremities (arms and legs)

Ans: B Feedback: When conducting a physical assessment, the nurse assesses and compares all bilateral body parts. The symmetry of parts of the body (such as the skull) and the extremities (arms and legs) is an important assessment to document.

19. Which activity does the nurse perform during the evaluating stage? Select all that apply. A) Validates with the client the problem of constipation. B) Collects data to determine the number of catheter-associated infections on the nursing unit. C) Increases the frequency of repositioning from every two hours to every one hour. D) Sets a goal of ambulating from bed to room door and back to bed. E) Identifies smoking and sedentary lifestyle as risk factors for hypertension.

Ans: B, C Feedback: During the evaluation stage, the nurse modifies the plan of care if desired outcomes are not achieved (increased frequency of repositioning) and collects data, such as number of infections, to monitor quality and effectiveness of nursing practice. During the diagnosis stage, the nurse identifies factors contributing to the client's health problem, such as smoking and sedentary lifestyle, and validates the identified health problems (such as constipation) with the clients. The nurse establishes plan priorities and sets goals with the client and family during the outcome identification and planning.

18. A nurse is counseling a novice nurse who gives 150% effort at all times and is becoming frustrated with a health care system that provides substandard care to clients. Which of the following advice would be appropriate in this situation? Select all that apply. A) Tell the new nurse to help other nurses perform their jobs, thus ensuring quality client care is being delivered. B) Encourage the new nurse to leave her problems at work behind, instead of rehashing them at home. C) After establishing a reputation for delivering quality nursing care, have her seek creative solutions for nursing problems. D) Tell her to view nursing care concerns as challenges rather than overwhelming obstacles, and seek help for solutions. E) State that if resources do not permit quality care, it is not the role of the new nurse to explore change strategies within the institution.

Ans: B, C, D Feedback: The following items are good advice for nurses experiencing burnout: Learn to give quality care during designated work period; leave on time; avoid the temptation to do the work of others; and leave work concerns at work. After establishing a reputation for delivering quality nursing care, seek creative solutions for nursing problems (strategies to increase nursing resources, motivation, morale) and try them — hopefully with a support network. View concerns as challenges rather than overwhelming obstacles. Develop a realistic sense of how much nursing care (and of what quality) can be delivered with existing resources. If resources do not permit quality care, explore change strategies within the institution. If administration is not supportive, explore other practice settings.

32. In which of the following cases should a progress note be written? Select all that apply. A) For any nurse-client interaction B) When admitting a client C) When receiving a client postoperatively D) When assisting a client with ADLs E) When a procedure is performed

Ans: B, C, E Feedback: A progress note should be written in the following instances: upon admission, transfer to another unit, and discharge; when a procedure is performed; upon receiving a client postoperatively or postprocedure; upon communicating with physicians regarding critical client information (e.g., abnormal lab value result); or for any change in client status.

22. Which of the following statements accurately describes a recommended guideline for implementation? Select all that apply. A) When implementing nursing care, remember to act independently, regardless of the wishes of the client/family. B) Before implementing any nursing action, reassess the client to determine whether the action is still needed. C) Assume that the nursing intervention selected is the best of all possible alternatives. D) Consult colleagues and the nursing and related literature to see if other approaches might be more successful. E) Reduce your repertoire of skilled nursing interventions to ensure a greater likelihood of success.

Ans: B, D Feedback: When implementing nursing care, the nurse should act in partnership with the client/family and reassess the client to determine if the nursing action is still needed. The nurse should always question that the nursing intervention selected is the best of all possible alternatives. The nurse should consult colleagues and related nursing literature to see if other approaches might be more successful. The nurse should develop a repertoire of skilled nursing interventions, and check to make sure that the ones selected are consistent with standards of care and within legal/ethical guidelines to practice.

7. A home health nurse is visiting a client who recently was hospitalized for repair of a fractured hip. The client tells the nurse, "I have had a lot of pain in my abdomen." What type of assessment would the nurse conduct? A) Comprehensive B) Ongoing partial C) Focused D) Emergency

Ans: C Feedback: A focused assessment is conducted to assess a specific problem. In this case, the nurse would ask the client about urinary frequency, bowel movements, and diet, and then take vital signs and assess the abdomen. Comprehensive assessments include a detailed health history and physical assessment. Ongoing partial assessments are conducted at regular intervals, and emergency assessments are carried out in emergency situations (such as prior to CPR).

28. A nurse in a nursing home is writing a note that addresses the care a resident has received during the day and the resident's response to care. What type of note does this represent? A) PIE note B) Flow sheet C) Narrative note D) SOAP note

Ans: C Feedback: A narrative note in a skilled nursing facility might include the type of morning care, nutritional intake, client activity pattern, and comfort measures provided, along with the client's response.

