Exam 1 all chapter

15. A nurse adds a nursing diagnosis to a patient's care plan. Which information did the nurse document? a.Decreased cardiac output related to altered myocardial contractility. b.Patient needs a low-fat diet related to inadequate heart perfusion. c.Offer a low-fat diet because of heart problems. d.Acute heart pain related to discomfort.

A

19. A nurse assesses that a patient has not voided in 6 hours. Which question should the nurse ask to assist in establishing a nursing diagnosis of Urinary retention? a."Do you feel like you need to go to the bathroom?" b."Are you able to walk to the bathroom by yourself?" c."When was the last time you took your medicine?" d."Do you have a safety rail in your bathroom at home?"

A

20. A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma 2. Writes a diagnostic label of impaired gas exchange 3. Organizes data into meaningful clusters 4. Interprets information from patient 5. Writes an etiology a.1, 3, 4, 2, 5 b.1, 3, 4, 5, 2 c.1, 4, 3, 5, 2 d.1, 4, 3, 2, 5

A

4. The nurse is reviewing a patient's plan of care, which includes the nursing diagnostic statement, Impaired physical mobility related to tibial fracture as evidenced by patient's inability to ambulate. Which part of the diagnostic statement does the nurse need to revise? a.Etiology b.Nursing diagnosis c.Collaborative problem d.Defining characteristic

A

7. The nurse is reviewing a patient's database for significant changes and discovers that the patient has not voided in over 8 hours. The patient's kidney function lab results are abnormal, and the patient's oral intake has significantly decreased since previous shifts. Which step of the nursing process should the nurse proceed to after this review? a.Diagnosis b.Planning c.Implementation d.Evaluation

A

9. A nurse administers an antihypertensive medication to a patient at the scheduled time of 0900. The nursing assistive personnel (NAP) then reports to the nurse that the patient's blood pressure was low when it was taken at 0830. The NAP states that was busy and had not had a chance to tell the nurse yet. The patient begins to complain of feeling dizzy and light-headed. The blood pressure is rechecked and it has dropped even lower. In which phase of the nursing process did the nurse first make an error? a.Assessment b.Diagnosis c.Implementation d.Evaluation

A

A goal for a patient with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome? a. States feels better after talking with family and friends b. Consumes high-carbohydrate foods when stressed c. Dislikes the support group meetings d. Spends most of the day in bed

A

A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next? a. Reassess the patient and situation. b. Revise the turning schedule to increase the frequency. c. Delegate turning to the nursing assistive personnel. d. Apply medication to the area of skin that is broken down.

A

A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse's priority when evaluating the patient? a. Identify factors interfering with goal achievement. b. Counsel the nursing assistive personnel on duty when the patient fell. c. Remove the fall risk sign from the patient's door because the patient has suffered a fall. d. Request that the more experienced charge nurse complete the documentation about the fall.

A

A nurse is evaluating an expected outcome for a patient that states heart rate will be less than 80 beats/min by 12/3. Which finding will alert the nurse that the goal has been met? a. Heart rate 78 beats/min on 12/3 b. Heart rate 78 beats/min on 12/4 c. Heart rate 80 beats/min on 12/3 d. Heart rate 80 beats/min on 12/4

A

A nurse is teaching the staff about alterations in breathing patterns. Which information will the nurse include in the teaching session? (Select all that apply.) a. Apnea—no respirations b. Tachypnea—regular, rapid respirations c. Kussmaul's—abnormally deep, regular, fast respirations d. Hyperventilation—labored, increased in depth and rate respirations e. Cheyne-Stokes—abnormally slow and depressed ventilation respirations f. Biot's—irregular with alternating periods of apnea and hyperventilation respirations

A B C

The patient is being encouraged to purchase a portable automatic blood pressure device to monitor blood pressure at home. Which information will the nurse present as benefits for this type of treatment? (Select all that apply.) a. Patients can actively participate in their treatment. b. Self-monitoring helps with compliance and treatment. c. The risk of obtaining an inaccurate reading is decreased. d. Blood pressures can be obtained if pulse rates become irregular. e. Patients can provide information about patterns to health care providers.

A B E

A nurse is caring for a group of patients. Which evaluative measures will the nurse use to determine a patient's responses to nursing care? (Select all that apply.) a. Observations of wound healing b. Daily blood pressure measurements c. Findings of respiratory rate and depth d. Completion of nursing interventions e. Patient's subjective report of feelings about a new diagnosis of cancer

A, B, C, E

The nurse is assessing the patient and family for probable familial causes of the patient's hypertension. The nurse begins by analyzing the patient's personal history, as well as family history and current lifestyle situation. Which findings will the nurse consider to be risk factors? (Select all that apply.) a. Obesity b. Cigarette smoking c. Recent weight loss d. Heavy alcohol intake e. Regular exercise sessions

A, B, D

The nurse is administering ibuprofen (Advil) to an older patient. Which assessment data causes the nurse to hold the medication? (Select all that apply.) a. Patient states allergy to aspirin. b. Patient states joint pain is 2/10 and intermittent. c. Patient reports past medical history of gastric ulcer. d. Patient reports last bowel movement was 4 days ago. e. Patient experiences respiratory depression after administration of an opioid medication.

A, C: A: Patient states allergy to aspirin, C: Patient reports past medical history of gastric ulcer.

A nurse is planning care for an older-adult patient who is experiencing pain. Which statement made by the nurse indicates the supervising nurse needs to follow up? a."As adults age, their ability to perceive pain decreases." b. "Older patients may have low serum albumin in their blood, causing toxic effects of analgesic drugs." c. "Patients who have dementia probably experience pain, and their pain is not always well controlled." d. "It is safe to administer opioids to older adults as long as you start with small doses and frequently assess the patient's response to the medication."

A: "As adults age, their ability to perceive pain decreases."

The nurse is teaching a student nurse about pain assessment scales. Which statement by the student indicates effective teaching? a. "You cannot use a pain scale to compare the pain of my patient with the pain of your patient." b. "When patients say they don't need pain medication, they aren't in pain." c. "A patient's behavior is more reliable than the patient's report of pain." d. "Pain assessment scales determine the quality of a patient's pain."

A: "You cannot use a pain scale to compare the pain of my patient with the pain of your patient."

A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with hydrocodone. Which important patient education does the nurse provide? a. "You need to drink plenty of fluids and eat a diet high in fiber." b. "Narcotics can be addictive, so do not take them unless you are in severe pain." c. "Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer." d."As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections."

A: "You need to drink plenty of fluids and eat a diet high in fiber."

A nurse is caring for a group of patients. Which patient will the nurse see first? a. A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg b. A patient lying very still in bed who reports no pain but is pale with warm, dry. c. A patient with severe pain who is nauseated and feels like he or she is about to vomit d. A patient writhing and moaning from abdominal pain after abdominal surgery

A: A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 110/60 mm Hg

The nurse is caring for a group of patients. Which task may the nurse delegate to the nursing assistive personnel (NAP)? a. Administer a back massage to a patient with pain. b. Assessment of pain for a patient reporting abdominal pain. c. Administer patient-controlled analgesia for a postoperative patient. d. Assessment of vital signs in a patient receiving epidural analgesia.

A: Administer a back massage to a patient with pain.

A nurse is caring for a patient with chronic pain from arthritis. Which action is best for the nurse to take? a. Give pain medications around the clock. b. Administer pain medication before any activity. c. Give pain medication after the pain is a 7/10 on the pain scale. d. Administer pain medication only when nonpharmacological measures have failed.

A: Give pain medications around the clock.

The nurse is caring for two patients; both are having a hysterectomy. The first patient is having the hysterectomy after a complicated birth. The second patient has uterine cancer. What will most likely influence the experience of pain for these two patients? a. Meaning of pain b. Neurological factors c. Competency of the surgeon d. Postoperative support personnel

A: Meaning of pain

A nurse teaches the patient about the gate control theory. Which statement made by a patient reflects a correct understanding about the relationship between the gate control theory of pain and the use of meditation to relieve pain? a. "Meditation controls pain by blocking pain impulses from coming through the gate." b. "Meditation alters the chemical composition of pain neuroregulators, which closes the gate." c. "Meditation will help me sleep through the pain because it opens the gate." d. "Meditation stops the occurrence of pain stimuli."

A: Meditation controls pain by blocking pain impulses from coming through the gate."

A nurse is caring for a patient with rheumatoid arthritis who is now going to be taking 2 acetaminophen (Tylenol) tablets every 6 hours to control pain. Which part of the patient's social history is the nurse most concerned about? a. Patient drinks 1 to 2 glasses of wine every night. b. Patient smokes 2 packs of cigarettes a day. c. Patient occasionally uses marijuana. d. Patient takes anti anxiety medications.

A: Patient drinks 1 to 2 glasses of wine every night.

The nurse is caring for a 4-year-old child who has pain. Which technique will the nurse use to best assess pain in this child? a. Use the FACES scale. b. Check to see what previous nurses have charted. c. Ask the parents if they think their child is in pain. d. Have the child rate the level of pain on a 0 to 10 pain scale.

A: Use the FACES scale.

1. The nurse is using critical thinking skills during the first phase of the nursing process. Which action indicates the nurse is in the first phase? a. Completes a comprehensive database b. Identifies pertinent nursing diagnoses c. Intervenes based on priorities of patient care d. Determines whether outcomes have been achieved

ANS: A

15. Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient? a. The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage. b. The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done. c. The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps. d. The nurse elevates a leg cast when the patient reports decreased mobility.

