Foundations Evolve questions

A registered nurse is admitting a patient of French heritage to the hospital. Which question asked by the nurse indicates that the nurse is stereotyping the patient? "What are your dietary preferences?" "What time do you typically go to bed?" "Do you bathe and use deodorant more than one time a week?" "Do you have any health issues that we should know about?"

"Do you bathe and use deodorant more than one time a week?"

A 62-year-old patient is being admitted to a surgical unit for a total hip replacement. The nurse reviews his medical record and learns that the patient has a history of impaired liver function and paresthesias in his feet. After assessing the patient's medical history further, the nurse is not sure what caused the liver impairment or paresthesia. To clarify, an appropriate question to ask the patient is which of the following? "Have you been treated for cancer in the past?" "What is the nature of your liver problem?" "Has the doctor discussed with you whether your liver problems will affect your recovery from surgery?" "How long have you had the numbness and tingling in your feet?"

"Have you been treated for cancer in the past?"

A patient with a 20-year history of diabetes mellitus had a lower leg amputation. Which statement made by the patient indicates that he is experiencing a problem with body image? "I just don't have any energy to get out of bed in the morning." "I've been attending church regularly with my wife since I got out of the hospital." "My wife has taken over paying the bills since I've been in the hospital." "I don't go out very much because everyone stares at me."

"I don't go out very much because everyone stares at me."

During a home health visit the nurse prepares to instruct a patient in how to perform range-of-motion (ROM) exercises for an injured shoulder. The nurse verifies that the patient took an analgesic 30 minutes before arrival at the patient's home. After discussing the purpose for the exercises and demonstrating each one, the nurse has the patient perform them. After two attempts with only the second of three exercises, the patient stops and says, "This hurts too much. I don't see why I have to do this so many times." The nurse applies the critical thinking attitude of integrity in which of the following actions?" "I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax." "I see that you're uncomfortable. I'll call your doctor to decide the next step." "Show me exactly where your pain is and rate it for me on a scale of 0 to 10." "Is anything else bothering you? Other than the pain, is there any other reason you might not want to do the exercises?"

"I understand your reluctance, but the exercises are necessary for you to regain function in your shoulder. Let's go a bit more slowly and try to relax."

Based on the transtheoretical model of change, what is the most appropriate response to a patient who states: "Me, exercise? I haven't done that since junior high gym class, and I hated it then!" "That's fine. Exercise is bad for you anyway." "OK. I want you to walk 3 miles 4 times a week, and I'll see you in 1 month." "I understand. Can you think of one reason why being more active would be helpful for you?" "I'd like you to ride your bike 3 times this week and eat at least four fruits and vegetables every day."

"I understand. Can you think of one reason why being more active would be helpful for you?"

The nurse is developing a health promotion program on healthy eating and exercise for high school students using the health belief model as a framework. Which statement made by a nursing student is related to the individual's perception of susceptibility to an illness? "I don't have time to exercise because I have to work after school every night." "I'm worried about becoming overweight and getting diabetes because my father has diabetes." "The statistics of how many teenagers are overweight is scary." "I've decided to start a walking club at school for interested students."

"I'm worried about becoming overweight and getting diabetes because my father has diabetes."

Katie, a child in remission for leukemia, and her mother come to the pediatrician's office for a routine physical examination. The nurse asks Katie about whether she is having continued symptoms. Her mom says," I don't know why you want all of this information about Katie's cancer treatment. The leukemia is gone." The best response from the nurse in support of the child and mother would be: "The doctor likes to keep the records complete on all of her patients." "Just because Katie is in remission does not mean that it will stay that way." "It is common for children to have delayed effects from treatment, so we need to know this to plan Katie's care properly." "I understand your concern. If you don't want to provide the information, sign this release form."

"It is common for children to have delayed effects from treatment, so we need to know this to plan Katie's care properly."

Which statement made by the nurse is an example of applying the principle of patient-centered care while focusing on alleviation of a patient's fear and anxiety? "Let's talk about the concerns that you have about going home." "I'll get the medication prescriptions for you before discharge" "I'll be back in 30 minutes to help you get cleaned up" "I'll make a referral to the home health nurse for you"

"Let's talk about the concerns that you have about going home."

Mr. Stewart is a 62-year-old patient diagnosed with prostate cancer who underwent surgical removal of the prostate 3 days ago. He lives with his wife at home. The nurse is planning to provide discharge instructions for the patient. What would be the most effective initial question to ask of the patient and family in determining the approach to discharge instructions? "Mr. Stewart, have you had surgery in the past?" "The doctor has ordered you to go home with a urinary catheter. Tell me how you think you can manage this." "Mrs. Stewart, do you find it difficult to look at your husband's incision? If so, tell me how you feel." "Mr. Stewart, describe for me how much your wife normally helps you at home and what you can do on your own."

"Mr. Stewart, describe for me how much your wife normally helps you at home and what you can do on your own."

A nurse in an oncology outpatient clinic has been seeing a woman and her husband since the woman was diagnosed with breast cancer. Sometimes the husband appears supportive, asking questions about his wife's care. At other times the husband seems easily distracted and uninterested. The nurse decides to reassess the psychosocial condition of the patient and her husband. Which of the following questions best elicits needed psychosocial information? "In what way does the pain you have affect you on a daily basis?" "Describe to me what you eat in a typical day." "Tell me how you think you and your husband are dealing with your cancer." "Are the two of you having any relational difficulties because of your cancer?"

"Tell me how you think you and your husband are dealing with your cancer."

Caring for a patient with cancer is unique because of the effects of the disease and associated treatment. An understanding of a patient's symptom experience is critical and best revealed by a nurse asking which of the following questions? (Select all that apply.) "What symptoms do you think you are having as a result of your cancer?" "Describe for me how the symptoms affect you in your daily life." "Let's focus on your pain. Tell me how it affects you." "Can you describe for me how your family provides care for your symptoms?"

"What symptoms do you think you are having as a result of your cancer?" "Describe for me how the symptoms affect you in your daily life." "Let's focus on your pain. Tell me how it affects you."

A patient comes to the local health clinic and states: "I've noticed how many people are out walking in my neighborhood. Is walking good for you?" What is the best response to help the patient through the stages of change for exercise? "Walking is OK. I really think running is better." "Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?" "Yes, I want you to begin walking. Walk for 30 minutes every day and start to eat more fruits and vegetables." "They probably aren't walking fast enough or far enough. You need to spend at least 45 minutes if you are going to do any good."

"Yes, walking is great exercise. Do you think you could go for a 5-minute walk next week?"

A patient on a surgical unit develops sudden shortness of breath and a drop in blood pressure. The staff respond, but the patient dies 30 minutes later. The manager on the nursing unit calls the staff involved in the emergency response together. The staff discusses what occurred over the 30-minute time frame, the actions taken, and whether other steps should have been implemented. The nurses in this situation are: Problem solving. Showing humility. Conducting reflective practice. Exercising responsibility.

..Conducting reflective practice.

For each of the following interventions, note which are direct and which are indirect nursing interventions. Place a D for direct or I for indirect in the space provided. 1. A nurse checks the monthly performance improvement report on fall occurrences on a unit. _______________ 2. A nurse discusses with the patient exercise restrictions to follow on return home. _______________ 3. A nurse consults with a dietitian about a patient's therapeutic diet food choices. _______________ 4. A nurse administers a tube feeding. _______________ 5. A nurse assists a colleague in applying a complex dressing to a patient's wound. _______________

1 (I), 2 (D), 3 (I), 4 (D), 5 (D).

Match the activity on the left with the source of diagnostic error on the right: Activity a. Nurse listens to lungs for first time and is not sure if abnormal lung sounds are present. b. After reviewing objective data, nurse selects diagnosis of fear before asking patient to discuss feelings. c. Nurse identifies incorrect diagnostic label. d. Nurse does not consider patient's cultural background when reviewing cues. e. Nurse prepares to complete decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern. Source of Diagnostic Error __ 1. Collecting data __ 2. Interpreting __ 3. Clustering __ 4. Labeling

1 a, 2 b and d, 3 e, 4 c.

A nurse on a cancer unit is reviewing and revising the written plan of care for a patient who has the nursing diagnosis of nausea. Place the following steps in their proper order: The nurse revises approaches in the plan for controlling environmental factors that worsen nausea. The nurse enters data in the assessment column showing new information about the patient's nausea. The nurse adds the current date to show that the diagnosis of nausea is still relevant. The nurse decides to use the patient's self-report of appetite and fluid intake as evaluation measures.

