Exam 1

The nurse is planning to administer a tuberculin test with a 27-gauge, 3/8-inch needle. The nurse should insert the needle at an angle of _____ degrees. a. 15 b. 45 c. 90 d. 180

ANS: A A 27-gauge, 3/8-inch needle is used for intradermal injections such as a tuberculin test, which should be inserted at a 15-degree angle, just under the dermis of the skin. Placing the needle at 45 degrees, 90 degrees, or 180 degrees will place the medication too deep.

An experienced medical-surgical nurse chooses to work in obstetrics. Which level of proficiency is the nurse upon initial transition to the obstetrical floor? a. Novice b. Proficient c. Competent d. Advanced beginner

ANS: A A beginning nursing student or any nurse entering a situation in which there is no previous level of experience (e.g., an experienced operating room nurse chooses to now practice in home health) is an example of a novice nurse. A proficient nurse perceives a patient's clinical situation as a whole, is able to assess an entire situation, and can readily transfer knowledge gained from multiple previous experiences to a situation. A competent nurse understands the organization and specific care required by the type of patients (e.g., surgical, oncology, or orthopedic patients). This nurse is a competent practitioner who is able to anticipate nursing care and establish long-range goals. A nurse who has had some level of experience with the situation is an advanced beginner. This experience may only be observational in nature, but the nurse is able to identify meaningful aspects or principles of nursing care.

The nurse realizes which patient is at greatest risk for an unintended synergistic effect? a. 72-year-old who is seeing four different specialists b. 4-year-old who has mistakenly taken the entire packet of his mother's birth control pills c. 50-year-old who was prescribed a second blood pressure medication d. 35-year-old drug addict who has ingested meth mixed with several household chemicals

ANS: A A synergistic effect occurs when two medications potentiate each other, creating a greater effect than a single medication on its own. The 72-year-old seeing four different providers is likely to experience polypharmacy. Polypharmacy places the patient at risk for unintended mixing of medications that potentiate each other. The child taking too much of a medication by mistake could experience overdose or toxicity. The 50-year-old is prescribed two different blood pressure medications for their synergistic effect, but this is a desired event. A drug addict mixing chemicals can be toxic.

The nurse knows to assess for signs of medication toxicity within older adults because of which physiological change? a. Reduced glomerular filtration b. Delayed esophageal clearance c. Decreased gastric peristalsis d. Decreased cognitive function

ANS: A All of the options are signs of aging; however, the glomerular filtration rate affects metabolism and medication clearance. The buildup of medication can cause toxicity in older patients.

A patient who is receiving IV fluids notifies the nurse that his arm feels tight. Upon assessment, the nurse notes that the arm is swollen and cool to the touch. What should the nurse's first action be? a. Discontinue the IV site, and apply a warm compress. b. Attached a syringe, and pull back on the plunger to aspirate the IV fluid. c. Start a new IV site distal from the site. d. Stop the IV fluids, and notify the physician immediately.

ANS: A An IV site that is puffy, swollen, and cool to the touch indicates infiltration. The IV site should be discontinued immediately because it is no longer a viable access point. Pulling back on the syringe will not result in fluid return because there is no longer venous access. A new IV should be started in the opposite arm after the old IV has been removed. The IV should be removed; it is not sufficient to only stop the fluids.

A drug requires a low pH to be metabolized. Knowing this, the nurse anticipates that the medication will be administered by which route? a. Oral b. Parenteral c. Buccal d. Inhalation

ANS: A An oral medication would pass through to the stomach—an area of low pH. The nurse would question an order for a medication that required an acidic environment to be metabolized. Buccal, inhalation, and parenteral routes provide neutral or alkaline environments.

A nurse is teaching a community group of school-aged parents about safety. The most important item to prioritize and explain is how to check the proper fit of a. a bicycle helmet. b. swimming goggles. c. soccer shin guards. d. baseball sliding shorts.

ANS: A Bicycle-related injuries are a major cause of death and disability among children. Proper fit of the helmet helps to decrease head injuries resulting from bicycle accidents. Goggles, shin guards, and sliding shorts are important sports safety equipment and should fit properly, but they do not protect from this leading cause of death.

The nurse knows that patient education about a buccal medication has been effective when the patient states a. "I should let the medication dissolve completely." b. "I can only drink water, not juice, with this medication." c. "For faster distribution, I should chew my medication first." d. "I should place the medication in the same location."

ANS: A Buccal medications should be placed in the side of the cheek and allowed to dissolve completely. Buccal medications act with the patient's saliva and mucosa. The patient should not chew or swallow the medication. Gastric secretions may destroy some medications. The patient should rotate sides of the check to avoid irritating the mucosal lining.

A 64-year-old quadriplegic patient needs an IM injection of antibiotic. What is the best site for the administration? a. Deltoid b. Dorsal gluteal c. Ventrogluteal d. Vastus lateralis

ANS: D Vastus lateralis is a large muscle that is easily accessible from the supine position. Because this patient no longer walks, the ventrogluteal muscle will begin to atrophy and is not the ideal location. The dorsal gluteal site is a location for a subcutaneous injection, and this patient requires an IM injection. The deltoid is easily accessible, but this muscle is not well developed in many adults.

A patient who has been receiving intermittent chemotherapy through a peripheral IV site is ordered to receive a high dose of vancomycin through the same vein. Why does this concern the nurse? a. Chemotherapy is irritating to the vascular system and may cause the vein to infiltrate. b. Two medications should never be placed into the same IV site. c. Once chemotherapy is in a patient's system, any additional medicine given will cause a synergistic effect. d. Chemotherapy treatments require a special pump designed solely for chemotherapy.

ANS: A Chemotherapy medications and vancomycin are irritating to the veins and introduce increased risk for infiltration. Infiltration of a chemotherapy medication can lead to extravasation, a serious IV complication. Medications can be placed into the same IV site if they are compatible. Chemotherapy does not cause a synergistic effect with antibiotics. Chemotherapy medications can be infused through the same device as maintenance IV fluids or even antibiotics.

A 2-year-old child is ordered to have ear irrigation performed daily. The nurse correctly performs the procedure by a. Pulling the auricle down and back to straighten the ear canal. b. Pulling the auricle upward and outward to straighten the ear canal. c. Instilling the irrigation solution by holding the syringe just inside the ear canal. d. Holding the fluid in the canal for 2 to 3 minutes with a cotton swab.

ANS: A Children up to 3 years of age should have the auricle pulled down and back, children 4 years of age to adults should have the auricle pulled upward and outward. Irrigation solution should be instilled 1 cm (1/2) above the opening of the ear canal. Irrigation solution should be allowed to drain freely during instillation.

Which situation will cause the nurse to intervene and follow up on the nurse aide's behavior? a. The nurse aide is calling the older adult patient "honey." b. The nurse aide is facing the older adult patient when talking. c. The nurse aide cleans the older adult patient's glasses. d. The nurse aide allows time for the older adult patient to respond.

ANS: A Communicate with older adults on an adult level, and avoid patronizing or speaking in a condescending manner. Avoid terms of endearment such as "honey," "dear," "grandma," or "sweetheart." Facing an older adult patient, making sure the older adult has clean glasses, and allowing time to respond facilitate communication with older adult patients and should be encouraged, not stopped.

A nursing instructor needs to evaluate students' abilities to synthesize data and identify relationships between nursing diagnoses. Which learning assignment is best suited for this instructor's needs? a. Concept mapping b. Reflective journaling c. Reading assignment with a written summary d. Lecture and discussion

ANS: A Concept maps challenge the student to synthesize data and identify relationships between nursing diagnoses. Reflective journaling involves thinking back to clarify concepts. Reading assignments and lecture do not best provide an instructor the ability to evaluate students' abilities to synthesize data.

Critical thinking characteristics include a. Considering what is important in a given situation. b. Accepting one, established way to provide patient care. c. Making decisions based on intuition. d. Being able to read and follow physician's orders.

ANS: A Critical thinking involves being able to decipher what is relevant and important in a given situation and to make a clinical decision based on that importance. Patient care can be provided in many ways. Clinical decisions should be based on evidence and research. Following physician's orders is not considered a critical thinking skill.

The nurse is caring for an elderly patient admitted with nausea, vomiting, and diarrhea. Upon completing the health history, which priority concern would require collaboration with social services to address the patient's health care needs? a. The electricity was turned off 2 days ago. b. The water comes from the county water supply. c. A son and family recently moved into the home. d. The home is not furnished with a microwave oven.

ANS: A Electricity is needed for refrigeration of food, and lack of electricity could have contributed to the nausea, vomiting, and diarrhea—potential food poisoning. This discussion about the patient's electrical needs can be referred to social services. The water supply, the increased number of individuals in the home, and not having a microwave may or may not be concerns but do not pertain to the current health care needs of this patient.

The staff is having a hard time getting an older adult patient to communicate. Which technique should the nurse suggest the staff use? a. Allow the patient to reminisce. b. Try changing topics often. c. Involve only the patient in conversations. d. Ask the patient for explanations.

ANS: A Encouraging older adults to share life stories and reminisce about the past has a therapeutic effect and increases their sense of well-being. Avoid sudden shifts from subject to subject. It is helpful to include the patient's family and friends and to become familiar with the patient's favorite topics for conversation. Asking for explanations is a nontherapeutic technique.

A patient needs assistance excreting a gaseous medication. What is the correct nursing action? a. Encourage the patient to cough and deep-breathe. b. Suction the patient's respiratory secretions. c. Administer the antidote via inhalation. d. Administer 100% FiO2 via simple face mask.

ANS: A Gaseous and volatile medications are excreted through gas exchange. Deep breathing and coughing will assist in clearing the medication more quickly.

The nurse knows that a subcutaneous injection takes longer to absorb because a. Fewer blood vessels are found under the subcutaneous level. b. Adipose tissue takes longer to metabolize medication. c. Connective tissue holds medication in place longer. d. Some medication leaks out after instillation.

ANS: A How quickly a medication is absorbed is dependent on blood flow to the site. Locations with less blood supply take longer to absorb. Absorption is not based on adipose tissue; however, excessive adipose tissue may cause the medication to take longer before reaching the blood supply. The connective tissue is not part of medication absorption. If a medication is properly administered, none of it should be wasted.

A provider has ordered a STAT medication to be administered. The nurse knows that the best route of administration is a. IV. b. IM. c. SQ. d. PO.

ANS: A IV medications have the quickest effect because they receive the most blood flow. A STAT order is to be carried out as quickly as possible, so the effect should be as immediate as possible. Oral, subcutaneous (SQ), and intramuscular (IM) are other ways to deliver medication but with less blood flow.

A nurse is using SOLER to facilitate active listening. Which technique should the nurse use for R? a. Relax b. Respect c. Reminisce d. Reassure

ANS: A In SOLER, the R stands for relax. It is important to communicate a sense of being relaxed and comfortable with the patient. Active listening enhances trust because the nurse communicates acceptance and respect for the patient, but it is not the R in SOLAR. Reminisce is a therapeutic communication technique, especially when used with the elderly. Reassuring can be therapeutic if the nurse reassures patients that there are many kinds of hope, and that meaning and personal growth can come from illness experiences. However, false reassurance can block communication.

A patient has been admitted to the hospital numerous times. The nurse asks the patient to share a personal story about the care that has been received. Which interaction is the nurse using? a. Narrative b. Socializing c. Nonjudgmental d. SBAR

ANS: A In a therapeutic relationship, nurses often encourage patients to share personal stories. Sharing stories is called narrative interaction. Socializing is an important initial component of interpersonal communication. It helps people get to know one another and relax. It is easy, superficial, and not deeply personal. Nonjudgmental acceptance of the patient is an important characteristic of the relationship. Acceptance conveys a willingness to hear a message or acknowledge feelings; it is not a technique that involves personal stories. SBAR is a popular communication tool that helps standardize communication among health care providers. SBAR stands for Situation, Background, Assessment, and Recommendation.

The patient appears to be in no apparent distress, but vital signs taken by assistive personnel reveal an extremely low pulse. The nurse then auscultates an apical pulse and asks the patient whether he has any complaints or a history of heart problems. The nurse is utilizing which critical thinking skill? a. Interpretation b. Evaluation c. Self-regulation d. Explanation

ANS: A Interpretation involves being orderly in data collection, looking for patterns to categorize data, and clarifying uncertain data. This nurse is clarifying the data in this situation. Evaluation involves determining the effectiveness of interventions. The nurse in this scenario is assessing the patient, not evaluating interventions. Self-regulation is reflecting on experiences. Explanation is supporting findings and conclusions. The nurse in this question is clarifying uncertain data (determining cause of the low pulse), not supporting the finding of a low pulse.

Which nurse most likely kept records on sanitation techniques and the effects on health? a. Florence Nightingale b. Mary Nutting c. Clara Barton d. Lillian Wald

ANS: A Nightingale was the first practicing nurse epidemiologist. Her statistical analyses connected poor sanitation with cholera and dysentery. Mary Nutting, Clara Barton, and Lillian Wald came after Nightingale, each contributing to the nursing profession in her own way. Mary Nutting was instrumental in moving nursing education into universities. Clara Barton founded the American Red Cross. Lillian Wald helped open the Henry Street Settlement.

Nurses who make the best communicators a. Develop critical thinking skills. b. Like different kinds of people. c. Learn effective psychomotor skills. d. Maintain perceptual biases.

ANS: A Nurses who develop critical thinking skills make the best communicators. Just liking people does not make an effective communicator because it is important to apply critical thinking standards to ensure sound effective communication. Just learning psychomotor skills does not ensure that the nurse will use those techniques and communication involves more than psychomotor skills.Critical thinking helps the nurse overcome perceptual biases or human tendencies that interfere with accurately perceiving and interpreting messages from others. Nurses who maintain perceptual biases do not make good communicators.