11. The arterial blood gases for a client in shock demonstrate increased carbon dioxide and decreased oxygen. What type of respirations would the nurse expect to assess based on these findings? A) Absent and infrequent B) Shallow and slow C) Rapid and deep D) Noisy and difficult

Ans: C Feedback: Any condition causing an increase in carbon dioxide and a decrease in oxygen in the blood tends to increase the rate and depth of respirations. An increase in carbon dioxide is the most powerful respiratory stimulant.

19. What site for taking body temperature with a glass thermometer is contraindicated in clients who are unconscious? A) Rectal B) Tympanic C) Oral D) Axillary

Ans: C Feedback: Assessing an oral temperature with a glass thermometer is contraindicated in unconscious, irrational, or seizure-prone adults, as well as in infants and young children. This is due to the danger of breaking the thermometer in the mouth.

17. When auscultating a client's abdomen, a nurse notes gurgling sounds. What characteristic of sound would the nurse document? A) Resonance B) Turgor C) Quality D) Texture

Ans: C Feedback: Auscultation is the act of listening with a stethoscope to sounds produced within the body. Four characteristics are assessed and documented: pitch (high to low), loudness (soft to loud), quality (gurgling or swishing), and duration (short, medium, long). Resonance is measured with percussion. Turgor and texture are assessed with palpation.

30. A nurse is caring for a middle-aged client who looks worried and flares his nostrils when breathing. The client complains of difficulty in breathing, even when he walks to the bathroom. Which of the following breathing disorders is most appropriate to describe the client's condition? A) Hyperventilation B) Hypoventilation C) Dyspnea D) Apnea

Ans: C Feedback: Clients with dyspnea usually appear anxious and worried. The nostrils flare as they fight to fill the lungs with air. Dyspnea is almost always accompanied by a rapid respiratory rate because clients work to improve the efficiency of their breathing. The client's condition cannot be termed hyperventilation, hypoventilation, or apnea. Hyperventilation and hypoventilation affect the volume of air entering and leaving the lungs. Apnea is total absence of breathing, which is life-threatening if it lasts more than four to six minutes.

34. During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. What nerve is being tested by this action? A) Cranial nerve I B) Cranial nerves II and III C) Cranial nerve VII D) Cranial nerve VIII

Ans: C Feedback: Cranial nerve VII is the facial nerve tested by smiling, frowning, wrinkling the forehead, and puffing out the cheeks. CNI is the olfactory nerve, CNII and III are the optic and oculomotor nerves, and CNVIII is the acoustic nerve.

10. What activity is carried out during the implementing step of the nursing process? A) Assessments are made to identify human responses to health problems. B) Mutual goals are established and desired client outcomes are determined. C) Planned nursing actions (interventions) are carried out. D) Desired outcomes are evaluated and, if necessary, the plan is modified.

Ans: C Feedback: During the implementing step of the nursing process, nursing actions (interventions) planned during the planning step are carried out.

26. Which is a responsibility of the nurse in the nurse-client-family team relationship? A) Provide creative leadership to make the nursing unit a satisfying and challenging place to work. B) Support the nursing care given by other nursing and non-nursing personnel. C) Educate the family to be informed and assertive consumers of health care. D) Coordinate the inputs of the multidisciplinary team into a comprehensive plan of care.

Ans: C Feedback: Educating the family to be informed and assertive consumers of health care is a role responsibility in the nurse-client-family relationship. Responsibilities of the nurse in the nurse-health care team relationship include coordinating the inputs of the multidisciplinary team into a comprehensive plan of care. In the nurse-nurse relationship, the nurse provides creative leadership to make the nursing unit a satisfying and challenging place to work, and supports the nursing care given by other nursing personnel.

30. The nurse is preparing to implement plans of care with several clients. Which action would be inappropriate for the nurse to perform? A) Ask the English-as-a-Second-Language (ESOL) client to state in his or her own words what it means to be NPO. B) Seek input from the family of how the client with aphasia normally communicates at home. C) Respond to the postoperative client's question that baths are given only in the morning. D) Request that family members provide ethnic/cultural foods of the African client's liking.

Ans: C Feedback: Guidelines for implementing indicate that the nurse implements care that is culturally sensitive and individualized for the client. The nurse forms a partnership with the client and family when implementing care. The response by the nurse indicating a set time for baths is not reflective of being open to individualizing client care. The other options are consistent with the guidelines for implementing.

