fundamentals final practice

A 22-year-old new mother is breastfeeding. You ask her if she is taking the correct quantities of nutrients. Which statement reflects that she understands the dietary guidelines?

"I am making eating choices according to the recommended dietary allowances."

A senior student nurse delegates the task of intake and output to a new nursing assistant. The student will verify that the nursing assistant understands the task of I&O when the nursing assistant states,

"I will record the amount of all voided urine."

The body's fluid and electrolyte balance is maintained partially by hormonal regulation. Which of the following statements shows an understanding of this mechanism?,

"The pituitary gland secretes antidiuretic hormone."

When a smiling and cooperative patient complains of discomfort nurses caring for this patient often harbor misconceptions about the patient's pain. Which of the following is true?

, Patients are the best judges of their pain.

Consultation occurs most often during which phase of the nursing process?

,Planning

While caring for a child you identify that additional safety teaching is needed when a young and inexperienced mother states that:

A 3-year-old can safely sit in the front seat of the car.

When meeting a patient for the first time it is important to establish a baseline assessment that will enable a nurse to refer back to

A pattern of findings identified when the patient is first assessed.

A nurse floats to a busy surgical unit and administers a wrong medication to a patient. This error can be classified as

A procedure-related accident.

A female patient has just found a large lump in her breast. The physician needs to perform a breast biopsy. The nurse helps the patient into the proper position and offers support during the biopsy. The nurse is demonstrating:,

A sense of presence.

You are caring for a patient. Visitors at the bedside include the patient's life partner widowed father brother and niece. The nurse acknowledges that current trends in American families include:,

A very different look from 15 years ago.

Vulnerable populations of patients are those who are more likely to develop health problems as a result of:,

Abusive habits.

If a nurse decides to withhold a medication because it might further lower the patient's blood pressure the nurse will be practicing the principle of:,

Accountability.

A nurse who has recently graduated has been assigned to be a primary nurse on a geriatric unit. After completing a review of development and aging the nurse recalls that changes for the older adult include:,

Adjusting to decreasing health and physical strength

A nurse is caring for a patient who states, "I just want to die." For the nurse to comply with this request, the nurse should discuss:,

Advance directives.

In identifying needs for health policy and health program development and services, a community assessment focuses on which of the following elements?,

All of the above

You are caring for a 5-year-old who is hospitalized for stabilization of asthma. To render age-specific care an action you can take would be to:,

Allow the child to handle medical equipment.

An elderly patient who lives in an adult assisted-living facility mentions that he is experiencing hearing and vision changes. During your assessment you would associate this type of sensory deprivation with:,

Altered perception.

You are a nurse working in the college student health center. You receive a call that an athlete has just fallen and has been injured. You know that according to the general adaptation syndrome the athlete will be exhibiting:,

An increased heart rate.

During a teaching session the nurse tells a patient with a recent neck injury that damage to the nerves is comparable to a water hose that has been pinched off. During this teaching session the nurse is using the process of:,

Analogy.

Nursing theories provide nurses with perspectives from which to

Analyzes patient data.

The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges:,

Are approximated.

A newly graduated nurse is assigned to care for a team consisting of herself and a certified nursing assistant. When delegating skills she needs to:,

Assess the knowledge of the certified nursing assistant.

A postoperative patient is breathing rapidly. You should immediately

Assess the oxygen saturation.

For a student to avoid a data collection error the student should

Assess the patient and, if unsure of the finding, ask a faculty member to assess the patient.

When a nurse enters a patient's room and says "Good morning" before starting care the nurse combines nursing tasks and conversation. An important aspect of care for the nurse to remember is the need to:,

Assess the patient's emotional needs.

You notice that a teenager has an irregular pulse. The best action you should take includes

Assessing the apical pulse rate for 1 full minute.

You notice a respiratory change in your immobilized postoperative patient. The change you note is most consistent with:,

Atelectasis.

A patient comes from a close-knit family. The patient's family functions as context. You will need to evaluate:,

Attainment of patient needs.

Which of the following might be a cause of stress for young adults?,

Being single Career Sexuality

Health disparities are unequal burdens of disease morbidity and mortality rates experienced by racial and ethnic groups. These disparities are often exacerbated by:,

Bias. Stereotyping. Prejudice.

You are assigned to care for a patient who has just undergone a mastectomy for a malignant tumor. You would most appropriately classify this self-concept component as:,

Body image stressor.

You are caring for an adolescent patient who underwent a gastric banding procedure 6 months previously. This adolescent tells you "There is still a fat person inside of me." This type of statement illustrates a flaw in the self-concept of:,

Body image.

A young girl with long hair is experiencing a problem with matting. The most appropriate action to take would be

Braiding the hair to reduce tangles.

