Online Final
a family member of an older hispanic patient admitted to the hospital tells the nurse that the patient has traditional beliefs about health and illness. being a patient advocate, what is the correct action by the nurse? a. ask the patient whether it is important that cultural healers are contacted b. explain the usual hospital routines for meal time, care, and family visits c. avoid asking any questions unless the patient initiates conversation d. obtain further information about the patient's cultural beliefs from the family member
a
a nurse administers an ordered dose of medication over the patient's refusal. what action has taken place? a. battery b. negligence c. assault d. malpractice
a
a patient has been newly diagnosed with type 2 diabetes. however, the patient continues to state, "i do not need to spend time doing all this because i will be fine once i get out from under all this stress." what patient situation describes the learning barrier that the nurse is dealing with? a. patient is in denial and she must accept the diagnosis before moving forward b. patient doesn't know what she doesn't know, so the circle will continue c. patient's blood sugar is keeping her from thinking clearly, so it is too soon to try to teach her d. patient already knows all she needs to know, so more education is not necessary
a
a patient has just been informed by the HCP that he will not be discharged today. the nurse brings in the patient lunch tray and puts it on the over bed table. the patient pushes it off onto the floor and shouts, "get out of my room and leave me alone." what is the nurse's therapeutic response? a. you seem angry. Can you tell me about it? b. this type of behavior is not acceptable c. ill order you another lunch, and ill be back when you're in a better mood d. why are you angry? you seemed so much happier earlier today
a
a patient is incontinent of loose stools and is mentally impaired. what nursing action will best promote skin integrity? a. bathe the area immediately after a bowel movement b. wash the buttocks with mild soap and water daily c. put a protective, water-proof pad under the buttocks d. place the call bell within the patient's easy reach
a
a patient on a medical-surgical floor is unhappy with the care he is receiving from his HCP and wants to speak to someone. who would the nurse consult? a. the nurse's immediate supervisor b. the chief nursing officer c. the patient's HCP d. the director of medical services
a
a stay at home mother of three children has a medical diagnosis that requires immediate surgery. which effect is her illness and hospitalization most likely to have on her family? a. alteration of family member's roles b. loss of the autonomy for the children c. loss of privacy for the family d. decrease in income for the family
a
a student is designing a study plan to prepare for NCLEX. the student analyzes testing processes and determines which goal is the best preparation process? a. answer 2500 to 3000 NCLEX-RN style questions before taking boards b. make flash cards to memorize lab values c. review disease processes 30 minutes every day for each disease process d. outline chapters for exams with a score of less than 80%
a
during an admission assessment of an adolescent, which nursing action is important? a. be attentive and try not to interrupt b. focus discussion on activities of the peer group c. use the same type of language as the adolescent d. maintain confidentiality without exceptions
a
in planning a primary prevention program for 7 year old children, which topic is appropriate for the school nurse to include? a. low fat/low calorie nutrition b. puberty development c. need for 12 hours sleep d. awareness of STDs
a
in preparing to relocate to another state, the nurse contacts the state board of nursing to obtain the necessary transfer of nursing license. where will the nurse learn about continuing education requirements for the new state of practice? a. state board of nursing b. school of original nursing education c. human resource department at new place of employment d. the joint commision
a
the RN is documenting the patient's report of pain rated 6 on a scale of 0-10. which chart entry by the nurse, would be appropriate? a. pt reporting pain rated a 6 on a scale of 0-10. states "my left leg is really hurting." pt grimacing, voice elevated. HCP notified b. pt reporting pain rated 6. wants more pain medication, appears to be drug-seeking. HCP notified c. pt reporting of pain. HCP notified d. pt reporting of pain rated a 6 on a scale of 0-10. appears to be in pain. HCP notified
a
the RN is planning care for the day. which would be an appropriate task for the UAP to complete? a. collecting a 24 hour urine specimen b. changing the dressing on an abdominal wound c. monitoring tube feeding d. feeding the patient who has difficulty swallowing
a
the nurse is educating a 52 year old client on vaccines. which vaccine is recommended for this client? a. herpes zoster b. human papillomavirus c. haemophilus influenzae type b d. pneumococcal conjugate
a
the nurse is listening to a lecture on Florence Nightingale. which statement indicates that the teaching has been effective? a. nursing involves helping the patient restore health and prevent disease or injury b. nursing is defined as doing as much as possible for each patient c. nursing is focused solely on the care of the sick patient d. nursing is management of the patient and control of the environment
a
the nurse is preparing to teach a class of adolescents about improving their diets. which approach would be helpful in achieving this goal? a. have the adolescents get involved in meal planning following a presentation on dietary needs b. show a film on dietary needs and what happens to the body if those needs are not met c. send dietary information and menu examples home with the adolescents d. conduct a series of interactive web-based instruction on dietary needs of the adolescent
a
which example demonstrates the principle that all adults learn best from prior experiences? a. showing the patient how the current hand washing procedure is similar to his previous method b. refraining from teaching two health care skills at one time c. teaching the attitude of personal responsibility for healthcare d. showing a patient newly diagnosed with diabetes the similarities between an insulin syringe and a 3 ml syringe
a
which source of guidance do novice nurses use when making decisions regarding patient care? a. procedure manual b. articles in journals c. trial and error d. advice from social networks
a
the nurse is preparing to administer a flu vaccine IM route to a client. the client asks "will this vaccine give me the flu?" which are appropriate responses? SATA a. you can experience some mild side effects b. the vaccine is not a live vaccine and will not give you the flu c. if you were immunized last year you do not need to get this again d. the nasal form is more effective e. this vaccine covers all strains of the influenza virus
ab
what nursing actions would be implemented to prevent falls in a health care environment? SATA a. perform morse fall risk assessment b. keep the floor free of clutter c. request a patient room near the nurse's station d. fall risk band placed on client e. fall sign placed on client's door frame