16. The staff in a long-term care facility often plays loud rock music on the radio and designs children's games as exercise. What is the staff doing in this situation? A) Considering the hearing level of older adults B) Failing to consider visual deficits that occur with aging C) Ignoring the developmental needs of older adults D) Meeting needs for sensory input and exercise

Ans: C Feedback: Nurses must be careful not to let stereotypes about developmental stages and tasks influence client care. Playing loud rock music and designing children's games ignore the older adults' needs and is demeaning.

11. What role of the nurse is crucial to the prevention of fragmentation of care? A) Advocate B) Educator C) Counselor D) Coordinator

Ans: C Feedback: One of nursing's major contributions to the health care team is the role of coordinator. Care can easily become fragmented when clients are seen by numerous specialists—each interested in a different aspect of the client. It is important for the nurse to make rounds with other health care professionals and to read the results of consultations that clients have had with specialists. They can then interpret the specialists' findings for clients and family members, prepare clients to participate maximally in the plan of care before and after discharge, and serve as a liaison among the members of the health care team.

10. A client is constipated and trying to have a bowel movement. How does holding the breath and pushing down (the Valsalva maneuver) affect the pulse? A) Left ventricle pumps more forcefully; pulse is stronger B) Stimulates the vagus nerve to increase the rate C) Stimulates the vagus nerve to decrease the rate D) Right ventricle is less efficient; pulse is thready

Ans: C Feedback: Parasympathetic stimulation via the vagus nerve decreases the heart rate. The Valsalva maneuver stimulates the vagus nerve, resulting in a slower pulse rate.

14. A nurse is conducting a health history for a client with a chronic respiratory problem. What question might the nurse ask to assess for orthopnea? A) "Do you have problems breathing when you walk up stairs?" B) "Does your medication help you breathe better?" C) "How many pillows do you sleep on at night to breathe better?" D) "Tell me about your breathing difficulties since you stopped smoking."

Ans: C Feedback: People with difficulty breathing can often breathe more easily in an upright position, a condition known as orthopnea. While sitting or standing, gravity lowers organs in the abdominal cavity away from the diaphragm, giving more room for the lungs to expand. People with orthopnea characteristically use many pillows during sleep to accomplish this.

32. The client's pulse oximetry reading is 97% on room air 30 minutes after removal of a nasal cannula. This is an example of what type of outcome? A) Affective outcome B) Psychomotor outcome C) Physiologic outcome D) Cognitive outcome

Ans: C Feedback: Physiologic outcomes are physical changes in the client, such as pulse oximetry. An affective outcome involves changes in the client's values, beliefs, and attitude. Cognitive outcomes demonstrate increases in client knowledge. Psychomotor outcomes describe the client's achievement of new skills.

12. A nurse is changing a sterile pressure ulcer dressing based on an established protocol. What does this mean? A) The nurse is using critical thinking to implement the dressing change. B) The client has specified how the dressing should be changed. C) Written plans are developed that specify nursing activities for this skill. D) The physician verbally requested specific steps of the dressing change.

Ans: C Feedback: Protocols (written plans that detail the nursing activities to be executed in specific situations) are nurse-initiated interventions. They expand the scope of nursing practice in certain clearly defined situations.

24. The nurse participates in a quality assurance program. Data from the previous year indicates a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. The nurse recognizes this is which type of evaluation? A) Design evaluation B) Process evaluation C) Outcome evaluation D) Structure evaluation

Ans: C Feedback: Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as a 2% reduction in the number of repeat admissions for clients who underwent hip replacement surgery. Structure evaluation focuses on the environment in which care is provided, whereas process evaluation focuses on the nature and sequence of activities carried out by implementing the nursing process. There is no design evaluation.

15. A nurse has access to computerized standardized plans of care. After printing one for a client, what must be done next? A) Date it and put it in the client's record. B) Sign it and put it in the Kardex. C) Individualize it to the specific client. D) Use it as printed, based on common needs.

Ans: C Feedback: Standardized care plans that identify common problems and needs with relation to select client cohorts may be used. Unless such care plans are individualized to a specific client, however, they may not address individual client needs.

27. A client in a physician's office has a single blood pressure (BP) reading of 150/92. Should the client be taught about hypertension? A) It depends on the time of day the BP was taken. B) It depends on whether the client is male or female. C) No, a single BP reading should not be used. D) Yes, this reading is high enough to be significant.

Ans: C Feedback: The American Heart Association recommends that blood pressure readings be averaged on two or more subsequent occasions before diagnosing hypertension.