If a nurse experiences a problem reading a physician's medication order the most appropriate action will be to

Call the physician to verify order.

Which of the following might be a cause of stress for the middle-aged adult?,

Caring for children and aging parents

You receive an order to begin enteral tube feedings. The first step is to

Check to see that the tube is properly placed.

While admitting a patient during the initial interview a family member tells you "My mom really means that she does not understand her medical diagnosis." The communication form used by the family member is:,

Clarifying.

When caring for a patient who has multiple health problems and related medical diagnoses nurses can best perform nursing diagnoses and nursing interventions by developing a

Concept map.

A newly admitted patient states that he has recently had a change in medications and reports that stools are now dry and hard to pass. This type of bowel pattern is consistent with:,

Constipation.

The nursing process organizes your approach while delivering nursing care. To provide the best professional care to patients nurses need to incorporate nursing process and:,

Critical thinking skills.

A patient is admitted to the hospital with shortness of breath. As the nurse assesses this patient the nurse is using the process of:

Data collection.

According to Kohlberg moral development is a component of psychosocial development. Moral development depends on the child's ability to integrate:,

Decisions of right and wrong.

To assess evaluate and support a patient's spirituality the best action a nurse can take is to:,

Determine the patient's perceptions and belief system.

Nurse-initiated interventions are,

Determined by state Nurse Practice Acts.

As a first-year nursing student you are assigned to care for a dying patient. To best prepare you for this assignment you will want to:,

Develop a personal understanding of your own feelings about grief and death.

Your patient has met the goals set for improvement of ambulatory status. You would now

Discontinue the care plan.

Technological advances in health care

Do not replace sound personal judgment.

A patient complains of chest pain. When assessing the pain you decide that its origin is cardiac—rather than respiratory or gastrointestinal—when it:,

Does not occur with respiratory variations.

A patient you are assisting has fallen in the shower. You must complete an incident report. The purpose of an incident report is to:,

Ensure proper care for the patient.

You are caring for a non-English-speaking male patient. When preparing to assist him with personal hygiene you should

Ensures that culture and ethnicity influence hygiene practices.

You are in the process of admitting an ethnically diverse patient. To plan culturally competent care you will conduct a cultural assessment that includes:,

Ethnohistory.

You are caring for a patient who has diabetes complicated by kidney disease. You need to make a detailed assessment when administering medications because this patient may experience problems with

Excretion.

When assessing the blood pressure of a school-age child using an adult cuff of normal size will affect the reading and produce a value that is

Falsely low

a nurse is communicating with a group of clients about what to expect during the postoperative phase of a total hip arthroplasty. Which of the following elements of the communication process should the nurse identify as a sign of effect communication?

Feedback is provided

Which of the following might be a cause of stress for the older adult?

Financial security Housing Adjusting to decreasing health and physical strength

A patient is admitted to a medical unit for a home-acquired pressure ulcer. The patient has Alzheimer's disease and has been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as

Foley catheter bag.

You will use the concept of primary prevention when instructing a patient to

Get a flu shot every year.

The use of diagnostic reasoning involves a rigorous approach to clinical practice and demonstrates that critical thinking cannot be done:,

Haphazardly.

A student nurse employed as a nursing assistant may perform care:,

Identified in the hospital's job description.

When completing the nursing data on a client to complete the admission and develop a plan of care the nurse will need to:,

Identify family unit form and attitudes.

Which of the following is the first step of the research process?

Identify problem

Upon admission when gathering a patient's sexual history nurses should:,

Include questions related to sexual function.

Every health care organization gathers data on health outcomes. Examples of key quality-of-care or performance indicators include

Infection rates.

When conducting an abdominal assessment the first skill a nurse puts to use is

Inspection.

A patient with glaucoma is being discharged from the hospital. When teaching the patient and family ways to improve home safety, the nurse tells the family to:

Install extra incandescent lighting.

The nursing process organizes your approach to delivering nursing care. To provide care to your patients you will need to incorporate nursing process and

Interview process.

Nursing process is central to nursing practice. Nursing practice

Is derived from a theory.

A postoperative patient arrives at an ambulatory care center and states "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be:,

It shows purulent drainage coming from the incision site

Information regarding a patient's health status may not be released to non-health care team members because:,

Legal and ethical obligations require health care providers to keep information strictly confidential.

An athletic young woman has just fractured her leg while training for a marathon. The use of meditation has many physiological properties that will help the young woman to

Lower muscle tension.

When caring for patients the nurse must understand the difference between religion and spirituality. Religious care helps individuals:,

Maintain their belief systems and worship practices.

To maintain normal elimination patterns in the hospitalized patient you should instruct the patient to defecate 1 hour after meals because:,

Mass colonic peristalsis occurs at this time.

You are caring for a patient who is depressed because the only child has gone away to college. The nurse will assess this type of depression as:,

Maturational loss.