abcde
the nurse is seeing a male client who has a family hx of diabetes. his blood sugar is 115, he is 5'10" tall and weighs 200 lbs. his blood pressure is 132/88. he has 3 children who are overweight. a favorite family activity is movie night with popcorn and soft drinks. how would the nurse promote health in his family? SATA a. teach alternatives to high fat, high sugar foods b. educate the client about the lifestyle and genetic risks present c. ask client how he and his family could increase exercise time together d. call HCP for prescriptions for an antihypertensive and antidiabetic medication e. discuss the importance of following a well balanced diet
abce
the nurse is documenting administration of a vaccine. what would be included in this documentation? SATA a. vial lot number b. administration site c. funding source d. manufacturer e. expiration date
abde
every 3 years the national council of state boards of nursing (NCBSN) conducts a practice analysis to determine the expectations for newly licensed, entry level nurses. which criteria is utilized when analyzing nursing care activities? SATA a. impact on maintaining client safety b. time in clinical setting without an error c. frequency of performance d. client care setting where the activities are performed e. clients length of stay
acd
which nursing actions demonstrate correct use of standard precautions? SATA a. wears masks, or face shields when at risk from sprays or splashing of infectious material b. apply alcohol based hand cleaner or handwashing before and after client contact c. in between procedures, wash gloved hands when gloves become contaminated d. discard all used sharps and needles in a hospital approved puncture resistant container e. use an alcohol based hand cleanser if hands come in contact with soiled material
acd
a mother of an infant asks the nurse why it is necessary for my child to get vaccines. i have been breastfeeding and my child has gotten natural immunity through my breast milk. what is the correct responses by the nurse? SATA a. children not protected by vaccines are left vulnerable to contracting the disease b. you are correct, she does not need any of these vaccines c. these antibodies do not last long, leaving the infant vulnerable to disease d. since the diseases are disappearing in the US, the child will be free from disease e. they do have temporary immunity to disease that the mother has had in her history
ace
a new nursing student knows that in order to be successful, one will need to practice effective listening. which actions demonstrate effective studying techniques? SATA a. review your notes immediately after class b. do not review anything before class c. scan over the material before class, looking at the main points and subpoints. d. read the text during class instead of listening to lecture e. read over assigned material the night before
ace
a nursing student is preparing to begin her first semester of nursing school. she is aware that academic and non-academic factors can affect her ability to pass the NCLEX-RN. Which statements indicate an understanding of the non-academic factors? SATA a. role strain is a factor in testing success b. my ability to focus on studying can lead to a pass or fail c. having anxiety can prevent me from testing well d. being good at testing would certainly help me pass e. my self-esteem can determine my ability to pass or fail
ace
what actions would the nurse implement in order to properly store vaccine for future use? SATA a. place light-sensitive vaccines in a darkened container b. lock all vaccines in the medication cart c. place vaccines requiring refrigeration in the middle of the refrigerator d. store bulk supplies of vaccines in a freezer e. establish periodic checks for expiration dates on the vaccines
ace
a fire is discovered in the client's room. what action would the nurse take first? a. pull, aim, squeeze and sweep to extinguish the fire b. remove patients in the most immediate danger c. close all doors, turn off oxygen, but leave lights on d. activate the nearest fire alarm by pulling lever
b
a male client had surgery yesterday. the HCP prescribes "up in chair in AM." what action will the nurse take? a. let the client stay in bed if he doesn't feel like getting up b. instruct client to call the nurse for assistance when first getting up c. encourage client to get up and walk when he wakes up d. tell client that he can get up whenever he wants
b
a new graduate has been working as an RN for 6 months and is no longer working with a preceptor. however, she still frequently checks with an experienced nurse to validate that she is following the rules and the policies she is still learning. the new graduate in this scenario exhibits the actions of what theoretical skill level? a. proficient b. novice c. expert d. competent
b
a new nursing student is struggling in class and did not make a good grade on her last exam. she has determined the problem to be her lack of skill in note taking. what can the student do in order to take more effective notes during lecture? a. practice memorization in class instead of taking notes b. focus on writing key words and phrases c. photocopy someone else's notes d. write verbatim all that is said
b
a newly admitted patient has several prescriptions the HCP has written. as manager of care, which task must the RN complete? a. collecting date for intake and output b. irrigating a urinary catheter c. reminding to use the incentive spirometer d. conducting fingerstick glucose tests
b
a novice nurse asks the experienced RN why the first dose of MMR vaccine is given only between 12-15 months of age and not any earlier? which explanation by the RN is correct? a. because MMR is a live virus, the chance of developing measles, mumps or rubella is much higher if given at an earlier age b. if administered earlier, the vaccine will neutralize the passive immunity to measles from the child's mother and no immunity will result c. the second dose of the vaccine is given before the child reaches puberty and giving the first dose as a toddler will allow the correct interval between doses d. a first dose at this age provides passive immunity and decreases the incidence of a child developing any of the diseases
b
a nurse manager is reviewing an occurrence report where the wrong IV antibiotic was given to a patient. what is the correct action for the nurse manager to address this incident with the nurse involved? a. ask the charge nurse to educate the nurse because she caught the error b. provide education to the nurse on how to assess the five rights before medication administration c. allow the nurse one error, and educate her if the mistake happens again d. punish the nurse for the error by sending her home for the day
b
a nurse senses that something about a critically ill child has changed, prompting the nurse to assess the child's situation. which critical thinking process is described? a. judgement b. intuition c. conceptualization d. observation
b
