exam 1 fundamentals

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.

A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which factors? (Select all that apply.) a. Confusion b. Evidence of abuse c. Incontinence d. Problems with behavior e. Sleep disorders

ANS: A, C, E SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of falls.

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

ANS: B Hemorrhage is a collaborative problem, not a nursing diagnosis; the nurse manager will need to correct this misunderstanding with the new nurse. Nurses manage collaborative problems such as hemorrhage, infection, and paralysis using medical, nursing, and allied health (e.g., physical therapy) interventions. Wandering, urinary retention, and impaired swallowing are all examples of nursing diagnoses.

A nurse is prioritizing care. Match the level of priority to the patients. a. Patient that needs to be turned to prevent pneumonia b. Patient with acute asthma attack c. Patient who will be discharged in 2 days who needs teaching 1. High priority 2. Intermediate priority 3. Low priority

1. ANS: B 2. ANS: A 3. ANS: C

A nurse is following the goals of Healthy People 2020 to provide care. Which action should the nurse take? a. Allow people to continue current behaviors to reduce the stress of change. b. Focus only on health changes that will lead to better local communities. c. Create social and physical environments that promote good health. d. Focus on illness treatment to provide fast recuperation.

ANS: C Healthy People 2020 includes four goals, one of which is to create social and physical environments that promote good health for all. The goals do not include continuing current behaviors to reduce stress, focusing only on health changes for communities, or focusing on fast recuperation.

The patient is terminally ill and is receiving hospice care. The nurse cares for the patient by bathing, shaving, and repositioning him. The patient would like a Catholic priest called to provide the Sacrament of the Sick. The nurse places a call and arranges for the priest's visit. Which theory does this nurse's care represent? a. Roy's theory b. Watson's theory c. Henderson's theory d. Orem's self-care deficit theory

ANS: C Henderson defines nursing as assisting the patient with 14 activities (hygiene, positioning) until patients can meet these needs for themselves—or assist patients to have a peaceful death. Roy's model is to help the person adapt to changes in physiological needs, self-concept, role function, and interdependence domains. Watson's theory believes that the purpose of nursing is to understand the interrelationship between health, illness, and human behavior. The goal of Orem's theory is to help the patient perform self-care.

A 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

ANS: C Impaired skin integrity is the only nursing diagnosis listed that will correlate to the patient information. While risk for infection is a nursing diagnosis, the patient is not at risk; the patient has an actual infection. Infection can be a medical diagnosis as well as a collaborative problem. Staphylococcal leg infection is a medical diagnosis.

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

The nurse is caring for a patient whose insurance coverage is Medicare. The nurse should consider which information when planning care for this patient? a. Capitation provides the hospital with a means of recovering variable charges. b. The hospital will be paid for the full cost of the patient's hospitalization. c. Diagnosis-related groups (DRGs) provide a fixed reimbursement of cost. d. Medicare will pay the national average for the patient's condition.

ANS: C In 1983, Congress established the prospective payment system (PPS), which grouped inpatient hospital services for Medicare patients into diagnosis-related groups (DRGs), each of which provides a fixed reimbursement amount based on assigned DRG, regardless of a patient's length of stay or use of services. Capitation means that providers receive a fixed amount per patient or enrollee of a health care plan. DRG reimbursement is based on case severity, rural/urban/regional costs, and teaching costs, not national averages.

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

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

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

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

A patient diagnosed with heart failure is learning to reduce salt in the diet. When will be the best time for the nurse to address this topic? a. At bedtime, while the patient is relaxed. b. At bath time, when the nurse is cleaning the patient. c. At lunchtime, while the nurse is preparing the food tray. d. At medication time, when the nurse is administering patient medication.

ANS: C In this situation, because the teaching is about food, coordinating it with routine nursing care that involves food can be effective. Many nurses find that they are able to teach more effectively while delivering nursing care. For example, while hanging blood, you explain to the patient why the blood is necessary and the symptoms of a transfusion reaction that need to be reported immediately. At bedtime would be a good time to discuss routines that enhance sleep. At bath time would be a good time to describe skin care and how to prevent pressure ulcers. At medication time would be a good time to explain the purposes and side effects of the medication.

A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will most likely be assisting the patient with which activity? a. Taking a bath b. Getting dressed c. Making a phone call d. Going to the bathroom

ANS: C Instrumental activities of daily living or IADLs (such as the ability to write a check, shop, prepare meals, or make phone calls) and activities of daily living or ADLs (such as bathing, dressing, and toileting) are essential to independent living.

A nurse is teaching young adults about health risks. Which statement from a young adult indicates a correct understanding of the teaching? a. "It's probably safe for me to start smoking. At my age, there's not enough time for cancer to develop." b. "My mother had appendicitis, so this increases my chance for developing appendicitis." c. "Controlling the amount of stress in my life may decrease the risk of illness." d. "I don't do drugs. I do drink coffee, but caffeine is not a drug."

ANS: C Lifestyle habits that activate the stress response increase the risk of illness; so, controlling this will decrease risk. Smoking is a well-documented risk factor for pulmonary, cardiac, and vascular disease as well as cancer in smokers and in individuals who receive secondhand smoke. The presence of certain chronic illnesses (not acute illnesses—appendicitis) in the family increases the family member's risk of developing a disease. Caffeine is a naturally occurring legal stimulant that is readily available. Caffeine stimulates catecholamine release, which, in turn, stimulates the central nervous system; it also increases gastric acid secretion, heart rate, and basal metabolic rate.

A nurse developed the following discharge summary sheet. Which critical information should the nurse add? TOPIC DISCHARGE SUMMARY Medication Diet Activity level Follow-up care Wound care Phone numbers When to call the doctor Time of discharge a. Clinical decision support system b. Admission nursing history c. Mode of transportation d. SOAP notes

ANS: C List actual time of discharge, mode of transportation, and who accompanied the patient for discharge summary information. Clinical decision support systems (CDSSs) are computerized programs used within the health care setting, to aid and support clinical decision making. The knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions in order to generate tailored recommendations for individual patients that are presented to nurses as alerts, warnings, or other information for consideration. A nurse completes a nursing history form when a patient is admitted to a nursing unit, not when the patient is discharged. SOAP notes are not given to patients who are being discharged. SOAP notes are a type of documentation style.

A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding? a. Oily skin b. Faster nail growth c. Decreased elasticity d. Increased facial hair in men

ANS: C Loss of skin elasticity is a common finding in the older adult. Other common findings include pigmentation changes, glandular atrophy (oil, moisture, and sweat glands), thinning hair (facial hair: decreased in men, increased in women), slower nail growth, and atrophy of epidermal arterioles.

A nurse determines that a middle-aged patient is a typical example of the "sandwich generation." What did the nurse discover the patient is caught between? a. Job responsibilities or family responsibilities b. Stopping old habits and starting new ones c. Caring for children and aging parents d. Advancing in career or retiring

ANS: C Middle-aged adults also begin to help aging parents while being responsible for their own children, placing them in the sandwich generation. It does not include job and family responsibilities; old habits and new ones; or career and retiring

A nurse discusses the risks of repeated sun exposure with a young-adult patient. Which response will the nurse most expect from this patient? a. "I should consider participating in a health fair about safe sun practices." b. "I'll make an appointment with my doctor right away for a full skin check." c. "I've had this mole my whole life. So, what if it changed color? My skin is fine." d. "I have a mole that has been bothering me. I'll call my family doctor for an appointment to get it checked."

ANS: C Most typically young adults would say that their skin is fine. Young adults often ignore physical symptoms and often postpone seeking health care. Making an appointment right away with the doctor and participating in health fairs are not typical behaviors of young adults for the same reason.

The nurse views the patient as an open system that needs help in coping with stressors. Which theorist is the nurse using? a. King b. Levine c. Neuman d. Johnson

ANS: C Neuman views a patient as being an open system that is in constant energy exchange with the environment that the nurse must help cope with stressors. King views a patient as a unique personal system that is constantly interacting/transacting with other systems that the nurse helps with goal attainment. Levine believes nurses promote balance between nursing interventions and patient participation to assist in conserving energy needed for healing. Johnson perceives patients as a collection of subsystems that forms an overall behavioral system focusing on balance.

Which behavior demonstrated by a nurse indicates the nurse is using Nightingale's theory to plan nursing care? a. Knows all about the disease processes affecting patients. b. Focuses on medication administration and treatments. c. Thinks about the patients and patients' environments. d. Considers nursing knowledge and medicine the same.

ANS: C Nightingale's theory provides nurses with a way to think about patients and their environment. Nightingale's concept of the environment was the focus of nursing care, and her firm conviction was that nursing knowledge is distinct from medical knowledge. Nightingale did not view nursing as limited to the administration of medications and treatments.

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

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

The nurse 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.

An older adult recently retired and reports being depressed and lonely. What information should the nurse assess as a priority? a. History of previous depression b. Previous stressful events c. Role of work in the adults life d. Usual leisure time activities

ANS: C Often older adults lose support systems when their roles change. For instance, when people retire, they may lose their entire social network, leading them to feeling depressed and lonely. The nurse should first assess the role that work played in the clients life. The other factors can be assessed as well, but this circumstance is commonly seen in the older population.

A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review? a. Barley soup b. Black beans c. White rice d. Whole wheat bread

ANS: C Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole wheat products.

4. A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue? a. Cut some sodium out of your diet. b. Dehydration can cause incontinence. c. Have something to drink every 1 to 2 hours. d. Take your diuretic in the morning.

ANS: C Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting some sodium from the diet will not address this issue. Although dehydration can cause incontinence from the irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the client to take a diuretic in the morning rather than in the evening also will not directly address this issue.

A hospital is using a computer system that allows all health care providers to use a protocol system to document the care they provide. Which type of system/design will the nurse be using? a. Clinical decision support system b. Nursing process design c. Critical pathway design d. Computerized provider order entry system

ANS: C One design model for Nursing Clinical Information Systems (NCIS) is the protocol or critical pathway design. This design facilitates interdisciplinary management of information because all health care providers use evidence-based protocols or critical pathways to document the care they provide. The knowledge base within a CDSS contains rules and logic statements that link information required for clinical decisions in order to generate tailored recommendations for individual patients, which are presented to nurses as alerts, warnings, or other information for consideration. The nursing process design is the most traditional design for an NCIS. This design organizes documentation within well-established formats such as admission and postoperative assessments, problem lists, care plans, discharge planning instructions, and intervention lists or notes. Computerized provider order entry (CPOE) systems allow health care providers to directly enter orders for patient care into the hospital's information system

The nurse is applying for a position with a home care organization that specializes in spinal cord injury. In which type of health care facility does the nurse want to work? a. Secondary acute b. Continuing c. Restorative d. Tertiary

ANS: C Patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability. Restorative care includes cardiovascular and pulmonary rehabilitation, sports medicine, spinal cord injury programs, and home care. Secondary acute care involves emergency care, acute medical-surgical care, and radiological procedures. Continuing care involves assisted living, psychiatric care, and older-adult day care. Tertiary care includes intensive care and subacute care.

A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first? a. Auscultate bowel sounds. b. Check skin turgor. c. Perform an oral assessment. d. Weigh the client.

ANS: C Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these problems exist. The other assessments are important, but will not yield information specific to the clients food preferences as they relate to constipation.

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.

A nurse is working as a public health nurse. What will be the nurse's primary focus? a. The individual as one member of a group b. Individuals and families c. Needs of a population d. Health promotion

ANS: C Public health nursing primary focus is understanding the needs of a population. Community-based care focuses on health promotion. Community health nursing focuses on health care of individuals, families, and groups within the community.

The nurse is trying to identify common general themes relative to the effectiveness of cardiac rehabilitation from patients who have had heart attacks and have gone through cardiac rehabilitation programs. The nurse conducts interviews and focus groups. Which type of research is the nurse conducting? a. Nonexperimental research b. Experimental research c. Qualitative research d. Evaluation research

ANS: C Qualitative research involves using inductive reasoning to develop generalizations or theories from specific observations or interviews. Evaluation and experimental research are forms of quantitative research. Nonexperimental descriptive studies describe, explain, or predict phenomena such as factors that lead to an adolescent's decision to smoke cigarettes.

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

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

A patient has been taught how to change a colostomy bag but is having difficulty manipulating the equipment and has many questions. To which resource should the nurse institute a referral to? a. A mental health specialist b. A wound care specialist c. An ostomy specialist d. A dietitian

ANS: C Resources that specialize in a particular health need (e.g., wound care or ostomy specialists) are integral to successful patient education. A mental health specialist is helpful for emotional issues rather than for physical problems. A dietitian is a resource for nutritional needs. A wound care specialist provides complex wound care.

A confused patient with a urinary catheter, nasogastric tube, and intravenous line keeps touching these needed items for care. The nurse has tried to explain to the patient that these lines should not be touched, but the patient continues. Which is the best action by the nurse at this time? a. Apply restraints loosely on the patient's dominant wrist. b. Notify the health care provider that restraints are needed immediately. c. Try other approaches to prevent the patient from touching these care items. d. Allow the patient to pull out lines to prove that the patient needs to be restrained.

ANS: C Restraints can be used when less restrictive interventions are not successful. The nurse must try other approaches than just telling. The situation states that the patient is touching the items, not trying to pull them out. At this time, the patient's well-being is not at risk so restraints cannot be used at this time nor does the health care provider need to be notified. Allowing the patient to pull out any of these items to prove the patient needs to be restrained is not acceptable.

A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? a. Disorientation b. Poor judgment c. Slower reaction time d. Loss of language skills

ANS: C Slower reaction time is a common change in the older adult. Symptoms of cognitive impairment, such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require further investigation of underlying causes.

A nurse is assessing the social system of a community. Which area should the nurse assess? a. Housing b. Economic status c. Volunteer programs d. Predominant ethnic groups

ANS: C Social systems include volunteer programs, education system, government, and health systems. Housing and economic status are included in the structure assessment. Predominant ethnic groups are a component of the population assessment.

A 70-year-old patient who is experiencing worsening dementia is no longer able to live alone. The nurse is discussing health care services and possible long-term living arrangements with the patient's only son. What will the nurse suggest? a. An apartment setting with neighbors close by. b. Having the patient utilize weekly home health visits. c. A nursing center because home care is no longer safe. d. That placement is irrelevant because the patient is retreating to a place of inactivity.

ANS: C Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult or when convalescence from hospitalization requires more assistance than the family is able to provide. An apartment setting and the use of home health visits are not appropriate because living at home is unsafe. Dementia is not a time of inactivity but an impairment of intellectual functioning.

A nurse attends a seminar on teaching/learning. Which statement indicates the nurse has a good understanding of teaching/learning? a. "Teaching and learning can be separated." b. "Learning is an interactive process that promotes teaching." c. "Teaching is most effective when it responds to the learner's needs." d. "Learning consists of a conscious, deliberate set of actions designed to help the teacher."

ANS: C Teaching is most effective when it responds to the learner's needs. It is impossible to separate teaching from learning. Teaching is an interactive process that promotes learning. Teaching consists of a conscious, deliberate set of actions that help individuals gain new knowledge, change attitudes, adopt new behaviors, or perform new skills.

A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to use? a. Provide several topics of discussion at once to promote independence and making choices. b. Avoid uncomfortable silences after questions by helping patients complete their statements. c. Ask patients to recall past experiences that correspond with their interests. d. Speak in a high pitch to help patients hear better.

ANS: C Teaching strategies include the use of past experiences to connect new learning with previous knowledge, focusing on a single topic to help the patient concentrate, giving the patient enough time in which to respond because older adults' reaction times are longer than those of younger persons, and keeping the tone of voice low; older adults are able to hear low sounds better than high-frequency sounds.

A patient is admitted to a rehabilitation facility following a stroke. The patient has right-sided paralysis and is unable to speak. The patient will be receiving physical therapy and speech therapy. Which level of preventive care is the patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: C Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities.

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

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

Which staff member does the nurse assign to provide morning care for an older-adult patient who requires assistance with activities of daily living? a. Licensed practical nurse b. Cardiac monitor technician c. Nursing assistive personnel (NAP) d. Another registered nurse on the floor

ANS: C The NAP is capable of caring for this patient and is the most cost-effective choice. The cardiac monitor technician's role is to watch the cardiac monitors for patients on the floor. The nurse and the licensed practical nurse are not the most cost-effective options in this case, even though each could assist with activities of daily living. These nurses would be better used to administer medications, perform assessments, etc.

Which approach will be most appropriate for a nurse to take when faced with the challenge of performing many tasks in one shift? a. Do as much as possible by oneself before seeking assistance from others. b. Evaluate the effectiveness of all tasks when all tasks are completed. c. Complete one task before starting another task. d. Delegate tasks the nurse does not like doing.