ANS: A

18. The nurse is interviewing a patient with a hearing deficit. Which area should the nurse use to conduct this interview? a. The patient's room with the door closed b. The waiting area with the television turned off c. The patient's room before administration of pain medication d. The waiting room while the occupational therapist is working on leg exercises

ANS: A

8. While interviewing an older female patient of Asian descent, the nurse notices that the patient looks at the ground when answering questions. What should the nurse do? a. Consider cultural differences during this assessment. b. Ask the patient to make eye contact to determine her affect. c. Continue with the interview and document that the patient is depressed. d. Notify the health care provider to recommend a psychological evaluation.

ANS: A

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

ANS: A Concept mapping challenges the student to synthesize data and identify relationships between nursing diagnoses. The primary purpose of concept mapping is to better synthesize relevant data about a patient, including assessment data, nursing diagnoses, health needs, nursing interventions, and evaluation measures. Reflective journaling involves thinking back to clarify concepts. Reading assignments and lecture do not best provide an instructor the ability to evaluate students' abilities to synthesize data.

20. In which order will the nurse use the nursing process steps during the clinical decision-making process? 1. Evaluating goals 2. Assessing patient needs 3. Planning priorities of care 4. Determining nursing diagnoses 5. Implementing nursing interventions a.2, 4, 3, 5, 1 b.4, 3, 2, 1, 5 c.1, 2, 4, 5, 3 d.5, 1, 2, 3, 4

ANS: A The American Nurses Association developed standards that set forth the framework necessary for critical thinking in the application of the five-step nursing process: assessment, diagnosis, planning, implementation, and evaluation.

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

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

3. The standing orders for a patient include acetaminophen 650 mg every 4 hours prn for headache. After assessing the patient, the nurse identifies the need for headache relief and determines that the patient has not had acetaminophen in the past 4 hours. Which action will the nurse take next? a. Administer the acetaminophen. b. Notify the health care provider to obtain a verbal order. c. Direct the nursing assistive personnel to give the acetaminophen. d. Perform a pain assessment only after administering the acetaminophen.

ANS: A A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems. The nurse will administer the medication. Notifying the health care provider is not necessary if a standing order exists. The nursing assistive personnel are not licensed to administer medications; therefore, medication administration should not be delegated to this person. A pain assessment should be performed before and after pain medication administration to assess the need for and effectiveness of the medication.

4. Which action indicates a nurse is using critical thinking for implementation of nursing care to patients? a. Determines whether an intervention is correct and appropriate for the given situation b. Reads over the steps and performs a procedure despite lack of clinical competency c. Establishes goals for a particular patient without assessment d. Evaluates the effectiveness of interventions

ANS: A As you implement interventions, use critical thinking to confirm whether the interventions are correct and still appropriate for a patient's clinical situation. You are responsible for having the necessary knowledge and clinical competency to perform interventions for your patients safely and effectively. The nurse needs to recognize the safety hazards of performing an intervention without clinical competency and seek assistance from another nurse. The nurse cannot evaluate interventions until they are implemented. Patients need ongoing assessment before establishing goals because patient conditions can change very rapidly.

20. The nurse is revising the care plan. In which order will the nurse perform the tasks, beginning with the first step? 1. Revise specific interventions. 2. Revise the assessment column. 3. Choose the evaluation method. 4. Delete irrelevant nursing diagnoses. a. 2, 4, 1, 3 b. 4, 2, 1, 3 c. 3, 4, 2, 1 d. 4, 2, 3, 1

ANS: A Modification of an existing written care plan includes four steps: 1. Revise data in the assessment column to reflect the patient's current status. Date any new data to inform other members of the health care team of the time that the change occurred. 2. Revise the nursing diagnoses. Delete nursing diagnoses that are no longer relevant and add and date any new diagnoses. Revise related factors and the patient's goals, outcomes, and priorities. Date any revisions. 3. Revise specific interventions that correspond to the new nursing diagnoses and goals. Be sure that revisions reflect the patient's present status. 4. Choose the method of evaluation for determining whether you achieved patient outcomes.

17. A staff development nurse is providing an inservice for other nurses to educate them about the Nursing Interventions Classification (NIC) system. During the inservice, which statement made by one of the nurses in the room requires the staff development nurse to clarify the information provided? a. "This system can help medical students determine the cost of the care they provide to patients." b. "If the nursing department uses this system, communication among nurses who work throughout the hospital may be enhanced." c. "We could use this system to help organize orientation for new nursing employees because we can better explain the nursing interventions we use most frequently on our unit." d. "The NIC system provides one way to improve safe and effective documentation in the hospital's electronic health record."

ANS: A NIC does not help determine the cost of services provided by nurses. The staff development nurse would need to correct this misconception. Because this system is specific to nursing practice, it would not help medical students determine the costs of care. The NIC system developed by the University of Iowa differentiates nursing practice from that of other health care disciplines. All the other statements are true. Benefits of using NIC include enhancing communication among nursing staff and documentation, especially within health information systems such as an electronic documentation system. NIC also helps nurses identify the nursing interventions they implement most frequently. Units that identify routine nursing interventions can use this information to develop checklists for orientation.

13. Which initial intervention is most appropriate for a patient who has a new onset of chest pain? a. Reassess the patient. b. Notify the health care provider. c. Administer a prn medication for pain. d. Call radiology for a portable chest x-ray.

ANS: A Preparation for implementation ensures efficient, safe, and effective nursing care; the first activity is reassessment. The cause of the patient's chest pain is unknown, so the patient needs to be reassessed before pain medication is administered or a chest x-ray is obtained. The nurse then notifies the patient's health care provider of the patient's current condition in anticipation of receiving further orders. The patient's chest pain could be due to muscular injury or a pulmonary issue. The nurse needs to reassess first.

19. The nurse is intervening for a patient that has a risk for a urinary infection. Which direct care nursing intervention is most appropriate? a. Teaches proper handwashing technique b. Properly cleans the patient's toilet c. Transports urine specimen to the lab d. Informs the oncoming nurse during hand-off

ANS: A Teaching proper handwashing technique is a direct care nursing intervention. All the rest are indirect nursing care: cleaning the toilet, transporting specimens, and performing hand-off reports.

1. Which findings will alert the nurse that stress is present when making a clinical decision? (Select all that apply.) a.Tense muscles b.Reactive responses c.Trouble concentrating d.Very tired feelings e.Managed emotions

ANS: A, B, C, D Learn to recognize when you are feeling stressed—your muscles will tense, you become reactive when others communicate with you, you have trouble concentrating, and you feel very tired. Emotions are not managed when stressed.

22.A nurse is providing nursing care to a group of patients. Which actions are direct care interventions? (Select all that apply.) a. Ambulating a patient b. Inserting a feeding tube c. Performing resuscitation d. Documenting wound care e. Teaching about medications

ANS: A, B, C, E All of the interventions listed (ambulating, inserting a feeding tube, performing resuscitation, and teaching) are direct care interventions involving patient and nurse interaction, except documenting wound care. Documenting wound care is an example of an indirect intervention.

24.Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.) a. Perform dressing changes twice a day as ordered. b. Teach the patient about signs and symptoms of infection. c. Instruct the family about how to perform dressing changes. d. Gently refocus patient from discussing body image changes. e. Administer medications to control the patient's blood sugar as ordered.

ANS: A, B, C, E Nursing priorities include interventions directed at enhancing wound healing. Teaching the patient about signs and symptoms of infection will help the patient identify signs of appropriate wound healing and know when the need for calling the health care provider arises. Performing dressing changes, controlling blood sugars through administration of medications, and instructing the family in dressing changes all contribute to wound healing. As long as a patient is stable and alert, it is appropriate to allow family to assist with care. The patient should be allowed to discuss body image changes.

23. A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.) a. Equipment b. Safe environment c. Confidence d. Assistive personnel e. Creativity

ANS: A, B, D A nurse will organize time and resources in preparation for implementing nursing care. Most nursing procedures require some equipment or supplies. Before performing an intervention, decide which supplies you need and determine their availability. Patient care staff (assistive personnel) work together as patients' needs demand it. A patient's care environment needs to be safe and conducive to implementing therapies. Confidence and creativity are needed to provide safe and effective patient care; however, these are critical thinking attitudes, not resources.

10. The nurse is attempting to prompt the patient to elaborate on the reports of daytime fatigue. Which question should the nurse ask? a. "Is there anything that you are stressed about right now that I should know?" b. "What reasons do you think are contributing to your fatigue?" c. "What are your normal work hours?" d. "Are you sleeping 8 hours a night?"

ANS: B

11. A nurse is conducting a nursing health history. Which component will the nurse address? a. Nurse's concerns b. Patient expectations c. Current treatment orders d. Nurse's goals for the patient

ANS: B

16. While completing an admission database, the nurse is interviewing a patient who states "I am allergic to latex." Which action will the nurse take first? a. Immediately place the patient in isolation. b. Ask the patient to describe the type of reaction. c. Proceed to the termination phase of the interview. d. Document the latex allergy on the medication administration record.

ANS: B

19. A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient's daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse? a. The nurse makes eye contact with the patient. b. The nurse speaks only to the patient's daughter. c. The nurse leans forward while talking with the patient. d. The nurse nods periodically while the patient is speaking.