a patient falls out of bed. the nurse must complete an occurrence report. what does the nurse need to know about this documentation? a. the occurrence report becomes part of the medical record b. this document should not be mentioned in the nurse's notes c. a health care provider must review the completed report d. the purpose of an occurrence report is to provide evidence for trial
b
a patient scheduled for surgery has a severe level of anxiety. which action, if taken by the nurse, would be most appropriate at this time? a. asking the patient what they normal take for anxiety b. asking the patient about her concerns, feelings and perceptions about the surgery c. providing teaching about the upcoming surgery and what to expect d. telling the patient that there is nothing to worry about, you hav a very experienced team
b
an expectant mother asks the nurse when the baby should start immunizations. what is the correct response by the nurse? a. 2 months b. at birth c. 1 month d. 3 months
b
if the RN has several LVN's on the shift to supervise, which task is exclusively the responsibility of the RN? a. delegating appropriate tasks to assistive personnel b. evaluating the care provided to the client c. performing dressing changes d. administering intramuscular medication
b
on admission to the hospital the male patient tells the nurse he has a living will. which statement best reflects the purpose of this document? a. it informs that he wishes to die without life sustaining treatments b. it gives specific instructions about end of life care desired c. it outlines that his spouse will make decisions regarding his care d. it dictates that all means available should be used to preserve his life
b
stress reduction is a vital part to maintaining one's health. in following the holistic cognitive theory, what is the correct step the nurse would teach a patient regarding stress reduction? a. concentrate on placing himself or herself in the center of everything b. become aware of the early physical signs of stress c. disqualify the positive in the experience d. mentally filter perceptions
b
the new nursing students are attending an information session on the NCLEX RN. which statement indicates the teaching has been effective? a. the more questions i answer, the more likely i am to pass the exam b. the number of questions does not indicate whether or not i have passed the exam c. if i answer only 75 questions, i have passed the exam d. if i am prompted to answer 265 question, i have failed the test
b
the nurse is caring for a patient 2 hours after a left above the knee amputation. the patient states, "my left leg is really hurting, and that medicine you gave me earlier didn't help." which response from the nurse would be therapeutic? a. you'll need to talk to your doctor b. i will call your HCP c. the pain will lessen with time d. the pain is phantom pain
b
the nurse is completing an assessment of a client who is complaining of abdominal pain and plans to do what action first when examining the client? a. auscultate the abdomen b. inspect the abdomen c. percuss the abdomen d. palpate the abdomen
b
the nurse is educating a newly diagnosed diabetic patient about the use of her insulin pump. which circumstance would likely be a learning barrier for this patient? a. ability to prioritize diabetes management b. tendency toward embarrassment about being seen with the pump c. curiosity about new experiences and equipment d. understanding that the patient can prioritize his/her own well-being
b
the nurse is planning individualized teaching plans for clients at a neighborhood health clinic. which client has the most need for teaching to promote wellness? a. a 50 year old pharmacist who smoked for 20 years before quitting b. a 60 year old divorcee, unemployed who drinks 24 cans of beer weekly c. a 35 year old nurse who has gained thirty pounds in the last year d. a 15 year old athlete who eats a hamburger every day
b
the nurse is preparing to administer a vaccine. which scenario would indicate the need to hold the immunization? a. 6 month old who is afebrile with mild cold b. 15 month old who has an upper respiratory infection and a temperature of 38.4 degrees celcius c. 4 month old who is teething and a temp of 36.4 degrees celsius d. 12 year old with mild diarrhea and a temp of 37 degrees celsius
b
the nurse working in family practice is assessing an older female patient and notices bruises on the patient's arm and back. which action is appropriate for the nurse to take? a. confront and accuse the daughter of elder abuse b. report the suspected abuse to appropriate authorities c. do nothing because you cannot prove anything d. ignore the bruises because her daughter tells you that her mother is clumsy
b
when caring for a patient who was admitted a few hours previously with nausea and vomiting, which nursing action can the RN delegate to an LVN? a. determine the patient's priority nursing diagnosis b. ask the patient about any current nausea c. obtain the health history from the patient's caregiver d. finish documenting the admission assessment
b
which health variable is affected when a nursing student is practicing stress reduction exercises before a test? a. sociocultural b. emotional c. intellectual d. environmental
b
which nursing intervention for the patient who has had right-sided breast conservation surgery and axillary lymph node dissection is appropriate to assign to an LVN? a. evaluating the patient's understanding of discharge instructions about drain care b. administering an analgesic 30 minutes before the scheduled arm exercises c. teaching the patient how to avoid injury to the right arm d. assessing the patient's range of motion for the right arm
b
which statement by the RN represents "right communication" when delegating a task to an unlicensed individual? a. assist the patient with lunch, and make sure he sits up and doesnt store food in his cheek between bites b. feed the patient his pureed diet at lunchtime. elevate the head of the bed to 90 degrees and make certain he swallows each bite c. feed the patient and watch for cheeking and choking d. i want you to help the patient to eat his lunch. you should elevate the head and feed him slowly enough so he does not choke
b
which statement made by the nursing student indicates an accurate understanding of culturally competent care? a. it is the ability to care only for individuals from one's own culture b. it means working within the cultural context of individuals, families and communities c. it means having knowledge of health-related beliefs and practices of all cultures d. it means avoiding discussing the patient's practices or beliefs because they may not agree with your own
b
which task is appropriate for the RN to delegate to a LPN? a. document patient teaching about a routine surgical procedure b. perform a sterile dressing change c. complete the initial admission assessment and plan of care d. teach a patient about the effects of prescribed medications
b
which task will the nurse delegate to the UAP first? a. refill the water pitcher for a client who is no longer on NPO status b. reposition a comatose client who has been on the right side for 3 hours c. provide AM care to a client who is demanding a bath now d. empty a catheter containing 500 ml of urine for a client who is NPO
b