ANS: C The appropriate clinical care coordination skill in these options is to complete one task before starting another task. Good time management involves setting goals to help the nurse complete one task before starting another task. Evaluation is ongoing and should not be completed just at the end of task completion. The nurse should not delegate tasks simply because the nurse does not like doing them. The nurse should use delegation skills and time-management skills instead of trying to do as much as possible with no help.

A novice nurse expresses frustration at not being to complete all interventions for a group of patients in a timely manner. The nurse leaves the rounds report sheets at the nurse's station when caring for patients and reports having to go back and forth between rooms for equipment and supplies. Which type of skill does the nurse need? a. Interpersonal communication b. Clinical decision making c. Organizational d. Evaluation

ANS: C The clinical care coordination skill the nurse needs to improve on is organization. This nurse needs to keep the patient report sheets in hand to anticipate what equipment and supplies a patient is going to need. Then the nurse may not have to leave the room so often; this will save time. The nurse is not having a problem communicating with others (interpersonal communication). The nurse is not having a problem using the nursing process for clinical decisions. The nurse is not having a problem comparing actual patient outcomes with expected outcomes (evaluation).

A novice nurse expresses frustration at not being to complete all interventions for a group of patients in a timely manner. The nurse leaves the rounds report sheets at the nurse's station when caring for patients and reports having to go back and forth between rooms for equipment and supplies. Which type of skill does the nurse need? a. Interpersonal communication b. Clinical decision making c. Organizational d. Evaluation

ANS: C The clinical care coordination skill the nurse needs to improve on is organization. This nurse needs to keep the patient report sheets in hand to anticipate what equipment and supplies a patient is going to need. Then the nurse may not have to leave the room so often; this will save time. The nurse is not having a problem communicating with others (interpersonal communication). The nurse is not having a problem using the nursing process for clinical decisions. The nurse is not having a problem comparing actual patient outcomes with expected outcomes (evaluation).

A nurse is working in a facility that has fewer directors which allows for managers and staff to make shared decisions. In which type of organizational structure is the nurse employed? a. Delegation b. Research-based c. Decentralization d. Philosophy of care

ANS: C The decentralized management structure often has fewer directors, and managers and staff are able to make shared decisions. The American Nurses Association defines delegation as transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. Research-based means care is based upon evidence. A philosophy of care includes the professional nursing staff's values and concerns for the way they view and care for patients. For example, a philosophy addresses the purpose of the nursing unit, how staff works with patients and families, and the standards of care for the work unit.

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 x 4-inch 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.

The patient's son requests to view documentation in the medical record. What is the nurse's best response to this request? a. "I'll be happy to get that for you." b. "You are not allowed to look at it." c. "You will need your mother's permission." d. "I cannot let you see the chart without a doctor's order."

ANS: C The mother's permission is needed. The nurse understands that sharing health information is governed by HIPAA legislation, which defines rights and privileges of patients for protection of privacy. Private health information cannot be shared without the patient's specific permission. The nurse cannot obtain the records without permission. The son can look at it after approval from the patient. While talking to the physician or getting an order is appropriate, the patient still has to give consent.

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 dresses that make my hips stick out." c. "I'll wear the blue dress. It matches my eyes." d. "I hope I can go to the pool next summer."

ANS: C The nurse is evaluating the improvement in body image. The only positive comment made is that the patient is wearing the blue dress to match her eyes. Worrying about others, making my hips stick out, and going to the pool next summer do not reflect positive changes in body image.

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document? a. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. VO Dr. Day/J. Winds, RN, read back. b. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN, read back. c. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO Dr. Day/J. Winds, RN, read back. d. 12/16/20XX 0915 Morphine, 2 mg, IV every 4 hours for incisional pain. TO J. Winds, RN.

ANS: C The nurse receiving a TO or VO enters the complete order into the computer using the computerized provider order entry (CPOE) software or writes it out on a physician's order sheet for entry in the computer as soon as possible. After you have taken the order, read the order back, using the "read back" process, and document that you did this to provide evidence that the information received (such as call back instructions and/or therapeutic orders) was verified with the provider. An example follows: "10/16/2015 (08:15), Change IV fluid to Lactated Ringers with Potassium 20 mEq/L to run at 125 mL/hr. TO: Dr. Knight/J. Woods, RN, read back." VO stands for verbal order, not telephone order. The health care provider's name and read back must be included in the chart entry.

The nurse is making a home visit to a Korean mother after the birth of girl. The spouse is pressing different parts of the patient's hand and lower arm to relieve a headache. What is the nurse's next action? a. Tell the spouse to stop and give the mother acetaminophen. b. Let the spouse finish and then give the mother medication. c. Ask the mother and/or spouse to explain the procedure. d. Explain to the spouse that it will not work.

ANS: C The nurse should not judge the patient's/family's beliefs and values about health. The nurse needs to understand cultural beliefs, values, and practices to determine their specific needs. Acetaminophen may not be an acceptable alternative for this family. Criticizing the family's beliefs and practices or saying they will not work may only create a barrier to care.

After assessing the patient and identifying the need for headache relief, the nurse administers acetaminophen. 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.

ANS: C The nurse's priority action for this patient is to evaluate whether the nursing intervention of administering acetaminophen was effective. The nurse does not have enough evaluative data at this point to determine whether headache needs to be discontinued. Assessment is the nurse's responsibility and is not to be delegated to nursing assistive personnel. The nurse does not have enough evaluative data to determine whether the patient's plan of care needs to be revised.

A nursing faculty member working with students explains that the fastest growing subset of the older population is which group? a. Elite old b. Middle old c. Old old d. Young old

ANS: C The old old is the fastest growing subset of the older population. This is the group comprising those 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years of age; and the elite old are over 100 years of age.

A nurse is discussing quality of life issues with another colleague. Which topic will the nurse acknowledge for increased attention paid to quality of life concerns? a. Health care disparities b. Aging of the population c. Abilities of disabled persons d. Health care financial reform

ANS: C The population of disabled persons in the United States and elsewhere has reshaped the discussion about quality of life (QOL). Health care disparities, an aging population, and health care reform are components impacted by personal definitions of quality but are not the underlying reason why QOL discussions have arisen.

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

ANS: C The signs the patient is exhibiting are consistent with deficient fluid volume (dehydration). Even without knowing the clinical manifestations of dehydration, the question can be answered by the process of elimination. Adult failure to thrive, hypothermia, and nausea are not appropriate diagnoses because data are insufficient to support these diagnoses.

The nurse is caring for a Chinese patient using the teach-back technique. Which action by the nurse indicates successful implementation of this technique? a. Asks, "Does this make sense?" b. Asks, "Do you think you can do this at home?" c. Asks, "What will you tell your spouse about changing the dressing?" d. Asks, "Would you tell me if you don't understand something, so we can go over it?"

ANS: C The teach-back technique asks open-ended questions, like what will you tell your spouse about changing the dressing, to verify a patient's understanding. When using the teach-back technique, do not ask a patient, "Do you understand?" or "Do you have any questions?" "Does this make sense?", and "Do you think you can do this at home?" are closed-ended questions. "Would you tell me if you don't understand something, so we can go over it?" is not verifying a patient's understanding about the teaching.

A patient is admitted with possible methicillin-resistant Staphylococcus aureus (MRSA) and is placed in isolation until cultures can be obtained and declared noninfectious. During the isolation process, the nurse encourages family visits. Which level of Maslow's hierarchy of needs is the nurse promoting when the family is encouraged to visit? a. First level b. Second level c. Third level d. Fourth level

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

A nurse and a patient work on strategies to reduce weight. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination

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

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

ANS: C Theories offer well-grounded rationales for how and why nurses perform specific interventions and for predicting and/or prescribing nursing care measures. Although nursing theory will help the nurse in graduate school, it is also an important basis for the nurse's approach to daily patient care, and it expands scientific knowledge of the profession

Which information from the nurse indicates a correct understanding of emerging adulthood? a. It is a type of young adulthood. b. It is a type of extended adolescence. c. It is a type of independent exploration. d. It is a type of marriage and parenthood.

ANS: C This newly identified stage of development from age 18 to 25 (emerging adulthood) has been described as neither an extended adolescence, as it is much freer from parental control and is much more a period of independent exploration, nor young adulthood, as most young people in their twenties have not made the transitions historically associated with adult status, especially marriage and parenthood.

A toddler is going to have surgery on the right ear. Which teaching method is most appropriate for this developmental stage? a. Encourage independent learning. b. Develop a problem-solving scenario. c. Wrap a bandage around a stuffed animal's ear. d. Use discussion throughout the teaching session.

ANS: C Use play to teach a procedure or activity (e.g., handling examination equipment, applying a bandage to a doll) to toddlers. Encouraging independent learning is for the young or middle adult. Use of discussion is for older children, adolescents, and adults, not for toddlers. Use problem solving to help adolescents make choices. Problem solving is too advanced for a toddler.

A nurse agrees with regulations for mandatory immunizations of children. The nurse believes that immunizations prevent diseases as well as prevent spread of the disease to others. Which ethical framework is the nurse using? a. Deontology b. Ethics of care c. Utilitarianism d. Feminist ethics

ANS: C Utilitarianism is a system of ethics that believes that value is determined by usefulness. This system of ethics focuses on the outcome of the greatest good for the greatest number of people. Deontology would not look to consequences of actions but on the "right-making characteristic" such as fidelity and justice. The ethics of care emphasizes the role of feelings. Relationships, which are an important component of feminist ethics, are not addressed in this case.

The nurse is caring for a patient who has been trying to quit smoking. The patient has been smoke free for 2 weeks but had two cigarettes last night and at least two this morning. What should the nurse anticipate? a. The patient does not want to and will never quit smoking. b. The patient must pick up the attempt right where the patient left off. c. The patient will return to the contemplation or precontemplation phase. d. The patient will need to adopt a new lifestyle for change to be effective.

ANS: C When relapse occurs, the person will return to the contemplation or precontemplation stage before attempting the change again. The patient cannot pick up the attempt where left off. It is believed that change involves movement through a series of stages (precontemplation, contemplation, preparation, action, and maintenance). Anticipating that the patient does not want to and will never quit is premature. While the patient will need to adopt a new lifestyle for change to be effective, it does not correlate to this scenario since the patient relapsed.

A nurse is teaching the staff about informatics. Which information from the staff indicates the nurse needs to follow up? a. To be proficient in informatics, a nurse should be able to discover, retrieve, and use information in practice. b. A nurse needs to know how to find, evaluate, and use information effectively. c. If a nurse has computer competency, the nurse is competent in informatics. d. Nursing informatics is a recognized specialty area of nursing practice.

ANS: C When the staff make an incorrect statement, then the nurse needs to follow up. Competence in informatics is not the same as computer competency. All the rest are correct information, so the nurse does not need to follow up. To become competent in informatics, you need to be able to use evolving methods of discovering, retrieving, and using information in practice. This means that you learn to recognize when information is needed and have the skills to find, evaluate, and use that information effectively. Nursing informatics is a specialty that integrates the use of information and computer technology to support all aspects of nursing practice, including direct delivery of care, administration, education, and research.

A nurse preceptor is working with a student nurse. Which behavior by the student nurse will require the nurse preceptor to intervene? a. Reading the patient's plan of care b. Reviewing the patient's medical record c. Sharing patient information with another student d. Documenting medication administered to the patient

ANS: C When you are a student in a clinical setting, confidentiality and compliance with the Health Insurance Portability and Accountability Act (HIPAA) are part of professional practice. When a student nurse shares patient information with a friend, confidentiality and HIPAA standards have been violated, causing the preceptor to intervene. You can review your patients' medical records only to seek information needed to provide safe and effective patient care. For example, when you are assigned to care for a patient, you need to review the patient's medical record and plan of care. You do not share this information with classmates and you do not access the medical records of other patients on the unit.

A nurse is teaching an older-adult patient about strokes. Which teaching technique is most appropriate for the nurse to use? a. Speak in a high tone of voice to describe strokes. b. Use a pamphlet about strokes with large font in blues and greens. c. Provide specific information about strokes in short, small amounts. d. Begin the teaching session facing the teaching white board with stroke information.

ANS: C With older adults, keep the teaching session short with small amounts of information. Also, if using written material, assess the patient's ability to read and use information that is printed in large type and in a color that contrasts highly with the background (e.g., black 14-point print on matte white paper). Avoid blues and greens because they are more difficult to see. Speak in a low tone of voice (lower tones are easier to hear than higher tones). Directly face the older-adult learner when speaking.

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. Asking the nursing assistive personnel if the wound looks better b. Documenting the progress of wound healing as "better" in the chart c. Measuring the wound and observe for redness, swelling, or drainage d. Leaving the dressing off the wound for easier access and more frequent assessments

ANS: C You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, and patient interview). The nurse performs evaluative measures, such as completing a wound assessment, to evaluate wound healing. Nurses do not delegate assessment to nursing assistive personnel. Documenting "better" is subjective and does not objectively describe the wound. Leaving the dressing off for the nurse's benefit of easier access is not a part of the evaluation process.

A nurse is teaching a patient about hypertension. In which order from first to last will the nurse implement the steps of the teaching process? 1. Set mutual goals for knowledge of hypertension. 2. Teach what the patient wants to know about hypertension. 3. Assess what the patient already knows about hypertension. 4. Evaluate the outcomes of patient education for hypertension. a. 1, 3, 2, 4 b. 2, 3, 1, 4 c. 3, 1, 2, 4 d. 3, 2, 1, 4

ANS: C Assessment is the first step of any teaching session, then diagnosing, planning (goals), implementation, and evaluation.

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

ANS: C, D Impaired physical mobility and Nausea are the only correctly written nursing diagnoses. All the rest are incorrectly written. Anxiety lists a diagnostic test as the etiology. Impaired gas exchange lists a medical diagnosis as the etiology. Risk for falls has a legally inadvisable statement for an etiology.

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.

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

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

Which areas should the nurse assess to determine the effects of external variables on a patient's illness? (Select all that apply.) a. Patient's perception of the illness b. Patient's coping skills c. Socioeconomic status d. Cultural background e. Social support

ANS: C, D, E External variables influencing a patient's illness behavior include the visibility of symptoms, social group, cultural background, economic variables, accessibility of the health care system, and social support. Internal variables include the patient's perceptions of symptoms and the nature of the illness, as well as the patient's coping skills and locus of control.

A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the client is malnourished. What actions by the nurse are best? (Select all that apply.) a. Contact Adult Protective Services or hospital social work. b. Notify the provider that the client needs a tube feeding. c. Perform and document results of a Braden Scale assessment. d. Request a dietary consultation from the health care provider. e. Suggest a high-protein oral supplement between meals.

ANS: C, D, E Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate actions by the nurse include assessing the clients risk for skin breakdown with the Braden Scale, requesting a consultation with a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the client is being abused or needs a feeding tube at this time.

A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess skin redness when turning. b. Document Braden Scale results. c. Keep the clients skin dry. d. Obtain a pressure-relieving mattress. e. Turn the client every 2 hours.

ANS: C, D, E The nurses aide or UAP can assist in keeping the clients skin dry, order a special mattress on direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide should be directed to report any redness noticed. Documenting the Braden Scale results is the RNs responsibility as the RN is the one who performs that assessment

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.

ANS: C, E Nursing Outcomes Classification (NOC) links outcomes to NANDA International nursing diagnoses. Such a rating system adds objectivity to judging a patient's progress. Using standardized nursing terminologies such as NOC makes it more possible to measure aspects of nursing care on a national and international level. The indicators for each NOC outcome allow measurement of the outcomes at any point on a 5-point Likert scale from most negative to most positive. This resource is an option you can use in selecting goals and outcomes (not interventions) for your patients. The Nursing Interventions Classification model includes three levels: domains, classes, and interventions for ease of use. The seven domains are the highest level (level 1) of the model, using broad terms (e.g., safety and basic physiological) to organize the more specific classes and interventions

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

ANS: D The related to factor of alveolar-capillary membrane changes is accurately written because it is a patient response to the disease process of pneumonia that the nurse can treat. The related to factor should be the cause of the problem (nursing diagnosis) that a nurse can address. The related to factors of dehydration and pneumonia are all medical diagnoses that the nurse cannot change. A diagnostic test or a chronic dysfunction is not an etiology or a condition that a nursing intervention is able to treat.

The novice 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 the nurse's preceptor? 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."

ANS: D Work from your plan of care and use patients' priorities to organize the order for delivering interventions and organizing documentation of care. When developing a plan of care, the nurse needs to rank the nursing diagnoses in order of priority, then select appropriate interventions. Choosing all the interventions should take place after ranking of the diagnoses, and interventions should be prioritized by patient needs, not just by time. The chosen interventions should be evidence based with scientific rationales, but the diagnoses need to be prioritized first to prioritize interventions. Goals for a patient should be mutually set, not just chosen by the nurse.

A nurse is standing beside the patient's bed and the following exchange occurs. Nurse: How are you doing? Patient: I don't feel good. Which element will be identified as feedback? a. Nurse b. Patient c. How are you doing? d. I don't feel good.