1,2,3,4

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

1,2,3,4

A 72-year-old patient has come to the health clinic with symptoms of a productive cough, fever, increased respiratory rate, and shortness of breath. His respiratory distress increases when he walks. He lives alone and did not come to the clinic until his neighbor insisted. He reports not getting his pneumonia vaccine this year. Blood tests show the patient's oxygen saturation to be lower than normal. The physician diagnoses the patient as having pneumonia. Match the priority level with the nursing diagnoses identified for this patient: Nursing Diagnoses 1. Impaired gas exchange _____ 2. Risk for activity intolerance _____ 3. Ineffective self-health management _____ Priority Level a. Long term b. Short term c. Intermediate

1b, 2c, 3a.

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: risk for fall, impaired physical mobility related to pain, and wandering related to cognitive impairment. The nursing staff identified several goals of care. Match the goals on the left with the appropriate outcome statements on the right. Goals 1. Patient will ambulate independently in 3 days. _____ 2. Patient will be injury free for 1 month. _____ 3. Patient will be less agitated. _____ 4. Patient will achieve pain relief. _____ Outcomes a. Patient will express fewer nonverbal signs of discomfort. b. Patient will follow a set care routine. c. Patient will walk correctly using a walker. d. Patient will exit a low bed without falling.

1c, 2d, 3b, 4a

A nurse who is working on a surgical unit is caring for four different patients. Patient A will be discharged home and is in need of instruction about wound care. Patients B and C have returned from the operating room within an hour of each other, and both require vital signs and monitoring of their intravenous (IV) lines. Patient D is resting following a visit by physical therapy. Which of the following activities by the nurse represent(s) use of clinical decision making for groups of patients? (Select all that apply.) Consider how to involve patient A in deciding whether to involve the family caregiver in wound care instruction. Think about past experience with patients who develop postoperative complications. Decide which activities can be combined for patients B and C. Carefully gather any assessment information and identify patient problems.

2. Think about past experience with patients who develop postoperative complications. 3. Decide which activities can be combined for patient B and C.

A nurse is conducting a patient-centered interview. Place the statements from the interview in the correct order. 1. "You say you've lost weight. Tell me how much weight you have lost in the last month." 2. "My name is Todd. I'll be the nurse taking care of you today. I'm going to ask you a series of questions to gather your health history." 3. "I have no further questions. Thank you for your patience." 4. "Tell me what brought you to the hospital." 5. "So, to summarize, you've lost about 6 pounds in the last month, and your appetite has been poor—correct?"

24153

A 67-year-old patient will be discharged from the hospital in the morning. The health care provider has ordered three new medications for her. Place the following steps of the nursing process in the correct order. ____ 1. The nurse returns to the patient's room and asks her to describe the medicines she will be taking at home. ____ 2. The nurse talks with the patient and family about who will be available if the patient has difficulty taking medicines and considers consulting with the health care provider about a home health visit. ____ 3. The nurse asks the patient if she is in pain, feels tired, and is willing to spend the next few minutes learning about her new medicines. ____ 4. The nurse brings the containers of medicines and information leaflets to the bedside and discusses each medication with her. ____ 5. The nurse considers what she learns from the patient and identifies the patient's nursing diagnosis.

3, 5, 2, 4, 1

The nurse follows a series of steps to objectively evaluate the degree of success in achieving outcomes of care. Place the steps in the correct order. 1. The nurse judges the extent to which the condition of the skin matches the outcome criteria. 2. The nurse tries to determine why the outcome criteria and actual condition of skin do not agree. 3. The nurse inspects the condition of the skin. 4. The nurse reviews the outcome criteria to identify the desired skin condition. 5. The nurse compares the degree of agreement between desired and actual condition of the skin.

4, 3, 5, 1, 2

A patient who visits the allergy clinic tells the nurse practitioner that he is not getting relief from shortness of breath when he uses his inhaler. The nurse decides to ask the patient to explain how he uses the inhaler, when he should take a dose of medication, and what he does when he gets no relief. On the basis of Gordon's functional health patterns, which pattern does the nurse assess? Health perception-health management pattern Value-belief pattern Cognitive-perceptual pattern Coping-stress tolerance pattern

A (Health perception-health management pattern)

Cancer survivors are at risk for treatment-related problems. Which of the patients listed below has the greatest risk for developing such a problem? An 80-year-old woman undergoing surgery for removal of a basal cell carcinoma on the face A 71-year-old man receiving high-dose chemotherapy and radiation for an advanced-stage lymphoma A 26-year-old man receiving chemotherapy for testicular cancer that is localized to the testicle A 48-year-old woman receiving radiation for Hodgkin's disease that involves lymph nodes extending above and below the diaphragm

A 71-year-old man receiving high-dose chemotherapy and radiation for an advanced-stage lymphoma

A nurse working in a medicine clinic knows that it is important to recognize cancer survivors who are most at risk for posttreatment symptoms. Which of the following patients will likely be at greatest risk for posttreatment symptoms? A 50-year-old mother of three who was diagnosed with late-stage breast cancer and has hypertension A 20-year-old male college student diagnosed with leukemia whose father had lung cancer A 32-year-old Hispanic woman who has been diagnosed with local cervical cancer and receives Medicaid A 72-year-old African American male who had colorectal cancer with surgery, radiation, and a second round of chemotherapy because of failure of initial treatment and has diabetes

A 72-year-old African American male who had colorectal cancer with surgery, radiation, and a second round of chemotherapy because of failure of initial treatment and has diabetes

The nurse is assessing the character of a patient's migraine headache and asks, "Do you feel nauseated when you have a headache?" The patient's response is "yes." In this case the finding of nausea is which of the following? An objective finding A clinical inference A validation A concomitant symptom

A concomitant symptom

Which activity represents secondary prevention? A home health care nurse visits a patient's home to change a wound dressing. A 50-year-old woman with no history of disease attends the local health fair and has her blood pressure checked. The school health nurse provides a program to the first-year students on healthy eating. The patient attends cardiac rehabilitation sessions weekly.

A home health care nurse visits a patient's home to change a wound dressing.

A nurse is working with a nursing assistive personnel (NAP) on a busy oncology unit. The nurse has instructed the NAP on the tasks that need to be performed, including getting patient A out of bed, collecting a urine specimen from patient B, and checking vital signs on patient C, who is scheduled to go home. Which of the following represent(s) successful delegation? (Select all that apply.) A nurse explains to the NAP the approach to use in getting the patient up and why the patient has activity limitations. A nurse is asked by a patient to help her to the bathroom; the nurse leaves the room and directs the NAP to assist the patient instead. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early. The nurse is in patient B's room to check an intravenous (IV) line and collects the urine specimen while in the room. The nurse offers support to the NAP when needed but allows her to complete patient care tasks without constant oversight.

A nurse explains to the NAP the approach to use in getting the patient up and why the patient has activity limitations. The nurse sees the NAP preparing to help a patient out of bed, goes to assist, and thanks the NAP for her efforts to get the patient up early. The nurse is in patient B's room to check an intravenous (IV) line and collects the urine specimen while in the room.

A nurse working on a medicine nursing unit is assigned to a 78-year-old patient who just entered the hospital with symptoms of H1N1 flu. The nurse finds the patient to be short of breath with an increased respiratory rate of 30 breaths/min. He lost his wife just a month ago. The nurse's knowledge about this patient results in which of the following assessment approaches at this time? (Select all that apply.) A problem-focused approach A structured comprehensive approach Using multiple visits to gather a complete database Focusing on the functional health pattern of role-relationship

A problem-focused approach Using multiple visits to gather a complete database

Evidence-based practice is defined as: Nursing care based on tradition Scholarly inquiry of nursing and biomedical research literature A problem-solving approach that integrates best current evidence with clinical practice Quality nursing care provided in an efficient and economically sound manner

A problem-solving approach that integrates best current evidence with clinical practice

Before consulting with a physician about a patient's need for urinary catheterization, the nurse considers the fact that the patient has urinary retention and has been unable to void on her own. The nurse knows that evidence for alternative measures to promote voiding exists, but none has been effective, and that before surgery the patient was voiding normally. This scenario is an example of which implementation skill? Cognitive Interpersonal Psychomotor Consultative

A) Cognitive

The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which of the following data form a cluster, showing a relevant pattern? (Select all that apply.) Vital sign results Abdominal distention Age of patient Change in bowel elimination pattern Abdominal pain No past history of hospitalization