while passing noon meds, an RN notes that one of her patients did not receive his 0600 dose of antibiotic during the prior shift. she calls the prior nurse to try to determine whether the medication was given, then fills out an occurrence report and follows through as institutional policy indicates. what is the best explanation for why the RN who found the error took action? a. because the prior nurse and administration needed to know about the error b. because she is accountable for not contributing to the error by ignoring it c. to keep the patient's family from discovering the error d. to protect herself and the hospital from a lawsuit
b
after receiving report, the RN has many tasks to accomplish during the next 12 hours. which tasks will the RN delegate to the UAP? SATA a. flushing a ng tube on a post surgical pt b. rechecking vs on a 30 yr old pt with bp of 100/60 c. measuring and recording hourly urine output on a nephrectomy pt d. irrigating a clogged urinary catheter on a confused older adult e. changing a dressing on a pt with an infected diabetic ulcer
bc
the nurse is providing discharge teaching to the family of a patient who's diagnosed with Alzheimer's disease. which safety interventions are appropriate for the nurse to recommend within the home environment? SATA a. increasing fluid intake b. ensuring a well-lit stairwell c. tacking down carpet edges d. installing rails by the toilet e. placing throw rugs on hardwood flooring
bcd
the RN takes on different care provider roles in the health care setting. which roles would the nurse assume when caring for a patient who has just been diagnosed with cancer? SATA a. power of attorney b. advocate c. collaborator d. educator e. counselor
bcde
the nurse incurred an accidental needlestick while initiating an IV. what steps will this nurse take to minimize the risk of infection? SATA a. immediately cleanse the area with copious amount of alcohol-based hand sanitizer b. submit to blood work to check for presence of blood-borne pathogens c. report the needlestick to other nursing staff at the facility d. arrange an appointment with HCP within the next 4 weeks e. complete an incident or injury report according to facility policy
be
a charge nurse and staff nurse are in disagreement over the team assignment for the shift that is about to begin. what is the charge nurse's first step to resolving this conflict collaboratively? a. design a plan to meet the shared goal b. determine the shared goal c. open a respectful dialogue to bring forth each point of view d. determine the roles of those involved in the plan
c
a newly hired UAP was trained on how to insert a foley catheter and checked off on the procedure by the nurse educator. the hospital policy states that the UAP can insert a foley catheter if trained and certified. the nurse delegates this task to the UAPm but the UAP states "even though i have done this task before, im still a little unsure of myself." which action would the nurse take? a. encourage the UAP to reschedule training with the education department b. assign the UAP less advanced skills like vital signs, bedbaths and I&O c. review the procedure with the UAP and supervise the UAP doing the skill d. encourage the UAP to do the procedure since competency has been verified
c
in a situation involving a medication error, the hospital policy is to use root-cause-analysis to evaluate the situation fully. in the root-cause-analysis process, which action would take place? a. a committee is formed to determine the risk of litigation b. a committee is formed to determine individual responsibility c. a committee is formed that can reconstruct the events leading to the error d. a committee is formed that can correct the error and avoid damages
c
the medical team determines that a patient needs to be transferred to another facility to continue receiving the most appropriate and beneficial care. the transfer process has been slow and difficult, and the nurse is struggling to care for the transferring patient along with her other assigned patients. what is the correct action for the nurse to take to improve her situation? a. ask her co-workers to manage her patient assignments b. continue to do the best that she can do for all her patients c. involve management so that the nurse can focus on patient care d. inform the medical team that the transfer will have to wait for the next shift
c
the nurse is passing by a client's room and hears someone yelling in that room. the nurse enters the room to find the client standing by the bed and swinging a food tray in front of him. the nurse also notices that the client's IV line is disconnected, and there is blood running down the client's arm. what will the nurse do in this situation? a. attempt to reconnect the client's IV b. ask the client to explain the problem c. back away from the client and wait for help d. loudly tell the client to return to bed
c
the nurse is preparing morning assignments. which activity would be delegated to the RN float nurse rather than the UAP? a. fasting blood sugar checks b. ambulation of postop patients c. skin integrity evaluation d. vital signs
c
the nurse threatens to initiate restraints on a verbally abusive patient. which offense will the nurse be held liable for by the patient? a. malpractice b. negligence c. assault d. battery
c
what nursing action will not reduce the risk of malpractice? a. document accurately b. administer medications carefully c. do not delegate any tasks d. think before speaking
c
which factor is an external variable affecting health for the client? a. gender b. age c. friends d. obesity
c
which nursing response demonstrates the ethical principle of fidelity? a. reporting an abnormal test result to the client's HCP b. explaining the need for a client's privacy to a newly employed aide c. keeping a promise to tell the case manager about a client's concerns d. helping the client consider all the options before making a decision
c
which type of managed care allows patients the greatest choice of providers, medication, and medical devices? a. health maintenance organization b. employment-based private practice insurance c. preferred provider organization d. integrated delivery network
c
what actions would the nurse take to reduce the risk of committing a professional boundary violation? SATA a. offer to assist the client with values clarification when a conflict arises b. influence client decision-making for upcoming procedure c. objectively document all nursing care measures provided to the client d. analyze behaviors to determine if they increase the client's vulnerability e. spending equal amounts of time with each patient
cde
what current evidence supports the need for increased nursing knowledge of geriatrics and home health care? SATA a. the older adults rely minimally on social security b. the older adults are typically well educated c. some older adults live alone and need assistance with care d. the older adult population utilizes more health care dollars per person than younger members of society e. by 2030 there is an expected 65 million dollar americans
cde
according to the TBON, which nursing tasks may be delegated to unlicensed staff? SATA a. administration of the first dose of a routine oral antibiotic b. admission assessment for a stable pt c. reinforcement of planned RN instruction d. development of a continuous nursing care plan e. maintenance of daily intake and output of pts