25. A newly hired nurse is participating in the orientation program for the health care facility. Part of the orientation focuses on the use of the SOAP (subjective, objective, assessment, and plan) method for documentation, which the facility uses. The nurse demonstrates understanding of this method by identifying which of the following as the first step? A) Plan of care B) Data, action, and response C) Problem selected D) Nursing activities during a shift

Ans: C Feedback: The SOAP method begins by selecting a problem from a list. PIE (problems, interventions, and evaluation) notes incorporate the plan of care into the progress notes. Focus DAR notes organizes entries by data, action, and response. The narrative notes are used to record relevant client and nursing activities throughout a shift.

9. A nurse is preparing a client for a physical assessment. The client appears anxious about the assessment. Which statement by the nurse would be most appropriate? A) "This is nothing to worry about. I won't hurt you." B) "Some of the examination may be painful, but I will be gentle." C) "Let me tell you what I will be doing. It should not be painful." D) "I have to do this, so just relax and it won't last long."

Ans: C Feedback: The client may be anxious for many reasons. Tell the client that the assessments should not be painful. Explaining the assessment in general terms can help decrease the client's embarrassment, fear of possible abnormal physical findings, or fear of "failing" a test.

5. What is the nurse's best defense if a client alleges nursing negligence? A) Testimony of other nurses B) Testimony of expert witnesses C) Client's record D) Client's family

Ans: C Feedback: The client record is the only permanent legal document that details the nurse's interactions with the client. It is the best defense if a client or client surrogate alleges nursing negligence.

14. A nurse is preparing to examine the breasts of a client. In what position should the nurse place the client? A) Prone B) Standing C) Dorsal recumbent D) Lithotomy

Ans: C Feedback: The dorsal recumbent position is used to assess the head, neck, anterior thorax, lungs, heart, breasts, extremities, and peripheral pulses. The prone position is used to assess the hip joint and posterior thorax. The standing position is used to assess posture, balance, and gait. The lithotomy position is used to assess female genitalia and rectum.

33. How would a nurse assess a client for pupillary accommodation? A) Using an ophthalmoscope, check the red reflex. B) Ask the client to focus on a finger and move the client's eyes through the six cardinal positions of gaze. C) Ask the client to focus on an object as it is brought closer to the nose. D) Ask the client to read the smallest possible line of letters on the Snellen chart.

Ans: C Feedback: The normal pupillary response is constriction, and convergence when focusing on a near object. Presence of the red reflex indicates that the cornea, anterior chamber, and lens are free of opacity and clouding. Answer B evaluates the function of each of the eye muscles and cranial nerves. The Snellen chart tests visual acuity.

27. The nurse is caring for a client with a diagnosis of colon disease. The client has expressed to various members of the health care team the desire to be kept comfortable and to not continue further treatment. The client asks the nurse to be present when the client discusses the decision with other family members. In which professional nursing relationship is the nurse participating? A) Nurse-client B) Nurse-nurse C) Nurse-client-family D) Nurse-health care team

Ans: C Feedback: The nurse is fulfilling role responsibilities of the nurse-client-family relationship when being present for a discussion of the matter by the client and family.

7. Which of the following data entries follows the recommended guidelines for documenting data? A) "Client is overwhelmed by the diagnosis of pancreatic cancer." B) "Client's kidneys are producing sufficient amount of measured urine." C) "Following oxygen administration, vital signs returned to baseline." D) "Client complained about the quality of the nursing care provided on previous shift."

Ans: C Feedback: The nurse should record client findings (observations of behavior) rather than an interpretation of these findings, and avoid words such as "good," "average," "normal," or "sufficient," which may mean different things to different readers. The nurse should also avoid generalizations such as "seems comfortable today." The nurse should avoid the use of stereotypes or derogatory terms when charting, and should chart in a legally prudent manner.

33. A nurse realizes that the dosage of the medication administered to the client has been entered incorrectly into the client records. Which of the following would be most appropriate for the nurse to do? A) Completely erase or delete the erroneous entry if possible. B) Use a highlighter to mark the incorrect entry and place initials next to it. C) Strike out the entry with a single line, place initials next to it, and write the correct entry. D) Black out the erroneous entry with a dark pen or marker.

Ans: C Feedback: The nurse should strike out the erroneous entry with a single line and place initials over it. When an error occurs, erasure or use of correction fluid is not permissible. Use of highlighters is not allowed and can draw attention to the erroneous documentation.

23. A nurse is conducting a health assessment for an African American client. What should the nurse consider in terms of cultural sensitivity? A) All individuals, regardless of culture, have the same anatomy and physiology. B) Asking specific questions about race during the health history C) Cultural risk factors for alterations in health and normal racial variations D) Differences in emotional, social, and spiritual basic human needs

Ans: C Feedback: The person's culture does not affect how a health assessment is conducted, but it is an integral component of nurse-client interactions. Nurses should know risk factors for alterations in health based on racial inheritance, as well as normal variations that occur among races.