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

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

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

After providing care, a nurse charts in the patient's record. Which entry will the nurse document? a. Appears restless when sitting in the chair. b. Drank adequate amounts of water. c. Apparently is asleep with eyes closed. d. Skin pale and cool.

ANS: D A factual record contains descriptive, objective information about what a nurse observes, hears, palpates, and smells. Objective data is obtained through direct observation and measurement (skin pale and cool). For example, "B/P 80/50, patient diaphoretic, heart rate 102 and regular." Avoid vague terms such as appears, seems, or apparently because these words suggest that you are stating an opinion, do not accurately communicate facts, and do not inform another caregiver of details regarding behaviors exhibited by the patient. Use of exact measurements establishes accuracy. For example, a description such as "Intake, 360 mL of water" is more accurate than "Patient drank an adequate amount of fluid."

A nurse wants to become a specialist in public health nursing. Which educational requirement will the nurse have to obtain? a. A baccalaureate degree in nursing b. Preparation at the basic entry level c. The same level of education as the community health nurse d. A graduate level education with a focus in public health science

ANS: D A specialist in public health has a graduate level education with a focus in public health science. Public health nursing requires preparation at the basic entry level and sometimes requires a baccalaureate degree in nursing. A community health nurse is not the same thing as a public health nursing specialist.

A staff nurse delegates a task to a nursing assistive personnel (NAP), knowing that the NAP has never performed the task before. As a result, the patient is injured, and the nurse defensively states that the NAP should have known how to perform such a simple task. Which element of the decision-making process is the nurse lacking? a. Authority b. Autonomy c. Responsibility d. Accountability

ANS: D Accountability refers to individuals being answerable for their actions. The nurse in this situation is not taking ownership of the inappropriate delegation of a task. Autonomy is freedom of choice and responsibility for the choices. Responsibility refers to the duties and activities that an individual is employed to perform. Authority refers to legitimate power to give commands and make final decisions specific to a given position.

A nurse identifies a clinical problem with pressure injuries. Which step should the nurse take next in the research process? a. Analyze results. b. Conduct the study. c. Determine method. d. Develop a hypothesis.

ANS: D After identifying an area of interest or clinical problem, the steps of the research process are as follows: develop research question(s)/hypotheses, determine how the study will be conducted, conduct the study, and analyze results of the study.

A male older-adult patient expresses concern and anxiety about decreased penile firmness during an erection. What is the nurse's best response? a. Tell the patient that libido will always decrease, as well as the sexual desires. b. Tell the patient that touching should be avoided unless intercourse is planned. c. Tell the patient that heterosexuality will help maintain stronger libido. d. Tell the patient that this change is expected in aging adults.

ANS: D Aging men typically experience an erection that is less firm and shorter acting and have a less forceful ejaculation. Testosterone lessens with age and sometimes (not always) leads to a loss of libido. However, for both men and women sexual desires, thoughts, and actions continue throughout all decades of life. Sexuality involves love, warmth, sharing, and touching, not just the act of intercourse. Touch complements traditional sexual methods or serves as an alternative sexual expression when physical intercourse is not desired or possible. Clearly not all older adults are heterosexual, and there is emerging research on older adult, lesbian, gay, bisexual, and transgender individuals and their health care needs.

A nurse is prioritizing care for four patients. Which patient should the nurse see first? a. A patient needing teaching about medications b. A patient with a healed abdominal incision c. A patient with a slight temperature d. A patient with difficulty breathing

ANS: D An immediate threat to a patient's survival or safety must be addressed first, like difficulty breathing. Teaching, healed incision, and slight temperature are not immediate needs.

An older-adult patient has extensive wound care needs after discharge from the hospital. Which facility should the nurse discuss with the patient? a. Hospice b. Respite care c. Assisted living d. Skilled nursing

ANS: D An intermediate care or skilled nursing facility offers skilled care from a licensed nursing staff. This often includes administration of IV fluids, wound care, long-term ventilator management, and physical rehabilitation. A hospice is a system of family-centered care that allows patients to live with comfort, independence, and dignity while easing the pains of terminal illness. Respite care is a service that provides short-term relief or "time off" for people providing home care to an individual who is ill, disabled, or frail. Assisted living offers an attractive long-term care setting with an environment more like home and greater resident autonomy.

Which behavior indicates the nurse is using a process recording correctly to enhance communication with patients? a. Shows sympathy appropriately. b. Uses automatic responses fluently. c. Demonstrates passive remarks accurately. d. Self-examines personal communication habits.

ANS: D Analysis of a process recording enables a nurse to evaluate the following: examine whether nursing responses blocked or facilitated the patient's efforts to communicate. Sympathy is concern, sorrow, or pity felt for the patient and is nontherapeutic. Clichés and stereotyped remarks are automatic responses that communicate the nurse is not taking concerns seriously or responding thoughtfully. Passive responses serve to avoid conflict or to sidestep issues.

A nurse is teaching a group of healthy adults about the benefits of flu immunizations. Which type of patient education is the nurse providing? a. Health analogies b. Restoration of health c. Coping with impaired functions d. Promotion of health and illness prevention

ANS: D As a nurse, you are a visible, competent resource for patients who want to improve their physical and psychological well-being. In the school, home, clinic, or workplace, you promote health and prevent illness by providing information and skills that enable patients to assume healthier behaviors. Injured and ill patients need information and skills to help them regain or maintain their level of health; this is referred to as restoration of health. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations; this is known as coping with impaired functions. Analogies supplement verbal instruction with familiar images that make complex information more real and understandable. For example, when explaining arterial blood pressure, use an analogy of the flow of water through a hose.

A nurse observes an outbreak of lice in a certain school district. The nurse collects data and identifies a common practice of sharing lockers, caps, and hair brushes. The nurse shares the information with the school. Which community-based nursing competency did the nurse use? a. Educator b. Caregiver c. Case manager d. Epidemiologist

ANS: D As an epidemiologist, you are involved in case finding, health teaching, and tracking incident rates of an illness (outbreak of lice). The nurse did not teach the students about lice. The nurse did not provide care for the lice. The nurse did not coordinate needed resources and services for a group of patient's well-being (case manager).

The nurse values autonomy above all other principles. Which patient assignment will the nurse find most difficult to accept? a. Older-adult patient who requires dialysis. b. Teenager in labor who requests epidural anesthesia. c. Middle-aged father of three with an advance directive declining life support. d. Family elder who is making the decisions for a young-adult female member.

ANS: D Autonomy refers to freedom from external control. A person who values autonomy highly may find it difficult to accept situations where the patient is not the primary decision maker regarding his or her care. A teenager requesting an epidural, a father with an advance directive, and an elderly patient requiring dialysis all describe a patient or family who can make their own decisions and choices regarding care.

A nurse is teaching the staff about integrated health care systems. Which model of care should the nurse include in the teaching about seam-less care delivery? a. Affordable Care Act b. Hospital Value-Based Purchasing c. Bundled Payments for Care Improvements d. The patient-centered medical home model

ANS: D Basically, two types of integrated health care systems are found: an organizational structure that follows economic imperatives (such as combining financing with all providers, from hospitals, clinics, and physicians to home care and long-term care facilities) and a structure that supports an organized care delivery approach (coordinating care activities and services into seamless functioning). The patient-centered medical home model is an example of an integrated health care system that strengthens the physician-patient relationship with coordinated, goal-oriented, individualized care. All the other options are more related to the financial accessibility of health care.

A nurse manager discovers that the readmission rate of hospitalized patients is very high on the hospital unit. The nurse manager desires improved coordination of care and accountability for cost-effective quality care. Which nursing care delivery model is best suited for these needs? a. Team nursing b. Total patient care c. Primary nursing d. Case-management

ANS: D Case-management is a care approach that coordinates and links health care services to patients and families while streamlining costs. In team nursing, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members.

A nurse is overseeing the care of patients diagnosed with either severe diabetes or with heart failure. The purpose of this nursing model is to improve cost-effectiveness and quality of care. Which nursing care delivery model is the nurse using? a. Team nursing b. Total patient care c. Primary nursing d. Case-management

ANS: D Case-management is unique because clinicians, either as individuals or as part of a collaborative group, oversee the management of patients with specific, complex health problems or are held accountable for some standard of cost management and quality. Case-management is a care approach that coordinates and links health care services to patients and families while streamlining costs. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members.

An older-adult patient in no acute distress reports being less able to taste and smell. What is the nurse's best response to this information? a. Notify the health care provider immediately to rule out cranial nerve damage. b. Schedule the patient for an appointment at a smell and taste disorders clinic. c. Perform testing on the vestibulocochlear nerve and a hearing test. d. Explain to the patient that diminished senses are normal findings.

ANS: D Diminished taste and smell senses are common findings in older adults. Scheduling an appointment at a smell and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out cranial nerve damage is unnecessary at this time as per the information provided.

Which entry will require follow-up by the nurse manager? 0800 Patient states, "Fell out of bed." Patient found lying by bed on the floor. Legs equal in length bilaterally with no distortion, pedal pulses strong, leg strength equal and strong, no bruising or bleeding. Neuro checks within normal limits. States, "Did not pass out." Assisted back to bed. Nurse call system within reach. Bed monitor on. -------------------Jane More, RN 0810 Notified primary care provider of patient's status. New orders received. -------------------Jane More, RN 0815 Portable x-ray of L hip taken in room. States, "I feel fine." -------------------Jane More, RN 0830 Incident report completed and placed on chart. -------------------Jane More, RN a. 0800 b. 0810 c. 0815 d. 0830

ANS: D Do not include any reference to an incident in the medical record; therefore, the nurse manager must follow up. A notation about an incident report in a patient's medical record makes it easier for a lawyer to argue that the reference makes the incident report part of the medical record and therefore subject to attorney review. When an incident occurs, document an objective description of what happened, what you observed, and the follow-up actions taken, including notification of the patient's health care provider in the patient's medical record. Remember to evaluate and document the patient's response to the incident.

The nurse is teaching a class to pregnant women about common physiological changes during pregnancy. Which information should the nurse include in the teaching session? a. Pregnancy is not a time to be having sexual activity. b. Urinary frequency will occur early in the pregnancy. c. Breast tenderness should be reported as soon as possible. d. Late in the pregnancy Braxton Hicks contraction may occur.

ANS: D During the third trimester (late pregnancy), increases in Braxton Hicks contractions (irregular, short contractions), fatigue, and urinary frequency (not early) occur. Normally, women commonly have morning sickness, breast enlargement and tenderness, and fatigue. Women need to be reassured that sexual activity will not harm the fetus.

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

ANS: D Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves and if goals have been met. Assessment, the first step of the process, includes data collection. Planning, the third step of the process, involves setting priorities, identifying patient goals and outcomes, and selecting nursing interventions. During implementation, nurses carry out nursing care, which is necessary to help patients achieve their goals.

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

ANS: D Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the first four steps of the nursing process, a patient's condition or well-being improves. Assessment involves gathering information about the patient. During the planning phase, patient outcomes are determined. Implementation involves carrying out appropriate nursing interventions.

A nurse is implementing nursing care measures for patients' special communication needs. Which patient will need the most nursing care measures? a. The patient who is oriented, pain free, and blind b. The patient who is alert, hungry, and has strong self-esteem c. The patient who is cooperative, depressed, and hard of hearing d. The patient who is dyspneic, anxious, and has a tracheostomy

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

A nurse teaches a patient with heart failure healthy food choices. The patient states that eating yogurt is better than eating cake. Which element represents feedback? a. The nurse b. The patient c. The nurse teaching about healthy food choices d. The patient stating that eating yogurt is better than eating cake

ANS: D Feedback needs to demonstrate the success of the learner in achieving objectives (i.e., the learner verbalizes information or provides a return demonstration of skills learned). The nurse is the sender. The patient (learner) is the receiver. The teaching is the message.

A nurse must make an ethical decision concerning vulnerable patient populations. Which philosophy of health care ethics would be particularly useful for this nurse? a. Teleology b. Deontology c. Utilitarianism d. Feminist ethics

ANS: D Feminist ethics particularly focuses on the nature of relationships, especially those where there is a power imbalance or a point of view that is ignored or invisible. Deontology refers to making decisions or "right-making characteristics," bioethics focuses on consensus building, while utilitarianism and teleology speak to the greatest good for the greatest number

The nurse is working on a committee to evaluate the need for increasing the levels of fluoride in the drinking water of the community. Which concept is the nurse fostering? a. Illness prevention b. Wellness education c. Active health promotion d. Passive health promotion

ANS: D Fluoridation of municipal drinking water and fortification of homogenized milk with vitamin D are examples of passive health promotion strategies. With active strategies of health promotion, individuals are motivated to adopt specific health programs such as weight reduction and smoking cessation programs. Illness prevention activities such as immunization programs protect patients from actual or potential threats to health. Wellness education teaches people how to care for themselves in a healthy way.

A nurse working in a community hospital's emergency department provides care to a patient having chest pain. Which level of care is the nurse providing? a. Continuing care b. Restorative care c. Preventive care d. Tertiary care

ANS: D Hospital emergency departments, urgent care centers, critical care units, and inpatient medical-surgical units provide secondary and tertiary levels of care. Patients recovering from an acute or chronic illness or disability often require additional services (restorative care) to return to their previous level of function or reach a new level of function limited by their illness or disability. Continuing care is available within institutional settings (e.g., nursing centers or nursing homes, group homes, and retirement communities), communities (e.g., adult day care and senior centers), or the home (e.g., home care, home-delivered meals, and hospice). Preventive care is more disease oriented and focused on reducing and controlling risk factors for disease through activities such as immunization and occupational health programs.

A registered nurse (RN) is the group leader of licensed practical nurses (LPNs) and nursing assistive personnel (NAP). Which nursing care model is being implemented? a. Case-management b. Total patient care c. Primary nursing d. Team nursing

ANS: D In team nursing, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Case-management is a care approach that coordinates and links health care services to patients and families while streamlining costs. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members

A registered nurse (RN) is the group leader of licensed practical nurses (LPNs) and nursing assistive personnel (NAP). Which nursing care model is being implemented? a. Case-management b. Total patient care c. Primary nursing d. Team nursing

ANS: D In team nursing, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. Case-management is a care approach that coordinates and links health care services to patients and families while streamlining costs. Total patient care involves an RN being responsible for all aspects of care for one or more patients. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members.

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

ANS: D In this case, the patient's goal is to not experience shortness of breath with activity in 3 days. If the lung sounds are clear following use of inhaler, the nurse can determine that the patient is making progress toward achieving the expected outcome. One way for the nurse to evaluate the expected outcome is to assess the patient's lung sounds. Goals are broad statements that describe changes in a patient's condition or behavior. Expected outcomes are measurable criteria used to evaluate goal achievement. When an outcome is met, you know that the patient is making progress toward goal achievement. The time frame of 4 days in the first option is not appropriate because this time frame exceeds the time frame stated in the goal. Congestion indicates fluid in the lungs, and a respiratory rate of 30 breaths per minute is elevated/abnormal. This indicates that the patient is still probably experiencing shortness of breath and secretions in the lungs.

A nurse is teaching a patient identified as having low health literacy about chronic obstructive pulmonary disease (COPD). Which technique is most appropriate for the nurse to use? a. Use complex analogies to describe COPD. b. Ask for feedback to assess understanding of COPD at the end of the session. c. Offer pamphlets about COPD written at the eighth-grade level with large type. d. Include the most important information on COPD at the beginning of the session.

ANS: D Include the most important information at the beginning of the session for patients with literacy or learning disabilities. Also, use visual cues and simple, not complex, analogies when appropriate. Another technique is to frequently ask patients for feedback to determine whether they comprehend the information. Additionally, provide teaching materials that reflect the reading level of the patient, with attention given to short words and sentences, large type, and simple format (generally, information written on a fifth-grade reading level is recommended for adult learners).

A home health nurse is preparing for an initial home visit. Which information should be included in the patient's home care medical record? a. Nursing process form b. Step-by-step skills manual c. A list of possible procedures d. Reports to third-party payers

ANS: D Information in the home care medical record includes patient assessment, referral and intake forms, interprofessional plan of care, a list of medications, and reports to third-party payers. An interprofessional plan of care is used rather than a nursing process form. A step-by-step skills manual and a list of possible procedures are not included in the record

A nurse's goal is to provide teaching for restoration of health. Which situation indicates the nurse is meeting this goal? a. Teaching a family member to provide passive range of motion for a stroke patient b. Teaching a woman who recently had a hysterectomy about possible adoption c. Teaching expectant parents about changes in childbearing women d. Teaching a teenager with a broken leg how to use crutches

ANS: D Injured or ill patients need information and skills to help them regain or maintain their levels of health. An example includes teaching a teenager with a broken leg how to use crutches. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations. New knowledge and skills are often necessary for patients and/or family members to continue activities of daily living. Teaching family members to help the patient with health care management (e.g., giving medications through gastric tubes, doing passive range-of-motion exercises) is an example of coping with long-term impaired functions. For a woman with a hysterectomy, teaching about adoption is not restoration of health; restoration of health in this situation would involve activity restrictions and incision care if needed. In childbearing classes, you teach expectant parents about physical and psychological changes in the woman and about fetal development; this is part of health maintenance.