Abdominal distention Change in bowel elimination pattern Abdominal pain

Which of the following is required in the delivery of culturally congruent care? Learning about vast cultures Motivation and commitment to caring Influencing treatment and care of patients Acquiring specific knowledge, skills, and attitudes

Acquiring specific knowledge, skills, and attitudes

The patient states she joined a fitness club and attends the aerobics class three nights a week. The patient is in what stage of behavioral change? Precontemplation Contemplation Preparation Action

Action

What technique(s) best encourage(s) a patient to tell his or her full story? (Select all that apply.) Active listening Back channeling Validating Use of open-ended questions Use of closed-ended questions

Active listening Back channeling Use of closed-ended questions

Review the following list of nursing diagnoses and identify those stated incorrectly. (Select all that apply.) Acute pain related to lumbar disk repair Sleep deprivation related to difficulty falling asleep Constipation related to inadequate intake of liquids Potential nausea related to nasogastric tube insertion

Acute pain related to lumbar disk repair Sleep deprivation related to difficulty falling asleep Potential nausea related to nasogastric tube insertion

A 46-year-old woman from Bosnia came to the United States 6 years ago. Although she did not celebrate Christmas when she lived in Bosnia, she celebrates Christmas with her family now. This woman has experienced assimilation into the culture of the United States because she: Chose to be bicultural. Adapted to and adopted the American culture. Had an extremely negative experience with the American culture. Gave up part of her ethnic identity in favor of the American culture.

Adapted to and adopted the American culture.

Middle-range theory

Addresses specific phenomena and reflect practice

Which of the following nursing activities is found in a tertiary health care environment? Administering influenza immunizations at the senior independent living facility Providing well-baby care in the clinic run by the local community health department Admitting a patient following open heart surgery to the cardiovascular intensive care unit Working the triage desk in the emergency department

Admitting a patient following open heart surgery to the cardiovascular intensive care unit

Which of the following best represents the dominant values in American society on individual autonomy and self-determination? Physician orders Advance directive Durable power of attorney Court-appointed guardian

Advance directive

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

Advocate

A nursing student is taking postoperative vital signs in the postanesthesia care unit. She knows that some ethnic groups are more prone to genetic disorders. Which of the following patients is most at risk for developing malignant hypertension? Ashkenazi Jew Chinese American African American Filipino

African American

A patient is admitted to an acute care area. The patient is an active business man who is worried about getting back to work. He has had severe diarrhea and vomiting for the last week. He is weak, and his breathing is labored. Using Maslow's hierarchy of needs, identify this patient's immediate priority. Self-actualization Air, water, and nutrition Safety Esteem and self-esteem needs

Air, water, and nutrition

While working in a community health clinic, it is important to obtain nursing histories and get to know the patients. Part of history taking is to develop the nurse-patient relationship. Which of the following apply to Peplau's theory when establishing the nurse-patient relationship? (Select all that apply.) An interaction between the nurse and patient must develop. The patient's needs must be clarified and described. The nurse-patient relationship is influenced by patient and nurse preconceptions. The nurse-patient relationship is influenced only by the nurse's preconceptions.

An interaction between the nurse and patient must develop. The patient's needs must be clarified and described. The nurse-patient relationship is influenced by patient and nurse preconceptions.

Which of the following is unique to the commitment level of critical thinking? Weighs benefits and risks when making a decision. Analyzes and examine choices more independently. Concrete thinking. Anticipates when to make choices without others' assistance.

Anticipates when to make choices without others' assistance.

Review the following nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) Anxiety related to fear of dying Fatigue related to chronic emphysema Need for mouth care related to inflamed mucosa Risk for infection

Anxiety related to fear of dying Risk for infection

The nurse at an outpatient clinic asks a patient who is Chinese American with newly diagnosed hypertension if he is limiting his sodium intake as directed. The patient does not make eye contact with the nurse but nods his head. What should the nurse do next? Ask the patient how much salt he is consuming each day Discuss the health implications of sodium and hypertension Remind the patient that many foods such as soy sauce contain "hidden" sodium Suggest some low-sodium dietary alternatives

Ask the patient how much salt he is consuming each day

Which of the following activities performed by the nurse is/are focused on the patient-centered care principle of physical comfort? (Select all that apply.) Asking the patient what a tolerable level of pain is for him or her following surgery Providing a back rub at bedtime Offering the patient a warm washcloth for his or her hands before eating Teaching the patient about the new antihypertensive medication ordered Scheduling the patient's follow-up appointments on discharge Changing the bed linens for a patient who is experiencing diaphoresis

Asking the patient what a tolerable level of pain is for him or her following surgery Providing a back rub at bedtime Offering the patient a warm washcloth for his or her hands before eating Changing the bed linens for a patient who is experiencing diaphoresis

An 18-year-old woman is in the emergency department with fever and cough. The nurse obtains her vital signs, auscultates her lung sounds, listens to her heart sounds, determines her level of comfort, and collects blood and sputum samples for analysis. Which standard of practice is performed? Diagnosis Evaluation Assessment Implementation

Assessment

Mr. Wallace is a 34-year-old who is a 5-year survivor of Hodgkin's disease. He continues to have symptoms related to his chemotherapy treatment. Mr. Wallace is a computer expert and enjoys Internet discussion groups. What is the best resource a nurse can recommend to help him access a survivorship care plan? Association of Cancer Online Resources National Coalition for Cancer Survivorship American Cancer Society National Cancer Institute

Association of Cancer Online Resources

Which activity performed by the nurse is related to maintaining competency in nursing practice? Asking another nurse about how to change the settings on a medication pump Regularly attending unit staff meetings Participating as a member of the professional nursing council Attending a review course in preparation for the certification examination

Attending a review course in preparation for the certification examination

A nurse checks a patient's intravenous (IV) line in his right arm and sees inflammation where the catheter enters the skin. She uses her finger to apply light pressure (i.e., palpation) just above the IV site. The patient tells her the area is tender. The nurse checks to see if the IV line is running at the correct rate. This is an example of what type of assessment? Agenda setting Problem-focused Objective Use of a structured database format

B (Problem-focused)

A nurse checks a physician's order and notes that a new medication was ordered. The nurse is unfamiliar with the medication. A nurse colleague explains that the medication is an anticoagulant used for postoperative patients with risk for blood clots. The nurse's best action before giving the medication is to: Have the nurse colleague check the dose with her before giving the medication. Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects. Ask the nurse colleague to administer the medication to her patient. Administer the medication as prescribed and on time.

B) Consult with a pharmacist to obtain knowledge about the purpose of the drug, the action, and the potential side effects.

The nurse reviews a patient's medical record and sees that tube feedings are to begin after a feeding tube is inserted. In recent past experiences the nurse has seen patients on the unit develop diarrhea from tube feedings. The nurse consults with the dietitian and physician to determine the initial rate that will be ordered for the feeding to lessen the chance of diarrhea. This is an example of what type of direct care measure? Preventive Controlling for an adverse reaction Consulting Counseling

B) Controlling for an adverse reaction

A patient is being discharged after abdominal surgery. The abdominal incision is healing well with no signs of redness or irritation. Following instruction, the patient has demonstrated effective care of the incision, including cleansing the wound and applying dressings correctly to the nurse. These behaviors are an example of: Evaluative measure. Expected outcome. Reassessment. Standard of care.

B) Expected outcome.

A patient is recovering from surgery for removal of an ovarian tumor. It is 1 day after her surgery. Because she has an abdominal incision and dressing and a history of diabetes, the nurse has selected a nursing diagnosis of risk for infection. Which of the following is an appropriate goal statement for the diagnosis? Patient will remain afebrile to discharge. Patient's wound will remain free of infection by discharge. Patient will receive ordered antibiotic on time over next 3 days. Patient's abdominal incision will be covered with a sterile dressing for 2 days.

B) Patient's wound will remain free of infection by discharge.

A nurse from home health is talking with a nurse who works on an acute medical division within a hospital. The home health nurse is making a consultation. Which of the following statements describes the unique difference between a nursing care plan from a hospital versus one for home care? The goals of care will always be more long term. The patient and family need to be able to independently provide most of the health care. The patient's goals need to be mutually set with family members who will care for him or her. The expected outcomes need to address what can be influenced by interventions.

B) The patient and family need to be able to independently provide most of the health care.

To enhance their cultural awareness, nursing students need to make an in-depth self-examination of their own: Motivation and commitment to caring. Social, cultural, and biophysical factors. Engagement in cross-cultural interactions. Background, recognizing her biases and prejudices.

Background, recognizing her biases and prejudices.