18. A nurse delegates a specific intervention to a UAP. What implications does this have for the nurse? A) The UAP is responsible and accountable for his or her own actions. B) Nurses do not have authority to delegate interventions. C) The nurse transfers responsibility but is accountable for the outcome. D) The UAP can function in an independent role for all interventions.

Ans: C Feedback: UAPs are trained to function in an assistive role to the RN in client activities as delegated and supervised by the RN. Delegation is the transfer of responsibility of an activity to another individual while retaining accountability for the outcome.

21. A registered nurse who provides care in a subacute setting is responsible for overseeing and delegating to unlicensed assistive personnel (UAP). Which of the following principles should the nurse follow when delegating to UAP? Select all that apply. A) Ensure that UAPs closely follow the nursing process when providing care. B) Audit the client documentation that UAPs record after they perform interventions. C) Take frequent mini-reports from UAPs to ensure changes in client status are identified. D) Know what clinical cues the UAP should be alert for and why. E) Make frequent walking rounds to assess clients.

Ans: C, D, E Feedback: The nurse must take careful action to ensure that delegation results in safe and competent client care. This necessitates such measures as taking frequent mini-reports, identifying the clinical cues that UAPs should be aware of, and performing rounds often. UAPs are not normally educated to follow the nursing process nor to perform documentation.

23. Two nurses collaborate in assessing an apical-radial pulse on a client. The pulse deficit is 16 beats/minute. What does this indicate? A) The radial pulse is more rapid than the apical pulse. B) This is a normal finding and should be ignored. C) The client's arteries are very compliant. D) Not all of the heartbeats are reaching the periphery.

Ans: D Feedback: A difference between the apical and radial pulse rates is the pulse deficit, and signals that all of the heartbeats are not reaching the peripheral arteries or are too weak to be palpated.

28. All of the following clients have a body temperature of 38°C (100.4°F). About which client would a nurse be most concerned? A) An older adult B) A pregnant adolescent C) A junior high football player D) An infant 2 months of age

Ans: D Feedback: A mild elevation in body temperature, as is given here, might indicate a serious infection in infants younger than 3 months of age, who do not have well-developed temperature control mechanisms.

20. The nurse palpating the skin of a client documents a firm 1.5 cm mass on the lower right leg. What type of skin lesion does this describe? A) Macule B) Wheal C) Vesicle D) Nodule

Ans: D Feedback: A nodule is a mass 0.5 cm to 2 cm that is firmer than a papule. A macule is a lesion that is 1 cm or smaller. A wheal is an irregular, superficial area of localized skin edema. A vesicle is a 1 cm or less lesion filled with serous fluid.

31. Nursing students need to learn to nurse themselves in order to prepare to be professional nurses. Which activities would fail to prepare nursing students for the delivery of nursing care? A) Time management, communication, and establishing a support system. B) Establishing a support system, a sense of humor, and self-awareness. C) Self-awareness, preparation for crisis, and stress management. D) A sense of humor, anticipation of loss, and developing negative body image.

Ans: D Feedback: Activities that would prepare nursing students for the delivery of nursing care include time management, communication, establishing a support system, self-awareness, stress management, a sense of humor, and preparation for crisis and loss. Negative body image is not desired.

23. The nurse assesses urine output following administration of a diuretic. Which step of the nursing process does this nursing action reflect? A) Assessment B) Outcome identification C) Implementation D) Evaluation

Ans: D Feedback: Assessing the client's response to a diuretic medication is an example of evaluation. During assessment, the nurse collects and synthesizes data to identify patterns. The nurse establishes desired outcomes with the client and family during the outcome identification and planning stage. The nurse initiates activities to achieve the desired outcomes during the implementation stage.

31. Which framework is used during the focused assessment? A) Functional health assessment B) Head-to-toe framework C) Conceptual framework D) Body systems framework

Ans: D Feedback: Body systems approach is used during the focused assessment of an acutely or critically ill client to determine function of a particular body system.

9. A nurse is evaluating the outcomes of a plan of care to teach an obese client about the calorie content of foods. What type of outcome is this? A) Psychomotor B) Affective C) Physiologic D) Cognitive

Ans: D Feedback: Cognitive goals involve increasing client knowledge. These goals may be evaluated by asking clients to repeat information or to apply new knowledge in their everyday lives.