A paradigm is useful in describing the domain of a discipline. Nursing's paradigm includes which of the following? (Select all that apply.) a. Person b. Disease c. Health d. Environment e. Nursing

ANS: A, C, D, E Nursing's paradigm includes four linkages: the person, health, environment/situation, and nursing. Disease is not part of nursing's paradigm.

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

ANS: A Orem's theory explains the factors within a patient's living situation that support or interfere with the patient's self-care ability. This theory has value in helping nursing design interventions with the patient that will help to promote the patient's self-care in managing an illness, such as diabetes or arthritis.

The nurse is visiting a patient at home after he was discharged from the hospital following a heart attack. She listens to the patient's concerns about being an invalid for the rest of his life because of his bad heart, but he is afraid of having "open heart" surgery. The nurse explains the different surgical procedures that are available to the patient, as well as other options such as cardiac rehabilitation. After several such visits, the patient states that he believes that cardiac rehabilitation therapy would be best for him, and asks the nurse how he can get in. The nurse calls the patient's physician and sets up a referral for cardiac rehabilitation. This action most closely fits which of the following theories? a. Peplau's theory b. Henderson's theory c. Nightingale's theory d. Orem's self-care deficit theory

ANS: A Peplau's theory focuses on the individual, the nurse, and the interactive process or nurse-patient relationship. Goals are to educate the patient and family and to help the patient define the problem and solutions. Henderson's theory focuses on helping the patient with activities that the patient would perform unaided if he or she were able. Nightingale viewed nursing not as limited to the administration of medications and treatments, but rather as oriented toward providing fresh air, light, warmth, cleanliness, quiet, and adequate nutrition. The goal of Orem's theory is to help the patient perform self-care.

The nurse researcher is evaluating whether holding pressure at an injection site after injecting the anticoagulant enoxaparin (Lovenox) will reduce bruising at the injection site. This study involves a prescriptive theory because it a. Tests a specific nursing intervention. b. Explains why bruising occurs. c. Is broad in scope and complex. d. Reflects a wide variety of nursing care situations.

ANS: A Prescriptive theories guide nursing research to develop and test specific nursing interventions. Grand theories are broad in scope and complex, and require further specification through research. Descriptive theories do not direct specific nursing activities but help to explain patient assessment. The phenomena within middle-range theories tend to cross different nursing fields and reflect a wide variety of nursing care situations.

Equipment-related accidents are risks in the health care agency. The nurse assesses for this risk when using a. Sequential compression devices. b. A measuring device that measures urine. c. Computer-based documentation. d. A manual medication-dispensing device.

ANS: A Sequential compression devices are used on a patient's extremities to assist in prevention of deep vein thrombosis and have the potential to malfunction and harm the patient. Measuring devices used by the nurse to measure urine, computer documentation, and manual dispensing devices can break or malfunction but are not used directly on a patient.

The nurse is teaching a group of older adults at an assisted-living facility about age-related physiological changes. Which question would be the most important to ask this group? a. "Are you able to hear the tornado sirens in your area?" b. "Are you able to read your favorite book?" c. "Are you able to remember the name of the person you just met?" d. "Are you able to open a jar of pickles?"

ANS: A The ability to hear safety alerts and seek shelter is imperative to life safety. Although age-related changes may cause a decrease in sight that affects reading, and although difficulties in remembering short-term information and opening jars as arthritis sets in are important to patients and to those caring for them, being able to hear safety alerts is the priority.

A nurse is using a guide that provides principles of right and wrong to provide care to patients. Which guide is the nurse using? a. Code of ethics b. Standards of practice c. Standards of professional performance d. Quality and safety education for nurses

ANS: A The code of ethics is the philosophical ideals of right and wrong that define the principles you will use to provide care to your patients. The Standards of Practice describe a competent level of nursing care. The ANA Standards of Professional Performance describe a competent level of behavior in the professional role. Quality and safety education for nurses addresses the challenge to prepare nurses with the competencies needed to continuously improve the quality of care in their work environments.

The patient has been diagnosed with a respiratory illness and complains of shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. What is the usual comfort range for most patients? a. 65° F to 75° F b. 60° F to 75° F c. 15° C to 17° C d. 25° C to 28° C

ANS: A The comfort zone for most individuals is the range between 65° F and 75° F (18.3° C to 23.9° C). The other ranges do not reflect the average person's comfort zone.

The nurse is caring for a patient who is actively bleeding. The physician orders blood transfusions. The nurse notes in the chart that the patient is a Jehovah's Witness and informs the patient of the physician's order. The patient states that she is a Jehovah's Witness and does not want blood products. The nurse contacts the physician to tell him that blood cannot be given to this patient and requests alternative treatment. In doing so, the nurse is operating within which of the following theories? a. Leininger's cultural care diversity and universality theory b. Roy's adaptation theory c. Watson's philosophy of transpersonal caring d. Orem's self-care deficit theory

ANS: A The goal of Leininger's theory is to provide the patient with culturally specific nursing care that integrates the patient's cultural traditions, values, and beliefs into the plan of care. The goal of Roy's model is to help the person adapt to changes in physiological needs, self-concept, role function, and relations. Watson's theory believes that the purpose of nursing action is to understand the interrelationship between health, illness, and human behavior. The goal of Orem's theory is to help the patient perform self-care.

A nurse has withdrawn a narcotic from the medication dispenser. Upon checking the drug against the medication administration record, the nurse notices that the narcotic order has expired. What should be the nurse's first action? a. Return the medication to the medication dispenser according to protocol. b. Exit the medication room to call the physician to request a reorder of the narcotic. c. Assess the patient to see if the narcotic is still needed; if so, administer the medication. d. Call the pharmacy and request that the narcotic be removed from the patient profile.

ANS: A The nurse should follow Nurse Practice Acts and safe narcotic administration guidelines by safely returning the medication to the secure medication dispenser. This allows for an accurate narcotic count. The nurse should not leave the medication room with a nonprescribed medication; the physician can be contacted once the medication is replaced safely. The nurse cannot administer a medication when there is no current order; this is a violation of the Six Rights of Medication Administration. The nurse should notify the pharmacist after safely returning the narcotic to the medication dispenser; removing the medication from the patient profile will reduce further medication errors.

The nurse is preparing to administer medications to two patients with the same last name. After the administration, the nurse realizes that she did not check the identification of the patient before administering medication. Which of the following actions should the nurse complete first? a. Return to the room to check and assess the patient. b. Administer the antidote to the patient immediately. c. Alert the charge nurse that a medication error has occurred. d. Complete proper documentation of the medication error in the patient's chart.

ANS: A The nurse's first priority is to establish the safety of the patient by assessing the patient. Second, notify the charge nurse and the physician. Administer antidote if required. Finally, the nurse needs to complete proper documentation.

The prospective nursing student is trying to decide on which nursing program to attend. She is examining the nursing philosophies of each program. She believes that the essence of nursing is "Caring." Which of the following theories would most likely meet her needs? a. Benner and Wrubel's theory of nursing b. Roy's adaptation theory c. Orem's self-care deficit theory d. Rogers' theory

ANS: A The primacy of caring is a model proposed by Patricia Benner and Judith Wrubel. Caring is central. Roy's model is to help the person adapt to changes in physiological needs, self-concept, role function, and relations. The goal of Orem's theory is to help the patient perform self-care. Roger's theory considers the individual as an energy field coexisting within the universe.

A confused patient is restless and continues to try to remove his oxygen and urinary catheter. What is the priority nursing diagnosis and intervention to implement for this patient? a. Risk for injury: Prevent harm to patient, use restraints if alternatives fail. b. Deficient knowledge: Explain the purpose of oxygen therapy and the urinary catheter. c. Disturbed body image: Encourage patient to express concerns about body. d. Caregiver role strain: Identify resources to assist with care.

ANS: A The priority nursing diagnosis is risk for injury. This patient could cause harm to himself by interrupting the oxygen therapy or by damaging the urethra by pulling the urinary catheter out. Before restraining a patient, it is important to implement and exhaust alternatives to restraint. Alternatives can include distraction and providing companionship or supervision. Patients may be moved to a location closer to the nurses' station; trained sitters or family members may be involved. Nurses need to ensure that patients are provided adequate food, liquid, toileting, and relief from pain. If these and other alternatives fail, this individual may need restraints; in this case, an order would need to be obtained for the restraint. This patient may have deficient knowledge; educating the patient about treatments could be considered as an alternative to restraints; however, the nursing diagnosis of highest priority is risk for injury. This scenario does not indicate that the patient has a disturbed body image or that the patient's caregiver is strained.

The nurse knows that the purpose of aspiration on IM injections is to a. Ensure proper placement of the needle. b. Increase the force of the injection. c. Reduce the discomfort of the injection. d. Prolong the absorption time of the medication.

ANS: A The purpose of aspiration is to ensure that the needle is in the belly of the muscle and not in the vascular system. Blood return upon aspiration indicates improper placement, and the injection should not be given. Increasing the force of the injection, reducing discomfort, and prolonging absorption time are not reasons for aspirating medications.

The nurse is preparing a patient for surgery. The nurse explains that the reason for writing in indelible ink on the surgical site the word "correct" is to a. Distinguish the correct surgical site. b. Label the correct patient. c. Comply with the surgeon's preference. d. Adhere to the correct regulatory standard.

ANS: A The purpose of writing on the surgical site as part of the Universal Protocol from the Joint Commission is to distinguish the correct site on the correct patient and match with the correct surgeon for patient safety and prevention of wrong site surgery. All patients who are having an invasive procedure should receive labeling in many different ways, including the record and patient armbands. Writing in indelible ink may comply with the surgeon's preference, but safety is the driving factor. Although labeling of the site helps to meet regulatory standards, this is not the reason to do this activity—the reason is to keep the patient safe.

Which nursing action is the number one priority for ensuring that medication stays in the target therapeutic range? a. Drawing the peak and trough levels at the same time each day b. Administering a double dose after a dose was missed c. Delivering the same amount of the drug at the same time each day d. Increasing absorption by holding all other medications 1 hour before administration

ANS: A The quantity and distribution of a medication in different body compartments change constantly. Drawing peak and trough levels allows health care providers to see whether the current medication dosage is effective for the patient, or if it needs to be adjusted. Administering a double dose is dangerous and could cause the medication to cross the toxic threshold. Delivering the same amount each day may not be therapeutic or may be toxic for the patient. Holding all other medications should not affect the peak or half-life of the medications, assuming that they are compatible.

Before meeting the patient, a nurse talks to other caregivers about the patient. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

ANS: A The time before the nurse meets the patient is called the pre-interaction phase. This phase can involve such things as reviewing available data, including the medical and nursing history, talking to other caregivers who have information about the patient, or anticipating health concerns or issues that can arise. The orientation phase occurs when the nurse and the patient meet and get to know one another. This phase can involve such things as setting the tone for the relationship by adopting a warm, empathetic, caring manner; recognizing that the initial relationship is often superficial, uncertain, and tentative; or expecting the patient to test the nurse's competence and commitment. The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. This phase can involve such things as encouraging and helping the patient express feelings about his or her health, encouraging and helping the patient with self-exploration, or providing information needed to understand and change behavior. The termination phase occurs during the ending of the relationship. This phase can involve such things as reminding the patient that termination is near, evaluating goal achievement with the patient, or reminiscing about the relationship with the patient.

A patient is aphasic, and the nurse notices that the patient's hands shake intermittently. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid.

ANS: A Using a pen and paper can be frustrating for a nonverbal (aphasic) patient whose handwriting is shaky; the nurse can revise the care plan to include use of a picture board instead. An interpreter is used for a patient who speaks a foreign language. A hearing aid is used for the hard of hearing, not for an aphasic patient.

What is the nurse's priority action to protect a patient from medication error? a. Requesting that the prescriber write out an order, rather than giving a verbal order b. Asking anxious family members to leave the room before giving a medication c. Checking the patient's room number against the medication administration record d. Administering as many of the medications as possible at one time

ANS: A Verbal orders should be limited to urgent situations where written communication is unavailable. The nurse should explain the reasons and logistics of a procedure to calm anxious family members, and should ask family members not to distract medication administration for the patient's safety. After proper education, if the family members are creating an unsafe environment, the nurse may ask them to step out of the room. The medication administration record should be checked against the patient's hospital identification band; a room number is not an acceptable identifier. Medications should be given when scheduled, and medications with special assessment indications should be separated.

The nurse is caring for an older adult who presents to the clinic after a fall. The nurse reviews fall prevention in the home. Which of the following should the patient avoid? (Select all that apply.) a. Watering outdoor plants with a nozzle and hose b. Purchasing light bulbs with strength greater than 60 watts c. Missing yearly eye examinations d. Using bathtubs without safety strips e. Unsecured rugs throughout the home f. Walking to the mailbox in the summer

ANS: A, C, D, E Unsecured rugs, using a hose to water plants, missing yearly eye examinations, and using tubs without safety strips are all items the patient should avoid to help in the prevention of falls in the home. Exercise is beneficial and increases strength, which helps with the prevention of falls. It is important that the home is well lit, so encourage the purchase of bulbs with strength of 60 watts or higher for the home

The nurse is instructing the student nurse regarding discharge teaching and medications. Which response by the student would indicate that learning has occurred? a. "I need to be precise when teaching a patient about Zyprexa (olanzapine) and Zyrtec (cetirizine)." b. "The medications can be picked up at the pharmacy on the way out of the hospital." c. "I need to be sure to give the patient leftover medications from the medication drawer." d. "I need to remember to teach the patient to take all medications at the same time of the day."