A nurse has been working on a surgical unit for 3 weeks. A patient requires a Foley catheter to be inserted, so the nurse reads the procedure manual for the institution to review how to insert it. The level of critical thinking the nurse is using is: Commitment. Scientific method. Basic critical thinking. Complex critical thinking.

Basic critical thinking.

A 41-year-old man who underwent a craniotomy for the removal of a brain tumor 6 months ago comes to the clinic for his monthly follow-up visit. In planning your assessment, you anticipate that the patient may possibly experience which of the following late effects of surgery? (Select all that apply.) Pain Fatigue Blurred vision Difficulty breathing Poor attention span

Blurred vision Poor attention span

Which of the following statements apply to theory generation? (Select all that apply.) Builds scientific knowledge base of nursing Discovers relationships of phenomena to practice Tests specific phenomenaIncorrect Identifies observations about a phenomenon

Builds scientific knowledge base of nursing Discovers relationships of phenomena to practice Identifies observations about a phenomenon

A patient tells the nurse during a visit to the clinic that he has been sick to his stomach for 3 days and he vomited twice yesterday. Which of the following responses by the nurse is an example of probing? So you've had an upset stomach and began vomiting—correct? Have you taken anything for your stomach? Is anything else bothering you? Have you taken any medication for your vomiting?

C (Is anything else bothering you?)

The nurse makes the following statement during a change of shift report to another nurse. "I assessed Mr. Diaz, my 61-year-old patient from Chile. He fell at home and hurt his back 3 days ago. He has some difficulty turning in bed, and he says that he has pain that radiates down his leg. He rates his pain at a 6, but I don't think it's that severe. You know that back patients often have chronic pain. He seems fine when talking with his family. Have you cared for him before?" What does the nurse's conclusion suggest? The nurse is making an accurate clinical inference. The nurse has gathered cues to identify a potential problem area. The nurse has allowed stereotyping to influence her assessment. The nurse wants to validate her information with the other nurse.

C (The nurse has allowed stereotyping to influence her assessment.)

When does implementation begin as the fourth step of the nursing process? During the assessment phase Immediately in some critical situations After the care plan has been developed After there is mutual goal setting between nurse and patient

C) After the care plan has been developed

A nurse caring for a patient with pneumonia sits the patient up in bed and suctions his airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following is an evaluative measure used by the nurse? Suctioning the airway Sitting patient up in bed Auscultating lung sounds Patient describing type of discomfort

C) Auscultating lung sounds

A nurse is preparing for change-of-shift rounds with the nurse who is assuming care for his patients. Which of the following statements or actions by the nurse are characteristics of ineffective handoff communication? This patient is anxious about his pain after surgery; you need to review the information I gave him about how to use a patient-controlled analgesia (PCA) pump this evening. The nurse refers to the electronic care plan in the electronic health record (EHR) to review interventions for the patient's care. During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient. The nurse gives her patient a pain medication before report so there is likely to be no interruption during rounding.

C) During walking rounds the nurse talks about the problem the patient care technicians created by not ambulating the patient.

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. Which of the following patient care goals are long term? Patient will explain relationship of insulin to blood glucose control. Patient will self-administer insulin. Patient will achieve glucose control. Patient will describe steps for preparing insulin in a syringe.

C) Patient will achieve glucose control.

A nursing student is talking with one of the staff nurses who works on a surgical unit. The student's care plan is to include nursing-sensitive outcomes for the nursing diagnosis of acute pain. A nursing-sensitive outcome suitable for this diagnosis would be: Patient will achieve pain relief by discharge. Patient will be free of a surgical wound infection by discharge. Patient will report reduced pain severity in 2 days. Patient will describe purpose of pain medicine by discharge.

C) Patient will report reduced pain severity in 2 days.

A patient is being discharged today. In preparation the nurse removes the intravenous (IV) line from the right arm and documents that the site was "clean and dry with no signs of redness or tenderness." On discharge the nurse reviews the care plan for goals met. Which of the following goals can be evaluated with what you know about this patient? Patient expresses acceptance of health status by day of discharge. Patient's surgical wound will remain free of infection. Patient's IV site will remain free of phlebitis. Patient understands when to call physician to report possible complications.

C) Patient's IV site will remain free of phlebitis.

A nurse is talking with a patient who is visiting a neighborhood health clinic. The patient came to the clinic for repeated symptoms of a sinus infection. During their discussion the nurse checks the patient's medical record and realizes that he is due for a tetanus shot. Administering the shot is an example of what type of preventive intervention? Tertiary Direct care Primary Secondary

C) Primary

The nurse enters a patient's room, and the patient asks if he can get out of bed and transfer to a chair. The nurse takes precautions to use safe patient handling techniques and transfers the patient. This is an example of which physical care technique? Meeting the patient's expressed wishes Indirect care measure Protecting a patient from injury Staying organized when implementing a procedure

C) Protecting a patient from injury

A nurse is orienting a new graduate nurse to the unit. The graduate nurse asks, "Why do we have standing orders for cases when patients develop life-threatening arrhythmias? Is not each patient's situation unique?" What is the nurse's best answer? Standing orders are used to meet our physician's preferences. Standing orders ensure that we are familiar with evidence-based guidelines for care of arrhythmias. Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation. Standing orders minimize the documentation we have to provide.

C) Standing orders allow us to respond quickly and safely to a rapidly changing clinical situation.

Which outcome allows you to measure a patient's response to care more precisely? The patient's wound will appear normal within 3 days. The patient's wound will have less drainage within 72 hours. The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4. The patient's wound will heal without redness or drainage by day 4.

C) The patient's wound will reduce in size to less than 4 cm (1 ½ inches) by day 4.

Contemporary nursing requires that the nurse has knowledge and skills for a variety of professional roles and responsibilities. Which of the following are examples? (Select all that apply.) Caregiver Autonomy and accountability Patient advocate Health promotion Lobbyist

Caregiver Autonomy and accountability Patient advocate Health promotion

Which of the following is closely aligned with Leininger's theory? Caring for patients from unique cultures Understanding the humanistic aspects of life Variables affecting a patient's response to a stressor Caring for patients who cannot adapt to internal and external environmental demands

Caring for patients from unique cultures

What type of interview techniques does the nurse use when asking these questions, "Do you have pain or cramping?" "Does the pain get worse when you walk?" (Select all that apply.) Active listening Open-ended questioning Closed-ended questioning Problem-oriented questioning

Closed-ended questioning Problem-oriented questioning

The nurse asks a patient, "Describe for me your typical diet over a 24-hour day. What foods do you prefer? Have you noticed a change in your weight recently?" This series of questions would likely occur during which phase of a patient-centered interview? Setting the stage Gathering information about the patient's chief concerns Collecting the assessment Termination

Collecting the assessment

The nurse checks the intravenous (IV) solution that is infusing into the patient's left arm. The IV solution of 9% NS is infusing at 100 mL/hr as ordered. The nurse reviews the nurses' notes from the previous shift to determine if the dressing over the site was changed as scheduled per standard of care. While in the room, the nurse inspects the condition of the dressing and notes the date on the dressing label. In what ways did the nurse evaluate the IV intervention? (Select all that apply.) Checked the IV infusion location in left arm Checked the type of IV solution Confirmed from nurses' notes the time of dressing change and checked label Inspected the condition of the IV dressing

Confirmed from nurses' notes the time of dressing change and checked label Inspected the condition of the IV dressing

The surgical unit has initiated the use of a pain-rating scale to assess patients' pain severity during their postoperative recovery. The registered nurse (RN) looks at the pain flow sheet to see the pain scores recorded for a patient over the last 24 hours. Use of the pain scale is an example of which intellectual standard? Deep Relevant Consistent Significant

Consistent

Two nurses are having a discussion at the nurses' station. One nurse is a new graduate who added, "Patient needs improved bowel function related to constipation" to a patient's care plan. The nurse's colleague, the charge nurse says, "I think your diagnosis is possibly worded incorrectly. Let's go over it together." A correctly worded diagnostic statement is: Need for improved bowel function related to change in diet. Patient needs improved bowel function related to alteration in elimination. Constipation related to inadequate fluid intake. Constipation related to hard infrequent stools.

Constipation related to inadequate fluid intake.

During their clinical post-conference meeting, several nursing students were discussing their patients with their instructor. One student from a middle-class family shared that her patient was homeless. This is an example of caring for a patient from a different: Ethnicity. Culture. Heritage. Religion.