7. A nurse places a fan in the room of a client who is overheated. This is an example of heat loss related to which of the following mechanisms of heat transfer? A) Evaporation B) Radiation C) Conduction D) Convection

Ans: D Feedback: Convection is the dissemination of heat by motion between areas of unequal density, as occurs with a fan blowing over a warm body. Evaporation is the conversion of a liquid to a vapor. Radiation is the diffusion or dissemination of heat by electromagnetic waves. Conduction is the transfer of heat to another object during direct contact.

25. While assessing breath sounds, a nurse hears crackles. What causes these abnormal sounds? A) Air in the lungs B) A narrowing of the upper airway C) Narrowed small air passages D) Moisture in air passages

Ans: D Feedback: Crackles are fine-to-coarse crackling sounds made as air moves through wet secretions. They are described as "fine" when air passes through moisture in small air passages, and as "coarse" when air passes through moisture in the bronchioles, bronchi, and trachea. A wheeze is produced by narrowed air passages. The lungs normally contain air.

27. What activity in charting will assist most in the avoidance of errors? A) Objectivity B) Organization C) Legibility D) Timeliness

Ans: D Feedback: Documentation in a timely manner can help avoid errors.

26. The client's expected outcome is The client will maintain skin integrity by discharge. Which of the following measures is best in evaluating the outcome? A) The client's ability to reposition self in bed. B) Pressure-relieving mattress on the bed. C) Percent intake of a diet high in protein. D) Condition of the skin over bony prominences.

Ans: D Feedback: During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse examines client data or behaviors that validate whether the outcome is met. The condition of the skin, especially over bony prominences, provides the best measure of whether skin integrity has been maintained.

27. An expected client outcome is, The client will remain free of infection by discharge. When evaluating the client's progress, the nurse notes the client's vital signs are within normal limits, the white blood cell count is 12,000, and the client's abdominal wound has a half-inch gap at the lower end with yellow-green discharge. Which statement would be an appropriate evaluation statement? A) Goal partially met; client identified fever and presence of wound discharge. B) Client understands the signs and symptoms of infection. C) Goal partially met; client able to perform activities of daily living. D) Goal not met; white blood cell count elevated, presence of yellow-green discharge from wound.

Ans: D Feedback: During evaluation, the nurse collects data and makes a judgment summarizing the findings. In making a decision about how well the outcome was met, the nurse has three options: met, partially met, or not met. An elevated white blood cell count and the presence of yellow-green wound discharge are clinical manifestations consistent with an infectious process, so the outcome has not been met.

12. When using assessment equipment that will touch the client, what should the nurse do before conducting the assessment? A) Describe the equipment and how it works. B) Show pictures of functions of the equipment. C) Draw pictures of the anatomy to be assessed. D) Warm the equipment with hands or warm water.

Ans: D Feedback: Equipment that will touch the client during a physical examination should be warmed by the examiner's hands or warm water before use.

35. What characteristic of a competent nurse practitioner enables nurses to be role models for clients? A) Sense of humor B) Writing ability C) Organizational skills D) Good personal health

Ans: D Feedback: Good personal health enables nurses not only to practice more efficiently, but also to be a health model for clients and their families. Nurses can help clients to imitate good health behaviors, and eventually integrate them into their daily life through the process of identification.

17. A nurse educator is teaching a client about a healthy diet. What information would be included to reduce the risk of hypertension? A) "Eat a diet high in fruits and vegetables." B) "Remember to drink eight to 10 glasses of water a day." C) "It is important to have increased fats in your diet." D) "Put away the salt shaker and eat low-salt foods."

Ans: D Feedback: High salt intake is a high risk factor for the development of hypertension.

6. A nurse is documenting the intensity of a client's pain. What would be the most accurate entry? A) "Client complaining of severe pain." B) "Client appears to be in a lot of pain and is crying." C) "Client states has pain; walking in hall with ease." D) "Client states pain is a 9 on a scale of 1 to 10."

Ans: D Feedback: Information should be documented in a complete, accurate, relevant, and factual manner. Avoid interpretations of behavior, generalizations, and words such as "good."

15. A nurse is using inspection as an assessment technique. What does the nurse use during inspection? A) Equipment such as a stethoscope B) Both hands to produce sounds C) Light palpation to detect surfaces D) Senses of vision, hearing, smell

Ans: D Feedback: Inspection is the process of performing deliberate, purposeful observations. The nurse observes visually but also uses hearing and smell to gather data throughout the assessment. A stethoscope is used for auscultation, and the hands are used to percuss and palpate.

17. A nurse administers a medication for pain but forgets to document it in the client's medical record. Legally, what does this mean? A) Nothing, the nurse's honesty will not be questioned. B) The nurse can add the documentation after the client goes home. C) The physician will verify that the nurse carried out the order. D) In the eyes of the law, if it is not documented, it was not done.