ANS: B

2. A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first? a. Complete the questions in chronological order. b. Focus on the patient's presenting situation. c. Make accurate interpretations of the data. d. Conduct an observational overview.

ANS: B

9. A nurse has already set the agenda during a patient-centered interview. What will the nurse do next? a. Begin with introductions. b. Ask about the chief concerns or problems. c. Explain that the interview will be over in a few minutes. d. Tell the patient "I will be back to administer medications in 1 hour."

ANS: B

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

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

3. Which action indicates a registered nurse is being responsible for making clinical decisions? a.Applies clear textbook solutions to patients' problems b.Takes immediate action when a patient's condition worsens c.Uses only traditional methods of providing care to patients d.Formulates standardized care plans solely for groups of patients

ANS: B Registered nurses are responsible for making clinical decisions to take immediate action when a patient's condition worsens. Patient care should be based on evidence-based practice, not on tradition. Most patients have health care problems for which there are no clear textbook solutions. Care plans should be individualized for each patient, not just for groups.

13. While caring for a hospitalized older-adult female post hip surgery, the nurse is faced with the task of inserting an indwelling urinary catheter, which involves rotating the hip into a contraindicated position. Which action should the nurse take? a.Postpone catheter insertion until the next shift. b.Adapt the positioning technique to the situation. c.Notify the health care provider for a urologist consult. d.Follow textbook procedure with contraindicated position.

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

19. A nurse is reviewing care plans. Which finding, if identified in a plan of care, should the registered nurse revise? a.Patient's outcomes for learning b.Nurse's assumptions about hospital discharge c.Identification of several actual health problems d.Documentation of patient's ability to meet the goal

ANS: B The nurse should not assume when a patient is going to be discharged and document this information in a plan of care. Making assumptions is not an example of a critical thinking skill. The purpose of the nursing process is to diagnose and treat human responses (e.g., patient symptoms, need for knowledge) to actual or potential health problems. Use of the process allows nurses to help patients meet agreed-on outcomes for better health. The patient's outcomes, having several actual health problems, and a description of the patient's abilities to meet the goal are all appropriate to document in the nursing plan of care.

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

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

2. The nurse is teaching a new nurse about protocols. Which information from the new nurse indicates a correct understanding of the teaching? a. Protocols are guidelines to follow that replace the nursing care plan. b. Protocols assist the clinician in making decisions and choosing interventions for specific health care problems or conditions. c. Protocols are policies designating each nurse's duty according to standards of care and a code of ethics. d. Protocols are prescriptive order forms that help individualize the plan of care.

ANS: B A clinical practice guideline or protocol is a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations. This guideline establishes interventions for specific health care problems or conditions. The protocol does not replace the nursing care plan. Evidence-based guidelines from protocols can be incorporated into an individualized plan of care. A clinical guideline is not the same as a hospital policy. Standing orders contain orders for the care of a specific group of patients. A protocol is not a prescriptive order form like a standing order.

18. The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate? a. Assisting with activities of daily living b. Counseling about respite care options c. Teaching range-of-motion exercises d. Consulting with a social worker

ANS: B Family caregivers need assistance in adjusting to the physical and emotional demands of caregiving. Sometimes they need respite (i.e., a break from providing care). Counseling is an example of a direct care nursing intervention. The other options do not address the identified problem of role strain (activities of daily living and range-of-motion exercises). Consulting is an indirect care nursing intervention.

10. A new nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take? a. Act as a leader of the health care team. b. Develop good communication skills. c. Work solely with nurses. d. Avoid conflict.

ANS: B Good communication between other health care providers builds trust and is related to the acceptance of your role in the health care team. As a beginning nurse, you will not be considered a leader of the health care team, but your input as an interdisciplinary team member is critical. Interdisciplinary involves other health care providers, not just nurses. Organizational culture includes leadership, communication processes, shared beliefs about the quality of clinical guidelines, and conflict resolution.

8. A patient visiting with family members in the waiting area tells the nurse "I don't feel good, especially in the stomach." What should the nurse do? a. Request that the family leave, so the patient can rest. b. Ask the patient to return to the room, so the nurse can inspect the abdomen. c. Ask the patient when the last bowel movement was and to lie down on the sofa. d. Tell the patient that the dinner tray will be ready in 15 minutes and that may help the stomach feel better.

ANS: B In this case, the environment needs to be conducive to completing a thorough assessment. A patient's care environment needs to be safe and conducive to implementing therapies. When you need to expose a patient's body parts, do so privately by closing room doors or curtains because the patient will then be more relaxed; the patient needs to return to the room for an abdominal assessment for privacy and comfort. The family can remain in the waiting area while the nurse assists the patient back to the room. Beginning the assessment in the waiting area (lie down on the sofa) in the presence of family and other visitors does not promote privacy and patient comfort. Telling the patient that the dinner tray is almost ready is making an assumption that the abdominal discomfort is due to not eating. The nurse needs to perform an assessment first.

15. The nurse establishes trust and talks with a school-aged patient before administering an injection. Which type of implementation skill is the nurse using? a. Cognitive b. Interpersonal c. Psychomotor d. Judgmental

ANS: B Nursing practice includes cognitive, interpersonal, and psychomotor skills. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly. Cognitive skills include critical thinking and decision-making skills. Psychomotor skill requires the integration of cognitive and motor abilities, such as administering the injection. Being judgmental is not appropriate in nursing; nurses are nonjudgmental.

14. Which statement by a nurse indicates a good understanding about the differences between data validation and data interpretation? a. "Data interpretation occurs before data validation." b. "Validation involves looking for patterns in professional standards." c. "Validation involves comparing data with other sources for accuracy." d. "Data interpretation involves discovering patterns in professional standards."

ANS: C

17. A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse's initial action in response to these observations? a. Proceed to the next patient's room to make rounds. b. Determine the patient does not want any pain medicine. c. Ask the patient about the facial grimacing with movement. d. Administer the pain medication ordered for moderate to severe pain.

ANS: C

3. After reviewing the database, the nurse discovers that the patient's vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? a. Administer scheduled medications assuming that the NAP would have reported abnormal vital signs. b. Have the patient transported to the radiology department for a scheduled x-ray, and review vital signs upon return. c. Ask the NAP to record the patient's vital signs before administering medications. d. Omit the vital signs because the patient is presently in no distress.

ANS: C

4. The nurse is gathering data on a patient. Which data will the nurse report as objective data? a. States "doesn't feel good" b. Reports a headache c. Respiration 16 d. Nauseated

ANS: C

5. A patient expresses fear of going home and being alone. Vital signs are stable and the incision is nearly completely healed. What can the nurse infer from the subjective data? a. The patient can now perform the dressing changes without help. b. The patient can begin retaking all of the previous medications. c. The patient is apprehensive about discharge. d. The patient's surgery was not successful.

ANS: C

6. Which method of data collection will the nurse use to establish a patient's database? a. Reviewing the current literature to determine evidence-based nursing actions b. Checking orders for diagnostic and laboratory tests c. Performing a physical examination d. Ordering medications

ANS: C

7. A nurse is gathering information about a patient's habits and lifestyle patterns. Which method of data collection will the nurse use that will best obtain this information? a. Carefully review lab results. b. Conduct the physical assessment. c. Perform a thorough nursing health history. d. Prolong the termination phase of the interview.

ANS: C

1. Which action should the nurse take when using critical thinking to make clinical decisions? a.Make decisions based on intuition. b.Accept one established way to provide care. c.Consider what is important in a given situation. d.Read and follow the heath care provider's orders.

ANS: C A critical thinker considers what is important in each clinical situation, imagines and explores alternatives, considers ethical principles, and makes informed decisions about the care of patients. Patient care can be provided in many ways. The use of evidence-based knowledge, or knowledge based on research or clinical expertise, makes you an informed critical thinker. Following health care provider's orders is not considered a critical thinking skill. If your knowledge causes you to question a health care provider's order, do so.

2. Which patient scenario of a surgical patient in pain is most indicative of critical thinking? a.Administering pain-relief medication according to what was given last shift b.Offering pain-relief medication based on the health care provider's orders c.Asking the patient what pain-relief methods, pharmacological and nonpharmacological, have worked in the past d.Explaining to the patient that self-reporting of severe pain is not consistent with the minor procedure that was performed

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

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

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

12. Which action should the nurse take to best develop critical thinking skills? a.Study 3 hours more each night. b.Attend all inservice opportunities. c.Actively participate in clinical experiences. d.Interview staff nurses about their nursing experiences.

ANS: C Nursing is a practice discipline. Clinical learning experiences are necessary to acquire clinical decision-making skills. Studying for longer hours, interviewing nurses, and attending inservices do not provide opportunities for clinical decision making, as do actual clinical experiences.

5. Which action demonstrates a nurse utilizing reflection to improve clinical decision making? a.Obtains data in an orderly fashion b.Uses an objective approach in patient situations c.Improves a plan of care while thinking back on interventions effectiveness d.Provides evidence-based explanations and research for care of assigned patients

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

9. A nurse is using the critical thinking skill of evaluation. Which action will the nurse take? a.Examine the meaning of data. b.Support findings and conclusions. c.Review the effectiveness of nursing actions. d.Search for links between the data and the nurse's assumptions.