Culture

A patient has the nursing diagnosis of nausea. The nurse develops a care plan with the following interventions. Which are examples of collaborative interventions? Provide frequent mouth care. Maintain intravenous (IV) infusion at 100 mL/hr. Administer prochlorperazine (Compazine) via rectal suppository. Consult with dietitian on initial foods to offer patient. Control aversive odors or unpleasant visual stimulation that triggers nausea.

D) Consult with dietitian on initial foods to offer patient.

Setting a time frame for outcomes of care serves which of the following purposes? Indicates which outcome has priority Indicates the time it takes to complete an intervention Indicates how long a nurse is scheduled to care for a patient Indicates when the patient is expected to respond in the desired manner

D) Indicates when the patient is expected to respond in the desired manner

The evaluation process includes interpretation of findings as one of its five elements. Which of the following is an example of interpretation? Evaluating the patient's response to selected nursing interventions Selecting an observable or measurable state or behavior that reflects goal achievement Reviewing the patient's nursing diagnoses and establishing goals and outcome statements Matching the results of evaluative measures with expected outcomes to determine patient's status

D) Matching the results of evaluative measures with expected outcomes to determine patient's status

A patient has limited mobility as a result of a recent knee replacement. The nurse identifies that he has altered balance and assists him in ambulation. The patient uses a walker presently as part of his therapy. The nurse notes how far the patient is able to walk and then assists him back to his room. Which of the following is an evaluative measure? Uses walker during ambulation Presence of altered balance Limited mobility in lower extremities Observation of distance patient is able to walk

D) Observation of distance patient is able to walk

The nurse writes an expected-outcome statement in measurable terms. An example is: Patient will be pain free. Patient will have less pain. Patient will take pain medication every 4 hours. Patient will report pain acuity less than 4 on a scale of 0 to 10.

D) Patient will report pain acuity less than 4 on a scale of 0 to 10.

A goal specifies the expected behavior or response that indicates: The specific nursing action was completed. The validation of the nurse's physical assessment. The nurse has made the correct nursing diagnoses. Resolution of a nursing diagnosis or maintenance of a healthy state.

D) Resolution of a nursing diagnosis or maintenance of a healthy state.

You are participating in a clinical care coordination conference for a patient with terminal cancer. You talk with your colleagues about using the nursing code of ethics for professional registered nurses to guide care decisions. A nonnursing colleague asks about this code. Which of the following statements best describes this code? A: Improves self-health care B:Protects the patient's confidentiality C: Ensures identical care to all patients D:Defines the principles of right and wrong to provide patient care

D:Defines the principles of right and wrong to provide patient care

Input

Data entering the system

A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: Data collection. Data clustering. Data interpretation. Making a diagnostic statement.

Data interpretation.

Feedback

Data related to system functioning

A nurse reviews the medical record of a 40-year-old patient newly admitted to the medical nursing unit for evaluation of diabetes. As the nurse reviews the patient's medical history, she notices that the patient had bladder surgery 3 years ago. Which of the following assessment questions is most appropriate for the nurse to ask to determine if the patient is a cancer survivor? Determining if the patient had additional surgeries recently Assessing the patient's medication history Determining if the surgery was cancer related Assessing if the patient's parents had cancer

Determining if the surgery was cancer related

Which of the following theories describe the life processes of an older adult facing chronic illness? Systems theories Developmental theories Interdisciplinary theories Health and wellness models

Developmental theories

A nurse is presenting information to a management class of nursing students on the topic of groups of inpatient hospital services that have a fixed reimbursement amount, with adjustments made on the basis of case severity and regional costs. The nurse is presenting information to the class on which topic? Utilization review committee Resource utilization group Capitation payment system Diagnosis-related groups

Diagnosis-related groups

The nurse sits down to talk with a patient who lost her sister 2 weeks ago. The patient reports she is unable to sleep, feels very fatigued during the day, and is having trouble at work. The nurse asks her to clarify the type of trouble. The patient explains she can't concentrate or even solve simple problems. The nurse records the results of the assessment, describing the patient as having ineffective coping. This is an example of: Diagnostic reasoning. Competency. Inference. Problem solving.

Diagnostic reasoning.

A male patient has been laid off from his construction job and has many unpaid bills. He is going through a divorce from his marriage of 15 years and has been seeing his pastor to help him through this difficult time. He does not have a primary health care provider because he has never really been sick and his parents never took him to the physician when he was a child. Which external variables influence the patient's health practices? (Select all that apply.) Difficulty paying his bills Seeing his pastor as a means of support Family practice of not routinely seeing a health care provider Stress from the divorce and the loss of a job

Difficulty paying his bills Family practice of not routinely seeing a health care provider Stress from the divorce and the loss of a job

When action is taken on one's prejudices: Discrimination occurs. Delivery of culturally congruent care is ensured. Effective intercultural communication develops. Sufficient comparative knowledge of diverse groups is obtained.

Discrimination occurs.

When interviewing a Native American patient on admission to the hospital emergency department, which questions are appropriate for the nurse to ask? (Select all that apply.) Do you use any folk remedies? Do you have a family physician? Do you use a Shaman? Does your family have a history of alcohol abuse?

Do you use any folk remedies? Do you have a family physician? Do you use a Shaman?

A 6-month-old child from Guatemala was adopted by an American family in Indiana. The child's socialization into the American midwestern culture is best described as: Assimilation. Acculturation. Biculturalism. Enculturation.

Enculturation.

Output

End product

A patient had hip surgery 16 hours ago. During the previous shift the patient had 40 mL of drainage in the surgical drainage collection device for an 8-hour period. The nurse refers to the written plan of care, noting that the health care provider is to be notified when drainage in the device exceeds 100 mL for the day. On entering the room, the nurse looks at the device and carefully notes the amount of drainage currently in it. This is an example of: Planning. Evaluation. Intervention. Diagnosis.

Evaluation

Which of the following statements correctly describe the evaluation process? (Select all that apply.) Evaluation is an ongoing process. Evaluation usually reveals obvious changes in patients. Evaluation involves making clinical decisions. Evaluation requires the use of assessment skills.

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

A support group of cancer survivors is discussing cancer-related fatigue (CRF). The survivor most likely to gain relief from CRF is the survivor who does which of the following? (Select all that apply.) Takes naps during the day and evening Drinks energy drinks daily Exercises every other day Eats a balanced diet

Exercises every other day Eats a balanced diet

As an art nursing relies on knowledge gained from practice and reflection on past experiences. As a science nursing relies on (select all that apply): Experimental research. Nonexperimental research. Research from other disciplines. Professional opinions.

Experimental research. Nonexperimental research. Research from other disciplines.

A theory is a set of concepts, definitions, relationships, and assumptions that: Formulate legislation. Explain a phenomenon. Measure nursing functions. Reflect the domain of nursing practice.

Explain a phenomenon.

A female Jamaican immigrant has been late to her last two clinic visits, which in turn had to be rescheduled. The best action that the nurse could take to prevent the patient from being late to her next appointment is: Give her a copy of the city bus schedule. Call her the day before her appointment as a reminder to be on time. Explore what has prevented her from being at the clinic in time for her appointment. Refer her to a clinic that is closer to her home.

Explore what has prevented her from being at the clinic in time for her appointment.

The period during which a cancer patient goes into remission following the basic, rigorous course of chemotherapy and enters a phase of watchful waiting, is called _______________.

Extended survival, Extended survival"

The nurse assesses the following risk factors for coronary artery disease (CAD) in a male patient. Which factors are classified as genetic and physiological? (Select all that apply.) Sedentary lifestyle Father died from CAD at age 50 History of hypertension Eats diet high in sodium Elevated cholesterol level Age is 44 years

Father died from CAD at age 50 History of hypertension Elevated cholesterol level Age is 44 years

Descriptive theory

First level in theory development and describes a phenomenon"

Advanced practice registered nurses generally: Function independently Function as unit directors Work in acute care settings Work in the university setting

Function independently

A nurse is working with a young childbearing family who has one child with a congenital heart disease. The parents are trying to determine the risks of a second child being born with congenital heart disease. Describe why genomics information is important in assisting the parents in this decision.

Genomics describes the study of all the genes in a person and the interactions of these genes with one another and with that person's environment. Genomic information allows health care providers to determine how genomic changes contribute to patient conditions and influence treatment decisions.