Ans: D Feedback: Nurses must carefully document each intervention. The legal truth is "if it wasn't documented, it wasn't done."

13. A client who was previously awake and alert suddenly becomes unconscious. The nursing plan of care includes an order to increase oral intake. Why would the nurse review the plan of care? A) To implement evidence-based practice B) To ensure the order follows hospital policy C) To be sure interventions are individualized D) To be sure the intervention is safe

Ans: D Feedback: Nurses reassess the client and review the plan of care before initiating any nursing intervention. This is done to make sure that the plan of care is still responsive to the client's needs, and is safe for the particular client. In this case, the nurse would not give oral fluids to an unconscious client.

19. A group of nurses visits selected clients individually at the beginning of each shift. What are these procedures called? A) Nursing care conferences B) Staff visits C) Interdisciplinary referrals D) Nursing care rounds

Ans: D Feedback: Nursing care rounds are procedures in which a group of nurses visits select clients individually at each client's bedside. The primary purposes are to gather information to help plan and evaluate nursing care and to provide the client with an opportunity to discuss care.

33. The nurse overhears two nursing students talking about nursing interventions. Which statement by one of the nursing students indicates further education is required? A) Nursing interventions must be consistent with standards of care and research findings. B) Nursing interventions must be culturally sensitive and individualized for the client. C) Nursing interventions must be compatible with other therapies planned for the client. D) Nursing interventions must be approved by other members of the health care team.

Ans: D Feedback: Nursing interventions should be based on the etiology in the nursing diagnosis, be compatible with other planned therapies, be consistent with standards of care and research, and individualized for the client. Nursing interventions can be independent, dependent, and interdependent. Independent nursing interventions are nurse-initiated interventions directed at the etiology of the client problem; they do not require approval from other members of the health care team.

25. The nurse participates in a quality assurance program and reviews evaluation data for the previous month. Which of the following does the nurse recognize as an example of process evaluation? A) A 10% reduction in the number of ventilator-associated pneumonia B) A 5% increase in the number of nosocomial catheter-related urinary tract infections C) 40% of all client rooms in the facility are private and equipped with a computer D) A nursing care plan was developed within the eight hours of admission for 97% of all admissions.

Ans: D Feedback: Process evaluation focuses on the nature and sequence of activities carried out by nurses implementing the nursing process, such as the timing of nursing care plan creation. Quality assurance programs focus on three types of evaluation: structure, process, and outcome. Outcome evaluation focuses on measurable changes in the health status of clients, such as the number of ventilator-associated pneumonia and nosocomial catheter-related urinary tract infections. Structure evaluation focuses on the environment in which care is provided, such as the number of private rooms equipped with a computer.

16. When a nursing supervisor evaluates the staff nurse's performance with a group of clients to whom the staff nurse has provided nursing care, the supervisor is performing which type of evaluation? A) Outcome evaluation B) Summary evaluation C) Structure evaluation D) Process evaluation

Ans: D Feedback: Process evaluation focuses on the nurse's performance and whether the nursing care provided was appropriate and competent.

15. What population is at greatest risk for hypertension? A) Hispanic B) White C) Asian D) African American

Ans: D Feedback: Race is a factor in hypertension, a disorder characterized by high blood pressure. It is more prevalent and more severe in African American men and women.

30. The nurse is caring for the client with pneumonia. An expected client outcome is, The client will maintain adequate oxygenation by discharge. Which outcome criterion indicates the goal is met? A) Client taking antibiotic as ordered. B) Client identifies signs and symptoms of recurrence of infection. C) Client coughing and deep breathing every one hour. D) Client no longer requires oxygen.

Ans: D Feedback: The client who is maintaining adequate oxygenation would not require oxygen. The client could be able to do the other three options and still have problems with oxygenation.

22. As adults age, the walls of their arterioles become less elastic, increasing resistance and decreasing compliance. How does this affect the blood pressure? A) The blood pressure does not change. B) The blood pressure is erratic. C) The blood pressure decreases. D) The blood pressure increases.

Ans: D Feedback: The elasticity and resistance of the walls of the arterioles help to maintain normal blood pressure. With aging, the walls of arterioles become less elastic, which interferes with their ability to stretch and dilate, contributing to a rising pressure within the vascular system. This is reflected in an increased blood pressure.

16. What part of the client's record is commonly used to document specific client variables, such as vital signs? A) Progress notes B) Nursing notes C) Critical paths D) Graphic record

Ans: D Feedback: The graphic record is a form used to document specific client variables such as vital signs, weight, intake and output, and bowel movements.