ANS: A Zyprexa and Zyrtec are sound-alike, look-alike medications. Zyprexa is an antipsychotic and Zyrtec an antihistamine; these agents treat two different conditions. Bringing the differences and similarities in spelling and sound to the attention of the patient is important for patient safety. Medications are not distributed by the hospital, and medications do not need to be administered at the same time each day.

A nurse is caring for an adult patient who has had a minor motor vehicle accident. The health history reveals that the patient is currently in the process of obtaining a divorce. Which of the following actions should the nurse take?(Select all that apply.) a. Agree upon and make time for the patient to talk. b. Use active listening skills and therapeutic touch as appropriate. c. Teach stress reduction strategies. d. Inform patient that stressed individuals are more likely to have accidents. e. Agree to witness telephone conversations with separated husband. f. Refer the patient to the nurse's church marriage counselor.

ANS: A, B, C, D Agreeing and making time for conversation, using active listening skills and therapeutic touch, teaching stress reduction strategies, and informing the patient of the risk to health associated with stress are interventions that are within the nurse's scope of practice. Agreeing to witness a telephone conversation could draw the nurse into divorce proceedings when the focus should be on the patient and his health. Referring the patient to the nurse's church counselor without a specific request from the patient may not take into consideration cultural care and could be considered unprofessional. If the patient requested a marriage counselor, a better solution would be to provide a referral to social services that may include a list of possible counselors from which the patient could choose.

The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which of the following should the nurse implement? (Select all that apply.) a. Close all doors. b. Note evacuation routes. c. Note oxygen shut-offs. d. Await direction from the fire department. e. Evacuate everyone from the building. f. Review "Stop, drop, and roll" with the nursing staff.

ANS: A, B, C, D Closing all doors helps to contain smoke and fire. Noting the evacuation routes and oxygen shut-offs is important in case the direction to evacuate comes from established channels. Evacuation from the building is determined by the established chain of command or the fire department. Evacuation is done only when necessary. Review of "stop, drop, and roll," although important, is not a priority at this time.

A nurse is preparing a teaching session about contemporary influences on nursing. Which examples should the nurse include? (Select all that apply.) a. Human rights b. Affordable Care Act c. Demographic changes d. Medically underserved e. Decreasing health care costs

ANS: A, B, C, D Multiple external forces affect nursing, including the need for nurses' self-care, Affordable Care Act (ACA) and rising (not decreasing) health care costs, demographic changes of the population, human rights, and increasing numbers of medically underserved.

Psychosocial theories are needed in nursing because nursing is a diverse discipline that strives to meet which criteria? (Select all that apply.) a. Physiological needs of the patient b. Psychological needs of the patient c. Sociocultural needs of the patient d. Spiritual needs of the patient e. The nurse-patient relationship

ANS: A, B, C, D Nursing is a diverse discipline that strives to meet the physiologic, psychological, sociocultural, developmental, and spiritual needs of patients. The nurse-patient relationship forms the basis for Hildegard Peplau's theory of nursing.

The nurse suspects the possibility of a bioterrorist attack. Which of the following factors is most likely related to this possibility? (Select all that apply.) a. A rapid increase in patients presenting with fever or respiratory or gastrointestinal symptoms b. Lower rates of symptoms among patients who spend time primarily indoors c. Large number of rapidly fatal cases of patients with presenting symptoms d. Shortage of personal protective equipment available from central supply e. An increase in the number of staff calling in sick for their assigned shift f. Patients with symptoms all coming from one location in the area

ANS: A, B, C, F A rapid increase in patients presenting with a specific symptom, lower rates of symptoms among individuals indoors, and large numbers of fatalities with these symptoms all coming from one location are triggers that lead the nurse to suspect a bioterrorist attack. A shortage of personal protective equipment and an increase in the number of staff calling in sick can occur and does occur at times in the hospital setting and may have nothing to do with bioterrorism.

The home health nurse is caring for a patient in the home who is using an electrical infusion device. While visiting the patient, the nurse smells smoke and notices an electrical fire started by this device. The nurse uses the fire extinguisher and fights the fire when (Select all that apply.) a. All occupants have left the home. b. Fire department has been called. c. Fire is confined to one room. d. An exit route is available. e. The correct extinguisher is available. f. The nurse thinks she can use the fire extinguisher.

ANS: A, B, D, E In a home setting, if the nurse is present during a fire, she first should remove all occupants and then should call the fire department by dialing 911. If the fire is small—not confined to just one room (this could be too large for the fire extinguisher), if the correct extinguisher is available, and if the nurse knows (not thinks) that she can use it, the nurse may attempt to extinguish the fire. Utilize PASS (Pull the pin, Aim low, Squeeze the handles, Sweep area from side to side) to activate the extinguisher.

The nursing process involves which of the following steps in the clinical decision-making process? (Select all that apply.) a. Identifying patient needs b. Diagnosing the disease process c. Determining priorities of care d. Setting goals e. Performing nursing interventions f. Evaluating effectiveness of medical treatments

ANS: A, C, D, E Diagnosing disease is not a nursing action. Evaluating the effectiveness of medical treatments is not a nursing action either. Nurses are to use the nursing process to evaluate the effectiveness of nursing interventions, not medical treatments. Identifying patient needs, determining priorities of care, setting realistic goals, and implementing nursing interventions are all steps in the clinical decision-making process.

The nurse manager from the oncology unit has had two callouts; the orthopedic unit has had multiple discharges and probably will have to cancel one or two of its nurses. The orthopedic unit has agreed to "float" two of its nurses to the oncology unit if oncology can "float" a nursing assistant to the orthopedic unit to help with obtaining vital signs. Which concepts does this situation entail? (Select all that apply.) a. Autonomy b. Informatics c. Accountability d. Political activism e. Teamwork and collaboration

ANS: A, C, E Staffing is an independent nursing intervention and is an example of autonomy. Along with increased autonomy comes accountability or responsibility for outcomes of an action. When nurses work together this is teamwork and collaboration. Informatics is the use of information and technology to communicate, manage knowledge, mitigate error, and support decision making. Political activism usually involves more than day-to-day activities such as unit staffing.

A nurse prepares the budget and policies for an intensive care unit. Which role is the nurse implementing? a. Educator b. Manager c. Advocate d. Caregiver

ANS: B A manager coordinates the activities of members of the nursing staff in delivering nursing care and has personnel, policy, and budgetary responsibility for a specific nursing unit or facility. As an educator, you explain concepts and facts about health, describe the reason for routine care activities, demonstrate procedures such as self-care activities, reinforce learning or patient behavior, and evaluate the patient's progress in learning. As a patient advocate, you protect your patient's human and legal rights and provide assistance in asserting these rights if the need arises. As a caregiver, you help patients maintain and regain health, manage disease and symptoms, and attain a maximal level function and independence through the healing process.

A patient has trouble speaking words, and the patient's speech is garbled. Which nursing diagnosis is most appropriate for this patient? a. Hopelessness b. Impaired verbal communication c. Hearing loss d. Self-care deficit

ANS: B A patient with impaired verbal communication has defining characteristics such as an inability to articulate words, inappropriate verbalization, difficulty forming words, and difficulty comprehending. Hopelessness implies that the patient has no hope for the future. Hearing loss is not a nursing diagnosis. Just because a patient has garbled speech does not mean that a hearing loss has occurred; a physical problem such as a stroke could cause the garbled speech. Self-care deficit does not apply in this situation because this usually relates to bathing, grooming, etc.

The nurse knows that an idiosyncratic event with the stimulant pseudoephedrine (Sudafed) is occurring when the patient a. Experiences blurred vision while driving. b. Falls asleep during daily activities. c. Presents with a pruritus rash. d. Develops xerostomia.

ANS: B An idiosyncratic event is a reaction opposite to what the side effects of the medication normally are, or the patient overreacts or underreacts to the medication. Blurred vision is a toxic effect. A rash could indicate an allergic reaction. Dry mouth is a typical response to a stimulant.

Which patient using an inhaler would benefit most from using a spacer? a. 3-year-old with a cleft palate b. 25-year-old with multiple sclerosis c. 50-year-old with hearing impairment d. 72-year-old with left-sided hemiparesis

ANS: B A spacer is indicated for a patient who has limited coordination or function. Individuals with multiple sclerosis often lose motor control and function and have difficulty seeing. Children often have difficulty using a spacer, so a simple face mask is preferred for infants and children younger than 4. Hearing impairment may make teaching the patient to use the inhaler difficult, but it does not indicate the need for a spacer. A patient with one-sided weakness would have a difficult time assembling and administering an inhaler by using a spacer, but the patient could use the inhaler single-handedly.

While providing care to a patient, the nurse is responsible, both professionally and legally. Which concept does this describe? a. Autonomy b. Accountability c. Patient advocacy d. Patient education

ANS: B Accountability means that the nurse is responsible, professionally and legally, for the type and quality of nursing care provided. Autonomy is an essential element of professional nursing that involves the initiation of independent nursing interventions without medical orders. As a patient advocate, the nurse protects the patient's human and legal rights and provides assistance in asserting these rights if the need arises. As an educator, the nurse explains concepts and facts about health, describes the reasons for routine care activities, demonstrates procedures such as self-care activities, reinforces learning or patient behavior, and evaluates the patient's progress in learning.

The nurse identifies that a patient has received Mylanta (simethicone) instead of the prescribed Pepto-Bismol (bismuth subsalicylate) for the problem of indigestion. The nurse's next intervention is to a. Do nothing, no harm has occurred. b. Assess and monitor the patient. c. Notify the physician, treat and document. d. Complete an incident report.

ANS: B After providing an incorrect medication, assessing and monitoring the patient to determine the effects of the medication is the first step. Notifying the physician and providing treatment would be the best next step. After the patient has stabilized, completing an incident report would be the last step in the process.

A confused older adult patient is wearing thick glasses and a hearing aid. Which intervention is priority to facilitate communication? a. Focus on tasks to be completed. b. Allow time for the patient to respond. c. Limit conversations with the patient. d. Use gestures and other nonverbal cues.

ANS: B Allowing time for the patient to respond will facilitate communication, especially for an older confused patient. Focusing on tasks to be completed and limiting conversations do not facilitate communication; in fact, they block communication. Using gestures and other nonverbal cues is not effective for visually impaired or cognitively impaired patients.

A smiling patient angrily states, "I will not cough and deep breathe." How will the nurse interpret this finding? a. The patient's personal space was violated. b. The patient's affect is inappropriate. c. The patient's vocabulary is poor. d. The patient's denotative meaning is wrong.

ANS: B An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect. The patient's personal space was not violated. The patient's vocabulary is not poor. Individuals who use a common language share denotative meaning: baseball has the same meaning for everyone who speaks English, but codedenotes cardiac arrest primarily to health care providers. The patient's denotative meaning is correct for cough and deep breathe.

Which of these patient scenarios is most indicative of critical thinking? a. Administering pain relief medication according to what was given last shift b. Asking a patient what pain relief methods, pharmacological and nonpharmacological, have worked in the past c. Offering pain relief medication based on physician orders d. Explaining to the patient that his reports of severe pain are not consistent with the minor procedure that was performed

ANS: B Asking the patient what pain relief methods have worked in the past is an example of exploring many options for pain relief. Administering medication based on a previous assessment is not practicing according to standards of care. The nurse is to conduct an assessment each shift on his/her patient and intervene accordingly. Nonpharmacological pain relief methods are available, as are medications for pain. Pain is subjective. The nurse should offer pain relief methods based on the patient's reports without being judgmental.

A patient says, "You are the worst nurse I have ever had." Which response by the nurse is the most assertive? a. "If I were you, I'd feel grateful for a nurse like me." b. "I feel uncomfortable hearing that statement." c. "How can you say that when I have been checking on you regularly?" d. "You shouldn't say things like that, it is not right."

ANS: B Assertive responses contain "I" messages such as "I want," "I need," "I think," or "I feel." Giving personal opinions ("If I were you") is nontherapeutic and not assertive. Arguing ("How can you say that?") is not assertive or therapeutic. Showing disapproval (using words like should, good, bad, right) is not assertive or therapeutic.

A nurse assesses a patient's fluid status and decides that the patient needs to drink more fluids. The nurse then encourages the patient to drink more fluids. Which concept is the nurse demonstrating? a. Licensure b. Autonomy c. Certification d. Accountability

ANS: B Autonomy is an essential element of professional nursing that involves the initiation of independent nursing interventions without medical orders. To obtain licensure in the United States, the RN candidate must pass the NCLEX-RN®. Beyond the NCLEX-RN®, the nurse may choose to work toward certification in a specific area of nursing practice. Accountability means that you are responsible, professionally and legally, for the type and quality of nursing care provided.

A nurse is teaching the staff about Benner's levels of proficiency. In which order should the nurse place the levels from beginning level to ending level? 1. Expert 2. Novice 3. Proficient 4. Competent 5. Advanced beginner a. 2, 4, 5, 1, 3 b. 2, 5, 4, 3, 1 c. 4, 2, 5, 3, 1 d. 4, 5, 2, 1, 3

ANS: B Benner's levels of proficiency are as follows: novice, advanced beginner, competent, proficient, and expert.

The nurse is giving an IM injection. Upon aspiration, the nurse notices blood return in the syringe. What should the nurse do? a. Administer the injection at a slower rate. b. Withdraw the needle and prepare the injection again. c. Pull the needle back slightly and inject the medication. d. Give the injection and hold pressure over the site for 3 minutes.

ANS: B Blood return upon aspiration indicates improper placement, and the injection should not be given. Instead withdraw the needle, dispose of the syringe and needle properly, and prepare the medication again. Administering the medication into a blood vessel could have dangerous adverse effects, and the medication will be absorbed faster than intended owing to increased blood flow. Holding pressure is not an appropriate intervention. Pulling back the needle slightly does not guarantee proper placement of the needle and medication administration.