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

7. The nurse is caring for a patient who requires a complex dressing change. While in the patient's room, the nurse decides to change the dressing. Which action will the nurse take just before changing the dressing? a. Gathers and organizes needed supplies b. Decides on goals and outcomes for the patient c. Assesses the patient's readiness for the procedure d. Calls for assistance from another nursing staff member

ANS: C Always be sure a patient is physically and psychologically ready for any interventions or procedures. After determining the patient's readiness for the dressing change, the nurse gathers needed supplies. The nurse establishes goals and outcomes before intervening. The nurse needs to ask another staff member to help if necessary after determining readiness of the patient.

9. A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom for the first time. Which action should the nurse take initially? a. Ask for at least two other assistive personnel to come to the room. b. Medicate the patient to alleviate discomfort while ambulating. c. Review the patient's activity orders. d. Offer the patient a walker.

ANS: C Before beginning care, review the plan to determine the need for assistance and the type required. Before intervening, the nurse must check the patient's orders. For example, if the patient is on bed rest, the nurse will need to explain the use of a bedpan rather than helping the patient get out of bed to go to the bathroom. Asking for assistive personnel is appropriate after making sure the patient can get out of bed. If the patient is obese, the nurse will likely need assistance in getting the patient to the bathroom. Medicating the patient before checking the orders is not advised in this situation. Before medicating for pain, the nurse needs to perform a pain assessment. Offering the patient a walker is a premature intervention until the orders are verified.

12. Vital signs for a patient reveal a high blood pressure of 187/100. Orders state to notify the health care provider for diastolic blood pressure greater than 90. What is the nurse's firstaction? a. Follow the clinical protocol for a stroke. b. Review the most recent lab results for the patient's potassium level. c. Assess the patient for other symptoms or problems, and then notify the health care provider. d. Administer an antihypertensive medication from the stock supply, and then notify the health care provider.

ANS: C Communication to other health care professionals must be timely, accurate, and relevant to a patient's clinical situation. The best answer is to reassess the patient for other symptoms or problems, and then notify the health care provider according to the orders. Reviewing the potassium level does not address the problem of high blood pressure. The nurse does not follow the protocol since the order says to notify the health care provider. The orders read to notify the health care provider, not administer medications.

1. A nurse is providing nursing care to patients after completing a care plan from nursing diagnoses. In which step of the nursing process is the nurse? a. Assessment b. Planning c. Implementation d. Evaluation

ANS: C Implementation, the fourth step of the nursing process, formally begins after a nurse develops a plan of care. With a care plan based on clear and relevant nursing diagnoses, a nurse initiates interventions that are designed to assist the patient in achieving the goals and expected outcomes needed to support or improve the patient's health status. The nurse gathers data during the assessment phase and mutually sets goals and prioritizes care during the planning phase. During the evaluation phase, the nurse determines the achievement of goals and effectiveness of interventions.

16. The nurse inserts an intravenous (IV) catheter using the correct technique and following the recommended steps according to standards of care and hospital policy. Which type of implementation skill is the nurse using? a. Cognitive b. Interpersonal c. Psychomotor d. Judgmental

ANS: C Nursing practice includes cognitive, interpersonal, and psychomotor skills. Psychomotor skill requires the integration of cognitive and motor abilities. The nurse in this example displayed the psychomotor skill of inserting an intravenous catheter while following standards of care and integrating knowledge of anatomy and physiology. Cognitive involves the application of critical thinking and use of good judgment in making sound clinical decisions. Interpersonal skills involve developing trusting relationships with patients, conveying caring and compassion, and communicating clearly.

5. A nurse is reviewing a patient's care plan. Which information will the nurse identify as a nursing intervention? a. The patient will ambulate in the hallway twice this shift using crutches correctly. b. Impaired physical mobility related to inability to bear weight on right leg. c. Provide assistance while the patient walks in the hallway twice this shift with crutches. d. The patient is unable to bear weight on right lower extremity.

ANS: C Providing assistance to a patient who is ambulating is a nursing intervention. The statement, "The patient will ambulate in the hallway twice this shift using crutches correctly" is a patient outcome. Impaired physical mobility is a nursing diagnosis. The statement that the patient is unable to bear weight and ambulate can be included with assessment data and is a defining characteristic for the diagnosis of Impaired physical mobility.

14. A nurse is making initial rounds on patients. Which intervention for a patient with poor wound healing should the nurse perform first? a. Reinforce the wound dressing as needed with 4 × 4 gauze. b. Perform the ordered dressing change twice daily. c. Observe wound appearance and edges. d. Document wound characteristics.

ANS: C The most appropriate initial intervention is to assess the wound (observe wound appearance and edges). The nurse must assess the wound first before the findings can be documented, reinforcement of the dressing, and the actual skill of dressing changes.

21. A nurse is implementing interventions for a group of patients. Which actions are nursing interventions? (Select all that apply.) a. Order chest x-ray for suspected arm fracture. b. Prescribe antibiotics for a wound infection. c. Reposition a patient who is on bed rest. d. Teach a patient preoperative exercises. e. Transfer a patient to another hospital unit.

ANS: C, D, E A nursing intervention is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. Repositioning, teaching, and transferring a patient are examples of nursing interventions. Ordering a chest x-ray and prescribing antibiotics are examples of medical interventions performed by a health care provider.

20. A nurse is completing an assessment. Which findings will the nurse report as subjective data? (Select all that apply.) a. Patient's temperature b. Patient's wound appearance c. Patient describing excitement about discharge d. Patient pacing the floor while awaiting test results e. Patient's expression of fear regarding upcoming surgery

ANS: C, E

12. While the patient's lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take? a. Tell the patient to just focus on the leg and cast right now. b. Document the sleep patterns and information in the patient's chart. c. Explain that a more thorough assessment will be needed next shift. d. Ask the patient about usual sleep patterns and the onset of having difficulty resting.

ANS: D

13. The nurse begins a shift assessment by examining a surgical dressing that is saturated with serosanguineous drainage on a patient who had open abdominal surgery yesterday (or 1 day ago). Which type of assessment approach is the nurse using? a. Gordon's Functional Health Patterns b. Activity-exercise pattern assessment c. General to specific assessment d. Problem-oriented assessment

ANS: D

14. The nurse enters a room to find the patient sitting up in bed crying. How will the nurse display a critical thinking attitude in this situation? a.Provide privacy and check on the patient 30 minutes later. b.Set a box of tissues at the patient's bedside before leaving the room. c.Limit visitors while the patient is upset. d.Ask the patient about the crying.

ANS: D A clinical sign or symptom (crying) often indicates a variety of problems. Explore and learn more about the patient so as to make appropriate clinical judgments. This is demonstrating curiosity, which is an attitude of critical thinking. Checking on the patient 30 minutes later, providing tissues, and limiting visitors may be appropriate actions but these actions do not address critical thinking.

17. A nurse is using professional standards to influence clinical decisions. What is the rationale for the nurse's actions? a.Establishes minimal passing standards for testing b.Utilizes evidence-based practice based on nurses' needs c.Bypasses the patient's feelings to promote ethical standards d.Uses critical thinking for the highest level of quality nursing care

ANS: D Professional standards promote the highest level of quality nursing care. Application of professional standards requires you to use critical thinking for the good of individuals or groups. Bypassing the patient's feelings is not practicing according to professional standards. The primary purpose of professional standards is not to establish minimal passing standards for testing. Patient care should be based on patient needs, not on nurses' needs.

4. A charge nurse is supervising the care of a new nurse. Which action by a new nurse indicates the charge nurse needs to intervene? a.Making an ethical clinical decision b.Making an informed clinical decision c.Making a clinical decision in the patient's best interest d.Making a clinical decision based on previous shift assessments

ANS: D The charge nurse must intervene when the nurse is using previous shift assessments to make a decision; this is inappropriate. Nurses are responsible for assessing their own patients to make decisions. Making informed, ethical decisions in the patient's best interest is practicing responsibly and does not need follow-up from the charge nurse.

7. A nurse is using a critical thinking model to provide care. Which component is first that helps a nurse make clinical decisions? a.Attitude b.Experience c.Nursing process d.Specific knowledge base

ANS: D The first component of the critical thinking model is a nurse's specific knowledge base. After acquiring a sound knowledge base, the nurse can then apply knowledge to different clinical situations using the nursing process to gain valuable experience. Clinical learning experiences are necessary to acquire clinical decision-making skills. The nursing process competency is the third component of the critical thinking model. Eleven attitudes define the central features of a critical thinker and how a successful critical thinker approaches a problem.

8. Which action by a nurse indicates application of the critical thinking model to make the best clinical decisions? a.Drawing on past clinical experiences to formulate standardized care plans b.Relying on recall of information from past lectures and textbooks c.Depending on the charge nurse to determine priorities of care d.Using the nursing process

ANS: D The nursing process competency is the third component of the critical thinking model. In your practice, you will apply critical thinking components during each step of the nursing process. Care plans should be individualized, and recalling facts does not utilize critical thinking skills to make clinical decisions. The new nurse should not rely on the charge nurse to determine priorities of care.

18. A nurse who is caring for a patient with a pressure ulcer applies the recommended dressing according to hospital policy. Which standard is the nurse following? a.Fairness b.Intellectual standards c.Independent reasoning d.Institutional practice guidelines

ANS: D The standards of professional responsibility that a nurse tries to achieve are the standards cited in Nurse Practice Acts, institutional practice guidelines (hospital/facility policy), and professional organizations' standards of practice (e.g., The American Nurses Association Standards of Professional Performance). Intellectual standards are guidelines or principles for rational thought. Fairness and independent reasoning are two examples of critical thinking attitudes that are designed to help nurses make clinical decisions.