Nurses are legally required to document medications that are administered to patients. The nurse is mandated to document which of the following?

Medication after administering it.

A surgical wound requires a Hydrogel dressing. The primary advantage of this type of dressing is that it provides:,

Moisture needed for wound healing.

A patient with a long-standing history of diabetes mellitus is voicing concerns about kidney disease. The patient asks the nurse where urine is formed in the kidney. The nurse's response is the:,

Nephron.

Your patient is about to undergo a controversial orthopaedic procedure. The procedure may cause periods of pain. Although nurses agree to do no harm, this procedure may be the patient's only treatment choice. This example describes the ethical principle of:,

Nonmaleficence.

You are about to administer an oral medication and you question the dosage. You should:,

Notify the physician.

You are caring for a patient who underwent surgery 48 hours ago. On physical assessment, you notice that the wound looks red and swollen. The patient's WBCs are elevated. You should:,

Notify the provider.

A nurse has just admitted a patient with a medical diagnosis of congestive heart failure. When completing the admission paper work, the nurse needs to record:,

Objective data that are observed.

Helping relationships serve as the foundation of clinical nursing practice. Contracts for a therapeutic helping relationship are formed during the:,

Orientation stage.

A patient has just undergone an appendectomy. When discussing with the patient several pain-relief interventions, the most appropriate recommendation would be

PCA pain management.

When evaluating a postthoracotomy patient with a chest tube the best method to properly maintain the chest tube would be to:,

Place the device below the patient's chest.

Nursing is defined as a profession because nurses

Practice Autonomy

Sally has decided to set aside 30 minutes a day to walk after work next week. Sally is in what stage of risk factor modification?

Preparation

A travel nurse has taken an assignment at a health care facility where nurses assume responsibility for a caseload of patients over a period of time. This type of nursing exemplifies:,

Primary nursing.

A patient newly diagnosed with diabetes needs to learn how to use a glucometer. Use of a glucometer constitutes:

Psychomotor learning.

A patient with a long history of arthritis complains of sensitivity and warmth in the knees. To determine the degree of limitation, the nurse should assess

Range of joint motion.

A patient who needs nursing and rehabilitation following a stroke would most benefit from receiving care at a:

Restorative care setting

A patient is admitted with pneumonia. When auscultating the patient's chest you hear low-pitched continuous sounds over the bronchi. These sounds are labelled as

Rhonchi.

You are assigned to care for a patient who retired 6 months ago. While providing care you identify that this patient is struggling emotionally with change. This situation is most likely associated with the self-concept component of:,

Role-performance stressor.

A patient is diaphoretic and has an oral temperature of 104° F. These are classic signs of:,

Sensible water loss.

According to Maslow's hierarchy of needs which of these needs would the patient seek to meet first?

Shelter

A patient comes into the emergency department complaining of chest pain. When discussing possible reasons why the chest pain has occurred the nurse learns that the patient is depressed because of the loss of a job. This type of crisis can be classified as:,

Situational.

A health care provider may suspect that a patient is experiencing urinary retention when the patient has:,

Small amounts of urine voided two to three times per hour.

You are invited to attend the weekly unit patient care conference. The staff discusses patient care issues. This type of communication is:,

Small group.

After evaluating a patient's external variables the nurse concludes that health beliefs and practices can be influenced by

Socioeconomic factors.

A pregnant teenager asks the clinic nurse why she should not smoke during the first trimester. The nurse's best response should be:,

The organ systems are beginning to develop.

A patient is suffering from shortness of breath. The correct goal statement would be written as:

The patient will breathe unlabored at 14 to 18 breaths per minute by the end of the shift.

You are writing a care plan for a newly admitted patient. Which one of these outcome statements is written correctly?

The patient will identify the need to increase dietary intake of fiber by June 5.

A postoperative patient is receiving morphine sulfate via patient-controlled analgesia (PCA). The nurse assesses that the patient's respirations are depressed. The effects of the morphine sulfate can be classified as

Toxic.

A patient with a tracheostomy has thick tenacious secretions. To maintain the airway, the most appropriate action for the nurse includes:,

Tracheal suctioning.

A newly admitted patient was found wandering the hallways for the past two nights. The most appropriate nursing interventions to prevent a fall for this patient would include

Use an electronic bed monitoring device.

You have delegated vital signs to assistive personnel. The assistant informs you that the patient has just finished a bowl of hot soup. The nurse's most appropriate advice would be to

Wait 30 minutes and take an oral temperature.

A postoperative patient is using PCA. You will evaluate the effectiveness of the medication when

You compare assessed pain w/baseline pain.

A patient complains of thirst and headache. The patient appears emaciated. Upon initial examination you find that the skin does not return to normal shape. This finding is consistent with

poor skin turgor.