A nurse is attempting to administer medication to a child, but the child refuses to take the medication. The nurse asks for the parent's cooperation by saying a. "Please hold your child's arms down at her sides, so I can get the full dose of medication into her mouth." b. "I will prepare the medication for you and observe if you would like to try to administer the medication." c. "Let's turn the lights off and give the child a moment to fall asleep before administering the medication." d. "Since your child loves applesauce, let's add the medication to it, so your child doesn't resist."

ANS: B Children often have difficulties taking medication, but it is less traumatic for the child if the parent administers the medication. Holding down the child is not the best option because it may further upset the child. Never administer an oral medication to a sleeping child. Don't mix medications into the child's favorite foods, because the child might start to refuse the food.

A nurse has compassion fatigue. What is the nurse experiencing? a. Lateral violence and intrapersonal conflict b. Burnout and secondary traumatic stress c. Short-term grief and single stressor d. Physical and mental exhaustion

ANS: B Compassion fatigue is a term used to describe a state of burnout and secondary traumatic stress. Compassion fatigue may contribute to what is described as lateral violence (nurse-nurse interactions, not intrapersonal). Frequent, intense, or prolonged exposure to grief and loss places nurses at risk for developing compassion fatigue. Stressors, not a single stressor, contribute to compassion fatigue. Physical and mental exhaustion describes burnout only.

A graduate of a baccalaureate degree program is ready to start working as an RN in the emergency department. Which action must the nurse take first? a. Obtain certification for an emergency nurse. b. Pass the National Council Licensure Examination. c. Take a course on genomics to provide competent emergency care. d. Complete the Hospital Consumer Assessment of Healthcare Providers Systems.

ANS: B Currently, in the United States, the most common way to become a registered nurse (RN) is through completion of an associate's degree or baccalaureate degree program. Graduates of both programs are eligible to take the National Council Licensure Examination for Registered Nurses (NCLEX-RN) to become registered nurses in the state in which they will practice. Certification can be obtained after passing the NCLEX and working for the specified amount of time. Genomics is a newer term that describes the study of all the genes in a person and interactions of these genes with one another and with that person's environment. Consumers can also access Hospital Consumer Assessment of Healthcare Providers Systems (HCAHPS) to obtain information about patients' perspectives on hospital care.

A nurse teaches a group of nursing students about nurse practice acts. Which information is most important to include in the teaching session about nurse practice acts? a. Protects the nurse b. Protects the public c. Protects the provider d. Protects the hospital

ANS: B The nurse practice acts regulate the scope of nursing practice and protect public health, safety, and welfare. They do not protect the nurse, provider, or hospital.

Many aspects of nursing theory are based on developmental theories because human growth and development is believed to be a. Erratic and difficult to predict. b. An orderly predictive process. c. An orderly process until adulthood. d. Unpredictable during childhood.

ANS: B Human growth and development is an orderly predictive process that begins with conception and continues through death. It is not erratic or difficult to predict. It does not stop at adulthood and is not unpredictable during childhood.

A new nurse is pulled from the surgical unit to work on the oncology unit. The nurse displays the critical thinking attitudes of humility and responsibility by a. Refusing the assignment. b. Asking for an orientation to the unit. c. Assuming that patient care will be the same as on the other units. d. Admitting lack of knowledge and going home.

ANS: B Humility and responsibility are displayed when the nurse realizes lack of knowledge and requests an orientation to the unit. The other answer choices represent inappropriate actions in this situation and are not examples of humility and responsibility. The nurse should explore all options before refusing an assignment. The nurse should not make assumptions. Assuming is not an example of critical thinking. Admitting lack of knowledge is an example of humility, but going home does not illustrate an example of responsibility.

A homeless adult patient presents to the emergency department. The nurse obtains the following vital signs: temperature 94.8° F, blood pressure 100/56, apical pulse 56, respiratory rate 12. Which of the vital signs should be addressed immediately? a. Respiratory rate b. Temperature c. Apical pulse d. Blood pressure

ANS: B Hypothermia is defined as a core body temperature of 95° F or below. Homeless individuals are more at risk for hypothermia owing to exposure to the elements.

An order is written for (phenytoin) Dilantin 500 mg IM q3-4h prn for pain. The nurse recognizes that treatment of pain is not a standard therapeutic indication for this drug. The nurse believes that the prescriber meant to write for hydromorphone (Dilaudid). What should the nurse do? a. Give the patient Dilaudid, as it was meant to be written. b. Call the prescriber to clarify and justify the order. c. Administer the medication and monitor the patient frequently. d. Refuse to give the medication and notify the nurse supervisor.

ANS: B If the nurse is apprehensive about the drug, dose, route, or reason for a medication, the nurse should first call the prescriber and clarify. The nurse should not change the order without the prescriber's consent. Ultimately, the nurse can be held responsible for administering an incorrect medication. If the prescriber is unwilling to change the order and does not justify the order in a reasonable and evidence-based manner, the nurse may refuse to give the medication and notify her supervisor.

The nurse has been called to a hospital room where a patient is using a hair dryer from home. The patient has received an electrical shock from the dryer. The patient is unconscious and is not breathing. What is the best next step? a. Ask the family to leave the room. b. Check for a pulse. c. Begin compressions. d. Defibrillate the patient.

ANS: B In this scenario, the patient is in a hospital setting, and it has been determined that the patient is not conscious and is not breathing. The next step is to check the pulse. An electrical shock can interfere with the heart's normal electrical impulses and can cause arrhythmias. Checking the pulse helps to determine the need for cardiopulmonary resuscitation (CPR) and defibrillation.

The patient presents to the clinic with a family member. The family member states that the patient has been wandering around the house and mumbling. What is the first assessment the nurse should do? a. Ask the patient why she has been wandering around the house. b. Introduce self and ask the patient her name. c. Take the patient's blood pressure, pulse, temperature, and respiratory rate. d. Immediately do a complete head-to-toe neurologic assessment.

ANS: B Introduce self and engage the patient by asking her name to assess orientation; ask the patient why she is visiting the clinic today. Continue the assessment with vital signs and a complete workup, including a neurologic assessment.

During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

ANS: B Letting the patient know when to expect the relationship to be terminated occurs in the orientation phase. Pre-interaction occurs before the nurse meets the patient. Working occurs when the nurse and the patient work together to solve problems and accomplish goals. Termination occurs during the ending of the relationship.

An elderly patient presents to the hospital with a history of falls, confusion, and stroke. The nurse determines that the patient is at high risk for falls. Which of the following interventions is most appropriate for the nurse to take? a. Place the patient in restraints. b. Lock beds and wheelchairs when transferring. c. Place a bath mat outside the tub. d. Silence fall alert alarm upon request of family.

ANS: B Locking the bed and wheelchairs when transferring will help to prevent these pieces of equipment from moving during transfer and will assist in the prevention of falls. Patients are not automatically placed in restraints. The restraint process consists of many steps, including thorough assessment and exhausting of alternatives. All mats and rugs should be secured to help prevent falls. Silencing alarms upon the request of family is not appropriate and could contribute to an unsafe environment.

A confused patient refuses his medication. What is the nurse's first response? a. Agrees with the patient's decision and documents it in his chart b. Educates the patient about the importance of the medication c. Discreetly hides the medication in the patient's favorite Jell-O d. Informs the patient that he must take the medication whether he wants to or not

ANS: B Much of a patient's apprehension about medication comes from lack of understanding, and educating the patient may lead to better compliance. Ultimately, the patient does have the right to refuse the medication; however, the nurse should first try to educate the patient. Hiding, deceiving, or forcing a patient into taking a medication is unethical and violates his right to autonomy.

As the initial model for nursing, Nightingale's "descriptive theory" encouraged nurses to a. Know all about the disease processes affecting their patient. b. Think about their patients and patients' environment. c. Combine nursing knowledge with medicine. d. Focus on medication administration and treatments.

ANS: B Nightingale's "descriptive theory" provides nurses with a way to think about patients and their environment. Nightingale's concept of the environment was the focus of nursing care, and her suggestion that nurses need not know all about the disease process represents early attempts to differentiate between nursing and medicine. Nightingale did not view nursing as limited to the administration of medications and treatments.

The nurse has a goal of becoming a certified registered nurse anesthetist (CRNA). Which activity is appropriate for a CRNA? a. Manages gynecological services such as PAP smears b. Works under the guidance of an anesthesiologist c. Obtains a PhD degree in anesthesiology d. Coordinates acute medical conditions

ANS: B Nurse anesthetists provide surgical anesthesia under the guidance and supervision of an anesthesiologist, who is a physician (health care provider) with advanced knowledge of surgical anesthesia. Nurse practitioners, not CRNAs, manage self-limiting acute and chronic stable medical conditions; certified nurse-midwives provide gynecological services such as routine Papanicolaou (Pap) smears. The CRNA is an RN with an advanced education in a nurse anesthesia accredited program. A PhD is not a requirement.

The nursing student can best develop critical thinking skills by doing which of the following? a. Studying 3 hours more each night b. Actively participating in all clinical experiences c. Interviewing staff nurses about their nursing experiences d. Attending all open skills lab opportunities

ANS: B Nursing is an applied science, and to apply knowledge learned and develop critical thinking skills to make clinical decisions, the student should actively participate in all clinical experiences. Studying for longer hours, interviewing nurses, and attending skills labs do not provide opportunities for clinical decision making, as do actual clinical experiences.

The nurse is caring for a patient diagnosed with essential hypertension. The physician orders blood pressure medication that the nurse administers. The nurse then monitors the patient's blood pressure for several days to help determine the effectiveness of the administration. In doing so, the nurse evaluates which of the following system components? a. Input b. Output c. Feedback d. Content

ANS: B Output is the end product of a system and, in the case of the nursing process, it is defined as whether the patient's health status improves or remains stable as a result of nursing care. Input consists of the data that come from a patient's assessment. Feedback serves to inform a system about how it functions. Content is the product and information obtained from the system.

An elderly patient is wearing a hearing aid. Which technique should the nurse use to facilitate communication? a. Speak clearly and loudly. b. Turn off the television. c. Chew gum. d. Use at least 14-point print.

ANS: B Patients who are hearing impaired benefit when the following techniques are used: Check for hearing aids and glasses, reduce environmental noise, get the patient's attention before speaking, do not chew gum, and speak at normal volume—do not shout. Using at least 14-point print is for sight/visually impaired, not hearing impaired.

A nurse is sitting at the patient's bedside taking a nursing history. Which zone of personal space is the nurse using? a.Intimate b. Personal c. Social d. Public

ANS: B Personal space is 18 inches to 4 feet and involves such things as sitting at a patient's bedside, taking a patient's nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves such things as performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. Social zone is 4 to 12 feet and involves such things as making rounds with a physician, sitting at the head of a conference table, or teaching a class for patients with diabetes. Public zone is 12 feet and greater and involves such things as speaking at a community forum, testifying at a legislative hearing, or lecturing.

The type of theory that is used to develop and test specific nursing interventions is known as _____ theory. a. Grand b. Prescriptive c. Descriptive d. Middle-range

ANS: B Prescriptive theories are action oriented and test the validity and predictability of a nursing intervention. These theories guide nursing research to develop and test specific nursing interventions. Grand theories are broad in scope and complex, and require further specification through research. Descriptive theories do not direct specific nursing activities but help to explain patient assessment. The phenomena within middle-range theories tend to cross different nursing fields and reflect a wide variety of nursing care situations.

A patient with an intravenous infusion requests a new gown after bathing. Which of the following actions is most appropriate? a. Disconnect the intravenous tubing, thread the end through the sleeve of the old gown and through the sleeve of the new gown, and reconnect. b. Thread the intravenous bag and tubing through the sleeve of the old gown and through the sleeve of the new gown without disconnecting. c. Inform the patient that a new gown is not an option while receiving an intravenous infusion in the hospital. d. Call the charge nurse for assistance because linen use is monitored and this is not a common procedure.

ANS: B Procedure-related accidents such as contamination of sterile items can occur in the health care setting. Keeping the intravenous tubing intact without breaks in the system is imperative to decrease the risk of infection while changing a patient's gown and satisfying the patient's request.

Professional nurses are responsible for making clinical decisions to a. Prove traditional methods of providing nursing care to patients. b. Take immediate action when a patient's condition worsens. c. Apply clear textbook solutions to patients' problems. d. Formulate standardized care plans for groups of patients.

ANS: B Professional nurses are responsible for making clinical decisions to take immediate action when a patient's condition worsens. Patient care should be based on evidence-based practice, not on tradition. Clear textbooks solutions to patient problems are not always available. Care plans should be individualized.

A nurse wants to present information about flu immunizations to the elderly in the community. Which type of communication should the nurse use? a. Interpersonal b. Public c. Transpersonal d. Small group

ANS: B Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. Intrapersonal communication is a powerful form of communication that occurs within an individual. Transpersonal communication is interaction that occurs within a person's spiritual domain. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process.

The nurse has placed a patient on high-risk alert for falls. Which of the following observations by the nurse would indicate that the patient has an understanding of this alert? a. The patient removes the high alert armband to bathe. b. The patient wears the red nonslip footwear. c. The call light is kept on the bedside table. d. The patient insists on taking a "water" pill on home schedule in the evening.

ANS: B Red nonslip footwear helps to grip the floor and decreases the chance of falling. The communication armband should stay in place and should not be removed, so that all members of the interdisciplinary team have the information about the high risk for falls. Call lights should be kept within reach of the patient. Taking diuretics early in the day assists with decreasing the number of bathroom trips at night—the time when falls are most frequent.