ce
a client is coming into the clinic for the first time. which action would the nurse implement in order to provide client comfort during the interview? a. sit at the desk and document findings b. stand at the side of the clients chair c. stand at the counter to take notes d. sit next to the client, a few feet apart
d
a nurse is assessing a client. what information collected by the nurse reflects subjective information? a. agitated behavior b. clammy skin c. coughing after a deep breath d. numbness of the feet
d
a nurse is preparing a patient care plan. which outcome statement is a properly written goal? a. the patient will demonstrate breathing techniques by the end of shift b. the patient will be free of pain c. the patient will verbalized the importance of lifestyle changes d. the patient will get up into the chair one time daily for 1 hour
d
a nurse is preparing to start teaching on a new diagnosis. what nursing action will assist with effective patient learning? a. the nurse asks the patient's spouse to leave before beginning the teaching b. the nurse administers pain medication to the new diabetic before she starts teaching just in case the patient is in pain c. the nurse decides that conversation works best during a meal, so she plans to teach while the patient eats. d. thirty minutes before the patient teaching, the nurse assess the patient for comfort, bathroom needs and ensures the patient has eaten
d
a nursing instructor is guiding nursing students on best practices for interviewing patients. which comment would indicate the need for further instruction? a. my patient is a young adult, so i plan to talk to her without parents in the room b. because my patient is old enough to be my grandfather, i will call him Mr c. when reading my patient's health record, i thought of a few questions to ask d. when i give my patient his pain medication, i will have time to ask questions
d
after a challenging exam, a nursing student is overheard in the hallways exclaiming, "that instructor is too hard! He only gave me a B on this exam." What trait is the nursing student exhibiting? a. pessimist b. realist c. perfectionist d. external locus of control
d
critical thinking in the expert nurse is greatly enhanced by which activity? a. following unit based protocols for patient care b. working with health care providers to provide patient care c. developing nursing diagnoses for commonly occurring illnesses d. applying evidence based theory in real patient situations
d
in a patient care conference, one of the nurses makes a controversial statement about the patient's behavior. the other HCPs raise their eyebrows, and silence follows the original comment. what action would a nurse leader take? a. agree with the comment about the patient, and direct the group to the next topic on the agenda b. ignore the statement about the patient's behavior and the nurse's judgmental attitude c. respond to the nurse that the comment is judgmental and inappropriate and ask the nurse to stay after the meeting d. gather input from the group about the patient's behavior, and elicit suggestions about how to best work with the patient
d
in applying the four key habits for managing the work of success, which action by the nurse demonstrates understanding? a. making a list of long term goals b. analyzing case studies on day off from work c. participating in self-care classes on the weekend d. taking time at the beginning of shift to plan for the day
d
the HCP prescribed a 2-gram sodium diet for a 75 year old pt with current SOB and HTN. during teaching for this diet, which factor will most likely interfere with patient teaching? a. hypertension b. reluctance to change c. age d. current shortness of breath
d
the RN is performing an assessment on a client being admitted for back pain. which patient information would the nurse interpret as a minor detail? a. involved in a car accident 2 days ago b. has not been able to void in 10 hours c. reports being unable to walk without assistance d. ate 90% of his breakfast and 100% of his lunch
d
the charge nurse is creating assignments for the oncoming shift. she notices that today staffing consists of three RNs and on LPN. which assignments would be appropriate for the LPN? a. acute MI; needs preparation for Cath Lab b. possible stroke; newly admitted to floor c. dehydration; needs IV fluid and close I&O monitoring d. flu-like symptoms; needs reassessment of vital signs every hour
d
the home health nurse is caring for a client with a communicable disease. when is the appropriate time for the nurse to visit this client? a. at lunch b. first thing in the morning c. mid-afternoon d. last visit of the day
d
the nurse is planning care for an elderly obese female patient with Alzheimer's dementia. the patient wanders, is unsteady on her feet, and is visually impaired. what should the nurse give priority to when developing the plan of care? a. laboratory results b. skin condition c. nutrition d. safety
d
the nurse treats a client with an infection by administering antibiotics. which term describes the situation? a. risk appraisal b. secondary prevention c. primary prevention d. tertiary prevention
d
the nursing student understands that the LPN/LVN role differs from the RN role in many areas. In which area is the LPN/LVN and RN roles similar? a. education preparation b. assessment skills c. leadership preparation d. basic psycho-motor skills
d
which action by a newly graduated RN working on the postsurgical unit indicates that more education about delegation and assignment is needed? a. assigning a LPN to administer oral medications to several patients b. assigning a float RN from pediatrics to care for a patient with diabetes c. delegating measurements of a patient's oral intake and urine output to a UAP d. delegating assessment of a patient's bowel sounds to an experienced UAP
d
which is an example of a measurable outcome for the patient who has undergone a surgical procedure with a pain rating of 7 on a scale of 0-10? a. the patient's pain will be under control by Sunday b. the patient will have no pain by the end of this shift c. the patient's pain will decrease by the end of shift on (date) d. the patient's pain will decrease to 2 or lower by the end of the shift on (date)
d
which nursing action will indicate that the RN is practicing at the proficient level? a. asks another nurse to be present while a urinary catheter is inserted b. becomes frazzled when two patients are unexpectedly admitted at the same time c. assumes the role of charge nurse while managing a tough patient assignment d. thinks critically about situations and is able to anticipate patient needs
d
which nursing statement reflects the assessment portion of the SBAR communication technique? a. would you like for me to obtain a CT scan for Mr. Smith? b. Mr. Smith was admitted to the hospital with COPD c. Mr. Smith was in his room at the time of the fall d. Mr. Smith may have injured his back when he fell
d
which of these tasks is appropriate for the RN to delegate to a LPN? a. complete the initial assessment and plan of care b. teach a patient about the effects of prescribed medications c. document patient teaching about a routine surgical procedure d. perform a sterile dressing change for an infected wound