11. Which action should the nurse take first during the initial phase of implementation? a. Determine patient outcomes and goals. b. Prioritize patient's nursing diagnoses. c. Evaluate interventions. d. Reassess the patient.

ANS: D Assessment is a continuous process that occurs each time the nurse interacts with a patient. During the initial phase of implementation, reassess the patient. Determining the patient's goals and prioritizing diagnoses take place in the planning phase before choosing interventions. Evaluation is the last step of the nursing process.

6. A patient recovering from a leg fracture after a fall reports having dull pain in the affected leg and rates it as a 7 on a 0 to 10 scale. The patient is not able to walk around in the room with crutches because of leg discomfort. Which nursing intervention is priority? a. Assist the patient to walk in the room with crutches. b. Obtain a walker for the patient. c. Consult physical therapy. d. Administer pain medication.

ANS: D The patient's pain is a 7, indicating the priority is pain relief (administer pain medication). Acute pain is the priority because the nurse can address the problem of immobility after the patient receives adequate pain relief. Assisting the patient to walk or obtaining a walker will not address the pain the patient is experiencing.

1. After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse's actions? a.To form a language that can be encoded only by nurses b.To distinguish the nurse's role from the physician's role c.To develop clinical judgment based on other's intuition d.To help nurses focus on the scope of medical practice

B

11. The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance? a.Decreased oral intake and decreased oxygen saturation when ambulating b.Decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed c.Reports of shortness of breath when getting out of bed and a productive cough d.Productive cough and decreased oral intake

B

13. A new nurse writes the following nursing diagnoses on a patient's care plan. Which nursing diagnosis will cause the nurse manager to intervene? a.Wandering b.Hemorrhage c.Urinary retention d.Impaired swallowing

B

18. Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea? a."What types of foods do you think caused your upset stomach?" b."How many bowel movements a day have you had?" c."Are you able to get to the bathroom in time?" d."What medications are you currently taking?"

B

2. Which diagnosis will the nurse document in a patient's care plan that is NANDA-I approved? a.Sore throat b.Acute pain c.Sleep apnea d.Heart failure

B

A new nurse is confused about using evaluative measures when caring for patients and asks the charge nurse for an explanation. Which response by the charge nurse is most accurate? a. "Evaluative measures are multiple-page documents used to evaluate nurse performance." b. "Evaluative measures include assessment data used to determine whether patients have met their expected outcomes and goals." c. "Evaluative measures are used by quality assurance nurses to determine the progress a nurse is making from novice to expert nurse." d. "Evaluative measures are objective views for completion of nursing interventions."

B

A nurse is getting ready to discharge a patient who has a problem with physical mobility. What does the nurse need to do before discontinuing the patient's plan of care? a. Determine whether the patient has transportation to get home. b. Evaluate whether patient goals and outcomes have been met. c. Establish whether the patient has a follow-up appointment scheduled. d. Ensure that the patient's prescriptions have been filled to take home.

B

A nurse is modifying a patient's care plan after evaluation of patient care. In which order, starting with the first step, will the nurse perform the tasks? 1. Revise nursing diagnosis. 2. Reassess blood pressure reading. 3. Retake blood pressure after medication. 4. Administer new blood pressure medication. 5. Change goal to blood pressure less than 140/90. a. 1, 5, 2, 4, 3 b. 2, 1, 5, 4, 3 c. 4, 3, 1, 5, 2 d. 5, 4, 5, 1, 2

B

A nurse is providing education to a patient about self-administering subcutaneous injections. The patient demonstrates the self-injection. Which type of indicator did the nurse evaluate? a. Health status b. Health behavior c. Psychological self-control d. Health service utilization

B

A nurse performed an assessment on the patient. Which of the following is objective? A.Pain in the left leg B.Elevated blood pressure C.Fear of impending surgery D. Discomfort upon breathing

B

In preparing to conduct a physical examination on a client, the nurse plans to: A.Take long, detailed notes of all the findings during the exam B.Perform painful procedures at the end of the exam C.Perform painful procedures at the beginning of the exam D. Keep the TV or radio on to distract the client throughout the exam

B

The client appears to be breathing faster than before. What should the nurse do? A.Ask the client if he has felt stressful B.Count the clients rate of respiration C.Palpate the clients own radial pulse D.Have the client lay down on the bed

B

The nurse is caring for a patient who has an order to change a dressing twice a day, at 0600 and 1800. At 1400, the nurse notices that the dressing is saturated and leaking. What is the nurse's next action? a. Wait and change the dressing at 1800 as ordered. b. Revise the plan of care and change the dressing now. c. Reassess the dressing and the wound in 2 hours. d. Discontinue the plan of care for wound care.

B

The nurse is evaluating whether patient goals and outcomes have been met for a patient with physical mobility problems due to a fractured leg. Which finding indicates the patient has met an expected outcome? a. The nurse provides assistance while the patient is walking in the hallways. b. The patient is able to ambulate in the hallway with crutches. c. The patient will deny pain while walking in the hallway. d. The patient's level of mobility will improve.

B

There are common misconceptions and myths about pain. In regard to the pain experience, which of these is TRUE? A.Chronic pain is mostly psychological in nature B.The client is the best authority on the pain experience C.The amount of tissue damage is eflected in the degree of pain perceived D. Regular use of analgesics leads to drug addiction

B

The patient has new-onset restlessness and confusion. Pulse rate is elevated, as is respiratory rate. Oxygen saturation is 94%. The nurse ignores the pulse oximeter reading and calls the health care provider for orders because the pulse oximetry reading is inaccurate. Which factors can cause inaccurate pulse oximetry readings? (Select all that apply.) a. O2 saturations (SaO2) > 70% b. Carbon monoxide inhalation c. Hypothermic fingers d. Intravascular dyes e. Nail polish f. Jaundice

B, C, D, E, F

Which nursing actions will the nurse perform in the evaluation phase of the nursing process? (Select all that apply.) a. Set priorities for patient care. b. Determine whether outcomes or standards are met. c. Ambulate patient 25 feet in the hallway. d. Document results of goal achievement. e. Use self-reflection and correct errors.

B, D, E

A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective? a. "I will only need to be on this pain medication." b. "I feel less anxiety about the possibility of overdosing." c "I can receive the pain medication as frequently as I need to." d. "I need the nurse to notify me when it is time for another dose."

B: "I feel less anxiety about the possibility of overdosing."

A nurse is caring for a patient with chronic pain. Which statement by the nurse indicates an understanding of pain management? a."This patient says the pain is a 5 but is not acting like it. I am not going to give any pain medication."b."I need to reassess the patient's pain 1 hour oral pain medication." c. "It wasn't time for the patient's medication, so when it was requested, I gave a placebo." d. "The patient is sleeping, so I pushed the PCA button."

B: "I need to reassess the patient's pain 1 hour oral pain medication."

The nurse is assessing how a patient's pain is affecting mobility. Which assessment question is most appropriate? a. "Have you considered working with a physical therapist?" b. "What activities, if any, has your pain prevented you from doing?" c. "Would you please rate your pain on a scale from 0 to 10 for me?" d. "When does your pain medication typically take effect on your pain?"

B: "What activities, if any, has your pain prevented you from doing?"

The nurse is caring for a patient to ease modifiable factors that contribute to pain. Which areas did the nurse focus on with this patient? a. Age and gender b. Anxiety and fear c. Culture and ethnicity d. Previous pain experiences and cognitive abilities

B: Anxiety and fear

An oriented patient has recently had surgery. Which action is best for the nurse to take to assess this patient's pain? a. Assess the patient's body language. b. Ask the patient to rate the level of pain. c. Observe the cardiac monitor for increased heart rate. d. Have the patient describe the effect of pain on the ability to cope.

B: Ask the patient to rate the level of pain.

The nurse is caring for an infant in the intensive care unit. Which information should the nurse consider when planning care for this patient?a. Infants cannot be assessed for pain. b. Infants respond behaviorally and physiologically to painful stimuli. c. Infants cannot tolerate analgesics owing to an underdeveloped metabolism. d. Infants have a decreased sensitivity to pain when compared with older children.

B: Infants respond behaviorally and physiologically to painful stimuli.

A patient is receiving opioid medication through an epidural infusion. Which action will the nurse take? a. Restrict fluid intake. b. Label the tubing that leads to the epidural catheter. c. Apply a gauze dressing to the epidural catheter insertion site. d. Ask the nursing assistive personnel to check on the patient at least once every 2 hours.

B: Label the tubing that leads to the epidural catheter.

A patient arrives at the emergency department experiencing a headache and rates the pain as 7 on a 0 to 10 pain scale. Which nonpharmacological intervention does the nurse implement for this patient while awaiting orders for pain medication from the health care provider? a. Reassures the patient that the provider will come to the emergency department soon b. Softly plays music that the patient finds relaxing c. Frequently reassesses the patient's pain scores d. Teaches the patient how to do yoga

B: Softly plays music that the patient finds relaxing

A nurse is caring for a patient who fell on the ice and has connective tissue damage in the wrist and hand. The patient describes the pain as throbbing. Which type of pain does the nurse document in this patient's medical record. a. Visceral pain b. Somatic pain c. Centrally generated pain d. Peripherally generated pain

B: Somatic pain

The nurse is assessing a patient for opioid tolerance. Which finding supports the nurse's assessment? a. The patient needed a substantial dose of naloxone (Narcan). b. The patient needs increasingly higher doses of opioid to control pain. c. The patient no longer experiences sedation from the usual dose of opioid. d. The patient asks for pain medication close to the time it is due around the clock.