The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint? a. The patient refuses to call for help to go to the bathroom. b. The patient continues to remove the nasogastric tube. c. The patient gets confused regarding the time at night. d. The patient does not sleep and continues to ask for items.

ANS: B Restraints are utilized only when alternatives have been exhausted, the patient continues a behavior that can be harmful to himself or others, and the restraint is clinically justified. In this circumstance, continuing to remove a needed nasogastric tube would meet these criteria. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.

The critical thinking skill of evaluation in nursing practice can be best described as a. Examining the meaning of data. b. Reviewing the effectiveness of nursing actions. c. Supporting findings and conclusions. d. Searching for links between data and the nurse's assumptions.

ANS: B Reviewing the effectiveness of interventions best describes evaluation. Examining the meaning of data is inference. Supporting findings and conclusions provides explanations. Searching for links between the data and the nurse's assumptions describes analysis.

The nurse has been working in the clinical setting for several years as an advanced practice nurse. However, the nurse has a strong desire to pursue research and theory development. To fulfill this desire, which program should the nurse attend? a. Doctor of Nursing Science degree (DNSc) b. Doctor of Philosophy degree (PhD) c. Doctor of Nursing Practice degree (DNP) d. Doctor in the Science of Nursing degree (DSN)

ANS: B Some doctoral programs prepare nurses for more rigorous research and theory development and award the research-oriented Doctor of Philosophy (PhD) in nursing. Professional doctoral programs in nursing (DSN or DNSc) prepare graduates to apply research findings to clinical nursing. The DNP is a practice doctorate that prepares advanced practice nurses such as nurse practitioners.

Which statement by the patient is an indication to use the Z-track method? a. "I'm really afraid that a big needle will hurt." b. "The last shot like that turned my skin colors." c. "I am allergic to many medications." d. "My legs are too obese for the needle to go through."

ANS: B The Z-track is indicated when the medication being administered has the potential to irritate sensitive tissues. The Z-track method is not meant to reduce discomfort from the procedure. If a patient is allergic to a medication, it should not be administered. If a patient has additional subcutaneous tissue to go through, a needle of a different size may be selected.

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

ANS: B The critically thinking nurse should explore all options for pain relief first. The nurse should use critical thinking to determine the cause of the pain and determine various options for pain, not just ordered pain medications. The nurse can act independently to determine all options for pain relief and does not have to wait until after the health care provider rounds are completed. Explaining the cause of the pain does not address options for pain relief.

The patient is newly diagnosed with diabetes and will be discharged in the next day or so. The nurse is teaching the patient how to draw up and self-administer his insulin. Which nursing theory is the nurse utilizing? a. Watson's philosophy of transpersonal caring b. Orem's self-care deficit theory c. Rogers' theory d. Henderson's theory

ANS: B The goal of Orem's theory is to help the patient perform self-care. In Watson's theory, the nurse is concerned with promoting and restoring health and preventing illness. Rogers' theory considers the individual as an energy field coexisting within the universe. Henderson defines nursing as "assisting the individual, sick or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death, and that the individual would perform unaided if he or she had the necessary strength, will, or knowledge."

A patient has an order to receive 20 units of U-50 insulin. The nurse is using a U-100 syringe. How many units should the nurse draw up in the syringe and administer? a. 0.04 mL b. 0.4 mL c. 4 mL d. 10 mL

ANS: B The nurse is careful to perform nursing calculations to ensure proper medication administration. U-50 insulin has 50 units of insulin in every milliliter, a U-100 syringe has 100 units in every milliliter. Conversion equals 20 units.

The nurse knows that caring for two patients with the same last name can lead to a medication error involving which right of medication administration? a. Right medication b. Right patient c. Right dose d. Right route

ANS: B The nurse should ask the patient to verify his identity and should check the patient's ID bracelet against the medication record to ensure proper patient. Acceptable patient identifiers include the patient's name, an identification number assigned by a health care agency, or a telephone number. Do not use the patient's room number as an identifier. To identify a patient correctly in an acute care setting, compare the patient identifiers on the MAR with the patient's identification bracelet while at the patient's bedside. Right medication, right dose, and right route are equally as important, but this example outlines right patient.

Which of these findings, if identified in a plan of care, should the registered nurse revise because it is not characteristic of critical thinking and the nursing process? a. Patient's reactions to diagnostic testing b. Nurse's assumptions about hospital discharge c. Identification of five different nursing diagnoses d. Documentation of patient's ability to cope with loss

ANS: B The nurse should not assume when a patient is going to be discharged and document this information in a plan of care. Making assumptions is not an example of a critical thinking skill. The patient's reactions to testing, having several nursing diagnoses, and a description of the patient's coping abilities are all appropriate to document in the nursing plan of care.

A patients states that she would prefer not to take her daily allergy pill this morning because it makes her too drowsy throughout the day. The nurse responds therapeutically by saying, a. "The physician ordered it; therefore you must take your medication every morning at the same time whether you're drowsy or not." b. "Let's change the time you take your pill to 9 PM, so the drowsiness occurs when you would normally be sleeping." c. "You can skip this medication on days when you need to be awake and alert." d. "Try to get as much done as you can before you take your pill, so you can sleep in the afternoon."

ANS: B The nurse should use knowledge about the medication to educate the patient about potential response to medications. Then the medication schedule can be altered based on that knowledge, after the physician has been notified. It is the patient's right to refuse her medication; however, the nurse should educate the patient on the importance and effects of her medication. Asking a patient to change her entire life schedule around a medication is unreasonable and will decrease compliance. The nurse should be supportive and should offer solutions to manage medication effects.

The patient is in severe pain and is requesting a prn medication before the prn time interval has elapsed. The nurse's priority is to a. Give the medication early for any pain score greater than 8. b. Call the prescriber and request a stat order. c. Explain to the patient why he will have to wait for the medication. d. Document the patient's request and pain score.

ANS: B The nurse should utilize clinical judgment to advocate for the patient by requesting a stat order for the patient's breakthrough pain. The nurse cannot give a medication without an order because this violates the "Right Time" portion of the Six Rights of Medication Administration. If a nurse assesses that a patient is in severe pain, she must use clinical judgment to find that patient a means of pain relief. Although the nurse should document the patient's request and pain score, this is not the priority.

The nurse asks a patient where the pain is, and the patient responds by pointing to the area of pain. Which form of communication did the patient use? a. Verbal b. Nonverbal c. Intonation d. Vocabulary

ANS: B The patient gestured (pointed), which is a type of nonverbal communication. Gestures emphasize, punctuate, and clarify the spoken word. Pointing to an area of pain is sometimes more accurate than describing its location. Verbal is the spoken word or message. Intonation or tone of voice dramatically affects the meaning of a message. Vocabulary consists of words used for verbal communication.

The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which of the following nursing diagnoses will the nurse add to the patient's plan of care? a. Risk for poisoning b. Deficient knowledge c. Risk for imbalanced body temperature d. Risk for suffocation

ANS: B The patient needs to understand the purpose of the compression devices and that proper application is needed for them to be effective. The patient has a knowledge need and requires instruction regarding the device and its purpose and procedure. The nurse will intervene by teaching the patient about the sequential compression device and instructing the patient to call for assistance when getting up to go to the bathroom in the future, so that the nurse may assist with removal and proper reapplication. No data support a risk for poisoning, imbalanced body temperature, or suffocation.

The nurse is caring for a patient with a urinary catheter. After the nurse empties the collection bag and disposes of the urine, the next step is to a. Use alcohol-based gel on hands. b. Wash hands with soap and water. c. Remove eye protection and dispose of in garbage. d. Remove gloves and dispose of in garbage.

ANS: D After disposing of the urine, the first step in removing personal protective equipment is removing gloves and disposing of them properly. In this scenario, the next step would be to remove eye protection followed by hand hygiene. Wash hands if the hands are visibly soiled; otherwise the use of alcohol-based gel is indicated for routine decontamination of hands.

The physician orders 4 mg of oxycodone to be delivered every 6 hours. After 4 hours, the patient is complaining that she is in more pain. The nurse advises the physician to make which medication adjustment? a. Add an additional narcotic on top of the oxycodone. b. Divide the dose in half and administer 2 mg every 3 hours. c. Give another 4 mg of oxycodone after 4 hours. d. Change the medication being administered for pain relief.

ANS: B The patient's metabolism causes the peak effect to occur when the medicine is at its highest concentration. After reaching its peak, the serum concentration of the medication falls progressively. By spreading out the dose, the patient should receive constant pain relief. Changing the medication, increasing the dose, or adding another medication is not the best course of action.

The patient requires routine gynecological services after giving birth to her son, and while seeing the nurse-midwife, the patient asks for a referral to a pediatrician for the newborn. Which action should the nurse-midwife take initially? a. Provide the referral as requested. b. Offer to provide the newborn care. c. Refer the patient to the supervising provider. d. Tell the patient that is not allowed to make referrals.

ANS: B The practice of nurse-midwifery involves providing independent care for women during normal pregnancy, labor, and delivery, as well as care for the newborn. After being apprised of the midwifery role, if the patient insists on seeing a pediatrician, the nurse-midwife should provide the referral. The supervising provider is an obstetric provider, not a pediatrician. A nurse-midwife can make referrals.

The patient is to receive phenytoin (Dilantin) at 0900. The nurse knows that the ideal time to draw a trough level is a. 0800. b. 0830. c. 0900. d. 0930.

ANS: B Trough levels are generally drawn 30 minutes before the drug is administered. If the medication is administered at 0900, the trough should be drawn at 0830.

What methods are used to properly discard narcotics? (Select all that apply.) a. Placing the syringe of narcotics in the sharps container b. Washing liquids down the sink c. Flushing tablets down the toilet d. Returning the open tablet to the medication dispenser e. Locking the narcotic in a secure cabinet f. Throwing tablets into the trash

ANS: B, C Proper disposal of wasted narcotics involves washing liquids down the sink and tablets down the toilet. This prevents others from accessing the wasted narcotics. Placing the syringe in the sharps container is not recommended; it could be accessed inappropriately. Once a medication is opened, it cannot be returned to the medication dispenser and must be wasted. Locking the narcotics in a secure cabinet is not a proper method of disposal; they could be accessed by someone other than the nurse. Throwing tablets into the trash is unsafe because pills may be recovered by inappropriate persons.

The nurse is completing an admission history on a new home health patient. The patient has been experiencing seizures as the result of a recent brain injury. The nurse diagnoses risk for injury with a goal of keeping the patient safe in the event of a seizure. Which interventions should the nurse utilize for this patient? (Select all that apply.) a. Teach the family how to insert an oral airway during the seizure. b. Assess the home for items that could harm the patient during a seizure. c. Provide information on how to obtain a Medical Alert bracelet. d. Teach the patient to communicate to the caregiver plans for bathing. e. Discuss with family steps to take if the seizure does not discontinue. f. Demonstrate how to restrain the patient in the event of a seizure.

ANS: B, C, D, E Assessment of the home for safety, providing information on Medical Alert bracelets, teaching the patient to communicate before bathing, and discussing steps to take with status epilepticus are important interventions for the patient who is having seizures. Inserting an airway may harm the patient by forcing the object into the mouth or by biting down on a hard object. Never restrain a patient who is having a seizure, but protect the patient from hitting his body on objects around him to prevent traumatic injury.

The nurse is caring for a patient in restraints. Which of the following pieces of information about restraints requires nursing documentation in the medical record? (Select all that apply.) a. The patient states that her gown is soiled and needs changing. b. Attempts to distract the patient with television are unsuccessful. c. The patient has been placed in bilateral wrist restraints at 0815. d. One family member has gone to lunch. e. Bilateral radial pulses present, 2+, hands warm to touch f. Released from restraints, active range-of-motion exercises complete

ANS: B, C, E, F Attempts at alternatives are documented in the medical record, as are type of restraint and time restrained. Assessments related to oxygenation, orientation, skin integrity, circulation, and position are documented, along with release from restraints and patient response. Comments about hygiene or the activities of one family member are not necessarily required in nursing documentation of restraints.

Which types of patients can cause challenging communication situations? (Select all that apply.) a. A male patient who is cooperative with treatments b. A female patient who is outgoing and flirty c. An older adult patient who is demanding d. An elderly patient who can clearly see small print e. A teenager frightened by the prospect of impending surgery f. A child who is developmentally delayed

ANS: B, C, E, F Challenging communication situations include patients who are flirtatious, demanding, frightened, or developmentally delayed. A child who has received little environmental stimulation possibly is behind in language development, thus making communication more challenging. Patients who are cooperative and have good eyesight (see small print) do not cause challenging communication situations.

After licensure, the nurse wants to stay current in knowledge and skills. Which programs are the most common ways nurses can do this? (Select all that apply.) a. Master's degree b. Inservice education c. Doctoral preparation d. Continuing education e. National Council Licensure Examination retakes

ANS: B, D Continuing education programs help nurses maintain current nursing skills, gain new knowledge and theory, and obtain new skills reflecting the changes in the health care delivery system. Inservice education programs are provided by a health care facility to increase the knowledge, skills, and competencies of nurses employed by the institution. Both can help the nurse stay current. Master's degree programs are valuable for those in the role of nurse educator, nurse administrator, or advanced practice nurse. Professional doctoral programs in nursing (DSN or DNSc) prepare graduates to apply research findings to clinical nursing. National Council Licensure Examination retakes are not to keep current; this test is taken to enter RN practice.

Which of the following concepts are important to utilize when evaluating orders for restraints? (Select all that apply.) a. Behaviors that necessitate the use of restraint are part of the nursing plan of care. b. A physician's order is required for restraint and includes a face-to-face evaluation. c. The physician's preference for the format of the order can override agency policy. d. Orders are time limited. Restraints are not ordered prn (as needed). e. It should be specified that restraints are to be removed periodically. f. Restraint orders are time dated and signed by the physician.