A patient has been in the hospital for 2 days because of newly diagnosed diabetes. His medical condition is unstable, and the medical staff is having difficulty controlling his blood sugar. The physician expects that the patient will remain hospitalized at least 3 more days. The nurse identifies one nursing diagnosis as deficient knowledge regarding insulin administration related to inexperience with disease management. What does the nurse need to determine before setting the goal of "patient will self-administer insulin?" (Select all that apply.) Goal within reach of the patient The nurse's own competency in teaching about insulin The patient's cognitive function Availability of family members to assist

Goal within reach of the patient The patient's cognitive function Availability of family members to assist

A nurse assesses a patient who comes to the pulmonary clinic. "I see that it's been over 6 months since you've been in, but your appointment was for every 2 months. Tell me about that. Also I see from your last visit that the doctor recommended routine exercise. Can you tell me how successful you have been following his plan?" The nurse's assessment covers which of Gordon's functional health patterns? Value-belief pattern Cognitive-perceptual pattern Coping-stress-tolerance pattern Health perception-health management pattern

Health perception-health management pattern

The nursing diagnosis readiness for enhanced communication is an example of a(n): Risk nursing diagnosis. Actual nursing diagnosis. Health promotion nursing diagnosis Wellness nursing diagnosis.

Health promotion nursing diagnosis

Which of the following are examples of collaborative problems? (Select all that apply.) Nausea Hemorrhage Wound infection Fear

Hemorrhage Wound infection

When taking care of patients, the nurse routinely asks them if they take any vitamins or herbal medications, encourages family members to bring in music that the patient likes to help the patient relax, and frequently prays with her patients if that is important to them. The nurse is practicing which model? Holistic Health belief Transtheoretical Health promotion

Holistic

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is diarrhea related to intestinal colitis. This is an incorrectly stated diagnostic statement, best described as: Identifying the clinical sign instead of an etiology. Identifying a diagnosis based on prejudicial judgment. Identifying the diagnostic study rather than a problem caused by the diagnostic study. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

Identifying the medical diagnosis instead of the patient's response to the diagnosis.

When illness occurs, different attitudes about it cause people to react in different ways. What do medical sociologists call this reaction to illness? Health belief Illness behavior Health promotion Illness prevention

Illness behavior

A patient in the emergency department has developed wheezing and shortness of breath. The nurse gives the ordered medicated nebulizer treatment now and in 4 hours. Which standard of practice is performed? Planning Evaluation Assessment Implementation

Implementation

Nurses at a community hospital are in an education program to learn how to use a new pressure-relieving device for patients at risk for pressure ulcers. This is which type of education? Continuing education Graduate education In-service education Professional Registered Nurse Education

In-service education

A nursing student is doing a community health rotation in an inner-city public health department. The student investigates sociodemographic and health data of the people served by the health department, and detects disparities in health outcomes between the rich and poor. This is an example of a(n): Illness attributed to natural and biological forces. Creation of the student's interpretation and descriptions of the data. Influence of socioeconomic factors in morbidity and mortality. Combination of naturalistic, religious, and supernatural modalities.

Influence of socioeconomic factors in morbidity and mortality.

A critical care nurse is using a computerized decision support system to correctly position her ventilated patients to reduce pneumonia caused by accumulated respiratory secretions. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? Patient-centered care Safety Teamwork and collaboration Informatics

Informatics

To practice in today's health care environment, nurses need a strong scientific knowledge base from nursing and other disciplines such as the physical, social, and behavioral sciences. This statement identifies the need for which of the following? Systems theories Developmental theories Interdisciplinary theories Health and wellness models

Interdisciplinary theories

Which of the following statements about theory-based nursing practice is incorrect? Contributes to evidence-based practice Provides a systematic process for designing nursing interventions Is not linked to nursing outcomes Guides the nurse's assessment

Is not linked to nursing outcomes

The nurse asks a patient how she feels about her impending surgery for breast cancer. Before the discussion the nurse reviewed the description of loss and grief and therapeutic communication principles in his textbook. The critical thinking component involved in the nurse's review of the literature is: Experience. Problem solving. Knowledge application. Clinical decision making.

Knowledge application.

A nurse is applying Henderson's theory as a basis for theory based-nursing practice. Which other elements are important for theory-based nursing practice? (Select all that apply.) Knowledge of nursing science Knowledge of related sciences Knowledge about current health care issues Knowledge of standards of practice

Knowledge of nursing science Knowledge of related sciences Knowledge of standards of practice

A 58-year-old patient with nerve deafness has come to his doctor's office for a routine examination. The patient wears two hearing aids. The advanced practice nurse who is conducting the assessment uses which of the following approaches while conducting the interview with this patient? (Select all that apply.) Maintain a neutral facial expression Lean forward when interacting with the patient Acknowledge the patient's answers through head nodding Limit direct eye contact

Lean forward when interacting with the patient Acknowledge the patient's answers through head nodding

Prescriptive theory

Linked to outcomes (consequences of specific nursing interventions)

Which of the following statements is true regarding Magnet status recognition for a hospital? Nursing is run by a Magnet manager who makes decisions for the nursing units Nurses in Magnet hospitals make all of the decisions on the clinical units Magnet is a term that is used to describe hospitals that are able to hire the nurses they need Magnet is a special designation for hospitals that achieve excellence in nursing practice

Magnet is a special designation for hospitals that achieve excellence in nursing practice

Health care reform will bring changes in the emphasis of care. Which of the following models is expected from health care reform? Moving from an acute illness to a health promotion, illness prevention model Moving from illness prevention to a health promotion model Incorrect Moving from an acute illness to a disease management model Moving from a chronic care to an illness prevention model

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

Which of the following nursing roles may have prescriptive authority in their practice? (Select all that apply.) Critical care nurse Nurse practitioner Certified clinical nurse specialist Charge nurse

Nurse practitioner

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

Nurse researcher

When a nurse uses information and technology to communicate, locate and use knowledge, reduce and eliminate errors, and help make decisions, the nurse is working in which area? Integrated delivery system Health care patient system Nursing informatics Computerized nursing network

Nursing informatics

A patient with diabetes is controlling the disease with insulin and diet. The nursing health care provider is focusing efforts to teach the patient self-management. Which of the following nursing theories is useful in promoting self management? Neuman Orem Roy Peplau

Orem

The nurse in a geriatric clinic collects the following information from an 82-year-old patient and her daughter, the family caregiver. The daughter explains that the patient is "always getting lost." The patient sits in the chair but gets up frequently and paces back and forth in the examination room. The daughter says, "I just don't know what to do because I worry she will fall or hurt herself." The daughter states that, when she took her mother to the store, they became separated, and the mother couldn't find the front entrance. The daughter works part time and has no one to help watch her mother. Which of the data form a cluster, showing a relevant pattern? (Select all that apply.) Daughter's concern of mother's risk for injury Pacing Patient getting lost easily Daughter working part time Getting up frequently

Pacing Patient getting lost easily Getting up frequently

Nurses on a nursing unit are discussing the processes that led up to a near-miss error on the clinical unit. They are outlining strategies that will prevent this in the future. This is an example of nurses working on what issue in the health care system? Patient safety Evidence-based practice Patient satisfaction Maintenance of competency

Patient safety

A clinic nurse assesses a patient who reports a loss of appetite and a 15-pound weight loss since 2 months ago. The patient is 5 feet 10 inches tall and weighs 135 pounds (61.2 kg). She shows signs of depression and does not have a good understanding of foods to eat for proper nutrition. The nurse makes the nursing diagnosis of imbalanced nutrition: less than body requirements related to reduced intake of food. For the goal of, "Patient will return to baseline weight in 3 months," which of the following outcomes would be appropriate? (Select all that apply.) Patient will discuss source of depression by next clinic visit. Patient will achieve a calorie intake of 2400 daily in 2 weeks. Patient will report improvement in appetite in 1 week. Patient will identify food protein sources.

Patient will achieve a calorie intake of 2400 daily in 2 weeks. Patient will report improvement in appetite in 1 week.

The nurse is providing restorative care to a patient following an extended hospitalization for an acute illness. Which of the following is an appropriate goal for restorative care? Patient will be able to walk 200 feet without shortness of breath Wound will heal without signs of infection Patient will express concerns related to return to home Patient will identify strategies to improve sleep habits

Patient will be able to walk 200 feet without shortness of breath

A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.) Patient will be turned every 2 hours within 24 hours. Patient will have normal bowel function within 72 hours. Patient's skin will remain intact through discharge. Patient's skin condition will improve by discharge.

Patient will have normal bowel function within 72 hours. Patient's skin will remain intact through discharge.

Which of the following outcome statements for the goal, "Patient will achieve a gain of 10 lbs (4.5 kg) in body weight in a month" are worded incorrectly? (Select all that apply.) Patient will eat at least three fourths of each meal by 1 week. Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. Patient will eat foods with high-calorie content by 1 week. Give patient liquid supplements 3 times a day.