Which assessment of a patient who is 1 day post-surgical repair a hip fracture requires immediate nursing intervention? a. Patient ate 40% of clear liquid breakfast. b. Patient's oral temperature is 98.9° F. c. Patient states, "I did not realize I would be so tired after this surgery." d. Patient reports severe pain 30 minutes after receiving pain medication.

ANS: D It is important to prioritize in all caregiving situations because it allows you to see relationships among patient problems and avoid delays in taking action that possibly leads to serious complications for a patient. The nurse needs to report severe pain that is unrelieved by pain medication to the health care provider. The nurse needs to recognize and differentiate normal from abnormal findings and set priorities. Eating 40% of breakfast, having a slightly elevated temperature, and being tired the day after surgery are expected findings following surgery and do not require immediate intervention.

A nurse is using Maslow's hierarchy of needs to prioritize care. Place the levels in order of basic priority to highest priority that the nurse will follow. 1. Physiological 2. Self-esteem 3. Self-actualization 4. Safety and security 5. Love and belonging a. 4, 1, 2, 3, 5 b. 1, 4, 5, 3, 2 c. 4, 5, 3, 2, 1 d. 1, 4, 5, 2, 3

ANS: D Maslow's hierarchy is as follows: physiological, safety and security, love and belonging, self-esteem, and self-actualization

The instructor is teaching student nurses about identifying members of vulnerable populations when the nursing student asks, "Why is it that not all poor people are considered members of vulnerable populations?" How should the nurse respond? a. "All poor people are members of a vulnerable population." b. "Poor people are members of a vulnerable population only if they take drugs." c. "Poor people are members of a vulnerable population only if they are homeless." d. "Members of vulnerable groups frequently have a combination of risk factors."

ANS: D Members of vulnerable groups frequently have many risks or a combination of risk factors that make them more sensitive to the negative effects of individual risk factors. Individual risk factors are not always overwhelming, depending on the patient's beliefs and values and sources of social support.

A young woman who is pregnant with a fetus exposed to multiple teratogens consents to have her fetus undergo serial PUBS (percutaneous umbilical blood sampling) to examine how exposure affects the fetus over time. Although these tests will not improve the fetus's outcomes and will expose it to some risks, the information gathered may help infants in the future. Which ethical principle is at greatest risk? a. Fidelity b. Autonomy c. Beneficence d. Nonmaleficence

ANS: D Nonmaleficence is the ethical principle that focuses on avoidance of harm or hurt. Repeated PUBS may expose the mother and fetus to some risks. Fidelity refers to the agreement to keep promises (obtain serial PUBS). Autonomy refers to freedom from external control (mother consented), and beneficence refers to taking positive actions to help others (may help infants in the future).

An older patient has fallen and suffered a hip fracture. As a consequence, the patient's family is concerned about the patient's ability to care for self, especially during this convalescence. What should the nurse do? a. Stress that older patients usually ask for help when needed. b. Inform the family that placement in a nursing center is a permanent solution. c. Tell the family to enroll the patient in a ceramics class to maintain quality of life. d. Provide information and answer questions as family members make choices among care options.

ANS: D Nurses help older adults and their families by providing information and answering questions as they make choices among care options. Some older adults deny functional declines and refuse to ask for assistance with tasks that place their safety at great risk. The decision to enter a nursing center is never final, and a nursing center resident sometimes is discharged to home or to another less-acute residence. What defines quality of life varies and is unique for each person

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 falls. Which initial action will the nurse take next to most effectively 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.

ANS: D Nurses revise a plan when a patient's status changes; assessment is the first step. Know also that a plan of care is dynamic and changes as the patient's needs change. Asking physical therapy to assist the patient is premature before assessing the patient and awaiting the health care provider's orders. The nurse may not need to disregard all previous diagnoses. Some diagnoses may still apply, but the patient needs to be assessed first. Setting new priorities is not recommended before assessment and establishing diagnoses.

Which learning objective/outcome has the highest priority for a patient with life-threatening, severe food allergies that requires epinephrine therapy? a. The patient will identify the main ingredients in several foods. b. The patient will list the side effects of epinephrine. c. The patient will learn about food labels. d. The patient will administer epinephrine.

ANS: D Once you assist in meeting patient needs related to basic survival (how to give epinephrine), you can discuss other topics, such as nutritional needs and side effects of medications. For example, a patient recently diagnosed with coronary artery disease has deficient knowledge related to the illness and its implications. The patient benefits most by first learning about the correct way to take nitroglycerin and how long to wait before calling for help when chest pain occurs. Thus, in this situation, the patient benefits most by first learning about the correct way to take epinephrine. "The patient will learn about food labels" is not objective and measurable and is not correctly written

A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital using? a. Document staff satisfaction. b. Focus on the family. c. Implement change on a grand scale. d. Reduce disparities.

ANS: D Organizations can implement equity-focused quality improvement by recognizing disparities and committing to reducing them. Staff diversity is a priority for equity-focused quality improvement, not staff satisfaction. While the family is important, the focus is on the patients. Organizations should start by implementing a change on a small scale (pilot testing), learning from each test, and refining the intervention through performance improvement cycles (e.g., plan, do, study, and act).

A patient asks the nurse what the term polypharmacy means. Which information should the nurse share with the patient? a. This is multiple side effects experienced when taking medications. b. This is many adverse drug effects reported to the pharmacy. c. This is the multiple risks of medication effects due to aging. d. This is concurrent use of many medications.

ANS: D Polypharmacy refers to the concurrent use of many medications. It does not have anything to do with side effects, adverse drug effects, or risks of medication use due to aging.

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

ANS: D Reflex urinary incontinence is highest priority. If a patient's incontinence is not addressed, then the patient is at higher risk of impaired skin integrity and infection. Remember that the Risk for diagnoses are potential problems. They may be prioritized higher in some cases but not in this situation. Spiritual distress is an actual diagnosis, but the adverse effects that could result from not assisting the patient with urinary elimination take priority in this case.

A nurse has a transformational leader as a manager. Which finding will the nurse anticipate from working with this leader? a. Increased turnover rate b. Increased patient mortality rate c. Increased rate of medication errors d. Increased level of patient satisfaction

ANS: D Research has found that on nursing units where the nurse manager uses transformational leadership there is an increased level of patient satisfaction, a lower patient mortality rate, and a lower rate of medication errors. Turnover rate is decreased since staff retention is increased with transformational leadership.

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

ANS: D Risk for falls is a risk (potential) nursing diagnosis; therefore, the nurse needs to implement actions that will prevent a fall. Assisting the patient into and out of bed is the most appropriate intervention to prevent the patient from falling. Encouraging activity builds muscle strength and helping the patient with transfers ensures patient safety. Encouraging the patient to stay in bed will not promote muscle strength. Decreased muscle strength is the risk factor placing the patient in jeopardy of falling. The side rails should be up, not down, according to agency policy. This will remind the patient to ask for help to get up and will keep the patient from rolling out of bed. The patient should be placed near the nurses' station, so a staff member can quickly get to the room and assist the patient if necessary

A nurse uses SBAR when providing a hands-off report to the oncoming shift. What is the rationale for the nurse's action? a. To promote autonomy b. To use common courtesy c. To establish trustworthiness d. To standardize communication

ANS: D SBAR is a popular communication tool that helps standardize communication among health care providers. Common courtesy is part of professional communication but is not the purpose of SBAR. Being trustworthy means helping others without hesitation. Autonomy is being self-directed and independent in accomplishing goals and advocating for others.

The nurse is caring for a patient supported with a ventilator who has been unresponsive since arrival via ambulance 8 days ago. The patient has not been identified, and no family members have been found. The nurse is concerned about the plan of care regarding maintenance or withdrawal of life support measures. Place the steps the nurse will use to resolve this ethical dilemma in the correct order. 1. The nurse identifies possible solutions or actions to resolve the dilemma. 2. The nurse reviews the medical record, including entries by all health care disciplines, to gather information relevant to this patient's situation. 3. Health care providers use negotiation to redefine the patient's plan of care. 4. The nurse evaluates the plan and revises it with input from other health care providers as necessary. 5. The nurse examines the issue to clarify opinions, values, and facts. 6. The nurse states the problem. 7. Nurse confirms that the problem is ethical in nature a. 6, 7, 1, 2, 5, 4, 3 b. 5, 6, 7, 2, 3, 4, 1 c. 1, 2, 5, 4, 7, 3, 6 d. 7, 2, 5, 6, 1, 3, 4

ANS: D Step 1. Ask the question: is this an ethical problem? Step 2. Gather as much information as possible that is relevant to the case. Step 3. Examine and determine your values about the issues. Step 4. Verbalize and name the problem. Step 5. Consider possible courses of action. Step 6. Negotiate the outcome by creating and implementing a plan of action. Step 7. Evaluate the action.

A nurse is reviewing research studies for evidence-based practice. Which article should the nurse use for qualitative nursing research? a. An article about the number of falls after use of no side rails b. An article about infection rates after use of a new wound dressing c. An article about the percentage of new admissions on a new floor d. An article about emotional needs of dying patients and their families

ANS: D Studying emotional needs is a qualitative study. Qualitative nursing research is the study of phenomena that are difficult to quantify or categorize, such as patients' perceptions of illness. The number of falls, infection rates, and percentages of new admissions are all examples of quantitative research.

A nurse is teaching a patient's family member about permanent tube feedings at home. Which purpose of patient education is the nurse meeting? a. Health promotion b. Illness prevention c. Restoration of health d. Coping with impaired functions

ANS: D Teach family members to help the patient with health care management (e.g., giving medications through gastric tubes and doing passive range-of-motion exercises) when coping with impaired functions. Not all patients fully recover from illness or injury. Many have to learn to cope with permanent health alterations. Health promotion involves healthy people staying healthy, while illness prevention is prevention of diseases. Restoration of health occurs if the teaching is about a temporary tube feeding, not a permanent tube feeding.

The nurse is caring for a patient with chronic low back pain. The nurse wants to determine the best evidence-based practice regarding clinical guidelines for low back pain. What is the best database for the nurse to access? a. MEDLINE b. EMBASE c. PsycINFO d. Agency for Healthcare Research and Quality (AHRQ)

ANS: D The Agency for Healthcare Research and Quality (AHRQ) includes clinical guidelines and evidence summaries. MEDLINE includes studies in medicine, nursing, dentistry, psychiatry, veterinary medicine, and allied health. EMBASE includes biomedical and pharmaceutical studies. PsycINFO deals with psychology and related health care disciplines.

A newly hired experienced nurse is preparing to change a patient's abdominal dressing and hasn't done it before at this hospital. Which action by the nurse is best? a. Have another nurse do it so the correct method can be viewed. b. Change the dressing using the method taught in nursing school. c. Ask the patient how the dressing change has been recently done. d. Check the policy and procedure manual for the facility's method

ANS: D The Joint Commission requires accredited hospitals to have written nursing policies and procedures. These internal standards of care are specific and need to be accessible on all nursing units. For example, a policy/procedure outlining the steps to follow when changing a dressing or administering medication provides specific information about how nurses are to perform. The nurse being observed may not be doing the procedure according to the facility's policy or procedure. The procedure taught in nursing school may not be consistent with the policy or procedure for this facility. The patient is not responsible for maintaining the standards of practice. Patient input is important, but it's not what directs nursing practice

A patient's son decides to stay at the bedside while his father is experiencing confusion. When developing the plan of care for this patient, what should the nurse do to best meet the patient's needs? 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.

ANS: D The family is often a resource to help the patient meet health care goals. Family should be included in the plan of care as much as possible. Meeting some of the family's needs as well as the patient's needs will possibly improve the patient's level of wellness. The son should not be asked to leave if at all possible. In some situations, it may be best that family members not remain in the room, but no evidence in the question stem suggests that this is the case in this situation. The suggestion of asking a female member to stay is not a justified action without a legitimate reason. No reason is given in this question stem for such a suggestion

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 only 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.

ANS: D The goal for this patient would address a decrease or absence of confusion. Thus, one possible sign that a patient's confusion is improving is seen when a patient can correctly state the names of family members in the room. You examine the results of care by using evaluative measures that relate to goals and expected outcomes. Keeping the side rails up and using a bed alarm are interventions to promote patient safety and prevent falls. The patient's denying pain indicates positive progress toward resolving pain. The patient's wandering the halls is a sign of confusion.

A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which psychosocial change does the nurse focus on as a priority? a. Sexuality b. Retirement c. Environment d. Social isolation

ANS: D The highest priority at this time is the potential for social isolation. This woman does not know how to drive and lives in a rural community that does not have public transportation. All of these factors contribute to her social isolation. Other possible changes she may be going through right now include sexuality related to her advanced age and recent death of her spouse; however, this is not the priority at this time. She has been retired for 5 years, so this is also not an immediate need. She may eventually experience needs related to environment, but the data do not support this as an issue at this time.

A nurse manager conducts rounds on the unit and discovers that expired stock medicine is still in the cabinet despite the e-mail that was sent stating that it had to be discarded. The staff nurse dress code is not being adhered to as requested in the same e-mail. Several staff nurses deny having received the e-mail. Which action should the nurse manager take? a. Close the staff lounge. b. Enforce a stricter dress code. c. Include the findings on each staff member's annual evaluation d. Place a hard copy of announcements and unit policies in each staff member's mailbox.

ANS: D The identified problem is lack of staff communication. Sending an e-mail was not effective; therefore, giving each staff member a hard copy along with e-mailing is another approach the manager can take. An effective manager uses a variety of approaches to communicate quickly and accurately to all staff. For example, many managers distribute biweekly or monthly newsletters of ongoing unit or facility activities. Including the findings on evaluations, closing the lounge, and enforcing stricter dress codes do not address the problem.

A nurse manager conducts rounds on the unit and discovers that expired stock medicine is still in the cabinet despite the e-mail that was sent stating that it had to be discarded. The staff nurse dress code is not being adhered to as requested in the same e-mail. Several staff nurses deny having received the e-mail. Which action should the nurse manager take? a. Close the staff lounge. b. Enforce a stricter dress code. c. Include the findings on each staff member's annual evaluation. d. Place a hard copy of announcements and unit policies in each staff member's mailbox.

ANS: D The identified problem is lack of staff communication. Sending an e-mail was not effective; therefore, giving each staff member a hard copy along with e-mailing is another approach the manager can take. An effective manager uses a variety of approaches to communicate quickly and accurately to all staff. For example, many managers distribute biweekly or monthly newsletters of ongoing unit or facility activities. Including the findings on evaluations, closing the lounge, and enforcing stricter dress codes do not address the problem.

After reviewing the literature, the evidence-based practice committee institutes a practice change that bedrails should be left in the down position and hourly nursing rounds should be conducted. The results indicate over a 40% reduction in falls. What is the committee's next step? a. Evaluate the changes in 1 month. b. Implement the changes as a pilot study. c. Wait a month before implementing the changes. d. Communicate to staff the results of this project

ANS: D The last step of evidence-based practice (EBP) is to share the outcomes of EBP changes with others. Changes must be evaluated before the outcomes are shared. Once communicated, changes should be put in place as the committee deems reasonable (i.e., either hospital wide or as a pilot study). Waiting should not be an option unless the results are not to the committee's liking.

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

ANS: D The nurse does not have prescriptive authority to order pain medications, unless the nurse is an advanced practice nurse. The intervention is therefore dependent. Administering a medication, implementing an invasive procedure (e.g., inserting a Foley catheter, starting an intravenous [IV] infusion), and preparing a patient for diagnostic tests are examples of health care provider-initiated interventions. A collaborative, or an interdependent, intervention involves therapies that require combined knowledge, skill, and expertise from multiple health care professionals. Nurse-initiated interventions are the independent nursing interventions, or actions that a nurse initiates without supervision or direction from others.

The nurse learns about cultural issues involved in the patient's health care belief system and enables patients and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating? a. Marginalized groups b. Health care disparity c. Transcultural nursing d. Culturally congruent care

ANS: D The nurse is demonstrating culturally congruent care. Culturally congruent care, or care that fits a person's life patterns, values, and system of meaning, provides meaningful and beneficial nursing care. Marginalized groups are populations left out or excluded. Health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g., screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications. Transcultural nursing is a comparative study of cultures in order to understand their similarities (culture that is universal) and the differences among them (culture that is specific to particular groups).

Which action indicates the nurse is using the nursing process in patient care? a. Generates nursing knowledge for use in nursing practice. b. Conceptualizes an aspect of nursing to predict nursing care. c. Develops nursing care as a specific, distinct phenomenon. d. Delivers nursing care using a systematic approach.