ANS: B, D, E, F Physicians are responsible for writing restraint orders and conducting face-to-face evaluations, as well as for putting time limits, specifying when to remove, and time dating and signing orders. Behaviors that necessitate the use of restraint not only are part of the nursing documentation but are to be included as part of the order for restraint. The physician's formatting is not a consideration for evaluating restraint orders. Formatting of restraint orders typically follows state rules and regulations, as well as regulatory agency standards.

Which of the following are methods to reduce the risk of needlestick injury? (Select all that apply.) a. Recap the needle after giving an injection. b. Have sharps boxes emptied when three-quarters full. c. Use two hands to dispose of sharps into the disposal. d. Never force a needle into the sharps disposal. e. Clearly mark sharps disposal containers. f. Use needleless devices whenever possible.

ANS: B, D, E, F To prevent the risk of needlesticks, the nurse should never recap needles. Empty sharps boxes before they become too full, so needles do not stick out the top. Needles should not be forced into the box. Clearly mark receptacles to warn of danger. Using needleless systems when possible will further reduce the risk of needlestick injury.

A patient is scheduled for surgery. When getting ready to obtain the informed consent, the patient tells the nurse, "I have no idea what is going to happen. I couldn't ask any questions." The nurse does not allow the patient to sign the permit and notifies the health care provider of the situation. Which role is the nurse displaying? a. Manager b. Patient educator c. Patient advocate d. Clinical nurse specialist

ANS: C As a patient advocate, the nurse protects the patient's human and legal rights, including the right of the patient to understand procedures before signing permits. Although nurses can be educators, it is the responsibility of the surgeon to provide education for the patient in preparation for surgery, and it is the nurse's responsibility to notify the health care provider if the patient is not properly educated. Managers coordinate the activities of members of the nursing staff in delivering nursing care, and clinical nurse specialists are experts in a specialized area of nursing practice in a variety of settings.

During the admission assessment, the nurse assesses the patient for fall risk. Which of the following has the greatest potential to increase the patient's risk for falls? a. The patient is 59 years of age. b. The patient walks 2 miles a day. c. The patient takes Benadryl (diphenhydramine) for allergies. d. The patient recently became widowed.

ANS: C Benadryl (diphenhydramine) has the potential to cause drowsiness and dizziness as a side effect, thereby increasing the risk for falls. Over 60 is the age typically found on fall assessments that increase the risk for falls. Walking has many benefits, including increasing strength, which would be beneficial in decreasing risk. Becoming widowed would increase stress and may affect concentration but is not the greatest risk.

A nurse attends a workshop on current nursing issues provided by the American Nurses Association. Which type of education did the nurse receive? a. Graduate education b. Inservice education c. Continuing education d. Registered nurse education

ANS: C Continuing education involves formal, organized educational programs offered by universities, hospitals, state nurses associations, professional nursing organizations, and educational and health care institutions. After obtaining a baccalaureate degree in nursing, you can pursue graduate education leading to a master's or doctoral degree in any number of graduate fields, including nursing. Inservice education programs are instruction or training provided by a health care facility or institution. Registered nurse education is the education preparation for an individual intending to be an RN.

A nurse believes that the nurse-patient relationship is a partnership, and that both are equal participants. Which term should the nurse use to describe this belief? a. Critical thinking b. Authentic c. Mutuality d. Attend

ANS: C Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship is a partnership, and that both are equal participants. Critical thinking in nursing, based on established standards of nursing care and ethical standards, promotes effective communication and uses such standards as humility, self-confidence, independent attitude, and fairness. To be authentic (one's self) and to respond appropriately to the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all of your attention to the patient.

The nurse is preparing to administer a 0.5-mL rabies vaccine into the deltoid muscle of a patient. Which needle size is best for the procedure? a. 20 gauge ´ 1 1/2 inch b. 23 gauge ´ 1/2 inch c. 25 gauge ´ 5/8 inch d. 27 gauge ´ 3/8 inch

ANS: C For an intramuscular injection into the deltoid, a 25-gauge, 5/8-inch needle is recommended. Needles that are 20 gauge ´ 11/2 inch, 23 gauge ´ 1/2 inch, and 27 gauge ´ 3/8 inch are not appropriately sized for this type of injection.

The patient is terminally ill and is under hospice care. The nurse cares for the patient by bathing, shaving, and repositioning him. The family believes that the end is very near and would like a Catholic priest called to provide the patient with the Sacrament of the Sick. The nurse places a call to the Catholic Church the patient attended and arranges for the priest's visit. Under which of the following theories does the nurse's care fall? a. Roy's adaptation theory b. Watson's philosophy of transpersonal caring c. Henderson's theory d. Orem's self-care deficit theory

ANS: C Henderson defines nursing as "assisting the individual, sick or well, in the performance of those activities that will contribute to health, recovery, or a peaceful death, and that the individual would perform unaided if he or she had the necessary strength, will, or knowledge." Roy's model is to help the person adapt to changes in physiological needs, self-concept, role function, and relations. Watson's theory believes that the purpose of nursing action is to understand the interrelationship between health, illness, and human behavior. The goal of Orem's theory is to help the patient perform self-care.

The nurse prescribes strategies and alternatives to attain expected outcome. Which standard of nursing practice is the nurse following? a. Assessment b. Diagnosis c. Planning d. Implementation

ANS: C In planning, the registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes. During assessment, the registered nurse collects comprehensive data pertinent to the patient's health and/or the situation. In diagnosis, the registered nurse analyzes the assessment data to determine the diagnoses or issues. During implementation, the registered nurse implements (carries out) the identified plan.

Which person is the best referral for a patient who speaks a foreign language? a. A family member b. A speech therapist c. An interpreter d. A mental health nurse specialist

ANS: C Interpreters are often necessary for patients who speak a foreign language. A family member can lead to legal issues, speech therapists help patients with aphasia, and mental health nurse specialists help angry or highly anxious patients to communicate more effectively.

The emergency department has been notified of a potential bioterrorist attack. The nurse assigned to the department realizes that the most important task for safety in this situation is to a. Carry out the role and responsibilities of the nurse quickly and efficiently. b. Cluster all patients with the same symptoms to a specific part of the department. c. Determine the biologic agent and manage all patients using Standard Precautions. d. Prepare for post-traumatic stress associated with this bioterrorist attack.

ANS: C It is essential to determine the agent and manage all patients who are symptomatic with the suspected or confirmed bioterrorism-related illness using Standard Precautions. For certain diseases, additional precautions may be necessary. Clustering patients may be helpful with staffing and, depending on the illness, may decrease the spread. All nurses every day should carry out their roles quickly and efficiently. Psychosocial concerns are important but are not the first priority at this moment.

The nurse is making rounds and finds her older adult patient sobbing and obviously upset. She states that her doctor told her that she has cancer, and she does not want to die. "What's the sense?" she says. "I might as well die. I'm going to anyway. I guess that shows how useless I really am. Nobody wants an old lady around." The nurse notices that the patient's respirations have increased, and the tip of her nose and ear lobes are becoming cyanotic. The nurse assesses the patient and finds that the patient's pulse rate is over 150 beats per minute. According to Maslow's hierarchy of needs, the nurse should first a. Call the physician to request a psychiatric consult. b. Reassure the patient that she has value as a human being. c. Place the patient on oxygen and try to calm her. d. Call the patient's family to help her realize that she is wanted.

ANS: C Maslow's hierarchy is useful in setting patient priorities. Basic physiological and safety needs are usually the first priority. These include physiological needs such as air, water, and food. Cyanosis and fast heart rate are indicators of physiological stress and must be dealt with first, or the patient may not survive. The second level includes psychological security. A psychiatric consult would come after physiological stabilization. The third level includes love and belonging needs that would also need to be addressed, and the family may be helpful in dealing with this, once the patient is stabilized. The fourth level involves self-esteem, which would also need to be addressed.

The nurse preceptor recognizes the new nurse's ability to determine patient safety risks when which behavior is observed? a. Checking patient identification once every shift b. Multitasking by gathering two patients' medications c. Disposing of used needles in a red needle container d. Raising all four side rails per family request

ANS: C Needles, syringes, and other single-use injection devices should be used once and disposed of in safety red needle containers that will be disposed of properly. Patient identification should be checked multiple times a day, including before each medication, treatment, procedure, blood administration, and transfer, and at the beginning of each shift. Gathering more than one patient's medication increases the likelihood of error. Raising all four side rails is considered a restraint and requires special orders, assessment, and monitoring of the patient.

A bill has been submitted to the State House of Representatives that is designed to reduce the cost of health care by increasing the patient-to-nurse ratio from a maximum of 2:1 in intensive care units to 3:1. What should the nurse realize? a. Legislation is politics beyond the nurse's control. b. National programs have no bearing on state politics. c. The individual nurse can influence legislative decisions. d. Focusing on nursing care provides the best patient benefit.

ANS: C Nurses can influence policy decisions at all governmental levels. One way is to get involved by participating in local and national efforts. This effort is critical in exerting nurses' influence early in the political process. Legislation is not beyond the nurse's control. National program can have bearing on state politics. The question is focusing on legislation and health care costs, not nursing care.

The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. Immediately, the nurse assigns a nursing diagnosis of risk for injury with a goal for the patient to be safe. Which of the following actions should the nurse take first? a. Activate the alarm. b. Extinguish the fire. c. Remove the patient. d. Confine the fire.

ANS: C Nurses use the mnemonic RACE to set priorities in case of fire. All of these interventions are necessary, but this patient is in immediate danger with the fire being over his head and should be rescued and removed from the situation.

The nurse using critical thinking to enhance communication with patients is one who a. Shows sympathy appropriately. b. Uses automatic responses fluently. c. Self-examines personal communication skills. d. Demonstrates passive remarks accurately.

ANS: C Nurses who use critical thinking skills interpret messages received from others, analyze their content, make inferences about their meaning, evaluate their effects, explain rationales for communication techniques used, and self-examine personal communication skills. Sympathy is concern, sorrow, or pity felt for the patient and is nontherapeutic. Clichés and stereotyped remarks are automatic phrases that communicate that the nurse is not taking concerns seriously or responding thoughtfully. Passive responses serve to avoid conflict or to sidestep issues.

The student nurse is learning nursing theories but fails to see how they relate to the nursing process. The professional nurse realizes that nursing theory a. Has a minor role in professional nursing. b. Requires the nursing process to develop knowledge. c. Can direct how a nurse uses the nursing process. d. is specific to certain patients only.

ANS: C Nursing theory can direct how a nurse uses the nursing process. Integration of theory into practice serves as the basis for professional nursing. The nursing process provides a systematic process for the delivery of care, not the knowledge component of the discipline. Useful theories are adaptable to different patients and to all care settings.

The nurse is discussing with a patient's physician the need for restraint. The nurse indicates that alternatives have been utilized. What behaviors would indicate that the alternatives are working? a. The patient continues to get up from the chair at the nurses' station. b. The patient apologizes for being "such a bother." c. The patient folds three washcloths over and over. d. The sitter leaves the patient alone to go to lunch.

ANS: C Offering diversionary activities such as something to hold is a way to keep the hands busy and provides an alternative to restraints. Assigning a room near the nurses' station or a chair at the desk can be an alternative for continuous monitoring. Getting up constantly can be cause for concern. Apologizing is not an alternative to restraints. Having a sitter sit with the patient to keep him occupied can be an alternative to restraints, but the sitter needs to be continuous.

Which of the following demonstrates proper oral medication administration? a. Removing the medication from the wrapper and placing it in a cup labeled with the patient's information b. Using the edge of the medicine cup to fill with 0.5 mL of liquid medication c. Placing all of the patient's medications in the same cup, except medications with assessments d. Combining liquid medications from 2 single dose cups into 1 medicine cup

ANS: C Placing medications that require preadministration assessment in a separate cup serves as a reminder to check before the medication is given, making it easier for the nurse to withhold medication if necessary. Medications should not be removed from their package until they are in the patient's room because this makes identification of the pill easier and reduces contamination. When measuring a liquid, the nurse should use the meniscus level to measure, not the edge. In addition, liquid medications measuring less than 10 mL should be drawn up in a needleless syringe. Single-dose medications should not be transferred to medicine cups to reduce unnecessary manipulation of the dose.

The nurse is presenting an educational session on safety for parents of adolescents. The nurse should include which of the following teaching points? a. Adolescents need unsupervised time with friends two to three times a week. b. Parents and friends should teach adolescents how to drive. c. Adolescents need information about the effects of beer on the liver. d. Adolescents need to be reminded to use seatbelts on long trips.

ANS: C Providing information about drugs and alcohol is important because adolescents may choose to participate in risk-taking behaviors. Adolescents need to socialize but need supervision. Parents can encourage and support learning processes associated with driving, but organized classes can help to decrease motor vehicle accidents. Seatbelts should be used all the time.

A nurse identifies gaps between local and best practices. Which Quality and Safety Education for Nurses (QSEN) competency is the nurse demonstrating? a. Safety b. Patient-centered care c. Quality improvement d. Teamwork and collaboration

ANS: C Quality improvement identifies gaps between local and best practices. Safety minimizes risk of harm to patients and providers through both system effectiveness and individual performance. Patient-centered care recognizes the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs. Teamwork and collaboration allows effective functioning within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making.

A nurse knows that patient education has been effective when the patient states a. "I must take my parenteral medication with food." b. "If I am 30 minutes late taking my medication, I should skip that dose." c. "I will rotate the location where I give myself injections." d. "Once I start feeling better, I will stop taking my medication."