Patient will verbalize relief of nausea and have no episodes of vomiting in 1 week. Give patient liquid supplements 3 times a day.

A nurse caring for a patient with pneumonia sits the patient up in bed and suctions the patient's airway. After suctioning, the patient describes some discomfort in his abdomen. The nurse auscultates the patient's lung sounds and gives him a glass of water. Which of the following would be appropriate evaluative criteria used by the nurse? (Select all that apply.) Patient drinks contents of water glass. Patient's lungs are clear to auscultation in bases. Patient reports abdominal pain on scale of 0 to 10. Patient's rate and depth of breathing are normal with head of bed elevated.

Patient's lungs are clear to auscultation in bases. Patient's rate and depth of breathing are normal with head of bed elevated.

A patient at the community clinic asks the nurse about health promotion activities that she can do because she is concerned about getting diabetes mellitus since her grandfather and father both have the disease. This statement reflects that the patient is in what stage of the health belief model? Perceived threat of the disease Likelihood of taking preventive health action Analysis of perceived benefits of preventive action Perceived susceptibility to the disease.

Perceived susceptibility to the disease.

During the review of systems in a nursing history, a nurse learns that the patient has been coughing mucus. Which of the following nursing assessments would be best for the nurse to use to confirm a lung problem? (Select all that apply.) Family report Chest x-ray film Physical examination with auscultation of the lungs Medical record summary of x-ray film findings

Physical examination with auscultation of the lungs Medical record summary of x-ray film findings

The nurse is participating at a health fair at the local mall giving influenza vaccines to senior citizens. What level of prevention is the nurse practicing? Primary prevention Secondary prevention Tertiary prevention Quaternary prevention

Primary prevention

While assessing a patient, the nurse observes that the patient's intravenous (IV) line is not infusing at the ordered rate. The nurse assesses the patient for pain at the IV site, checks the flow regulator on the tubing, looks to see if the patient is lying on the tubing, checks the point of connection between the tubing and the IV catheter, and then checks the condition of the site where the intravenous catheter enters the patient's skin. After the nurse readjusts the flow rate, the infusion begins at the correct rate. This is an example of: Inference. Diagnostic reasoning. Competency. Problem solving.

Problem solving.

Content

Product and information obtained from the system

Which of the following is/are characteristics of managed care systems? (Select all that apply.) Provider receives a predetermined payment for each patient in the program. Payment is based on a set fee for each service provided. System includes a voluntary prescription drug program for an additional cost. System tries to reduce costs while keeping patients healthy. Focus of care is on prevention and early intervention.

Provider receives a predetermined payment for each patient in the program. System tries to reduce costs while keeping patients healthy. Focus of care is on prevention and early intervention.

The examination for registered nurse licensure is exactly the same in every state in the United States. This examination: Guarantees safe nursing care for all patients Ensures standard nursing care for all patients Ensures that honest and ethical care is provided Provides a minimal standard of knowledge for a registered nurse in practice

Provides a minimal standard of knowledge for a registered nurse in practice

Grand theory

Provides a structural framework for broad concepts about nursing

Which of the following is an example of the nurse participating in primary care activities? Providing prenatal teaching on nutrition to a pregnant woman during the first trimester Working with patients in a cardiac rehabilitation program Assessing a patient at an emergent care facility Providing home wound care to a patient

Providing prenatal teaching on nutrition to a pregnant woman during the first trimester

When a nurse properly positions a patient and administers an enema solution at the correct rate for the patient's tolerance, this is an example of what type of implementation skill? Interpersonal Cognitive Collaborative Psychomotor

Psychomotor

Which of the following are examples of the principle of patient-centered care that is focused on respect, values, preferences, and expressed needs? (Select all that apply.) Administer antihypertensive medications to patient daily. Pulling the curtain around the patient bed before changing the wound dressing on the patient's leg Allowing the patient to ask questions and express his or her concern about surgery Explaining a colonoscopy procedure to the patient Working with the family to bring in ethnic foods that the patient prefers

Pulling the curtain around the patient bed before changing the wound dressing on the patient's leg Allowing the patient to ask questions and express his or her concern about surgery Working with the family to bring in ethnic foods that the patient prefers

A patient signals the nurse by turning on the call light. The nurse enters the room and finds the patient's drainage tube disconnected, 100 mL of fluid in the intravenous (IV) line, and the patient asking to be turned. Which of the following does the nurse perform first? Reconnect the drainage tubing Inspect the condition of the IV dressing Improve the patient's comfort and turn onto her side. Obtain the next IV fluid bag from the medication room

Reconnect the drainage tubing

Unmet and partially met goals require the nurse to do which of the following? (Select all that apply.) Redefine priorities Continue intervention Discontinue care plan Gather assessment data on a different nursing diagnosis Compare the patient's response with that of another patient

Redefine priorities Continue intervention

A nurse is starting on the evening shift and is assigned to care for a patient with a diagnosis of impaired skin integrity related to pressure and moisture on the skin. The patient is 72 years old and had a stroke. The patient weighs 250 pounds and is difficult to turn. As the nurse makes decisions about how to implement skin care for the patient, which of the following actions does the nurse implement? (Select all that apply.) Review the set of all possible nursing interventions for the patient's problem Review all possible consequences associated with each possible nursing action Consider own level of competency Determine the probability of all possible consequences

Review the set of all possible nursing interventions for the patient's problem Review all possible consequences associated with each possible nursing action Determine the probability of all possible consequences

A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. Place the following steps for making a nursing diagnosis in the correct order. _____ 1. Considers context of patient's health problem and selects a related factor _____ 2. Reviews assessment data, noting objective and subjective clinical criteria _____ 3. Clusters clinical criteria that form a pattern _____ 4. Chooses diagnostic label

Reviews assessment data, noting objective and subjective clinical criteria Clusters clinical criteria that form a pattern Chooses diagnostic label Considers context of patient's health problem and selects a related factor

The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? Risk for aspiration Acute confusion Readiness for enhanced coping Sedentary lifestyle

Risk for aspiration

A nurse is caring for an older-adult couple in a community-based assisted living facility. During the family assessment he notes that the couple has many expired medications and multiple medications for their respective chronic illnesses. They note that they go to two different health care providers. The nurse begins to work with the couple to determine what they know about their medications and helps them decide on one care provider rather than two. This is an example of which Quality and Safety in the Education of Nurses (QSEN) competency? Patient-centered care Safety Teamwork and collaboration Informatics

Safety

The nurse is conducting a home visit with an older adult couple. She assesses that the lighting in the home is poor and there are throw rugs throughout the home and a low footstool in the living room. She discusses removing the rugs and footstool and improving the lighting with the couple. The nurse is addressing which level of need according to Maslow? Physiological Safety and security Love and belonging Self-actualization

Safety and security

A nurse works in a special care unit for children with severe immunology problems and is caring for a 3-year-old boy from Greece. The boy's father is with him while his mother and sister are back in Greece. The nurse is having difficulty communicating with the father. What action does the nurse take? Care for the boy as she would any other patient Ask the manager to talk with the father and keep him out of the unit Have another nurse care for the boy because maybe that nurse will do better with the father Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community

Search for help with interpretation and understanding of the cultural differences by contacting someone from the local Greek community

In which of the following examples is a nurse applying critical thinking attitudes when preparing to insert an intravenous (IV) catheter? (Select all that apply.) Following the procedural guideline for IV insertion Seeking necessary knowledge about the steps of the procedure from a more experienced nurse Showing confidence in performing the correct IV insertion technique Being sure that the IV dressing covers the IV site completely

Seeking necessary knowledge about the steps of the procedure from a more experienced nurse Showing confidence in performing the correct IV insertion technique

Which steps does the nurse follow when he or she is asked to perform an unfamiliar procedure? (Select all that apply.) Seeks necessary knowledge Reassesses the patient's condition Collects all necessary equipment Delegates the procedure to a more experienced staff member Considers all possible consequences of the procedure

Seeks necessary knowledge Collects all necessary equipment Considers all possible consequences of the procedure

A community health nurse is making a healthy baby visit to a new mother who recently emigrated to the United States from Ghana. When discussing contraceptives with the new mom, the mother states that she won't have to worry about getting pregnant for the time being. The nurse understands that the mom most likely made this statement because: She won't resume sexual relations until her baby is weaned. She is taking the medroxyprogesterone (Depo-Provera) shot. Her husband was recently deployed to Afghanistan. She has access to free condoms from the clinic.