ANS: D The nursing process provides a systematic approach for the delivery of nursing care. Theory generates nursing knowledge for use in practice; the nursing process is not a theory. A nursing theory conceptualizes an aspect of nursing to describe, explain, predict, or prescribe nursing care. An interdisciplinary theory explains a phenomenon specific to the discipline that developed the theory.

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.

A nurse is teaching a patient with a risk for hypertension how to take a blood pressure. Which action by the nurse is the priority to assist learning? a. Assess laboratory results for high cholesterol and other data. b. Identify that teaching is the same as the nursing process. c. Perform nursing care therapies to address hypertension. d. Focus on a patient's learning needs and objectives.

ANS: D The teaching process focuses on the patient's learning needs, motivation, and ability to learn; writing learning objectives and goals is also included. Nursing and teaching processes are not the same. Assessing laboratory results for high cholesterol and performing nursing care therapies are all components of the nursing process, not the teaching process.

A nurse admits an older client from a home environment where she lives with her adult son and daughterin-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by the nurse is most appropriate? a. Ask the family how these problems occurred. b. Call the police department and file a report. c. Notify Adult Protective Services. d. Report the findings as per agency policy.

ANS: D These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse should notify social work, case management, or whomever is designated in policies. That person can then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective Services is notified in the community setting.

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 understands the need for regular turning d. Absence of skin breakdown

ANS: D To determine whether a turning schedule is successful, the nurse needs to assess for the presence of skin breakdown. Redness on any part of the body, including only the patient's heels, indicates that the turning schedule was not successful. Documentation of interventions does not evaluate whether patient outcomes were met. While it is helpful that the patient understands the importance of the intervention, it is not criteria for successfulness of the turning schedule.

A nurse wants to reduce data entry errors on the computer system. Which action should the nurse take? a. Use the same password all the time. b. Share password with only one other staff member. c. Print out and review computer nursing notes at home. d. Chart on the computer immediately after care is provided.

ANS: D To increase accuracy and decrease unnecessary duplication, many health care agencies keep records or computers near a patient's bedside to facilitate immediate documentation of information as it is collected. A good system requires frequent, random changes in personal passwords to prevent unauthorized persons from tampering with records. When using a health care agency computer system, it is essential that you do not share your computer password with anyone under any circumstances. You destroy all papers containing personal information immediately after you use them. Taking nursing notes home is a violation of the Health Insurance Portability and Accountability Act (HIPAA) and confidentiality.

A nurse is choosing an appropriate topic for a young-adult health fair. Which topic should the nurse include? a. Retirement b. Menopause c. Climacteric factors d. Unplanned pregnancies

ANS: D Unplanned pregnancies are a continued source of stress that can result in adverse health outcomes for the mother (young adult), infant, and family. Retirement is an issue for middle-aged, not young adults. The onset of menopause and the climacteric affect the sexual health of the middle-aged adult, not the young adult.

A female nursing student in the final term of nursing school is overheard by a nursing faculty member telling another student that she got to insert a nasogastric tube in the emergency department while working as a nursing assistant. Which advice is best for the nursing faculty member to give to the nursing student? a. "Just be careful when you are doing new procedures and make sure you are following directions by the nurse." b. "Review your procedures before you go to work, so you will be prepared to do them if you have a chance." c. "The nurse should not have allowed you to insert the nasogastric tube because something bad could have happened." d. "You are not allowed to perform any procedures other than those in your job description even with the nurse's permission."

ANS: D When nursing students work as nursing assistants or nurse's aides when not attending classes, they should not perform tasks that do not appear in a job description for a nurse's aide or assistant. The nursing student should always follow the directions of the nurse, unless doing so violates the institution's guidelines or job description under which the nursing student was hired, such as inserting a nasogastric tube or giving an intramuscular medication. The nursing student should be able to safely complete the procedures delegated as a nursing assistant, and reviewing those not done recently is a good idea, but it has nothing to do with the situation. The focus of the discussion between the nursing faculty member and the nursing student should be on following the job description under which the nursing student is working.

A nurse wants to find the daily weights of a hospitalized patient. Which resource will the nurse consult? a. Database b. Progress notes c. Patient care summary d. Graphic record and flow sheet

ANS: D Within a computerized documentation system, flow sheets and graphic records allow you to quickly and easily enter assessment data about a patient, such as vital signs, admission and or daily weights, and percentage of meals eaten. In the problem-oriented medical record, the database section contains all available assessment information pertaining to the patient (e.g., history and physical examination, nursing admission history and ongoing assessment, physical therapy assessment, laboratory reports, and radiologic test results). Many computerized documentation systems have the ability to generate a patient care summary document that you review and sometimes print for each patient at the beginning and/or end of each shift; it includes information such as basic demographic data, health care provider's name, primary medical diagnosis, and current orders. Health care team members monitor and record the progress made toward resolving a patient's problems in progress notes.

A nurse is preparing to document a patient who has reported chest pain. Which information provided by the patient is critical for the nurse to include? a. "My family doesn't believe I'm in pain." b. Pupils equal and reactive to light. c. Had poor results from the pain medication. d. Reports sharp pain of 8 on a scale of 1 to 10.

ANS: D You need to ensure the information within a recorded entry or a report is complete, containing appropriate and essential information (pain of 8). Document subjective and objective assessment. While pupils equal and reactive to light is data, it does not relate to the chest pain; this information would be critical for a head injury. Derogatory or inappropriate comments about the patient or family is not appropriate. This kind of language can be used as evidence for nonprofessional behavior or poor quality of care. Avoid using generalized, empty phrases like "poor results." Use complete, concise descriptions.

A nurse is planning care for young-adult patients. Which information should the nurse consider when planning care? a. Fertility issues do not occur in young adulthood. b. Young adults tend to suffer more from severe illness. c. Substance abuse is easy to observe in young-adult patients. d. Young adults are quite active but are at risk for illness in later years.

ANS: D Young adults are generally active and experience severe illnesses less frequently. However, their lifestyles may put them at risk for illnesses or disabilities during their middle or older-adult years. An estimated 10% to 15% of reproductive couples are infertile, and many are young adults. Substance abuse is not always diagnosable, particularly in its early stages.

Which behaviors indicate the student nurse has a good understanding of confidentiality and the Health Insurance Portability and Accountability Act (HIPAA)? (Select all that apply.) a. Writes the patient's room number and date of birth on a paper for school. b. Prints/copies material from the patient's health record for a graded care plan. c. Reviews assigned patient's record and another unassigned patient's record. d. Gives a change-of-shift report to the oncoming nurse about the patient. e. Reads the progress notes of assigned patient's record. f. Discusses patient care with the hospital volunteer.

ANS: D, E When you are a student in a clinical setting, confidentiality and compliance with HIPAA are part of professional practice. Reading the progress notes of an assigned patient's record and giving a change-of-shift report to the oncoming nurse about the patient are behaviors that follow HIPAA and confidentiality guidelines. Do not share information with other patients or health care team members who are not caring for a patient. Not only is it unethical to view medical records of other patients, but breaches of confidentiality lead to disciplinary action by employers and dismissal from work or nursing school. To protect patient confidentiality, ensure that written materials used in your student clinical practice do not include patient identifiers (e.g., room number, date of birth, demographic information), and never print material from an electronic health record for personal use.

A nurse is using focused charting referred to as DAR. Match the chart entry to the correct letter of the acronym. a. Applied oxygen, stayed with patient, and instructed to slow breathing. b. Patient states, "feel better," respirations 16 with O2 saturations 96%. c. Patient states, "can't catch my breath and chest hurts." Confused. 1. D 2. A 3. R

1. ANS: C 2. ANS: A 3. ANS: B

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

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

A nurse is using Campinha-Bacote's model of cultural competency to improve cultural care. Which actions describe the components the nurse is using? a. In-depth self-examination of one's own background b. Ability to assess factors that influence treatment and care c. Sufficient comparative understanding of diverse groups d. Motivation and commitment to continue learning about cultures e. Cross-cultural interaction that develops communication skills 1. Cultural skills 2. Cultural desires 3. Cultural awareness 4. Cultural knowledge 5. Cultural encounters

1. ANS: B 2. ANS: D 3. ANS: A 4. ANS: C 4. ANS: C

A nurse is prioritizing care. Match the level of priority to the patients. a. Patient that needs to be turned to prevent pneumonia b. Patient with acute asthma attack c. Patient who will be discharged in 2 days who needs teaching 1. High priority 2. Intermediate priority 3. Low priority

1. ANS: B DIF: Apply (application) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice. TOP: Planning MSC: Management of Care 2. ANS: A DIF: Apply (application) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice. TOP: Planning MSC: Management of Care 3. ANS: C DIF: Apply (application) OBJ: Discuss ways to apply clinical care coordination skills in nursing practice. TOP: Planning MSC: Management of Care

A nurse is assessing a community. Match each community element the nurse will assess with the correct example. a. Education level b. Housing c. Government 1. Structure 2. Population 3. Social system

1. ANS: B DIF: Understand (comprehension) OBJ: Describe elements of a community assessment. TOP: Assessment MSC: Health Promotion and Maintenance 2. ANS: A DIF: Understand (comprehension) OBJ: Describe elements of a community assessment. TOP: Assessment MSC: Health Promotion and Maintenance 3. ANS: C DIF: Understand (comprehension) OBJ: Describe elements of a community assessment. TOP: Assessment MSC: Health Promotion and Maintenance

A nurse is assessing young and middle-aged adults for work-related conditions. Match the job to the work-related conditions that the nurse is assessing. a. Liver disease b. Carpal tunnel syndrome c. Asbestosis d. Farmer's lung e. Bladder cancer 1. Insulators 2. Dry cleaners 3. Dye workers 4. Office computer workers 5. Agricultural workers

1. ANS: C 2. ANS: A 3. ANS: E 4. ANS: B 5. ANS: D

A nurse is using AIDET to communicate with patients and families. Match the letters of the acronym to the behavior a nurse will use. a. Nurse describes procedures and tests. b. Nurse lets the patient know how long the procedure will last. c. Nurse recognizes the person with a positive attitude. d. Nurse thanks the patient. e. Nurse tells the patient "I am an RN and will be managing your care." 1. A 2. I 3. D 4. E 5. T

1. ANS: C 2. ANS: E 3. ANS: B 4. ANS: A 5. ANS: D

A nurse is discussing nursing actions that can lead to breaches of nursing practice. Match the example to the term it describes. a. Nurse posts about patient's loud and unruly family members. b. Nurse immediately applies restraints to make patient stay in bed. c. Nurse leaves bed in high position, causing patient to fall and break hip. d. Nurse states that she will wrap a bandage over patient's mouth if he won't be quiet. e. Nurse applies abdominal bandage after refusal. f. Nurse gets angry at patient and nurse leaves the hospital. 1. Assault 2. Battery 3. Abandonment 4. False imprisonment 5. Invasion of privacy 6. Malpractice

1. ANS: D 2. ANS: E 3. ANS: F 4. ANS: B 5. ANS: A 6. ANS: C

A nurse is teaching about the different types of health care model. Match the correct information to the type of health care model the nurse should include in the teaching session. a. Insurance for low-income families b. Federal insurance for people aged 65 and older c. Ties payment to organizations offering Medicare Advantage plans to the quality ratings of the coverage they offer d. Uses diagnosis-related group model 1. Prospective payment system (IPPS) 2. Affordable Care Act 3. Medicaid 4. Medicare

1. ANS: D DIF: Understand (comprehension) OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning MSC: Management of Care 2. ANS: C DIF: Understand (comprehension) OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning MSC: Management of Care 3. ANS: A DIF: Understand (comprehension) OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning MSC: Management of Care 4. ANS: B DIF: Understand (comprehension) OBJ: Compare the various methods for financing health care. TOP: Teaching/Learning MSC: Management of Care

A nurse is using different strategies to meet older patients' psychosocial needs. Match the strategy the nurse is using to its description. a. Respecting the older adult's uniqueness b. Improving level of awareness c. Listening to the patient's past recollections d. Accepting describing of patient's perspective e. Offering help with grooming and hygiene 1. Body image 2. Validation therapy 3. Therapeutic communication 4. Reality orientation 5. Reminiscence

1. ANS: E 2. ANS: D 3. ANS: A 4. ANS: B 5. ANS: C

A nurse is taking a history on a patient who cannot speak English. Which action will the nurse take to provide effective care? a. Obtain an interpreter. b. Refer to a speech therapist. c. Let a close family member talk. d. Find a mental health nurse specialist.

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

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

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

The nurse uses statistics on increased incidence of communicable disease to influence legislatures to pass a bill for mandatory vaccinations to enroll in school. Which type of nursing will the nurse use in this process? a. Public health nursing b. Community-based nursing c. Community health nursing d. Vulnerable population nursing

ANS: A A public health nurse understands factors that influence health promotion and health maintenance, the trends and patterns influencing the incidence of disease within populations, environmental factors contributing to health and illness, and the political processes used to affect public policy. Community health nursing is nursing practice in the community, with the primary focus on the health care of individuals, families, and groups within the community. Community-based nursing care takes place in community settings such as the home or a clinic, where the focus is on the needs of the individual or family. While there is no specific vulnerable population nursing, all types of nursing should care for these populations.

A nurse is working as a community health nurse. Which action is a priority for this nurse? a. Provide direct care to subpopulations. b. Focus on the needs of the ill individual. c. Provide first level of contact to health care systems. d. Focus on providing care in various community settings.

ANS: A Community health nursing is nursing practice in the community, with the primary focus on the health care of individuals, families, and groups within the community. In addition, the community health nurse provides direct care services to subpopulations within a community. Community-based nursing centers function as the first level of contact between members of a community and the health care system. Community-based nursing focuses on providing care in various community settings, such as the home or a clinic and involves acute and chronic care

Which action by the nurse indicates a safe and efficient use of social networks? a. Promotes support for a local health charity. b. Posts a picture of a patient's infected foot. c. Vents about a patient problem at work. d. Friends a patient.

ANS: A Social networks can be a supportive source of information about patient care or professional nursing activities. Even if you post an image of a patient without any obvious identifiers, the nature of shared media reposting can result in the image surfacing in a place where just the context of the image provides clues for friends or family to identify the patient. The ANA and NCSBN states, "Effective nurse-patient relationships are built on trust. Patients need to be confident that their most personal information and their basic dignity will be protected by the nurse." Becoming friends in online chat rooms, Facebook, or other public sites can interfere with your ability to maintain a therapeutic relationship.

A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally congruent care? a. Provides care that fits the patient's valued life patterns and set of meanings. b. Provides care that is based on meanings generated by predetermined criteria. c. Provides care that makes the nurse the leader in determining what is needed. d. Provides care that is the same as the values of the professional health care system

ANS: A The goal of transcultural nursing is to provide culturally congruent care, or care that fits the person's life patterns, values, and system of meaning. Patterns and meanings are generated from people themselves, rather than from predetermined criteria. Discovering patients' cultural values, beliefs, and practices as they relate to nursing and health care requires you to assume the role of learner (not become the leader) and to partner with your patients and their families to determine what is needed to provide meaningful and beneficial nursing care. Culturally congruent care is sometimes different from the values and meanings of the professional health care system.

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.

ANS: A The identified problem, or nursing diagnosis, is constipation. Therefore, the outcome should be that the constipation is relieved. To measure constipation relief, the nurse will be observing for the patient to have a bowel movement. During planning, you select goals and expected outcomes for each nursing diagnosis or problem to provide clear direction for the type of interventions needed to care for your patient and to then evaluate the effectiveness of these interventions. Not taking pain medications may or may not relieve the constipation. Although not taking pain medicines might be an intervention, the nurse doesn't want the patient to be in pain to relieve constipation. Other measures, such as administering laxatives or stool softeners, might be appropriate interventions but they are not outcomes. The patient walking unassisted to the bathroom addresses mobility, not constipation. The patient may need to walk to the bathroom to have a bowel movement, but the appropriate outcome for constipation is that the constipation is relieved as evidenced by a bowel movement—something that the nurse can observe.

A home health nurse notices that a patient's preschool children are often playing on the sidewalk and in the street unsupervised and repeatedly takes them back to the home and talks with the patient, but the situation continues. Which immediate action by the nurse is mandated by law? a. Contact the appropriate community child protection facility. b. Tell the parents that the authorities will be contacted shortly. c. Take pictures of the children to support the overt child abuse. d. Discuss with both parents about the safety needs of their children.

ANS: A The nurse has a duty to report this situation to protect the children. Any health care professional who does not report suspected child abuse or neglect may be liable for civil or criminal legal action. Talking with both parents is not mandated by law. There is no obligation to tell the parents that they will be reported to authorities. There is no obligation for the nurse to take pictures of the children.