ANS: C Rotating injection sites provides greater consistency in absorption of medication. Parenteral medication absorption is not affected by the timing of meals. Taking a medication 30 minutes late is within the 60-minute window of the time medications should be taken. Medications should be stopped based on the provider's orders. With some medications, such as antibiotics, it is crucial that the full course of medication is taken to avoid relapse of infection.

Which of the following demonstrates a nurse utilizing self-reflection to improve clinical decision making? a. Uses an objective approach in all situations b. Obtains data in an orderly fashion c. Improves a plan of care while thinking back on interventions performed d. Provides evidence-based explanations for all nursing interventions

ANS: C Self-reflection utilizes critical thinking when thinking back on the effectiveness of interventions and how they were performed. The other options are not the best examples of self-reflection but do represent good nursing practice. Using an objective approach and obtaining data in an orderly fashion does not involve purposefully thinking back to discover the meaning or purpose of a situation. Providing evidence-based explanations for nursing interventions does not always involve thinking back to discover the meaning of a situation.

A patient was admitted 2 days ago with pneumonia and a history of angina. The patient is now having chest pain with a pulse rate of 108. Using the SBAR, which piece of data will the nurse use for B? a. Having chest pain b. Pulse rate of 108 c. History of angina d. Oxygen is needed.

ANS: C The B in SBAR stands for background information. The background information in this situation is the history of angina. Having chest pain is the Situation (S). Pulse rate of 108 is the Assessment (A). Oxygen is needed is the Recommendation (R).

The prescriber wrote for a 40-kg child to receive 25 mg of medication 4 times a day. The therapeutic range is 5 to 10 mg/kg/day. What is the nurse's priority? a. Administer the medication because it is within the therapeutic range. b. Notify the physician that the prescribed dose is in the toxic range. c. Notify the physician that the prescribed dose is below the therapeutic range. d. Change the dose to one that is within range.

ANS: C The dosage range is 200 to 400 mg a day. The prescribed dose is 100 mg/day, which is below therapeutic range. The nurse should notify the physician first and ask for clarification on the order. The dose is not above the therapeutic range and is not at a toxic level. The nurse should never alter an order without the prescriber's approval and consent.

The nurse knows that four categories of risk have been identified in the health care environment. Which of the following provides the best examples of those risks? a. Tile floors, cold food, scratchy linen, and noisy alarms b. Carpeted floors, ice machine empty, unlocked supply cabinet, and call light in reach c. Wet floors, pinching fingers in door, failure to use lift for patient, and alarms not functioning properly d. Dirty floors, hallways blocked, medication room locked, and alarms set

ANS: C The four categories are falls, patient-inherent accidents, procedure-related accidents, and equipment-related accidents. Wet floors contribute to falls, pinching finger in door is patient inherent, failure to use the lift is procedure related, and an alarm not functioning properly is equipment related. Tile floors and carpeted or dirty floors do not necessarily contribute to falls. Cold food, ice machine empty, and hallways blocked are not patient-inherent issues in the hospital setting but are more of patient satisfaction or infection control issues or fire safety issues. Scratchy linen, unlocked supply cabinet, and medication room locked are not procedure-related accidents. These are patient satisfaction issues and control of supply issues, and are examples of actually following a procedure correctly. Noisy alarms, call light within reach, and alarms set are not equipment-related accidents but are patient satisfaction issues and examples of following a procedure correctly.

A patient who is being discharged today is going home with an inhaler. The patient is to administer 2 puffs of his inhaler twice daily. The inhaler contains 200 puffs. When should the nurse appropriately advise the patient to refill his medication? a. As soon as he leaves the hospital b. When the inhaler is half empty c. 6 weeks from the start of using the inhaler d. 50 days after discharge

ANS: C The inhaler should last the patient 50 days; the nurse should advise the patient to refill the prescription when he has 7 to 10 days of medication remaining. Refilling it as soon as he leaves the hospital or when the inhaler is half empty is too early. If the patient waits 50 days, the patient will run out of medication before it can be refilled.

While caring for a hospitalized older adult female post hip surgery, the new graduate nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. The nurse exhibits critical thinking to perform this task by a. Following textbook procedure. b. Notifying the physician of the need for a urologist consult. c. Adapting the positioning technique to the situation. d. Postponing catheter insertion until the next shift.

ANS: C The nurse must use critical thinking skills in this situation to adapt positioning technique. In practice, patient procedures are not always presented as in a textbook, but they are individualized. A urologist consult is not warranted for position, but perhaps instead for difficulty in insertion. Postponing insertion of the catheter is not an appropriate action.

The nurse enters a room to find the patient sitting up in bed crying. How would the nurse display a critical thinking attitude in this situation? a. Tell the patient she'll be back in 30 minutes. b. Set a box of tissues at the patient's bedside before leaving the room. c. Ask the patient why she is crying. d. Limit visitors while the patient is upset.

ANS: C The nurse should try to find out why the patient is crying to intervene appropriately. Telling the patient that she will return, providing tissues, and limiting visitors may be appropriate actions but do not address the reason why the patient is crying.

A nurse is in the hallway assisting a patient to ambulate and hears an alarm sound. What is the best next step for the nurse to take? a. Seek out the source of the alarm. b. Wait to see if the alarm discontinues. c. Ask another nurse to check on the alarm. d. Continue ambulating the patient.

ANS: C The nurse who heard the alarm has a duty to address it even though she is busy with another patient. Ask someone to check on the alarm. The nurse cannot leave the patient in the hallway to look for the source of the alarm and cause a potentially unsafe situation for this patient, but a patient on the unit may have an urgent need. Someone needs to seek out the source of the alarm and address it. Never ignore an alarm. Alarms are in place to maximize the safety of the patient. Waiting to see if an alarm stops may cause a delay in a possible emergency situation.

The nurse is completing discharge education for the patient regarding home medications. Which patient behavior is an indication that the patient understands the directions regarding the antibiotic medication? a. The patient nods throughout the educational session. b. The patient reads the medication prescription out loud. c. The patient states, "I will finish the antibiotic in ten days." d. The patient asks where to get the prescription filled.

ANS: C The patient stating the time frame for when the medication will be complete is the best answer. Nodding, reading the prescription out loud, or knowing where to get the prescription filled does not indicate understanding regarding directions for taking the antibiotic.

The patient is admitted to the ICU to rule out a myocardial infarction (MI). During the admission process, the patient is noted to have a history of methicillin-resistant Staphylococcus aureus(MRSA) and is placed in isolation until cultures can be obtained and the patient declared noninfectious. During the isolation process, the nurse encourages family visits, realizing that which level of Maslow's hierarchy of needs is at risk? a. First level b. Second level c. Third level d. Fourth level e. Fifth level

ANS: C The third level contains love and belonging needs, including friendship, social relationships, and sexual love. The first level includes physiological needs. The second level includes safety and security needs. The fourth level encompasses esteem and self-esteem needs. The fifth and final level is the need for self-actualization.

A nurse and patient take action to meet health-related goals. The nurse is in which phase of the helping relationship? a. Pre-interaction b. Orientation c. Working d. Termination

ANS: C The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. Pre-interaction occurs before the nurse meets the patient. Orientation occurs when the nurse and the patient meet and get to know each other. Termination occurs during the ending of the relationship.

Nursing has its own body of knowledge that is both theoretical and practical. Which of the following is an example of theoretical knowledge? a. Reflection on care experiences b. Synthesis and integration of the art and science of nursing c. Reflection on basic values and principles d. Creating a narrow understanding of nursing practice

ANS: C Theoretical knowledge includes and reflects on the basic values, guiding principles, elements, and phases of nursing. The goals of theoretical knowledge are to stimulate thinking and create a broad understanding of the "science" and practices of the nursing discipline. Practical knowledge is achieved through personal knowing gained through reflection on care experiences, synthesis, and integration of the art and science of nursing.

The nurse is administering an intravenous medication that is to be administered over 10 minutes. Which method should the nurse choose to efficiently administer the medication? a. Place the medication in a large-volume cath-tipped syringe. b. Mix the medication into the patient's maintenance fluids. c. Attach separate tubing and set the medication syringe in a mini-infusion pump. d. Stand at the patient's bedside and carefully watch the clock while pushing the medication.

ANS: C To administer this medication efficiently, the nurse should use an infusion pump to run the medication in over a prolonged time. This method is more accurate and is more time efficient than other methods because the nurse can leave the room. The nurse should not mix medication into the maintenance bag without pharmacist and physician approval. Pushing the medication is not a time-efficient method for the nurse. A cath-tipped syringe is an inappropriate device for administration of a medication.

A system is made up of separate components. A closed system a. Interacts with the environment. b. Is exemplified by the human organism. c. Does not interact with the environment. d. Is exemplified by the nursing process.

ANS: C Two types of systems have been identified: open and closed. An open system, such as a human organism or processes like the nursing process, interacts with the environment. A closed system does not interact with the environment.

A registered nurse interprets that a scribbled medication order reads 25 mg. The nurse administers 25 mg of the medication to a patient, and then discovers that the dose was incorrectly interpreted and should have been 15 mg. Who is ultimately responsible for the error? a. Physician b. Pharmacist c. Nurse d. No fault

ANS: C Ultimately, the person administering the medication is responsible for ensuring that it is correct. The nurse administered the medication, so in this case it is the nurse. This is the importance of verifying the Six Rights of Medication Administration.

Professional standards influence a nurse's clinical decisions by a. Bypassing the patient's feelings to promote ethical standards. b. Establishing minimal passing standards for testing. c. Requiring the nurse to use critical thinking for the highest level of quality nursing care. d. Utilizing evidence-based practice based on nurses' needs.

ANS: C Upholding professional standards requires nurses to use critical thinking for the highest level of quality nursing care. Bypassing the patient's feelings is not practicing according to professional standards. The primary purpose of professional standards is not to establish minimal passing standards for testing. Patient care should be based on patient needs, not on nurses' needs.

The nurse is caring for a patient who suddenly becomes confused and tries to remove an intravenous infusion. The nurse begins to develop a plan to care for the patient. Which nursing intervention should take priority? a. Gather restraint supplies. b. Try alternatives to restraint. c. Assess the patient. d. Call the physician for a restraint order.

ANS: C When a patient becomes suddenly confused, the priority is to assess the patient, including checking laboratory test and oxygen status and treating and eliminating the cause of the change in mental status. If interventions and alternatives are exhausted, the nurse working with the physician may determine the need for restraints.

Which critical thinking standards should the nurse use to ensure sound effective communication with patients? (Select all that apply.) a. Faith b. Supportiveness c. Self-confidence d. Humility e. Independent attitude f. Spiritual expression

ANS: C, D, E A self-confident attitude is important because the nurse who conveys confidence and comfort while communicating more readily establishes an interpersonal helping-trusting relationship. In addition, an independent attitude encourages the nurse to communicate with colleagues and share ideas about nursing interventions. An attitude of humility is necessary to recognize and communicate the need for more information before making a decision. Faith, supportiveness, and spiritual expression are attributes of caring, not critical thinking standards.

A nurse wants to become an advanced practice registered nurse. Which options should the nurse consider? (Select all that apply.) a. Patient advocate b. Nurse administrator c. Certified nurse-midwife d. Clinical nurse specialist e. Certified nurse practitioner

ANS: C, D, E Although all nurses should function as patient advocates, "advanced practice nurse" is an umbrella term for an advanced clinical nurse such as a certified nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, or certified nurse-midwife. A nurse administrator is not an example of advanced practice.

A nurse is standing beside the patient's bed. Nurse: How are you doing? Patient: I don't feel good. In this situation, which element is the feedback? a. Nurse b. Patient c. How are you doing? d. I don't feel good.

ANS: D "I don't feel good" is the feedback because the feedback is the message the receiver returns. The sender is the person who encodes and delivers the message, and the receiver is the person who receives and decodes the message. The nurse is the sender. The patient is the receiver. "How are you doing?" is the message.

When making rounds, the nurse finds a patient who is not able to sleep because of surgery in the morning. Which therapeutic response is most appropriate? a. "It will be okay. Your surgeon will talk to you in the morning." b "Why can't you sleep? You have the best surgeon in the hospital." c. "Don't worry. The surgeon ordered a sleeping pill to help you sleep." d. "It must be difficult not to know what the surgeon will find. What can I do to help?"

ANS: D "It must be difficult not to know what the surgeon will find. What can I do to help?" is using therapeutic communication techniques of empathy and offering of self. False reassurances ("It will be okay" and "Don't worry") tend to block communication. Patients frequently interpret "why" questions as accusations or think the nurse knows the reason and is simply testing them.

What is the first component of the critical thinking model for clinical decision making? a. Experience b. Nursing process c. Attitude d. A scientific knowledge base

ANS: D A scientific knowledge base is the first component for clinical decision making. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. A critical thinking attitude is a guideline for how to approach a problem and apply knowledge to make a clinical decision

A patient is to receive medication through a nasogastric tube. What is the most important nursing action to ensure effective absorption? a. Thoroughly shake the medication before administering. b. After all medications are administered, flush tube with 15 to 30 mL of water. c. Position patient in the supine position for 30 minutes. d. Clamp suction for 30 to 60 minutes after medication administration.

ANS: D Absorption time for a medication administered through a nasogastric (NG) tube is the same as for an oral medication: 30 to 60 minutes. Therefore, the nurse would need to hold the suction for that amount of time to let the medication absorb. Thoroughly shaking the medication mixes the medication before administration but does not affect absorption. Flushing the medications ensures that all were administered. Patients with NG tubes should never be positioned supine but instead should be positioned at a 30- to 90-degree angle to prevent aspiration, provided no contraindication condition is known.