B: The patient needs increasingly higher doses of opioid to control pain.

A patient who had a motor vehicle crash 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). Which assessment finding indicates effective pain management with the PCA? a. The patient is sleeping and is difficult to arouse. b. The patient rates pain at a level of 2 on a 0 to 10 scale. c. The patient has sufficient medication left in the PCA syringe. d. The patient presses the control button to deliver pain medication.

B: The patient rates pain at a level of 2 on a 0 to 10 scale.

A nurse is caring for a patient who recently had spinal surgery. The nurse knows that patients usually experience acute pain following this type of surgery. The patient refuses to get up and walk and is not moving around in the bed. However, the patient is stoic and denies experiencing pain at this time. What most likely explains this patient's behavior? a. The surgery successfully cured the patient's pain. b. The patient's culture is possibly influencing the patient's experience of pain. c. The primary health care provider did not prescribe the correct amount of medication. d. The nurse is allowing personal beliefs about pain to influence pain management at this time.

B: The patient's culture is possibly influencing the patient's experience of pain.

10. A nurse adds the following diagnosis to a patient's care plan: Constipation related to decreased gastrointestinal motility secondary to pain medication administration as evidenced by the patient reporting no bowel movement in seven days, abdominal distention, and abdominal pain. Which element did the nurse write as the defining characteristic? a.Decreased gastrointestinal motility b.Pain medication c.Abdominal distention d.Constipation

C

12. A nurse performs an assessment on a patient. Which assessment data will the nurse use as an etiology for Acute pain? a.Discomfort while changing position b.Reports pain as a 7 on a 0 to 10 scale c.Disruption of tissue integrity d.Dull headache

C

14. A patient has a bacterial infection in left lower leg. Which nursing diagnosis will the nurse add to the patient's care plan? a.Infection b.Risk for infection c.Impaired skin integrity d.Staphylococcal leg infection

C

16. A charge nurse is evaluating a new nurse's plan of care. Which finding will cause the charge nurse to follow up? a.Assigning a documented nursing diagnosis of Risk for infection for a patient on intravenous (IV) antibiotics b.Completing an interview and physical examination before adding a nursing diagnosis c.Developing nursing diagnoses before completing the database d.Including cultural and religious preferences in the database

C

17. A patient exhibits the following symptoms: tachycardia, increased thirst, headache, decreased urine output, and increased body temperature. The nurse analyzes the data. Which nursing diagnosis will the nurse assign to the patient? a.Adult failure to thrive b.Hypothermia c.Deficient fluid volume d.Nausea

C

5. A nurse is using assessment data gathered about a patient and combining critical thinking to develop a nursing diagnosis. What is the nurse doing? a.Assigning clinical cues b.Defining characteristics c.Diagnostic reasoning d.Diagnostic labeling

C

6. A patient presents to the emergency department following a motor vehicle crash and suffers a right femur fracture. The leg is stabilized in a full leg cast. Otherwise, the patient has no other major injuries, is in good health, and reports only moderate discomfort. Which is the most pertinent nursing diagnosis the nurse will include in the plan of care? a.Posttrauma syndrome b.Constipation c.Acute pain d.Anxiety

C

8. A patient with a spinal cord injury is seeking to enhance urinary elimination abilities by learning self-catheterization versus assisted catheterization by home health nurses and family members. The nurse adds Readiness for enhanced urinary elimination in the care plan. Which type of diagnosis did the nurse write? a.Risk b.Problem focused c.Health promotion d.Collaborative problem

C

A new nurse asks the preceptor to describe the primary purpose of evaluation. Which statement made by the nursing preceptor is most accurate? a. "An evaluation helps you determine whether all nursing interventions were completed." b. "During evaluation, you determine when to downsize staffing on nursing units." c. "Nurses use evaluation to determine the effectiveness of nursing care." d. "Evaluation eliminates unnecessary paperwork and care planning."

C

A nurse is evaluating the goal of acceptance of body image in a young teenage girl. Which statement made by the patient is the best indicator of progress toward the goal? a. "I'm worried about what those other girls will think of me." b. "I can't wear that color. It makes my hips stick out." c. "I'll wear the blue dress. It matches my eyes." d. "I will go to the pool next summer."

C

After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen for the patient's headache. Which action by the nurse is priority for this patient? a. Eliminate headache from the nursing care plan. b. Direct the nursing assistive personnel to ask if the headache is relieved. c. Reassess the patient's pain level in 30 minutes. d. Revise the plan of care.

C

As the nurse enters the room, they see their client ambulating, saying, "I feel dizzy". The nurse should: A.Scream for help B.Take the clients blood pressure C.Assist the client into a sitting position D.Tell the client to take several deep breaths

C

The nurse is caring for a patient who has an open wound and is evaluating the progress of wound healing. Which priority action will the nurse take? a. Ask the nursing assistive personnel if the wound looks better. b. Document the progress of wound healing as "better" in the chart. c. Measure the wound and observe for redness, swelling, or drainage. d. Leave the dressing off the wound for easier access and more frequent assessments.

C

21. A nurse is developing nursing diagnoses for a group of patients. Which nursing diagnoses will the nurse use? (Select all that apply.) a.Anxiety related to barium enema b.Impaired gas exchange related to asthma c.Impaired physical mobility related to incisional pain d.Nausea related to adverse effect of cancer medication e.Risk for falls related to nursing assistive personnel leaving bedrail down

C D

A nurse is caring for a patient who is experiencing pain following abdominal surgery. Which information is important for the nurse to share with the patient when providing patient education about effective pain management?a."To prevent overdose, you need to wait to ask for pain medication until you begin to experience pain."b."You should take your medication after you walk to make sure you do not fall while you are walking."c."We should work together to create a schedule to provide regular dosing of medication."d."When you experience severe pain, you will need to take oral pain medications."

C: "We should work together to create a schedule to provide regular dosing of medication."

A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient's blood pressure is 110/60 mm Hg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic? a. "Your vitals do not show that you are having pain; can you describe your pain?" b. "OK, I will go get you some narcotic pain relievers immediately." c. "What would you like to try to alleviate your pain?" d. "You do not look like you are in pain."

C: "What would you like to try to alleviate your pain?"

The nurse has brought a patient the scheduled pain medication. The patient asks the nurse to wait to give pain medication until the time for the dressing change, which is 2 hours away. Which response by the nurse is most therapeutic? a. "This medication will still be providing you relief at the time of your dressing change." b. "OK, swallow this pain pill, and I will return in a minute to change your dressing." c. "Would you like medication to be given for dressing changes in addition to your regularly scheduled medication?" d. "Your medication is scheduled for this time, and I can't adjust the time for you. I'm sorry, but you must take your pill right now."

C: "Would you like medication to be given for dressing changes in addition to your regularly scheduled medication?"

The nurse is preparing pain medications. To which patient does the nurse anticipate administering an opioid fentanyl patch? a. A 15-year-old adolescent with a fractured femur b. A 30-year-old adult with cellulitis c. A 50-year-old patient with prostate cancer d. An 80-year-old patient with a broken hip

C: A 50-year-old patient with prostate cancer

A nurse receives an order from a health care provider to administer hydrocodone and acetaminophen (Vicodin ES 7.5/750), to a patient who is experiencing 8/10 postsurgical pain. The order is to give 2 tablets every 6 hours by mouth as needed for pain. What is the nurse's next best action? a. Give the Vicodin ES to the patient immediately because the patient is experiencing severe pain. b. Ask the health care provider for a nonsteroidal antiinflammatory drug (NSAID) order. c. Ask the health care provider to verify the dosage and frequency of the medication. d. Give the Vicodin ES in addition to playing soothing music for the patient.

C: Ask the health care provider to verify the dosage and frequency of the medication.

The nurse is evaluating the effectiveness of guided imagery for pain management as used for a patient who has second- and third-degree burns and needs extensive dressing changes. Which finding best indicates the effectiveness of guided imagery? a. The patient's facial expressions are stoic during the procedure. b. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10. c .The patient's need for analgesic medication decreases during the dressing changes. d. The patient asks for pain medication during the dressing changes only once throughout the procedure.

C: The patient's need for analgesic medication decreases during the dressing changes.

3. A nurse develops a nursing diagnostic statement for a patient with a medical diagnosis of pneumonia with chest x-ray results of lower lobe infiltrates. Which nursing diagnosis did the nurse write? a.Ineffective breathing pattern related to pneumonia b.Risk for infection related to chest x-ray procedure c.Risk for deficient fluid volume related to dehydration d.Impaired gas exchange related to alveolar-capillary membrane changes

D

A nurse completes a thorough database and carries out nursing interventions based on priority diagnoses. Which action will the nurse take next? a. Assessment b. Planning c. Implementation d. Evaluation

D

A nurse determines that the patient's condition has improved and has met expected outcomes. Which step of the nursing process is the nurse exhibiting? a. Assessment b. Planning c. Implementation d. Evaluation

D

A nurse is evaluating goals and expected outcomes for a confused patient. Which finding indicates positive progress toward resolving the confusion? a. Patient wanders halls at night. b. Patient's side rails are up with bed alarm activated. c. Patient denies pain while ambulating with assistance. d. Patient correctly states names of family members in the room.