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

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

A 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 after the fall? a. Identifying factors interfering with goal achievement b. Counseling the nursing assistive personnel on duty when the patient fell c. Removing the fall risk sign from the patient's door because the patient has suffered a fall d. Requesting that the more experienced charge nurse complete the documentation about the fall

ANS: A When goals and outcomes are not met, you identify the factors that interfere with their achievement. The nurse identifies factors that interfered with goal achievement to determine the cause of the fall. The fall may not have been due to an error by the nursing assistive personnel; therefore, counseling should be reserved until after the cause has been determined. The patient remains a fall risk, so the fall risk sign should remain on the door. The nurse witnessing the fall or the nurse assigned to the patient needs to complete the documentation. The charge nurse can be consulted to review the documentation.

During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old female patient reports pain and redness in the right breast. Which action is best for the nurse to take in response to this finding? a. Assess the patient as thoroughly as possible. b. Explain to the patient that breast tenderness is normal at her age. c. Tell the patient that redness is not a cause for concern and is quite common. d. Inform her that redness is the precursor to normal unilateral breast enlargement.

ANS: A A comprehensive assessment offers direction for health promotion recommendations, as well as for planning and implementing any acutely needed intervention. Redness or painful breasts are abnormal physical assessment findings in the middle-aged adult. Increased size of one breast is an abnormal physical assessment finding in the middle-aged adult.

A nurse is developing a care plan for a patient prescribed bed rest as a result of a pelvic fracture. 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.

ANS: A A goal is a broad statement of desired change; the patient will increase activity level is a broad statement. Turning is the expected outcome. When determining goals, the nurse needs to ensure that the goal is individualized and realistic for the patient. Since the patient is on bed rest, using a walker and bedside commode is contraindicated

A nurse writes the following PICOT question: How do patients with breast cancer rate their quality of life? How should the nurse evaluate this question? a. A true PICOT question regardless of the number of elements b. A true PICOT question because the intervention comes before the control c. Not a true PICOT question because the comparison comes after the intervention d. Not a true PICOT question because the time is not designated

ANS: A A meaningful PICOT question can contain only a P and O: How do patients with breast cancer (P) rate their quality of life (O)? Note that a well-designed PICOT question does not have to follow the sequence of P, I, C, O, and T. The aim is to ask a question that contains as many of the PICOT elements as possible.

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.

A patient has a diagnosis of pneumonia. Which entry should the nurse chart to help with financial reimbursement? a. Used incentive spirometer to encourage coughing and deep breathing. Lung congested upon auscultation in lower lobes bilaterally. Pulse oximetry 86%. Oxygen per nasal cannula applied at 2 L/min per standing order. b. Cooperative, patient coughed and deep breathed using a pillow as a splint. Stated, "felt better." Finally, patient had no complaints. c. Breathing without difficulty. Sitting up in bed watching TV. Had a good day. d. Status unchanged. Remains stable with no abnormal findings. Checked every 2 hours.

ANS: A Accurately documenting services provided, including the supplies and equipment used in a patient's care, clarifies the type of treatment a patient received. This documentation also supports accurate and timely reimbursement to a health care agency and/or patient. None of the other options had equipment or supplies listed. Avoid using generalized, empty phrases such as "status unchanged" or "had good day." Do not enter personal opinions—stating that the patient is cooperative is a personal opinion and should be avoided. "Finally, patient had no complaints" is a critical comment about the patient and if charted can be used as evidence of nonprofessional behavior or poor quality of care

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

ANS: A After a thorough assessment, the nurse should proceed to analyzing the data and formulating a nursing diagnosis before proceeding with developing the plan of care and determining appropriate interventions; this is the diagnosis phase. The evaluation phase involves determining whether the goals were met, and interventions were effective.

A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Financial planning seminar series for older adults c. Social events such as dances and group dinners d. Workshop on prevention from becoming an abuse victim

ANS: A All activities would be beneficial for the older population in the community. However, failure in performing ones own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need.

Which action indicates the nurse is meeting a primary goal of cultural competent care for patients? a. Provides care to transgender patients. b. Provides care to restore relationships. c. Provides care to patients that is individualized. d. Provides care to surgical patients.

ANS: A Although cultural competence and patient-centered care both aim to improve health care quality, their focus is slightly different. The primary aim of cultural competence care is to reduce health disparities and increase health equity and fairness by concentrating on people of color and other marginalized groups, like transgender patients. Patient-centered care, rather than cultural competence care, provides individualized care and restores an emphasis on personal relationships; it aims to elevate quality for all patients.

An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client? a. Keep the light on in the bathroom at night. b. Order a bedside commode for the client. c. Put the client on a toileting schedule. d. Use siderails to keep the client in bed.

ANS: A Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the likelihood of falling. The client does not need a commode or a toileting schedule. Siderails used to keep the client in bed are considered restraints and should not be used in that fashion.

The following statements are on a patient's nursing care plan. When creating a nursing care plan, which statement should 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.

ANS: A An expected outcome is a specific and measurable change that is expected as a result of nursing care. Verbalizing decreased pain on a 0 to 10 scale is an outcome. The other three options in this question are goals. Demonstrating increased mobility in 2 days and understanding necessary dietary changes by discharge are short-term goals because they are expected to occur in less than a week. Demonstrating increased tolerance to activity over a month-long period is a long-term goal because it is expected to occur over a longer period of time

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.

A patient diagnosed with chronic emphysema (lung disease) states "I would be better off dead." The nurse learns that the patient, has recently become unemployed because of oxygen dependency. The patient's spouse will have to go to work to support the family. Which action should the nurse take? a. Develop a plan of care for the family. b. Contact psychiatric services for a referral. c. Assure the patient that things will work out. d. Focus the plan of care solely on maximizing patient function.

ANS: A Because of the effects of chronic illness, family dynamics often change. The nurse must view the whole family as a patient under stress, planning care to help the family regain its maximal level of functioning and well-being. Psychiatric services may be a part of that plan but do not represent the entire plan. Offering false assurance is never acceptable. Focusing only on the patient will not help the family adjust.

A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which step should the nurse take first? a. Assessing own biases and attitude b. Learning about the world view of others c. Understanding organizational forces d. Developing cultural skills

ANS: A Becoming more aware of your biases and attitudes about human behavior is the first step in providing patient-centered care, leading to culturally competent care. It is helpful to think about cultural competence as a lifelong process of learning about others and also about yourself. Learning about the world view, developing cultural skills, and understanding organizational forces are not the first steps

A nurse performs cardiopulmonary resuscitation (CPR) on a 92 year old with brittle bones and breaks a rib during the procedure, which then punctures a lung. The patient recovers completely without any residual problems and sues the nurse for pain and suffering and for malpractice. Which key point will the prosecution attempt to prove against the nurse? a. The CPR procedure was done incorrectly. b. The patient would have died if nothing was done. c. The patient was resuscitated according to the policy. d. The older patient with brittle bones might sustain fractures when chest compressions are done.

ANS: A Certain criteria are necessary to establish nursing malpractice. The prosecution would try to prove that a breach of duty had occurred (CPR done incorrectly), which had caused injury. The defense team, not the prosecution, would explain the correlation between brittle bones and rib fractures during CPR and that the patient was resuscitated according to policy. In this situation, although harm was caused, it was not because of failure of the nurse to perform a duty according to standards, the way other nurses would have performed in the same situation. The fact that the patient sustained injury, as a result of age and physical status, does not mean the nurse breached any duty to the patient. The nurse would need to make sure the defense attorney knew that the cardiopulmonary resuscitation (CPR) was done correctly. Without intervention, the patient most likely would not have survived.

A patient states that she is pregnant and concerned because she does not know what to expect, and she wants her partner to play an active part in the birthing process. Which information should the nurse share with the patient? a. Lamaze classes can prepare pregnant women and their partners for what is coming. b. The frequency of sexual intercourse is key to helping the husband feel valued. c. After the birth, the stress of pregnancy will disappear and will be replaced by relief. d. After the baby is born, the wife should accept the extra responsibilities of motherhood.

ANS: A Childbirth education classes (like Lamaze) can prepare pregnant women, their partners, and other support persons to participate in the birthing process. The psychodynamic aspect of sexual activity is as important as the type or frequency of sexual intercourse to young adults; however, this does not relate to the issue the patient reports (lack of knowledge and participation). The stress that many women experience after childbirth has a significant impact on the health of postpartum women. Ideally partners should share all responsibilities; however, this does not relate to the patient's concerns.

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.

ANS: A Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. If the etiology is impaired verbal communication, then the nurse should choose an intervention that will address the problem. Providing the patient with a writing board will allow the patient to communicate by writing because the patient is unable to communicate verbally at this time. Obtaining an interpreter might be an appropriate intervention if the patient spoke a foreign language. Assisting with swallowing exercises will help the patient with swallowing, which is a different etiology than impaired verbal communication. Asking the family to provide a sitter at all times is many times unrealistic and does not relate to the impaired verbal communication; the goal would relate to the loneliness.

The nurse finds it difficult to care for a patient whose advance directive states that no extraordinary resuscitation measures should be taken. Which step may help the nurse to find resolution in this assignment? a. Review one's own personal values. b. Call for an ethical committee consult. c. Decline the assignment on religious grounds. d. Convince the family to challenge the directive.

ANS: A Clarifying values—your own, your patients', your co-workers'—is an important and effective part of ethical discourse. Calling for a consult, declining the assignment, and convincing the family to challenge the patient's directive are not ideal resolutions because they do not address the reason for the nurse's discomfort, which is the conflict between the nurse's values and those of the patient. The nurse should value the patient's decisions over the nurse's personal values.

Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? a. Confusion b. Presbycusis c. Temperature of 97.9° F d. Death of a spouse 2 months ago

ANS: A Confusion is a common manifestation in older adults with urinary tract infection; however, the cause requires further assessment. There may be another reason for the confusion. Confusion is not a normal finding in the older adult, even though it is commonly seen with concurrent infections. Difficulty hearing, presbycusis, is an expected finding in an older adult. Older adults tend to have lower core temperatures. Coping with the death of a spouse is a psychosocial concern to be addressed after the acute physiological concern in this case.

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.

ANS: A Decreased cardiac output related to altered myocardial contractility is a correctly written nursing diagnosis. Patient needs a low-fat diet related to inadequate heart perfusion is a goal phrased statement, not a nursing diagnosis. Offer a low-fat diet is an intervention, not a diagnosis. Acute pain related to discomfort is a circular diagnosis and gives no direction to nursing care.

A patient has sued a post-surgical unit nurse who provided care after abdominal surgery with nursing malpractice. Which resource would be used to determine whether the nurse has acted in a prudent manner? a. Scope and Standards of Nursing Care b. The typical level of care provided by other unit nurses c. The testimony of the patient's primary health care provider d. Comparison of documentation of the care provided by the nurse to similar patients

ANS: A During a malpractice suit, a nurse's actual conduct is compared to nursing standards of care (i.e., Scope and Standards of Nursing Care [ANA, 2015]) to determine whether the nurse acted as any reasonably prudent nurse would act under the same or similar circumstances. None of the other options would serve to validate the care that was appropriate for the patient at this time and by the nurse providing the care.

While conducting a community assessment, the nurse seeks data on the average household income and the number of residents on public assistance. In doing so, the nurse is evaluating which component of a community assessment? a. Structure b. Population c. Social system d. Welfare system

ANS: A Economic status is part of the community structure. Population would involve age and gender distribution, growth trends, density, education level, and ethnic or religious groups. The welfare system is part of the social system that also includes the education, government, communication, and health systems.

A goal for a patient diagnosed with diabetes is to demonstrate effective coping skills. Which patient behavior will indicate to the nurse achievement of this outcome? a. States, "It really helps talking about my health with family and friends." b. Observed consuming high-carbohydrate foods when stressed. c. Expresses a dislikes with the support group meetings. d. Spends most of the day reading in bed.

ANS: A Evaluative data that show signs of effective coping will help the nurse determine whether the patient has met the outcome. Talking to family and friends is the only positive option. During evaluation, you perform evaluative measures that allow you to compare clinical data, patient behavior measures, and patient self-report measures collected before implementation with the evaluation findings gathered after administering nursing care. Next, you evaluate whether the results of care match the expected outcomes and goals set for a patient. Consuming high-carbohydrate foods (patient is a diabetic), disliking support group, and spending the day in bed indicate unsuccessful progress toward meeting the patient's goal.

A nurse uses evidence-based practice (EBP) to provide nursing care. What is the best rationale for the nurse's behavior? a. EBP is a guide for nurses in making clinical decisions. b. EBP is based on the latest textbook information. c. EBP is easily attained at the bedside. d. EBP is always right for all situations.

ANS: A Evidence-based practice (EBP) is a guide for nurses to structure how to make appropriate, timely, and effective clinical decisions. A textbook relies on the scientific literature, which may be outdated by the time the book is published. Unfortunately, much of the best evidence never reaches the bedside. EBP is not to be blindly applied without using good judgment and critical thinking skills

A nurse is working in community-based nursing. Which competency is priority for this nurse? a. Caregiver b. Collaborator c. Change agent d. Case manager

ANS: A First and foremost is the role of caregiver. While collaborator, change agent, and case manager are important, they are not the priority.

A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping? a. I have had the same best friend for decades. b. I think I am coping very well on my own. c. My kids come to see me every weekend. d. Oh, I have lots of friends at the senior center.

ANS: A Friendship and support enhance coping. The quality of the relationship is what is most important, however. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis.

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

ANS: A Heart rate 78 beats/min on 12/3 indicates the goal has been met. Comparing expected and actual findings allows you to interpret and judge a patient's condition and whether predicted changes have occurred. Expected outcome states less than 80, not 80. The date is by 12/3, not 12/4.

A nurse needs to begin discharge planning for a patient admitted with pneumonia and a congested cough. When is the best time the nurse should start discharge planning for this patient? a. Upon admission b. Right before discharge c. After the congestion is treated d. When the primary care provider writes the order

ANS: A Ideally, discharge planning begins at admission. Right before discharge is too late for discharge planning. After the congestion is treated is also too late for discharge planning. Usually the primary care provider writes the order too close to discharge, and nurses do not need an order to begin the teaching that will be needed for discharge. By identifying discharge needs early, nursing and other health care professionals begin planning for discharge to the appropriate level of care, which sometimes includes support services such as home care and equipment needs.

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.

ANS: A If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. The nurse must assess before revising, delegating, and applying medication. The breakdown may be a result of inadequate nutritional intake and medication cannot be applied unless there is an order.

A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistive personnel (NAP). The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. Which action should the nurse take next? a. Asks the nursing assistive personnel to observe while the nurse performs catheter care. b. Leaves the room and ask the nursing assistive personnel to go back and perform proper catheter care. c. Tells the nursing assistive personnel that the incident will be reported to the nurse manager. d. Remove the catheter

ANS: A If the staff member's performance is not satisfactory, give constructive and appropriate feedback. You may discover the need to review a procedure with staff and offer demonstration. Because the nursing assistant is new, it is best for the nurse to perform catheter care while the assistant observes. This action will ensure that the assistant has been shown the proper way to perform the task and fosters collaboration rather than leaving the room just to tell the assistant to come back. The catheter does not need to be removed since there is no indication that the reason for its insertion has been resolved. Neither of the remaining options serve to correct the problem; the NAP's catheter care technique.

A patient with an indwelling urinary catheter has been given a bed bath by a new nursing assistive personnel (NAP). The nurse evaluating the cleanliness of the patient notices crusting at the urinary meatus. Which action should the nurse take next? a. Asks the nursing assistive personnel to observe while the nurse performs catheter care. b. Leaves the room and ask the nursing assistive personnel to go back and perform proper catheter care. c. Tells the nursing assistive personnel that the incident will be reported to the nurse manager. d. Remove the catheter.

ANS: A If the staff member's performance is not satisfactory, give constructive and appropriate feedback. You may discover the need to review a procedure with staff and offer demonstration. Because the nursing assistant is new, it is best for the nurse to perform catheter care while the assistant observes. This action will ensure that the assistant has been shown the proper way to perform the task and fosters collaboration rather than leaving the room just to tell the assistant to come back. The catheter does not need to be removed since there is no indication that the reason for its insertion has been resolved. Neither of the remaining options serve to correct the problem; the NAP's catheter care technique.

A nurse is teaching a patient about the Speak Up Initiatives. Which information should the nurse include in the teaching session? a. If you still do not understand, ask again. b. Ask a nurse to be your advocate or supporter. c. The nurse is the center of the health care team. d. Inappropriate medical tests are the most common mistakes.

ANS: A If you still do not understand, ask again is part of the S portion of the Speak Up Initiatives. Speak up if you have questions or concerns. You (the patient) are the center of the health care team, not the nurse. Ask a trusted family member or friend to be your advocate (advisor or supporter), not a nurse. Medication errors are the most common health care mistakes, not inappropriate medical tests.