A home health nurse is performing a home assessment for safety. Which of the following comments by the patient would indicate a need for further education? a. "I will schedule an appointment with a chimney inspector next week." b. "Daylight savings is the time to change batteries on the carbon monoxide detector." c. "If I feel dizzy when using the heater, I need to have it inspected." d. "When it is cold outside in the winter, I can warm my car up in the garage."

ANS: D Allowing a car to run in the garage introduces carbon monoxide into the environment and decreases the available oxygen for human consumption. Garages should be opened and not just cracked to allow fresh air into the space and allay this concern. Checking the chimney and heater,changing the batteries on the detector, and following up on symptoms such as dizziness, nausea, and fatigue are all statements that would indicate that the individual has understood the education.

The nursing process is a. The generation of nursing knowledge for use in practice. b. A systematic view of a phenomenon specific to inquiry. c. A method used to inform a system about how it functions. d. A systematic process for the delivery of nursing care.

ANS: D Although the nursing process is central to nursing, it is not a theory. It provides a systematic process for the delivery of nursing care. Theory generates nursing knowledge for use in practice. An interdisciplinary theory explains a systematic view of a phenomenon specific to the discipline of inquiry. Feedback serves to inform a system about how it functions.

A patient is at risk for aspiration. What nursing action is most appropriate? a. Hold the patient's cup for him so he can concentrate on taking pills. b. Thin out liquids so they are easier to swallow. c. Give the patient a straw to control the flow of liquids. d. Have the patient self-administer the medication.

ANS: D Aspiration occurs when food, fluid, or medication intended for GI administration inadvertently enters the respiratory tract. To minimize aspiration risk, allow the patient, if capable, to self-administer medication. Patients should also hold their own cup to control how quickly they take in fluid. Liquids should be thickened to reduce the risk of aspiration. Patients at risk for aspiration should not be given straws because use of a straw decreases the control the patient has over volume intake.

The patient that will cause the greatest communication concerns for a nurse is the patient who is a. Alert, has strong self-esteem, and is hungry. b. Oriented, pain free, and blind. c. Cooperative, depressed, and hard of hearing. d. Dyspneic, has a tracheostomy, and is anxious.

ANS: D Facial trauma, laryngeal cancer, or endotracheal intubation often prevents movement of air past vocal cords or mobility of the tongue, resulting in inability to articulate words. An extremely breathless person needs to use oxygen to breathe rather than speak. Persons with high anxiety are sometimes unable to perceive environmental stimuli or hear explanations. People who are alert, have strong self-esteem, and are cooperative and pain free do not cause communication concerns. Although hunger, blindness, and difficulty hearing can cause communication concerns, dyspnea, a tracheostomy, and anxiety all contribute to communication concerns.

The nurse knows that children in late infancy and toddlerhood are at risk for injury owing to a. Learning to walk. b. Trying to pull up on furniture. c. Being dropped by a caregiver. d. Growing ability to explore and oral activity.

ANS: D Injury is a leading cause of death in children over age 1, which is closely related to normal growth and development because of the child's increased oral activity and growing ability to explore the environment.

A nurse who is caring for a patient with a pressure ulcer fails to apply the recommended dressing according to hospital policy. If the patient is harmed, the nurse could be subject to legal action for not adhering to a. Fairness. b. Intellectual standards. c. Independent reasoning. d. Institutional practice guidelines.

ANS: D Institutional practice guidelines are established standards and policies that can be used in court to make judgments about nursing actions. Intellectual standards are guidelines or principles for rational thought. Fairness and independent reasoning are two examples of critical thinking attitudes that are designed to help nurses make clinical decisions.

A physician orders 1000 mL of normal saline to infuse at a rate of 50 mL/hr. The nurse plans on hanging a new bag at what time? a. 2 hours b. 5 hours c. 10 hours d. 20 hours

ANS: D It will take 20 hours for a liter (1000 mL) of fluid to infuse at a rate of 50 mL/hr. After 2 hours, only 100 mL would have infused. After 5 hours, only 250 mL would have infused. At 10 hours, 500 mL would have infused.

The nurse discussed threats to adult safety with a college group. Which of the following statements would indicate understanding of the topic? a. "Our campus is safe; we leave our dorms unlocked all the time." b. "As long as I have only two drinks, I can still be the designated driver." c. "I am young, so I can work nights and go to school with 2 hours' sleep." d. "I guess smoking even at parties is not good for my body."

ANS: D Lifestyle choices frequently affect adult safety. Smoking conveys great risk for pulmonary and cardiovascular disease. It is prudent to secure belongings. When an individual has been determined to be the designated driver, that individual does not consume alcohol, beer, or wine. Sleep is important no matter the age of the individual and is important for rest and integration of learning. The average young adult needs 6 1/2 to 8 hours of sleep each night.

The nurse is precepting a student nurse and is careful to check with the student all components of the medication process. The nurse explains to the student that most errors occur in a. Ordering and transcribing. b. Dispensing and administering. c. Dispensing and transcribing. d. Ordering and administering.

ANS: D Most medication errors occur in the ordering and administering stages of the medication process

A patient has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include a. Encouraging visitors in the early evening. b. Placing all four side rails in the "up" position. c. Checking on the patient once a shift. d. Placing a high risk for falls armband on the patient.

ANS: D Placing a high risk for falls armband on the patient encourages communication among the whole interdisciplinary team. Anyone who interacts with the patient should see this armband, understand its meaning, and assist the patient as necessary. The timing of visitors would not affect falls. All four side rails are considered a restraint and can contribute to falling. Individuals on high risk for fall alerts should be checked frequently, at least every hour.

The nurse is providing information regarding safety and accidental poisoning to a grandmother who will be taking custody of a 1-year-old grandchild. Which of the following comments would indicate that the grandmother needs further instruction? a. "The number for poison control is 800-222-1222." b. "Never induce vomiting if my grandchild drinks bleach." c. "I should call 911 if my grandchild loses consciousness." d. "If my grandchild eats a plant, I should provide syrup of ipecac."

ANS: D Syrup of ipecac to induce vomiting after ingestion of a poison has not been proven effective in preventing poisoning. This medication should not be administered to the child. The poison control number is 800-222-1222. After a caustic substance such as bleach has been drunk, do not induce vomiting. This can cause further burning and injury as the medication is eliminated. Loss of consciousness associated with poisoning requires calling 911.

A patient has an order to receive 10 units of U-50 insulin. The nurse is using a U-100 syringe. How many units should the nurse draw up in the syringe and administer? a. 0.2 units b. 2 units c. 5 units d. 20 units

ANS: D The nurse is careful to perform nursing calculations to ensure proper medication administration. U-50 insulin has 50 units of insulin in every milliliter, a U-100 syringe has 100 units in every milliliter. Conversion equals 20 units.

A patient is having trouble reaching the water fountain while holding on to crutches. The nurse suggests that the patient place the crutches against the wall while stabilizing himself with two hands on the water fountain. Which critical thinking attitude is utilized in this situation? a. Humility b. Confidence c. Risk taking d. Creativity

ANS: D The nurse uses creativity in this situation to figure out how the patient can stabilize himself while getting a drink of water. Humility is recognizing when more information is needed to make a decision. Confidence is being well prepared to perform nursing care safely. This question best illustrates the attitude of creativity. Risk taking is demonstrating the courage to speak out or to question orders based on the nurse's own knowledge base.

A patient informs the nurse that his urine is starting to look discolored. How should the nurse respond? a. "Don't worry, that is a normal side effect of your medication." b. "That is an unusual side effect. I'll notify your provider immediately." c. "You need to drink more fluids to flush the medication from your system." d. "Other than the discoloration, has anything changed with your urination?"

ANS: D The nurse wants to gather additional assessment information about the change in urine color. Information is insufficient to recommend drinking more fluids, or to know whether this is a normal or abnormal side effect. The other options do not provide a focused assessment and are not therapeutic responses.

The older patient presents to the emergency department after stepping in front of a car at a crosswalk. After the patient has been triaged, the nurse interviews the patient. Which of the following comments would require follow-up by the nurse? a. "I try to exercise, so I walk that block almost every day." b. "I waited and stepped out when the traffic sign said go." c. "The car was going too fast, the speed limit is 20." d. "I was so surprised; I didn't see or hear the car coming."

ANS: D The patient did not see or hear the car coming. As patients age, sensory impairment can increase the risk for injury. This statement by the patient would require follow-up by the nurse. The patient needs hearing and eye examinations. Exercise is important at every stage of development. The patient seemed to comprehend how to cross an intersection correctly and was able to determine the speed of the car.

A nurse is caring for a patient who is in hypertensive crisis. When the nurse is flushing the patient's peripheral IV, the patient complains of pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? a. Notify the physician. b. Administer pain medication. c. Discontinue the IV. d. Apply a cool compress to the site.

ANS: D The patient has phlebitis; the initial nursing action would be to apply a cool compress. The nurse should start a new IV before discontinuing the old one because it is important to always have an IV access site in case of emergency. Then the physician can be notified. Pain medication may need to be administered.

The patient is confused, is trying to get out of bed, and is pulling at the intravenous infusion tubing. These data would help to support a nursing diagnosis of a. Risk for poisoning. b. Knowledge deficit. c. Impaired home maintenance. d. Risk for injury.

ANS: D The patient's behaviors support the nursing diagnosis of risk for injury. The patient is confused, is pulling at the intravenous line, and is trying to climb out of bed. Injury could result if the patient falls out of bed or begins to bleed from a pulled line. Nothing in the scenario indicates that this patient lacks knowledge or is at risk for poisoning. Nothing in the scenario refers to the patient's home maintenance.

The nurse needs a reminder of professional responsibility when performing which of these actions? a. Making an informed clinical decision b. Making an ethical clinical decision c. Making a clinical decision in the patient's best interest d. Making a clinical decision based on previous shift assessments

ANS: D The professional nurse is responsible for assessing patients each shift. Making informed, ethical decisions in the patient's best interest is practicing responsibly.

Aspirin is an analgesic, antipyretic, antiplatelet, and anti-inflammatory agent. A physician writes for aspirin 650 mg every 4 to 6 hours prn: febrile. For which patient would this order be appropriate? a. 7-year-old with hemophilia b. 21-year-old with a sprained ankle c. 35-year-old with a severe headache d. 62-year-old female with pneumonia

ANS: D The provider wrote for the medication to be given for a fever. Hemophilia is a bleeding disorder; therefore, antiplatelets would be contraindicated. Although it can be used for inflammatory problems and pain, this is not what the order was written for.

The nursing instructor is teaching a class on nursing theory. One of the students asks, "Why do we need to know this stuff? It doesn't really affect patients." The instructor's best response would be a. "You are correct, but we have to learn it anyway." b. "Exposure to theories will help you later in graduate school." c. "Theories help keep the focus of nursing narrow." d. "Theories help explain why nurses do what they do."

ANS: D Theories offer well-grounded rationales or reasons for how and why nurses perform specific interventions. Learning about theories is important because these theories help to describe, explain, predict, and/or prescribe nursing care measures. Although nursing theory will help the nurse in graduate school, it is also an important basis for the nurse's approach to daily patient care, and it expands scientific knowledge of the profession.

Which technique will be most successful in ensuring effective communication? The nurse uses a. Interpersonal communication to change negative self-talk to positive self-talk. b. Small group communication to present information to an audience. c. Intrapersonal communication to build strong teams. d. Transpersonal communication to enhance meditation.

ANS: D Transpersonal communication is interaction that occurs within a person's spiritual domain. Many people use prayer, meditation, guided reflection, religious rituals, or other means to communicate with their "higher power."Interpersonal communication is one-on-one interaction between the nurse and another person that often occurs face to face. Meaningful interpersonal communication results in exchange of ideas, problem solving, expression of feelings, decision making, goal accomplishment, team building, and personal growth. Small group communication is interaction that occurs when a small number of persons meet. This type of communication is usually goal directed and requires an understanding of group dynamics. When nurses work on committees, lead patient support groups, form research teams, or participate in patient care conferences, they use a small group communication process. Intrapersonal communication is a powerful form of communication that occurs within an individual. For example, you improve your health and self-esteem through positive self-talk by replacing negative thoughts with positive assertions.

A new graduate nurse will make the best clinical decisions by applying the components of the nursing critical thinking model and which of the following? a. Drawing on past clinical experiences to formulate standardized care plans b. Relying on recall of information from past lectures and textbooks c. Depending on the charge nurse to determine priorities of care d. Using the nursing process

ANS: D Using the nursing process along with applying components of the nursing critical thinking model will help the new graduate nurse make the most appropriate clinical decisions. Care plans should be individualized, and recalling facts does not utilize critical thinking skills to make clinical decisions. The new nurse should not rely on the charge nurse to determine priorities of care.

A nurse uses SBAR during hand-offs. The purpose of SBAR is to a. Use common courtesy. b. Establish trustworthiness. c. Promote autonomy. d. Standardize communication.

ANS: D When patients move from one nursing unit to another or from one provider to another, also known as hand-offs, a risk of miscommunication arises. Accurate communication is essential to prevent errors. SBAR is a popular communication tool that helps standardize communication among health care providers. Common courtesy is part of professional communication but is not the purpose of SBAR. Being trustworthy means helping others without hesitation. Autonomy is being self-directed and independent in accomplishing goals and advocating for others.

A patient is in need of immediate pain relief for a severe headache. The nurse knows that which medication will be absorbed the quickest? a. Tylenol 650 mg PO b. Morphine 4 mg SQ c. Ketorolac (Toradol) 8 mg IM d. Hydromorphone (Dilaudid) 4 mg IV

NS: D IV is the fastest route for absorption owing to the increase in blood flow. Oral, subcutaneous (SQ), and intramuscular (IM) are others ways to deliver medication but with less blood flow.