d
Using SBAR label the following statements that the nurse would make to communicate a change in patient status to a HCP. Label S for situation, B for background, A for assessment, R for recommendation: 1. Mr. A was admitted 2 days ago with a heart failure and has been receiving furosemide for diuresis, but his urine output has been low 2. I think that he needs to be evaluated immediately and may need intubation and mechanical ventilation 3. This is the nurse on the surgical unit. I am calling about Mr. A in room 3. After assessing him, I am very concerned about his shortness of breath 4. Today he has crackles audible throughout the posterior chest and his O2 saturation is 89%. His condition is very unstable
1b2r3s4a
studies have found that nursing students tend to answer questions at a slower pace as they proceed through exams. what would nursing students focus on when preparing for the NCLEX-RN? a. the wording of each question b. joining a study group c. amount of time spent on each question d. what types of questions are on the test
c
the RN has several LVN and UAP care providers on the shift to supervise. the RN is exclusively accountable for which responsibility? a. supervising care given by UAP b. administering scheduled injectable medications c. evaluating the care provided to patients d. performing complex dressing changes
c
the nurse is charting on the patient who is status post-surgery for an abdominal abscess and notes. "Pt's temperature has not exceeded 37 degrees Celsius this shift." how would the nurse classify this documentation? a. outcome b. plan c. diagnosis or analysis d. intervention
c
the nurse needs to conduct an interview with an older adult client who is alert and orientated. the client has family in the hospital room who are watching television. which situation would be conducive for a successful interview by the nurse? a. introduce yourself and ask, "Dear, what name do you prefer to go by?" before asking questions b. Ask the client if you can talk with her while her family is watching the television c. after the family leaves, ask the client if she's comfortable and willing to answer a few questions d. provide enough chairs so the family and you are able to sit facing the client
c
upon assessing the client, the nurse has identified various health concerns. which resource will the nurse find useful in prioritizing these identified needs? a. standardized care plans b. a nursing diagnosis book c. maslow's hierarchy of needs d. medical-surgical textbook
c
what is the purpose of communicating essential information when a patient is being transferred from one location to another? a. ensure the receiving staff won't have to ask questions about the patient b. provide the new staff information so that they don't have to read the medical record c. provide pertinent clinical and background information to ensure patient safety d. help the patient and their family adapt to new surroundings
c
when assessing the circulation to the lower leg of a patient who has had knee surgery, which action would the nurse take first? a. compress the nail beds to determine capillary refill time b. check the patient's pedal pulses using the fingertips c. visually inspect the color of the foot d. feel for the temperature of the foot
c
when the nurse considers if a care plan is consistent with what a reasonable and prudent nurse should do, the nurse is demonstrating which professional quality? a. team work b. supervision c. independence d. accountability
c
which attribute of critical thinking is the nurse demonstrating by considering alternative solutions and potential actions to help the patient? a. reflection b. curiosity c. creativity d. rational thought
c
which component of the nursing profession is found in the guidelines of professionalism? a. power b. healing c. teamwork d. licensure
c
which finding is significant when assessing a 94 year old client? a. diminished short term memory b. prolonged reaction time to verbal stimulus c. decreased level of consciousness d. reduced ability to perform fine motor skills
c
which nursing question is an example of an open-ended question? a. have you had surgery before? b. when was your last menstrual period? c. what happens when you have a headache? d. do you have a family history of heart disease?
c
which social factor has developed the role of nursing to what it is today? a. society's lack of education about health care b. society's lack of resources to pay for health care c. society's attitude toward the role of women d. society's lack of qualified health professionals
c
a student in an LPN to RN transition program is at the clinical site and monitoring the vital signs of a patient receiving blood. at 15 minutes into the infusion, the patient begins to complain of itching and shortness of breath. which action by the student nurse demonstrates critical thinking skills? a. calls the HCP and asks if the transfusion rate can be modified b. call for the patient's primary nurse and asks whether she can slow the infusion down c. continues with routine monitoring and reports changes in patient condition to primary nurse d. stops the infusion, calls for the patient's nurse, and reports a possible reaction to the blood
d
after studying the students learning styles, the nursing instructor believes reflective observation is the best for the lab activity. which approach demonstrates reflective observation? a. present information and allow the students to be directly involved in a hands-on setting b. present the information in a lecture while students take notes c. set up stations so students can try to "figure it out for themselves" d. allow the students to observe a preparation
d
an RN has been working with a patient on a nursing unit for the past 12 hour shift. the nurse recognizes that each time the patient is turned to the left, the blood pressure drops 15 mm Hg. the same RN has seen this phenomenon in several other patients and makes the connection that patients with right-sided heart failure will experience a blood pressure drop if they are turned to their left side. what type of reasoning is the nurse implementing? a. reflective b. deductive c. reductive d. inductive
d
as the nurse assesses the patient's neck, the patient says "My neck is so stiff I can hardly move it." which type of assessment would the nurse perform? a. emergency assessment b. comprehensive assessment c. screening assessment d. focused assessment
d
the nurse has received a shift report. which patient would the nurse assess first? a. a patient with a stomach virus who vomited three times during previous shift b. a patient scheduled for a CT scan and transport has arrived to take them to radiology c. a patient with Type 2 diabetes mellitus who is complaining of dizziness with FSBS of 80 d. a patient with diverticulitis who has a hard, rigid abdomen and an elevated temperature
d
the nurse should start with which type of communication during an admission assessment? a. are you feeling better or worse today? b. are you having any pain? c. is there anything i can do for you? d. what brings you to the hospital?