She won't resume sexual relations until her baby is weaned.

Culture strongly influences pain expression and need for pain medication. However, cultural pain is: Not expressed verbally or physically. Expressed only to others from a similar culture. Usually more intense than physical pain. Suffered by a patient whose valued way of life is disregarded by practitioners.

Suffered by a patient whose valued way of life is disregarded by practitioners.

To successfully assess if a patient is experiencing cognitive changes as a result of cancer treatment or complications of treatment, which of the following questions by a nurse is likely most relevant? Describe for me your medication schedule. How distressed are you feeling right now on a scale of 0 to 10? Tell me about when you first noticed symptoms from your chemotherapy. Tell me what you notice differently in your ability to get work done at your office.

Tell me what you notice differently in your ability to get work done at your office.

A patient experienced a myocardial infarction 4 weeks ago and is currently participating in the daily cardiac rehabilitation sessions at the local fitness center. In what level of prevention is the patient participating? Primary prevention Secondary prevention Tertiary prevention Quaternary prevention

Tertiary prevention

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. The patient has recurrent redness in the perineal area, and there is concern that he is developing a pressure ulcer. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. She calls the ostomy and wound care specialist and asks that he visit the patient to recommend skin care measures. Which of the following describe the nurse's actions? (Select all that apply.) The application of the skin barrier is a dependent care measure. The call to the ostomy and wound care specialist is an indirect care measure. The cleansing of the skin is a direct care measure. The application of the skin barrier is a direct care measure.

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

Mr. Timmons has been receiving treatment for colon cancer on and off for a year. He received multiple chemotherapy regimens and a course of radiation. The 58-year-old patient is able to perform his own hygiene but needs assistance from his wife to move about safely in the home because of ongoing fatigue and weakness. His wife assists him with dressing when he becomes excessively tired. This caregiving skill pattern is best described as which of the following? The self-caregiving pattern The collaborative care pattern The family caregiving pattern The team caregiving pattern

The collaborative care pattern

Ben, a 31-year-old nursing student, is caring for Maria, a 45-year-old Latina woman who is receiving chemotherapy following surgery for breast cancer. Based on the evidence about cultural influences on cancer patients, Ben knows that which factor will likely influence this patient's ability to cope with her cancer? Transportation resources to the oncology clinic Whether the patient's physician is male or female The stigma family members place on cancer The level of social support available to the patient

The level of social support available to the patient

Which of the following are examples of data validation? (Select all that apply.) The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record. The nurse asks the patient if he is having pain and then asks the patient to rate the severity. The nurse observes a patient reading a teaching booklet and asks the patient if he has questions about its content. The nurse obtains a blood pressure value that is abnormal and asks the charge nurse to repeat the measurement. The nurse asks the patient to describe a symptom by saying, "Go on."

The nurse assesses the patient's heart rate and compares the value with the last value entered in the medical record. The nurse asks the patient to describe a symptom by saying, "Go on."

In the following examples, which nurses are making nursing diagnostic errors? (Select all that apply.) The nurse who listens to lung sounds after a patient reports "difficulty breathing" The nurse who considers conflicting cues in deciding which diagnostic label to choose The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema The nurse who identifies a diagnosis on the basis of a single defining characteristic

The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema The nurse who identifies a diagnosis on the basis of a single defining characteristic

In which of the following examples is the nurse not applying critical thinking skills in practice? The nurse considers personnel experience in performing intravenous (IV) line insertion and ways to improve performance. The nurse uses a fall risk inventory scale to determine a patient's fall risk. The nurse observes a change in a patient's behavior and considers which problem is likely developing. The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.

The nurse explains the procedure for giving a tube feeding to a second nurse who has floated to the unit to assist with care.

Which of the following is an example of the principle of patient-centered care focused on continuity and transition? The nurse asks the patient who in the family should have access to patient information The nurse is teaching the patient how to change the wound dressing at home The nurse responds promptly to the patient's request for pain medication The nurse schedules the patient's diagnostic scan following the physical therapy session

The nurse is teaching the patient how to change the wound dressing at home

A nurse is assigned to a patient who has returned from the recovery room following surgery for a colorectal tumor. After an initial assessment the nurse anticipates the need to monitor the patient's abdominal dressing, intravenous (IV) infusion, and function of drainage tubes. The patient is in pain, reporting 6 on a scale of 0 to 10, and will not be able to eat or drink until intestinal function returns. The family has been in the waiting room for an hour, wanting to see the patient. The nurse establishes priorities first for which of the following situations? (Select all that apply.) The family comes to visit the patient. The patient expresses concern about pain control. The patient's vital signs change, showing a drop in blood pressure. The charge nurse approaches the nurse and requests a report at end of shift.

The patient expresses concern about pain control. The patient's vital signs change, showing a drop in blood pressure.

A patient comes to a medical clinic with the diagnosis of asthma. The nurse practitioner decides that the patient's obesity adds to the difficulty of breathing; the patient is 5 feet 7 inches tall and weighs 200 pounds (90.7 kg). Based on the nursing diagnosis of imbalanced nutrition: more than body requirements, the practitioner plans to place the patient on a therapeutic diet. Which of the following are evaluative measures for determining if the patient achieves the goal of a desired weight loss? (Select all that apply.) The patient eats 2000 calories a day. The patient is weighed during each clinic visit. The patient discusses factors that increase the risk of an asthma attack. The patient's food diary that tracks intake of daily meals is reviewed.

The patient is weighed during each clinic visit. The patient's food diary that tracks intake of daily meals is reviewed.

Which of the following are components of the paradigm of nursing? The person, health, environment, and theory Incorrect Health, theory, concepts, and environment Nurses, physicians, health, and patient needs The person, health, environment/situation, and nursing

The person, health, environment/situation, and nursing

A nurse gathers the following assessment data. Which of the following cues form(s) a pattern suggesting a problem? (Select all that apply.) The skin around the wound is tender to touch. Fluid intake for 8 hours is 800 mL. Patient has a heart rate of 78 and regular. Patient has drainage from surgical wound. Body temperature is 101° F (38.3° C). Patient asks, "I'm worried that I won't return to work when I planned."

The skin around the wound is tender to touch. Patient has drainage from surgical wound. Body temperature is 101° F (38.3° C).

Theory-based nursing practice uses a theoretical approach for nursing care. This approach moves nursing forward as a science. This suggests that: One theory will guide nursing practice. Scientists will decide nursing decisions. Incorrect Nursing will only base patient care on the practice of other sciences. Theories will be tested to describe or predict patient outcomes.

Theories will be tested to describe or predict patient outcomes.

The patient tells the nurse that she is enrolled in a preferred provider organization (PPO) but does not understand what this is. What is the nurse's best explanation of a PPO? This health plan is for people who cannot afford their own health insurance This health plan is operated by the government to provide health care to older adults This health plan provides you with a preferred list of physicians, hospitals, and providers from which you can choose This is a fee-for-service plan in which you can choose any physician or hospital

This health plan provides you with a preferred list of physicians, hospitals, and providers from which you can choose

A nurse identifies several interventions to resolve the patient's nursing diagnosis of impaired skin integrity. Which of the following are written in error? (Select all that apply.) Turn the patient regularly from side to back to side. Provide perineal care, using Dove soap and water, every shift and after each episode of urinary incontinence. Apply a pressure-relief device to bed. Apply transparent dressing to sacral pressure ulcer.

Turn the patient regularly from side to back to side. Apply a pressure-relief device to bed.

The nursing staff is developing a quality program for the floor. Which of the following are nursing-sensitive indicators from the National Database of Nursing Quality Indicators that the nurses can use to measure patient safety and quality for the unit? (Select all that apply.) Number of medication errors committed by registered nurses (RNs) Turnover rate of nurses on the unit Incidence of patient falls Number of certified RNs Number of emergency department admissions per year

Turnover rate of nurses on the unit Incidence of patient falls Number of certified RNs

A nurse has worked on an oncology unit for 3 years. One patient has become visibly weaker and states, "I feel funny." The nurse knows how patients often have behavior changes before developing sepsis when they have cancer. The nurse asks the patient questions to assess thinking skills and notices the patient shivering. The nurse goes to the phone, calls the physician, and begins the conversation by saying, "I believe that your patient is developing sepsis. I want to report symptoms I'm seeing." What examples of critical thinking concepts does the nurse show? (Select all that apply.) Experience Ethical Analyticity Self-confidence Risk taking

analyticity and self-confidence