A nurse is using SURETY to facilitate active listening. What is the focus of the letter R? a. Projection of a sense of relaxation b. Demonstrating respect for the patient c. Implementing reminisce to support memory d. Continuously provide reassurance to the patient

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

A nurse hears a co-worker state that anybody could be a nurse since it is so automated with infusion devices and electronic monitoring; technology is doing the work. What is the nurse's best response? a. "Technology use has to be combined with nursing judgment." b. "The focus of effective nursing care is technology." c. "If it's so easy, why don't you do it?" d. "That is true in the twentieth century."

ANS: A In many ways, technology makes work easier, but it does not replace nursing judgment. Technology does not replace your critical eye and clinical judgment. Most importantly, it is essential to remember that the focus of nursing care is not the machine or the technology; it is the patient. Using "why" is not beneficial when communicating with others. Agreeing with the statement furthers misconceptions.

A 17-year-old patient, dying of heart failure, wants to have organs removed for transplantation after death. Which action by the nurse is correct? a. Instruct the patient to talk with parents about the desire to donate organs. b. Notify the health care provider about the patient's desire to donate organs. c. Prepare the organ donation form for the patient to sign while still oriented. d. Contact the United Network for Organ Sharing after talking with the patient.

ANS: A In this situation, the parents would need to sign the form because the teenager is under age 18. An individual who is at least 18 may sign the form allowing organ donation upon death. The nurse cannot allow the patient to sign the organ donation document because the patient is younger than age 18. The health care provider will be notified about the patient's wishes after the parents agree to donate the organs. The United Network for Organ Sharing (UNOS) has a contract with the federal government and sets policies and guidelines for the procurement of organs.

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.

ANS: A Incorporate the consultant's recommendations into the care plan. The wound nurse clearly recommends that nurses on the unit, not the patient, should continue dressing changes. The nurses should not make a wrong assumption that the wound nurse is doing all the dressing changes. The recommendation states for the nurses to do the dressing changes. If the nurses feel strongly about obtaining another opinion, then the health care provider should be contacted. No evidence in the question suggests that the patient needs a second opinion.

A nurse has collected several research findings for evidence-based practice. Which article will be the best for the nurse to use? a. An article that uses randomized controlled trials (RCT). b. An article that is an opinion of expert committees. c. An article that uses qualitative research. d. An article that is peer-reviewed.

ANS: A Individual RCTs are the highest level of evidence or "gold standard" for research. A peer-reviewed article means that a panel of experts has reviewed the article; this is not a research method. Qualitative research is valuable in identifying information about how patients cope with or manage various health problems and their perceptions of illness. It does not usually have the robustness of an RCT. Expert opinion is on the bottom of the hierarchical pyramid of evidence.

A nurse is assessing internal variables that are affecting the patient's health status. Which area should the nurse assess? a. Perception of functioning b. Socioeconomic factors c. Cultural background d. Family practices

ANS: A Internal variables include a person's developmental stage, intellectual background, perception of functioning, and emotional and spiritual factors. External variables influencing a person's health beliefs and practices include family practices, socioeconomic factors, and cultural background.

Four patients in labor all request epidural analgesia to manage their pain at the same time. Which ethical principle is most compromised when only one nurse anesthetist is on call? a. Justice b. Fidelity c. Beneficence d. Nonmaleficence

ANS: A Justice refers to fairness and is used frequently in discussion regarding access to health care resources. Here the just distribution of resources, in this case pain management, cannot be justly apportioned. Nonmaleficence refers to avoidance of harm; beneficence refers to taking positive actions to help others. Fidelity refers to the agreement to keep promises. Each of these principles is partially expressed in the question; however, justice is most comprised because not all laboring patients have equal access to pain management owing to lack of personnel resources

A nurse is preparing to teach a kinesthetic learner about exercise. Which technique will the nurse use? a. Let the patient touch and use the exercise equipment. b. Provide the patient with pictures of the exercise equipment. c. Let the patient listen to a video about the exercise equipment. d. Provide the patient with a case study about the exercise equipment.

ANS: A Kinesthetic learners process knowledge by moving and participating in hands-on activities. Return demonstrations and role-playing work well with these learners. Patients who are visual-spatial learners enjoy learning through pictures and visual charts to explain concepts. The verbal/linguistic learner demonstrates strength in the language arts and therefore prefers learning by listening or reading information. Patients who learn through logical-mathematical reasoning think in terms of cause and effect and respond best when required to predict logical outcomes. Specific teaching strategies could include open-ended questioning or problem-solving exercises, like a case study.

While preparing a teaching plan, the nurse describes what the learner will be able to accomplish after the teaching session about healthy eating. Which action is the nurse completing? a. Developing learning objectives b. Providing positive reinforcement c. Presenting facts and knowledge d. Implementing interpersonal communication

ANS: A Learning objectives describe what the learner will exhibit as a result of successful instruction. Positive reinforcement follows feedback and reinforces good behavior and promotes continued compliance. Interpersonal communication is necessary for the teaching/learning process but describing what the learner will be able to do after successful instruction constitutes learning objectives. Facts and knowledge will be presented in the teaching session.

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.

Which information presented by a co-worker on a gerontological unit will cause the nurse to intervene? a. Most older people have dependent functioning. b. Most older people have strengths we should focus on. c. Most older people should be involved in care decision. d. Most older people should be encouraged to have independence.

ANS: A Most older people remain functionally independent despite the increasing prevalence of chronic disease; therefore, this misconception should be addressed. It is critical for you to respect older adults and actively involve them in care decisions and activities. You also need to identify an older adult's strengths and abilities during the assessment and encourage independence as an integral part of your plan of care.

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

A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse's suspicions? a. Flea bites and lice infestation. b. Left at a grocery store. c. Refuses to take a bath. d. Cuts and bruises.

ANS: A Neglect is the failure to provide basic necessities such as food, water, shelter, hygiene, and medical care. Caregiver neglect includes unsafe and unclean living conditions, soiled bedding, and animal or insect infestation. Abandonment includes desertion at a hospital, nursing facility, or public location such as a shopping center. Self-neglect includes refusal or failure to provide oneself with basic necessities such as food, water, clothing, shelter, personal hygiene, medication, and safety. Physical abuse includes hitting, beating, pushing, slapping, kicking, physical restraint, inappropriate use of drugs, fractures, lacerations, rope burns, and untreated injuries.

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

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

The patient reports to the nurse of being afraid to speak up regarding a desire to end care for fear of upsetting spouse and children. Which principle in the nursing code of ethics ensures that the nurse will promote the patient's cause? a. Advocacy b. Responsibility c. Confidentiality d. Accountability

ANS: A Nurses advocate for patients when they support the patient's cause. A nurse's ability to adequately advocate for a patient is based on the unique relationship that develops and the opportunity to better understand the patient's point of view. Responsibility refers to respecting one's professional obligations and following through on promises. Confidentiality deals with privacy issues, and accountability refers to answering for one's actions.

A nurse is completing an Outcome and Assessment Information Set (OASIS) data set on a patient. The nurse works in which area of patient care? a. Home health b. Intensive care unit c. Skilled nursing facility d. Long-term care facility

ANS: A Nurses use two different data sets to document the clinical assessments and care provided in the home care setting, the Outcome and Assessment Information Set (OASIS), and the Omaha System. The intensive care unit does not use the OASIS data set. The long-term health care setting includes skilled nursing facilities (SNFs) in which patients receive 24-hour day care

A nurse is completing a minimum data set. Which area is the nurse working? a. Nursing center b. Psychiatric facility c. Rehabilitation center d. Adult day care center

ANS: A Nurses who work in a nursing center (nursing home or nursing facility) are required to complete a minimum data set on each patient. Minimum data set is not needed for psychiatric, rehabilitation, or adult day care centers. Patients who suffer emotional and behavioral problems such as depression, violent behavior, and eating disorders often require special counseling and treatment in psychiatric facilities. Rehabilitation restores a person to the fullest physical, mental, social, vocational, and economic potential possible. Patients require rehabilitation after a physical or mental illness, injury, or chemical addiction. Adult day care centers provide a variety of health and social services to specific patient populations who live alone or with family in the community. Services offered during the day allow family members to maintain their lifestyles and employment and still provide home care for their relatives.

A nurse is teaching the staff about health care reimbursement. Which information should the nurse include in the teaching session? a. Home health, long-term care, and hospital nurses' documentation can affect reimbursement for health care. b. A clinical information system must be installed by 2014 to obtain health care reimbursement. c. A "near miss" helps determine reimbursement issues for health care. d. HIPAA is the basis for establishing reimbursement for health care.

ANS: A Nurses' documentation practices in home health, long-term care, and hospitals can determine reimbursement for health care. A "near miss" is an incident where no property was damaged and no patient or personnel were injured, but given a slight shift in time or position, damage or injury could have easily occurred. A clinical information system (CIS) does not have to be installed by 2014 to obtain reimbursement. CIS programs include monitoring systems; order entry systems; and laboratory, radiology, and pharmacy systems. Diagnosis-related groups (DRGs) are the basis for establishing reimbursement for patient care, not HIPAA. Legislation to protect patient privacy regarding health information is the Health Insurance Portability and Accountability Act (HIPAA).

In order to receive payment for care provided, nursing centers must comply with requirements outlined in what federal legislation? a. Omnibus Budget Reconciliation Act b. Medicare Act c. Medicaid Act d. Affordable Care Act

ANS: A Nursing centers must comply with the Omnibus Budget Reconciliation Act of 1987 and its minimum requirements for nursing facilities to receive payment from Medicare and Medicaid. The Affordable Care Act ties payment to organizations offering Medicare Advantage plans to the quality ratings of the coverage they offer.

A nurse is using nursing theory and the nursing process simultaneously to plan nursing care. How will the nurse use nursing theory and the nursing process in practice? a. Nursing theory can direct how a nurse uses the nursing process. b. Nursing theory requires the nursing process to develop knowledge. c. Nursing theory with the nursing process has a minor role in professional nursing. d. Nursing theory combined with the nursing process is specific to certain ill patients.

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

A nurse is conducting research about the needs of depressed patients. The nurse writes the following: Depression is a patient reporting a score above 7 on the Hamilton Depression Rating Scale. What did the nurse write? a. Operational definition b. Conceptual definition c. Paradigm d. Concept

ANS: A Operational definitions state how concepts are measured (Hamilton Depression Rating Scale). Theoretical or conceptual definitions simply define a particular concept, much like what can be found in a dictionary, based on the theorist's perspective (a mood disorder causing severe sadness and apathy). A paradigm is a pattern of beliefs used to describe a discipline's domain. Think of concepts as ideas and mental images, like depression is a concept.

A nurse is preparing to teach the patient about cane use after a stroke. Which learning objective/outcome is most appropriate for the nurse to include in the teaching plan? a. The patient will walk to the bathroom and back to bed using a cane. b. The patient will understand the importance of using a cane. c. The patient will know the correct use of a cane. d. The patient will learn how to use a cane.

ANS: A Outcomes often describe a behavior that identifies the patient's ability to do something on completion of teaching such as will empty a colostomy bag or will administer an injection. Understand, learn, and know are not behaviors that can be observed or evaluated.

An older patient diagnosed with dementia and confusion is admitted to the nursing unit after hip replacement surgery. Which action will the nurse include in the plan of care? a. Maintain a routine. b. Continue to reorient. c. Allow several choices. d. Socially isolate patient.

ANS: A Patients experiencing dementia need a routine. Continuing to reorient a patient with dementia is nonproductive and not advised. Patients with dementia need limited choices. Social interaction based on the patient's abilities is to be promoted.

The home health nurse listens to the patient's concerns about having "open-heart" surgery. The nurse explains the different surgical procedures and other options, like cardiac rehabilitation. After several visits, the patient wants cardiac rehabilitation. The nurse notifies the health care provider and sets up a referral. Which theory is the nurse using? a. Peplau's theory b. Henderson's theory c. Nightingale's theory d. Orem's self-care deficit theory

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

A nurse is using research findings to improve clinical practice. Which technique is the nurse using? a. Performance scores b. Integrated delivery networks c. Nursing-sensitive outcomes d. Utilization review committees

ANS: A Performance improvement activities are typically clinical projects conceived in response to identified clinical problems and designed to use research findings to improve clinical practice by applying earned scores. Larger health care systems have integrated delivery networks (IDNs) that include a network of facilities, providers, and services organized to deliver a continuum of care to a population of patients at a capitated cost in a particular setting. Nursing-sensitive outcomes are patient outcomes and nursing workforce characteristics that are directly related to nursing care such as changes in patients' symptom experiences, functional status, safety, psychological distress, registered nurse (RN) job satisfaction, total nursing hours per patient day, and costs. Medicare-qualified hospitals had physician-supervised utilization review (UR) committees to review the admissions and to identify and eliminate overuse of diagnostic and treatment services ordered by physicians caring for patients on Medicare.

A nurse is trying to decrease the rate of falls on the unit. After reviewing the literature, a strategy is implemented on the unit. After 3 months, the nurse finds that the falls have decreased. Which process did the nurse institute? a. Performance improvement b. Peer-reviewed project c. Generalizability study d. Qualitative research

ANS: A Performance improvement focuses on performance issues like falls or pressure injury incidence. A peer-reviewed article is reviewed for accuracy, validity, and rigor and approved for publication by experts before it is published. Generalizability is not a study/research; it is if the results of a study can be compared to other patients with similar experiences. This is a quantitative study, not a qualitative study.

An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the patient correctly understands the teaching on safety concerns? a. "I'll take my time getting up from the bed or chair." b. "I should dim the lighting outside to decrease the glare in my eyes." c. "I'll leave my throw rugs in place so that my feet won't touch the cold tile." d. "I should wear my favorite smooth bottom socks to protect my feet when walking around."

ANS: A Postural hypotension is an intrinsic factor that can cause falls. Changing positions slowly indicates a correct understanding of this concept. Environmental hazards outside and within the home such as poor lighting, slippery or wet flooring, and items on floor that are easy to trip over such as throw rugs are other factors that can lead to falls. Impaired vision and poor lighting are other risk factors for falls and should be avoided (dim lighting). Inappropriate footwear such as smooth bottom socks also contributes to falls.

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.

The nurse is working in a clinic that is designed to provide health education and immunizations. Which type of preventive care is the nurse providing? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Risk factor prevention

ANS: A Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Primary prevention includes health education programs, immunizations, and physical and nutritional fitness activities. Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration. While risk factor modification is an integral component of health promotion, it is not a type of preventive care.

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

ANS: A Public communication is interaction with an audience. Nurses have opportunities to speak with groups of consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom discussions with peers or students. When nurses work on committees or participate in patient care conferences, they use a small group communication process. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. Intrapersonal communication is a powerful form of communication that you use as a professional nurse. This level of communication is also called self-talk.

Which action can the nurse take legally when charting on a patient's record? a. Charts in a legible manner. b. States the patient is belligerent. c. Writes entry for another nurse. d. Uses correction fluid to correct error.

ANS: A Record all entries legibly. Do not write personal opinions (belligerent). Enter only objective and factual observations of patient's behavior; quote all patient comments. Do not erase, apply correction fluid, or scratch out errors made while recording. Chart only for yourself.

After a teaching session on taking blood pressures, the nurse tells the patient, "You took that blood pressure like an experienced nurse." Which type of reinforcement did the nurse use? a. Social acknowledgment b. Pleasurable activity c. Tangible reward d. Entrusting

ANS: A Reinforcers come in the form of social acknowledgments (e.g., nods, smiles, words of encouragement), pleasurable activities (e.g., walks or play time), and tangible rewards (e.g., toys or food). The entrusting approach is a teaching approach that provides a patient the opportunity to manage self-care. It is not a type of reinforcement.

A young-adult patient is brought to the hospital by police after crashing the car in a high-speed chase when trying to avoid arrest for spousal abuse. Which action should the nurse take? a. Question the patient about drug use. b. Offer the patient a cup of coffee to calm nerves. c. Discretely assess the patient for sexually transmitted infections. d. Deal with the issue at hand, not asking about previous illnesses.

ANS: A Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for the nurse to investigate the possibility of drug abuse more carefully. Caffeine is a naturally occurring legal stimulant that stimulates the central nervous system and is not the choice for calming nerves. Although sexually transmitted infections occur in the young adult, this is not an action a nurse should take in this situation. The nurse may obtain important information by making specific inquiries about past medical problems, changes in food intake or sleep patterns, and problems of emotional lability.

A nurse is describing a patient's perceived ability to successfully complete a task. Which term should the nurse use to describe this attribute? a. Self-efficacy b. Motivation c. Attentional set d. Active participation

ANS: A Self-efficacy, a concept included in social learning theory, refers to a person's perceived ability to successfully complete a task. Motivation is a force that acts on or within a person (e.g., an idea, an emotion, a physical need) to cause the person to behave in a particular way. An attentional set is the mental state that allows the learner to focus on and comprehend a learning activity. Learning occurs when the patient is actively involved in the educational session.