d
when will the nurse collect evaluation data for this expected outcome? "Patient will maintain urine output of at least 30ml/hr." a. every 12 hours b. every 4 hours c. every 12 hours d. every hour
d
which action by the nurse demonstrates that the nurse values accountability? a. the nurse comforts a child who is crying after his parents went home b. the nurse shuts the patient's door prior to taking the patient's vital signs c. the nurse asks the patient to inform a staff member when taking a shower d. the nurse reports to the unit manager that a medication error has occured
d
which behavior demonstrates a nurse establishing presence with a client who is too ill to respond? a. standing at the client's door and stating, "ill be with you shortly" b. describing a time in the past when the nurse was also very ill c. assessing the iv site in the client's arm and repositioning in bed d. sitting quietly at the bedside of the client and holding their hand
d
which nursing action defines the nurse as a care provider in an inpatient setting? a. running a blood pressure screening in the lobby of facility b. holding an information session on diabetes management and prevention c. handing out pamphlets on how to lower cholesterol d. assisting new parents after the delivery of preterm twins
d
a novice RN is caring for a patient who is saying that something is wrong. Vital signs are all WNL, and there are no new specific findings. the novice RN calls another, more experienced RN who briefly talks with the patient, and calls the HCP. Which description reflects the actions of the experienced RN? a. expert nurse with intuitive judgement that the novice nurse cannot quite explain b. proficient in assessment and knows when to disregard hospital protocol c. arrogant, foolish, and likely to get in trouble for her assertive behavior d. advanced beginner with better assessment skills than the novice nurse
a
a nurse has a plan for teaching the patient about a newly diagnosed disease. on entering the room, the nurse realizes that the patient is blind. what considerations for communication would the nurse be aware of? a. tone, pitch, inflection, and intensity affect how messages are communicated b. messages are clearer when verbal communication and nonverbal cues are opposite c. facial expressions and eye contact are characteristics of verbal communication d. verbal communication must be understood within the context of the patient's culture, gender and age
a
a nurse is reviewing pediatric physical exam techniques. which statement is correct about performing a pediatric physical assessment? a. physical exams proceed systematically unless considerations dictate otherwise b. the physical examination is completed only when the child is cooperative c. measurement of head circumference is measured until the child is 5 years old d. the exam should be performed with parents in the room for children of any age
a
a nursing intervention directs the patient to be turned every 2 hours to prevent skin breakdown from immobility. upon assessment, the nurse notes new reddened areas on the lateral aspects of the right knee and ankle. how will the nurse use these findings when evaluating the plan of care? a. the intervention will change to have the patient turned every hour b. the nursing diagnosis will be changed from an actual problem to a potential problem c. the information will be added to the relevant area of the electronic medical record d. the new intervention of calling the HCP will be added to the care plan
a
the nurse has completed the initial assessment of a client and has analyzed and clustered the data. what is the nurse's next step in the diagnostic process? a. identify the client's problems, health risks, and strengths b. verify assessment findings with the case manage c. formulate a collaborative plan of care with the physician d. evaluate current related nursing interventions and goals
a
the nurse is performing a musculoskeletal assessment on a client admitted with a possible stroke. what would the nurse ask the client to do for muscle grip strength testing? a. grasp the nurse's index and middle fingers while the nurse tries to pull the fingers out b. shrug the shoulders against the resistance of the nurse's hands c. hold an arm up and resist while the nurse tries to push it down d. flex each arm and then try to extend it against the nurse's attempt to keep the arm in flexion
a
the nurse is performing an abdominal assessment and inspects the skin on the abdomen. which additional technique will the nurse perform? a. auscultates bowel sounds in all four quadrants b. palpate the visible aortic pulsations for size c. deeply palpates the abdomen for tenderness d. auscultates for dull percussion tones
a
the student nurse is listening to a lecture on therapeutic communication. which statement indicates that teaching has been effective? a. therapeutic communication develops a trusting relationship b. therapeutic communication is emotional commitment to another c. therapeutic communication is psychotherapy d. therapeutic communication is social communication
a
what is the function of continuous quality improvement in the nursing profession? a. to assess patient care, from admission to discharge b. to improve collaboration of staff team members c. to improve staff compliance with training d. to assist staff in building individual nursing skills
a
what modification is appropriate for the nurse to make when performing a physical assessment on an older adult client? a. sequence the exam to limit the number of position changes b. examine the client without any covering to fully assess for skin changes c. shout all questions to ensure that the client can hear and understand d. perform the examination on a chair so the client doesn't have to lie down
a
which assessment finding warrants action by the nurse? a. coarse crackles heard bilaterally in the dependent lobes b. soft, low-pitched sounds heard posteriorly in the lung bases c. loud, harsh tubular sounds heard over the larynx and trachea area d. medium-pitched sounds with equal inspiration and expiration heard anteriorly
a
which contribution of Florence Nightingale had an immediate impact on improving patient's health? a. providing a clean environment b. changing the delivery of care in hospitals c. establishing nursing as a distinct profession d. improving nursing education
a
which nursing action is an example of an ongoing assessment? a. taking the temperature one hour after giving acetaminophen b. asking the patient in detail how he will return to normal exercise activities c. examining the patients mouth at the time she complains of a sore throat d. requesting the patient to rate intensity on a pain scale with the first perception of pain
a
which nursing action would indicate the nurse fulfilling the care provider role of educator? a. answering a new mother's questions about breastfeeding b. requesting more pain medications for a patient who is recovering from a total hip replacement c. leading a hand-washing initiative to reduce infection rates d. working with colleagues to transfer a patient into a rehab center
a
which nursing activity reflects the planning phase of the nursing process? a. decision to monitor intake and output on the client b. maintenance of iv infusion c. instruction regarding how to prevent dehydration d. assessment of urinary output at end of shift
a
the nursing instructor provides a program on the state board of nursing for students preparing to graduate from a school of nursing. what would the instructor emphasize about the role of the state boards of nursing? SATA a. approve nursing education programs b. define the scope of practice for nursing c. develop rules and regulations for nursing practice d. provide guidance on knowledge, skills and attitudes e. publish statements of duties for competent performance
abc
nurses demonstrate critical thinking in which of the following ways? SATA a. anticipation of care needs b. implementation of prescribed care c. revision of care plans d. collection of data e. conversation with others
abcd
a nursing student completed a stressful week of work, class and clinical. what coping mechanisms could the nursing student utilize in stress reduction? SATA a. empathy b. distraction c. relaxation d. catharsis e. reframing
abcde
the nurse is utilizing SBAR as a communication tool. which statements are true? SATA a. provides an opportunity to make a recommendation b. sets the context by providing background information c. communicates pertinent assessment data to assist decision making d. provides a template to have someone else report the information e. explains the situation or problem concerning the patient
abce
when studying for an upcoming test, the nursing student has read the assigned text once and is ready to highlight. which actions indicate understanding on how to highlight? SATA a. marks a section with a star for future reference b. uses circles to highlight words or phrases c. draws an asterisk next to an important paragraph or sentence d. draw an "x" across words for emphasis e. underlines sentences of importance