D

A patient was recently diagnosed with pneumonia. The nurse and the patient have established a goal that the patient will not experience shortness of breath with activity in 3 days with an expected outcome of having no secretions present in the lungs in 48 hours. Which evaluative measure will the nurse use to demonstrate progress toward this goal? a. No sputum or cough present in 4 days b. Congestion throughout all lung fields in 2 days c. Shallow, fast respirations 30 breaths per minute in 1 day d. Lungs clear to auscultation following use of inhaler

D

A student nurse is working with a client who has asthma. What does the student expect to hear? A.Coarse crackles and bubbling B.Dry, grating noises C.Gasping zombie sounds D. High pitched musical sounds

D

The nurse is assessing a patient with chest pain the the Emergency Department - what is the most important information? A.A family history of heart problems B.Medications currently being taken at home C.Questions or concerns about the hospitalization D. he onset, severity, and duration of the chest pain

D

The nurse is evaluating whether a patient's turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule? a. Staff documentation of turning the patient every 2 hours b. Presence of redness only on the heels of the patient c. Patient's eating 100% of all meals d. Absence of skin breakdown

D

A patient who has had type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower leg. The nurse is providing education to the patient to prevent injury to the feet by wearing shoes or slippers when walking. Which statement made by the nurse best explains the rationale for this instruction? a. "Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet." b. "Shoes provide non pharmacological pain relief to people with diabetes and peripheral neuropathy." c. "The neurological gates open when wearing shoes, which protects your feet." d. "If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot."

D: "If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot."

The nurse is caring for a patient who suddenly experiences chest pain. What is the nurse's first priority? a. Call the rapid response team. b. Start an intravenous (IV) line. c. Administer pain-relief medications. d. Ask the patient to rate and describe the pain.

D: Ask the patient to rate and describe the pain.

A nurse is providing medication education to a patient who just started taking ibuprofen. Which information will the nurse include in the teaching session? a. Ibuprofen helps to depress the central nervous system to decrease pain perception. b. Ibuprofen reduces anxiety, which will help you cope with your pain. c. Ibuprofen binds with opiate receptors to reduce your pain. d. Ibuprofen inhibits the production of prostaglandins.

D: Ibuprofen inhibits the production of prostaglandins.

A woman is in labor and refuses to receive any sort of anesthesia medication. Which alternative treatment is best for this patient?a. Transcutaneous electrical nerve stimulation (TENS) b. Herbal supplements with analgesic effects c. Pudendal block (regional anesthesia) d. Relaxation and guided imagery

D: Relaxation and guided imagery

The nurse is administering pain medication for several patients. Which patient does the nurse administer medication to first? a. The patient who needs to be premedicated before walking b. The patient who has a PCA running that needs the syringe replaced c. The patient who needs to take a scheduled dose of maintenance pain medication d. The patient who is experiencing 8/10 pain and has an immediate order for pain medication

D: The patient who is experiencing 8/10 pain and has an immediate order for pain medication

A nurse is assessing a patient who started to have severe pain 3 days ago. When the nurse asks the patient to describe the pain, the patient states, "The pain feels like it is in my stomach. It is a burning pain, and it spreads out in a circle around the spot where it hurts the most." Which type of pain does the nurse document the patient is having at this time? a. Superficial pain b. Idiopathic pain c. Chronic pain d. Visceral pain

D: Visceral pain

A nurse is preparing to make a consult. In which order, beginning with the first step, will the nurse take? 1. Identify the problem. 2. Discuss the findings and recommendation. 3. Provide the consultant with relevant information about the problem. 4. Contact the right professional, with the appropriate knowledge and expertise. 5. Avoid bias by not providing a lot of information based on opinion to the consultant. a. 1, 4, 3, 5, 2 b. 4, 1, 3, 2, 5 c. 1, 4, 5, 3, 2 d. 4, 3, 1, 5, 2

a. 1, 4, 3, 5, 2

The nurse is caring for a newborn infant in the hospital nursery and notices that the infant is breathing rapidly but is pink, warm, and dry. Which normal respiratory rate will the nurse consider when planning care for this newborn? a. 30 to 60 b. 22 to 28 c. 16 to 20 d. 10 to 15

a. 30 to 60

A hospital's wound nurse consultant made a recommendation for nurses on the unit about how to care for the patient's dressing changes. Which action should the nurses take next? a. Include dressing change instructions and frequency in the care plan. b. Assume that the wound nurse will perform all dressing changes. c. Request that the health care provider look at the wound. d. Encourage the patient to perform the dressing changes.

a. Include dressing change instructions and frequency in the care plan.

A nurse is caring for a patient with a nursing diagnosis of Constipation related to slowed gastrointestinal motility secondary to pain medications. Which outcome is most appropriate for the nurse to include in the plan of care? a. Patient will have one soft, formed bowel movement by end of shift. b. Patient will walk unassisted to bathroom by the end of shift. c. Patient will be offered laxatives or stool softeners this shift. d. Patient will not take any pain medications this shift.

a. Patient will have one soft, formed bowel movement by end of shift.

A nurse is developing a care plan for a patient with a pelvic fracture on bed rest. Which goal statement is realistic for the nurse to assign to this patient? a. Patient will increase activity level this shift. b. Patient will turn side to back to side with assistance every 2 hours. c. Patient will use the walker correctly to ambulate to the bathroom as needed. d. Patient will use a sliding board correctly to transfer to the bedside commode as needed.

a. Patient will increase activity level this shift.

The patient with heart failure is restless with a temperature of 102.2° F (39° C). Which action will the nurse take? a. Place the patient on oxygen. b. Encourage the patient to cough. c.Restrict the patient's fluid intake d. Increase the patient's metabolic rate

a. Place the patient on oxygen.

The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement? a. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist. b. Place the tips of the first two fingers over the groove along the little finger side of the patient's wrist. c. Place the thumb over the groove along the little finger side of the patient's wrist. d. Place the thumb over the groove along the thumb side of the patient's wrist.

a. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist.

A nurse is developing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Risk for loneliness related to impaired verbal communication? a. Provide the patient with a writing board each shift. b. Obtain an interpreter for the patient as soon as possible. c. Assist the patient in performing swallowing exercises each shift. d. Ask the family to provide a sitter to remain with the patient at all times.

a. Provide the patient with a writing board each shift.

A nurse is planning care for a patient with a nursing diagnosis of Impaired skin integrity. The patient needs many nursing interventions, including a dressing change, several intravenous antibiotics, and a walk. Which factors does the nurse consider when prioritizing interventions? (Select all that apply.) a. Rank all the patient's nursing diagnoses in order of priority. b. Do not change priorities once they've been established. c. Set priorities based solely on physiological factors. d. Consider time as an influencing factor. e. Utilize critical thinking.

a. Rank all the patient's nursing diagnoses in order of priority. d. Consider time as an influencing factor. e. Utilize critical thinking.

The following statements are on a patient's nursing care plan. Which statement will the nurse use as an outcome for a goal of care? a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. b. The patient will demonstrate increased tolerance to activity over the next month. c. The patient will understand needed dietary changes by discharge. d. The patient will demonstrate increased mobility in 2 days.

a. The patient will verbalize a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift.

When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding? a. This is normal for an infant. b. This is too fast for an infant. c. This is too slow for an infant. d. This is not a rate for an infant but for a toddler.

a. This is normal for an infant.

The nurse is caring for a patient who has a temperature reading of 100.4° F (38° C). The patient's last two temperature readings were 98.6° F (37° C) and 96.8° F (36° C). Which action will the nurse take? a. Wait 30 minutes and recheck the patient's temperature. b. Assume that the patient has an infection and order blood cultures. c. Encourage the patient to move around to increase muscular activity. d. Be aware that temperatures this high are harmful and affect patient safety

a. Wait 30 minutes and recheck the patient's temperature.

The patient's blood pressure is 140/60. Which value will the nurse record for the pulse pressure? a. 60 b. 80 c. 140 d. 200

b. 80

The patient requires temperatures to be taken every 2 hours. Which task will the nurse assign to an RN? a. Using appropriate route and device b. Assessing changes in body temperature c. Being aware of the usual values for the patient d. Obtaining temperature measurement at ordered frequency

b. Assessing changes in body temperature

The nurse is caring for an infant and is obtaining the patient's vital signs. Which artery will the nurse use to best obtain the infant's pulse? a. Radial b. Brachial c. Femoral d. Popliteal

b. Brachial

Which action will the nurse take after the plan of care for a patient is developed? a. Place the original copy in the chart, so it cannot be tampered with or revised. b. Communicate the plan to all health care professionals involved in the patient's care. c. File the plan of care in the administration office for legal examination. d. Send the plan of care to quality assurance for review.

b. Communicate the plan to all health care professionals involved in the patient's care.