22. A nurse at a health care facility has just reported for duty. Which of the following should the nurse do to ensure maximum efficiency of change-of-shift reports? A) Pay courtesy calls to staff members before attending the meeting. B) Wait for the physicians to arrive before exchanging notes. C) Avoid asking questions related to the medical record. D) Come prepared with material required to take notes.

Ans: D Feedback: The nurse should come prepared with material required to take notes during the change-of-shift reports. The nurse should not delay the meeting for change-of-shift report by paying courtesy calls to staff members before attending the meeting. Change-of-shift reports are not conducted in the presence of physicians, thus the nurse does not need to wait for the physicians to arrive before exchanging notes. The nurse should ask questions related to the medical record if any information is unclear.

35. A nurse walks into a client's room and finds him having difficulty breathing and complaining of chest pain. He has bradycardia and hypotension. What should the nurse do next? A) Take vital signs again in 15 to 30 minutes. B) Document the data and report it later. C) Ask the client if he is anxious or afraid. D) Report findings to the physician immediately.

Ans: D Feedback: The nurse should immediately report bradycardia associated with difficult breathing, changes in level of consciousness, hypotension, ECG changes, and angina (chest pain). Emergency treatment is by administering atropine intravenously to block vagal stimulation and restore normal heart rate.

29. The nursing student is caring for a Native American client who is admitted for deep vein thrombosis. The nursing student speaks with a nurse regarding the client's lack of eye contact with the student. The nurse responds that Native Americans view eye contact as an invasion of privacy. Which error did the nursing student make? A) Failure to act in partnership with the client. B) Failure to approach the client caringly. C) Failure to seek the client's input in the plan of care. D) Failure to provide culturally sensitive care.

Ans: D Feedback: The nursing student failed to provide culturally sensitive care by expecting the client to engage in eye contact. There is no information to suggest the nursing student failed to act in partnership with the client, approach the client caringly, or seek the client's input in the plan of care.

31. A nurse needs to measure the pulse of a client admitted to the health care facility. Which site would the nurse most likely use? A) Femoral B) Temporal C) Pedal D) Radial

Ans: D Feedback: The radial artery is the site most commonly assessed in a clinical setting. The radial pulse is palpated on the thumb side of the inner aspect of the wrist. Deep palpation is required to detect the femoral pulse beneath the subcutaneous tissue, in the anterior medial aspect of the thigh, just below the inguinal ligament, about halfway between the anterior superior iliac spine and the symphysis pubis. The pulsation of the temporal artery is palpated in front of the upper part of the ear; however, it is not the site most commonly assessed in the clinical setting. The pedal pulse or dorsalis pedis pulse can be felt on the dorsal aspect of the foot; however, the dorsalis pedis pulse may be congenitally absent in some clients.

26. When assessing the abdomen, which assessment technique is used last? A) Inspection B) Auscultation C) Percussion D) Palpation

Ans: D Feedback: The sequence of techniques used to assess the abdomen is inspection, auscultation, percussion, and palpation. Percussion and palpation stimulate bowel sounds and thus are done after auscultation of the abdomen.

15. A student is ambulating a client for the first time after surgery. What would the student do to anticipate and plan for an unexpected outcome? A) Take the client's vital signs after ambulation. B) Ask the client's wife to assist with ambulation. C) Delay ambulation until the following shift. D) Ask another student to help with ambulation.

Ans: D Feedback: Unexpected outcomes do occur, such as the risk of a fall for the postoperative client who is ambulated for the first time. In anticipation, the student caregiver could ask another student to help ambulate the client, thus decreasing this risk.

23. A nurse is manually documenting information related to a client's condition. When documenting this information, the nurse makes an error on the manual record sheet. Which is the best technique for recording the error made in documentation? A) Erase the incorrect statement and write the correct one. B) Cross out the wrong statement in a way that is not readable. C) Use correction fluid to obliterate what has been written. D) Cross out the incorrect statement with a single line.

Ans: D Feedback: When recording an error in documentation, the nurse should always cross out the incorrect statement with a single line so that it remains readable, add the date, initial, and then document the correct information. The nurse should not erase the incorrect statement and replace it with the correct one, nor cross out the wrong statement in a way that makes the statement unreadable, nor use correction fluid to obliterate what has been written. These methods render the medical record a poor legal defense.

28. The nurse is caring for a client who is experiencing an asthma attack. Ten minutes after administering an inhaled bronchodilator to the client, the nurse returns to ask if the client's breathing is easier. The nurse is engaging in which phase of the nursing process? A) Assessment B) Diagnosing C) Planning D) Implementing E) Evaluating

Ans: E Feedback: The nurse is collecting evaluative data to determine whether or not the client is achieving the therapeutic response to the bronchodilator.