abce
the nurse suspects that a post-operative client has developed a problem related to fluid volume. in clustering cues to support the correct nursing diagnostic label/problem, which data will the nurse include? SATA a. amount of surgical drainage b. urinary output c. appearance of surgical incision d. white blood cell count e. pulse volume
abe
which nursing actions are examples of a health-promotion activity? SATA a. helping a client develop a plan for a low-fat, low-cholesterol diet b. disinfecting an abraded knee after a child falls off a bicycle c. educating about the need for a tetanus vaccination after an injury from a car accident d. distributing educational brochures about the benefits of exercise e. administering a measles, mumps, rubella immunization to a toddler at 15 months of age
acde
which statements in regard to the electronic health record would make the transition from paper charts to electronic charts more appealing to the nursing staff? SATA a. able to access patient's progress from each department b. increases time spent in charting patient information c. allows the nurse to spend more time at the bedside d. narrative charting is required for all assessment entries e. provides legible documentation for all patient charting
ace
a nursing student knows that effective learning requires attention and preparation. what actions can be taken to ensure competency of the lecture material? SATA a. read over the assigned material before lecture begins b. no special attention or preparation is required c. read the material during class d. read over the material as soon as class is over e. study independently during discussion time
ad
which actions would the nurse initiate to eliminate self-defeating behaviors? SATA a. accept responsibility for his or her actions b. strive for perfection in daily tasks c. believe his or her actions do not make a difference d. say, "i know i can do this" e. worry about things out of his or her control
ad
a 62 year old woman is brought to the clinic by her daughter, who is concerned about her mother's increasing sleep disturbances and inability to solve common problems. when obtaining the nursing history from the client and daughter, the nurse would ask for more information about which area? a. any changes in her eating habits b. lost recollection of recent events and new information c. multiple complaints of physical dysfunction d. weight loss and vivid dreams
b
a client comes to the emergency department with report of crushing chest pain that radiates down the left arm. while the RN is reviewing the health history, the client reports that he has been getting over a cold, is severely allergic to peanuts and eggs, and has hypertension. what would the nurse document as the chief concern for this client? a. has hypertension b. experiencing crushing chest pain c. severe peanut and egg allergy d. getting over a cold
b
the nurse reviews assessment findings for assigned patients. based on this information, which patient demands the nurse's immediate attention? a. endocarditis who has a loud heart murmur b. abdominal aneurysm whose blood pressure is 170/90 c. renal failure on dialysis whose WBC is 10,000 mm3 d. atrial fibrillation whose lab results show an INR of 2.5
b
what action would the nurse take first to promote safety for a confused patient? a. observe gait and balance b. put bed in lowest position c. have someone sit with client d. put all four side-rails up
b
what patient characteristic must a nurse consider when planning teaching for that patient? a. pain medication b. literacy level c. discharge instructions d. good lighting
b
what position is best for the nurse to use when performing a physical assessment on a 9 month old? a. in the nurse's arms b. in the parent's arms c. flat on the examination table d. in the child carrier
b
when admitting a client to the unit, which nursing action is appropriate? a. review the client's medical diagnosis with the family for accuracy b. obtain data to complete the nursing history and physical assessment forms c. discuss tests or procedures that may be done while the client is hospitalized d. notify the HCP provider that the admissions VS are stable
b
when taking a nursing exam the student remains positive, steady and is able to handle stressors. how would this student behavior be interpreted? a. confidence b. control c. common sense d. content
b
which nursing action is an example of professional behavior? a. obtaining consent after a procedure b. utilizing delegation as a charge nurse c. not reporting sexual misconduct and harassment d. updating social media sites with patient experiences
b
a home health nurse is teaching a patient about a new medication. the patient replies "I just can't learn new information like I used to." what does the nurse need to plan for? a. telling the patient it is not safe to take the medication independently b. teaching the patient's family members to give the medication c. providing privacy, minimize distractions, and reteach as necessary d. scheduling the patient for daily visits for medication administration
c
a nursing student is giving a presentation on the different organizations that support nurses. which statement is a correct understanding of the american nurses association (ANA)? a. sets guidelines for entrance into nursing programs b. determines state guidelines for nursing practice c. represents and advocates for nurse d. evaluates and updates licensure exams
c
a nursing student is learning about effective time management in nursing school. which action by the student indicates understanding of the first step? a. prioritizing goals in order of simple to complex b. setting goals based on the desired outcome c. assessing the reality of the complete situation d. place tasks in a chronological order
c
a nursing student is planning for the first day of lecture. which action will help the student become successful? a. take notes from the book during the lecture b. skip the first day of class and read the syllabus at home c. sit in the front of the room, away from distractions d. sit in the back of the class, next to a best friend
c
a nursing student is reviewing new material for an upcoming test. she has decided to highlight so that she can come back later to easily review the material. how can she use highlighting to be successful? a. use only one color of highlighting b. highlight the first time the material is read c. highlight no more than 20% of the material d. highlight up to 50% of the material
c
a patient with pneumonia has been using the incentive spirometer four times daily while awake during his 3 day hospitalization. how would the nurse explore the effectiveness of this intervention? a. watch the patient use the incentive spirometer b. ask whether the patient was breathing better c. auscultate the lungs for adventitious breath sounds d. add turn, cough, and deep breathing exercises
c
a student nurse is utilizing critical thinking when making decisions. what is critical thought? a. thoughtful process that relies on the nurse's experience b. persuasive process leading to sound decisions c. disciplined, rational, and self directed activities that uses standards and criteria d. reactive activities after an intervention is implemented and completed
c
it is helpful to understand the difference between school exams and the NCLEX-RN in order to ensure that students are prepared adequately. which statement by the nursing student demonstrates adequate understanding of the NCLEX-RN? a. it will primarily test recognition of knowledge b. it will test knowledge of how to care for clients in acute care areas c. it will test critical and higher thinking skills d. it will test understanding of nursing concepts
c
patients seeking health care have increased autonomy and insist on taking an active role in their medical treatment decisions. what aspect of a nurse's role does this affect? a. coordination of human and material resources that are directly used in the delivery of care at the bedside b. use of professional communication when doing patient teaching and admitting patients to the unit c. patient collaboration with health care team members involved with the development of focused, quality care d. evaluation of performance and skills of nursing staff members involved in direct patient care
c
which statement assists the nurse in planning care for the patient who is not adhering to the treatment regimen? a. patients usually go to the hospital without preconceived ideas about what is wrong with them b. most patients adhere to the advice of health care providers even if they do not believe that the treatment will not work c. noncompliance with prescribed treatment is irrational behavior d. patient's health attitudes directly affect behavior and therefore influence adherance
d