The patient has a temperature of 105.2° F. The nurse is attempting to lower temperature by providing tepid sponge baths and placing cool compresses in strategic body locations. Which technique is the nurse using to lower the patient's temperature? a. Radiation b. Conduction c. Convection d. Evaporation

b. Conduction

The nurse is preparing to obtain an oxygen saturation reading on a toddler. Which action will the nurse take? a. Secure the sensor to the toddler's earlobe. b. Determine whether the toddler has a latex allergy. c. Place the sensor on the bridge of the toddler's nose. d. Overlook variations between an oximeter pulse rate and the toddler's pulse rate.

b. Determine whether the toddler has a latex allergy.

Which action indicates the nurse is using a PICOT question to improve care for a patient? a. Practices nursing based on the evidence presented in court b. Implements interventions based on scientific research c. Uses standardized care plans for all patients. d. Plans care based on tradition

b. Implements interventions based on scientific research

When assessing the temperature of newborns and children, the nurse decides to utilize a temporal artery thermometer. What is the rationale for the nurse's action? a. It is not affected by skin moisture. b. It has no risk of injury to patient or nurse. c. It reflects rapid changes in radiant temperature. d. It is accurate even when the forehead is covered with hair.

b. It has no risk of injury to patient or nurse.

The patient was found unresponsive in an apartment and is being brought to the emergency department. The patient has arm, hand, and leg edema, temperature is 95.6° F, and hands are cold secondary to a history of peripheral vascular disease. It is reported that the patient has a latex allergy. What should the nurse do to quickly measure the patient's oxygen saturation? a. Attach a finger probe to the patient's index finger. b. Place a nonadhesive sensor on the patient's earlobe. c. Attach a disposable adhesive sensor to the bridge of the patient's nose. d. Place the sensor on the same arm that the electronic blood pressure cuff is on.

b. Place a nonadhesive sensor on the patient's earlobe.

The nurse is caring for an older-adult patient and notes that the temperature is 96.8° F (36° C). How will the nurse interpret this finding? a. The patient has hyperthermia. b. The patient has a normal temperature. c. The patient is suffering from hypothermia. d. The patient is demonstrating increased metabolism.

b. The patient has a normal temperature.

A nurse is completing a care plan. Which intervention is most appropriate for the nursing diagnostic statement Impaired skin integrity related to shearing forces? a. Administer pain medication every 4 hours as needed. b. Turn the patient every 2 hours, even hours. c. Monitor vital signs, especially rhythm. d. Keep the bed side rails up at all times.

b. Turn the patient every 2 hours, even hours.

When taking an adult blood pressure, the onset of the sound the nurse hears is at 138, the muffled sound the nurse hears is at 70, and the disappearance of the sound the nurse hears is at 62. How should the nurse record this finding? a. 68 b. 76 c. 138/62 d. 138/70

c. 138/62

A nurse is teaching the staff about the benefits of Nursing Outcomes Classification. Which information should the nurse include in the teaching session? (Select all that apply.) a. Includes seven domains for level 1 b. Uses an easy 3-point Likert scale c. Adds objectivity to judging a patient's progress d. Allows choice in which interventions to choose e. Measures nursing care on a national and international level

c. Adds objectivity to judging a patient's progress e. Measures nursing care on a national and international level

The nurse is caring for a small child and needs to obtain vital signs. Which site choice from the nursing assistive personnel (NAP) will cause the nurse to praise the NAP? a. Ulnar site b. Radial site c. Brachial site d. Femoral site

c. Brachial site

The patient is found to be unresponsive and not breathing. Which pulse site will the nurse use? a. Radial b. Apical c. Carotid d. Brachial

c. Carotid

A patient presents with heatstroke. The nurse uses cool packs, cooling blanket, and a fan. Which technique is the nurse using when the fan produces heat loss? a. Radiation b. Conduction c. Convection d. Evaporation

c. Convection

The nurse is caring for a patient who has an elevated temperature. Which principle will the nurse consider when planning care for this patient? a. Hyperthermia and fever are the same thing. b. Hyperthermia is an upward shift in the set point. c. Hyperthermia occurs when the body cannot reduce heat production. d. Hyperthermia results from a reduction in thermoregulatory mechanisms

c. Hyperthermia occurs when the body cannot reduce heat production.

. The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform? a. Dependent b. Independent c. Interdependent d. Physician-initiated

c. Interdependent

Which information indicates a nurse has a good understanding of a goal? a. It is a statement describing the patient's accomplishments without a time restriction. b. It is a realistic statement predicting any negative responses to treatments. c. It is a broad statement describing a desired change in a patient's behavior. d. It is a measurable change in a patient's physical state.

c. It is a broad statement describing a desired change in a patient's behavior.

The nurse is assessing the patient's respiration's. Which action by the nurse is most appropriate? a. Inform the patient that she is counting respirations. b. Do not touch the patient until completed. c. Obtain without the patient knowing. d. Estimate respirations.

c. Obtain without the patient knowing.

A nurse is focusing on temperature regulation of newborns and infants. Which action will the nurse take? a. Apply just a diaper. b. Double the clothing. c. Place a cap on their heads. d. Increase room temperature to 90 degrees.

c. Place a cap on their heads.

The nurse completes a thorough assessment of a patient and analyzes the data to identify nursing diagnoses. Which step will the nurse take next in the nursing process? a. Assessment b. Diagnosis c. Planning d. Implementation

c. Planning

A nurse is caring for a patient who smokes and drinks caffeine. Which point is important for the nurse to understand before assessing the patient's BP? a. Smoking increases BP for up to 3 hours. b. Caffeine increases BP for up to 15 minutes. c. Smoking result in vasoconstriction, falsely elevating BP. d. Caffeine intake should not have occurred 30 to 40 minutes before BP measurement.

c. Smoking result in vasoconstriction, falsely elevating BP.

A patient has a head injury and damages the hypothalamus. Which vital sign will the nurse monitor most closely? a. Pulse b. Respirations c. Temperature d. Blood pressure

c. Temperature

A charge nurse is reviewing outcome statements using the SMART approach. Which patient outcome statement will the charge nurse praise to the new nurse? a. The patient will ambulate in hallways. b. The nurse will monitor the patient's heart rhythm continuously this shift. c. The patient will feed self at all mealtimes today without reports of shortness of breath. d. The nurse will administer pain medication every 4 hours to keep the patient free from discomfort.

c. The patient will feed self at all mealtimes today without reports of shortness of breath.

The patient is being admitted to the emergency department following a motor vehicle accident.The patient's jaw is broken with several broken teeth. The patient is ashen, has cool skin, and is diaphoretic. Which route will the nurse use to obtain an accurate temperature reading? a. Oral b. Axillary c. Tympanic d. Tempora

c. Tympanic

The new nurse is caring for six patients in this shift. After completing their assessments, the nurse asks where to begin in developing care plans for these patients. Which statement is an appropriate suggestion by another nurse? a. "Choose all the interventions and perform them in order of time needed for each one." b. "Make sure you identify the scientific rationale for each intervention first." c. "Decide on goals and outcomes you have chosen for the patients." d. "Begin with the highest priority diagnoses, then select appropriate interventions."

d. "Begin with the highest priority diagnoses, then select appropriate interventions."

A nurse is reviewing capnography results for adult patients. Which value will cause the nurse to follow up? a. 35 mm Hg b. 40 mm Hg c. 45 mm Hg d. 50 mm Hg

d. 50 mm Hg

A patient's plan of care includes the goal of increasing mobility this shift. As the patient is ambulating to the bathroom at the beginning of the shift, the patient suffers a fall. Which initial action will the nurse take next to revise the plan of care? a. Consult physical therapy. b. Establish a new plan of care. c. Set new priorities for the patient. d. Assess the patient.

d. Assess the patient.

A patient has reduced muscle strength following a left-sided stroke and is at risk for falling. Which intervention is most appropriate for the nursing diagnostic statement Risk for falls? a. Keep all side rails down at all times. b. Encourage patient to remain in bed most of the shift. c. Place patient in room away from the nurses' station if possible. d. Assist patient into and out of bed every 4 hours or as tolerated.

d. Assist patient into and out of bed every 4 hours or as tolerated.

A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing? a. Collaborative b. Independent c. Interdependent d. Dependent

d. Dependent

A patient's son decides to stay at the bedside while his father is confused. When developing the plan of care for this patient, what should the nurse do? a. Individualize the care plan only according to the patient's needs. b. Request that the son leave at bedtime, so the patient can rest. c. Suggest that a female member of the family stay with the patient. d. Involve the son in the plan of care as much as possible.

d. Involve the son in the plan of care as much as possible.

The nurse is working the night shift on a surgical unit and is making 4:00 AM rounds. The nurse notices that the patient's temperature is 96.8° F (36° C), whereas at 4:00 PM the preceding day, it was 98.6° F (37° C). What should the nurse do? a. Call the health care provider immediately to report a possible infection. b. Administer medication to lower the temperature further. c. Provide another blanket to conserve body temperature. d. Realize that this is a normal temperature variation.

d. Realize that this is a normal temperature variation.

A nursing assessment for a patient with a spinal cord injury leads to several pertinent nursing diagnoses. Which nursing diagnosis is the highest priority for this patient? a. Risk for impaired skin integrity b. Risk for infection c. Spiritual distress d. Reflex urinary incontinence

d. Reflex urinary incontinence

The patient requires routine temperature assessment but is confused, easily agitated, and has a history of seizures. Which route will the nurse choose to obtain the pt's temp? a. Oral b. Rectal c. Axillary d. Tympanic

d. Tympanic