An older-adult patient has developed acute confusion. The patient has been taking tranquilizers for the past week. The patient's vital signs are normal. What should the nurse do? a. Consider age-related changes in body systems that affect pharmacokinetic activity. b. Increase the dose of tranquilizer if the cause of the confusion is an infection. c. Note when the confusion occurs and medicate before that time. d. Restrict phone calls to prevent further confusion.

ANS: A Some sedatives and tranquilizers prescribed for acutely confused older adults sometimes cause or exacerbate confusion. Carefully administer drugs used to manage confused behaviors, considering age-related changes in body systems that affect pharmacokinetic activity. When confusion has a physiological cause (such as an infection), specifically treat that cause, rather than the confused behavior. When confusion varies by time of day or is related to environmental factors, nonpharmacological measures such as making the environment more meaningful, providing adequate light, etc., should be used. Making phone calls to friends or family members allows older adults to hear reassuring voices, which may be beneficial.

A nurse's goal for an older adult is to reduce the risk of adverse medication effects. Which action will the nurse take? a. Review the patient's list of medications at each visit. b. Teach that polypharmacy is to be avoided at all cost. c. Avoid information about adverse effects. d. Focus only on prescribed medications.

ANS: A Strategies for reducing the risk for adverse medication effects include reviewing the medications with older adults at each visit, examining for potential interactions with food or other medications, simplifying and individualizing medication regimens, taking every opportunity to inform older adults and their families about all aspects of medication use, and encouraging older adults to question their health care providers about all prescribed and over-the-counter medications. Although polypharmacy often reflects inappropriate prescribing, the concurrent use of multiple medications is often necessary when an older adult has multiple acute and chronic conditions. Older adults are at risk for adverse drug effects because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs. Work collaboratively with the older adult to ensure safe and appropriate use of all medications—both prescribed medications and over-the-counter medications and herbal options.

The nurse is caring for a hospitalized young-adult male who works as a dishwasher at a local restaurant. He states that he would like to get a better job but has no education. How can the nurse best assist this patient psychosocially? a. By providing information and referrals b. By focusing on the patient's medical diagnoses c. By telling the patient that he needs to go back to school d. By expecting the patient to be flexible in decision making

ANS: A Support from the nurse, access to information, and appropriate referrals provide opportunities for achievement of a patient's potential. Health is not merely the absence of disease (focusing on medical diagnoses) but involves wellness in all human dimensions. Telling a patient what to do (go back to school) is inappropriate. Each person (not the nurse) needs to make these decisions based on individual factors. Insecure persons tend to be more rigid in making decisions.

The nurse is intervening for a patient with 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.

A nurse is caring for a patient with limited English-speaking skills. What intervention should be implemented to best assist in educating the patient about their disease process? a. Request a trained medical interpreter. b. Provide information in graphic form when possible. c. Use handouts prepared in the patient's native language. d. Ask that a family member be present during educational teaching.

ANS: A The National Culturally and Linguistically Appropriate Services (CLAS) Standards include standards for communication and language assistance. The standards apply when you are caring for patients who have limited English proficiency and/or other communication needs. All United States health care organizations must provide language assistance resources (e.g., trained medical interpreters, qualified translators, telecommunication devices for the deaf) for individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services. None of the other options provides the best form of communication since they all are subject to misinterpretation and nursing evaluation.

A nurse in a long-term care setting that is funded by Medicare and Medicaid is completing standardized protocols for assessment and care planning for reimbursement. Which task is the nurse completing? a. A minimum data set b. An admission assessment and acuity level c. A focused assessment/specific body system d. An intake assessment form and auditing phase

ANS: A The Resident Assessment Instrument (RAI), which includes the Minimum Data Set (MDS) and the Care Area Assessment (CAA), is the data set that is federally mandated for use in long-term care facilities by CMS. MDS assessment forms are completed upon admission, and then periodically, within specific guidelines and time frames for all residents in certified nursing homes. The MDS also determines the reimbursement level under the prospective payment system. A focused assessment is limited to a specific body system. An admission assessment and acuity level is performed in the hospital. An intake form is for home health. There is no such thing as an auditing phase in an assessment intake.

A nurse is auditing and monitoring patients' health records. Which action is the nurse taking? a. Determining the degree to which standards of care are met by reviewing patients' health records b. Realizing that care not documented in patients' health records still qualifies as care provided c. Basing reimbursement upon the diagnosis-related groups documented in patients' records d. Comparing data in patients' records to determine whether a new treatment had better outcomes than the standard treatment

ANS: A The auditing and monitoring of patients' health records involve nurses periodically auditing records to determine the degree to which standards of care are met and identifying areas needing improvement and staff development. The mistakes in documentation that commonly result in malpractice include failing to record nursing actions; this is the aspect of legal documentation. The financial billing or reimbursement purpose involves diagnosis-related groups (DRGs) as the basis for establishing reimbursement for patient care. For research purposes, the researcher compares the patient's recorded findings to determine whether the new method was more effective than the standard protocol. Data analysis contributes to evidence-based nursing practice and quality health care.

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

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

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

ANS: A The diagnostic process flows from the assessment process (observing and gathering data) and includes decision-making steps. These steps include data clustering, identifying patient health problems, and formulating the diagnosis (diagnosis is written as problem or NANDA-I approved diagnosis then etiology or cause).

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 re-checked, 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

ANS: A The diagnostic process should flow from the assessment. In this case, the nurse should have assessed the patient's blood pressure before giving the medication. The nurse could have prevented the patient's untoward reaction if the low blood pressure was assessed first. Diagnosis follows assessment. Administering the medication occurs in implementation, but this is not the first error. There are no errors in evaluation.

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

ANS: A The etiology, or related to factor, of tibial fracture is a medical diagnosis and needs to be revised. The nursing diagnosis is appropriate because the patient is unable to ambulate. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status; there is no collaborative problem listed. The defining characteristic (subjective and objective data that support the diagnosis) is appropriate for Impaired physical mobility.

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

ANS: A The first step in making a consultation is to assess the situation and identify the general problem area. Second, direct the consultation to the right professional such as another nurse or social worker. Third, provide a consultant with relevant information about the problem area and seek a solution. Fourth, do not prejudice or influence consultants. Fifth, be available to discuss a consultant's findings and recommendations.

The nurse is preparing a smoking cessation class for family members of patients with lung cancer. The nurse believes that the class will convert many smokers to nonsmokers once they realize the benefits of not smoking. Which health care model is the nurse following? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs

ANS: A The health belief model addresses the relationship between a person's beliefs and behaviors. The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health promotion model focuses on the following three areas: (1) individual characteristics and experiences, (2) behavior-specific knowledge and affect, and (3) behavioral outcomes, in which the patient commits to or changes a behavior. Maslow's' hierarchy of needs is based on the theory that all people share basic human needs, and the extent to which basic needs are met is a major factor in determining a person's level of health.

A nurse is reviewing literature for an evidence-based practice study. Which study should the nurse use for the most reliable level of evidence that uses statistics to show effectiveness? a. Meta-analysis b. Systematic review c. Single random controlled trial d. Control trial without randomization

ANS: A The main difference is that in a meta-analysis the researcher uses statistics to show the effect of an intervention on an outcome. In a systematic review, no statistics are used to draw conclusions about the evidence. A single random controlled trial (RCT) is not as conclusive as a review of several RCTs on the same question. Control trials without randomization may involve bias in how the study is conducted.

A 55-year-old female presents to the outpatient clinic describing irregular menstrual periods and hot flashes. Which information should the nurse share with the patient? a. The patient's assessment points toward normal menopause. b. Those symptoms are normal when a woman undergoes the climacteric. c. An assessment is not really needed because these problems are normal for older women. d. The patient should stop regular exercise because that is probably causing these symptoms. .

ANS: A The most significant physiological changes during middle age are menopause in women and the climacteric in men. Menopause typically occurs between 45 and 60 years of age. The nurse should continue with the examination because a comprehensive assessment offers direction for health promotion recommendations, as well as for planning and implementing any acutely needed interventions. Exercise should not be stopped, especially in middle-aged adults

A nurse is assigned to care for the following patients who all need vital signs scheduled to be taken now. Which patient is most appropriate for the nurse to delegate vital sign measurement to the nursing assistive personnel (NAP)? a. Patient scheduled for a procedure in the nuclear medicine department b. Patient transferring from the intensive care unit (ICU) c. Patient returning from a cardiac catheterization d. Patient returning from hip replacement surgery

ANS: A The nurse does not assign vital sign measurement or other tasks to NAP when patients are experiencing a change in level of care. The patient awaiting the procedure in nuclear medicine is the only patient who has not experienced a change in level of care. According to the rights of delegation, tasks that are repetitive, require little supervision, are relatively noninvasive, have results that are predictable, and have minimal risk can be delegated to assistive personnel. The patient in this question with the most predictable condition is the patient awaiting the nuclear medicine procedure. Once the nurse determines that the other patients are stable, the nurse could delegate their future vital sign measurement to the NAP. However, it is important for the nurse to assess patients coming from the ICU, the cardiac cath lab, and surgery when they first arrive on the unit.

A nurse manager sent one of the staff nurses on the unit to a conference about new, evidence-based wound care techniques. The nurse manager asks the staff nurse to prepare a poster to present at the next unit meeting, which will be mandatory for all nursing staff on the unit. Which type of opportunity is the nurse manager providing for the staff? a. Staff education b. Interprofessional collaboration c. Providing a professional shared governance council d. Establishing a nursing practice committee

ANS: A The nurse manager is planning a staff education opportunity. Staff education is one way the nurse manager supports staff involvement in a shared decision-making model. Interprofessional collaboration between nurses and health care providers (e.g., MD, PT, TR, etc.) is critical to the delivery of quality, safe patient care and the creation of a positive work culture for practitioners. The question does not state that the nurse is establishing a practice committee or a professional shared governance council. Chaired by senior clinical staff nurses, these groups establish and maintain care standards for nursing practice on their work unit

A nurse manager sent one of the staff nurses on the unit to a conference about new, evidence-based wound care techniques. The nurse manager asks the staff nurse to prepare a poster to present at the next unit meeting, which will be mandatory for all nursing staff on the unit. Which type of opportunity is the nurse manager providing for the staff? a. Staff education b. Interprofessional collaboration c. Providing a professional shared governance council d. Establishing a nursing practice committee

ANS: A The nurse manager is planning a staff education opportunity. Staff education is one way the nurse manager supports staff involvement in a shared decision-making model. Interprofessional collaboration between nurses and health care providers (e.g., MD, PT, TR, etc.) is critical to the delivery of quality, safe patient care and the creation of a positive work culture for practitioners. The question does not state that the nurse is establishing a practice committee or a professional shared governance council. Chaired by senior clinical staff nurses, these groups establish and maintain care standards for nursing practice on their work unit.

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?"

ANS: A The nurse must establish that the patient feels the urge and is unable to void. The question "Do you feel like you need to go to the bathroom?" is the most appropriate to ask. This question can be answered without knowledge of the diagnosis of Urinary retention. Discussing the ability to walk to the bathroom and asking about safety rails pertain to mobility and safety issues, not to retention of urine. Taking certain medications may lead to urinary retention, but that information would establish the etiology. The question is asking for the nurse to first establish the correct diagnosis.

The nurse is working in a drug rehabilitation clinic and is in the process of admitting a patient for "detox." What should the nurse do next? a. Identify the patient's stage of change. b. Realize that the patient is ready to change. c. Teach the patient that choices will have to change. d. Instruct the patient that relapses will not be tolerated.

ANS: A The nurse should identify the stage of change and assess where the patient is currently in this situation. To be most effective, nursing interventions should match the stage of change. The nurse cannot realize the patient is ready for change because only a minority of people are actually in the action stage of changing. While teaching that choices will have to change, it will follow later after the nurse has determined which stage the person is in. As individuals attempt a change in behavior, relapse followed by recycling through the stages occurs frequently.

A nurse is teaching about the goals of Healthy People 2020. Which information should the nurse include in the teaching session? a. Eliminate health disparities in America. b. Eliminate health behaviors in America. c. Eliminate quality of life in America. d. Eliminate healthy life in America.

ANS: A The nurse should include eliminating health disparities in America. Healthy People 2020 promotes a society in which all people live long, healthy lives. There are four overarching goals: (1) attain high-quality, longer lives free of preventable disease, disability, injury, and premature death; (2) achieve health equity, eliminate disparities, and improve the health of all groups; (3) create social and physical environments that promote good health for all; and (4) promote quality of life, healthy development, and healthy behaviors across all life stages.

A nurse is making a home visit and discovers that a patient's wound infection has gotten worse. The nurse cleans and redresses the wound. What should the nurse do next? a. Notify the health care provider of the findings before leaving the home. b. Ask the home health facility nurse manager to contact the health care provider. c. Document the findings and confirm with the patient the date of the next home visit. d. Tell the patient that the health care provider will be notified before the next home visit.

ANS: A The nurse should notify the health care provider before leaving the home. Regardless of the setting, an enriching professional environment is one in which staff members respect one another's ideas, share information, and keep one another informed. The manager should avoid taking care of problems for staff. The staff nurse needs to learn how to professionally communicate with other members of the health care team and demonstrate interprofessional collaboration.

Which finding indicates the best quality improvement process? a. Staff identifies the wait time in the emergency department is too long. b. Administration identifies the design of the facility's lobby increases patient stress. c. Director of the hospital identifies the payment schedule does not pay enough for overtime. d. Health care providers identify the inconsistencies of some of the facility's policy and procedures.

ANS: A The quality improvement process begins at the staff level, where problems are defined by the staff. It is not identified by administration, the hospital director, or health care providers.

A nurse is teaching about the transtheoretical model of change. In which order will the nurse place the progression of the stages from beginning to end? 1. Action 2. Preparation 3. Maintenance 4. Contemplation 5. Precontemplation a. 5, 4, 2, 1, 3 b. 2, 5, 4, 3, 1 c. 4, 5, 3, 1, 2 d. 1, 5, 2, 3, 4

ANS: A The stages of change in the transtheoretical model of change include five stages. These stages range from no intention to change (precontemplation), considering a change within the next 6 months (contemplation), making small changes (preparation), and actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance stage).

A nurse is using the research process. Place in order the sequence that the nurse will follow. 1. Analyze results. 2. Conduct the study. 3. Identify clinical problem. 4. Develop research question. 5. Determine how study will be conducted. a. 3, 4, 5, 2, 1 b. 4, 3, 5, 2, 1 c. 3, 5, 4, 2, 1 d. 4, 5, 3, 2, 1

ANS: A The steps of the research process are as follows: (1) identify area of interest or clinical problem, (2) develop research question(s)/hypotheses, (3) determine how study will be conducted, (4) conduct the study, and (5) analyze results of the study.

Before meeting the patient, a nurse talks to other caregivers about the patient. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination

ANS: A The time before the nurse meets the patient is called the preinteraction phase. This phase can involve things such as reviewing available data, including the medical and nursing history, talking to other caregivers who have information about the patient, or anticipating health concerns or issues that can arise. The orientation phase occurs when the nurse and the patient meet and get to know one another. This phase can involve things such as setting the tone for the relationship by adopting a warm, empathetic, caring manner. The working phase occurs when the nurse and the patient work together to solve problems and accomplish goals. The termination phase occurs during the ending of the relationship. This phase can involve things such as reminding the patient that termination is near.

A nurse is using theoretical knowledge in nursing practice to provide patient care. Which nursing behavior is an example of theoretical knowledge? a. Reads about different concepts. b. Reflects on clinical experiences. c. Combines the art and science of nursing. d. Creates a narrow understanding of nursing practice.

ANS: A Theoretical knowledge is acquired through "reading, observing, or discussing" concepts. The goals of theoretical knowledge are to stimulate thinking and create a broad understanding of nursing science and practices. Experiential, or clinical, knowledge is formed from nurses' clinical experiences. Both types of knowledge are needed in order to provide safe, comprehensive nursing care.

A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult? a. Building strength and flexibility b. Improving exercise endurance c. Increasing aerobic capacity d. Providing personal training

ANS: A This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase functional ability for activities of daily living. Strength and flexibility will help the client to be able to maintain independence longer. The other plans are good but will not specifically maintain the clients functional abilities.

A patient who is going to surgery has been taught how to cough and deep breathe. Which evaluation method will the nurse use? a. Return demonstration b. Computer instruction c. Verbalization of steps d. Cloze test

ANS: A To demonstrate mastery of the skill, have the patient perform a return demonstration under the same conditions that will be experienced at home or in the place where the skill is to be performed. Computer instruction is use of a programmed instruction format in which computers store response patterns for learners and select further lessons on the basis of these patterns (programs can be individualized). Computer instruction is a teaching tool, rather than an evaluation tool. Verbalization of steps can be an evaluation tool, but it is not as effective as a return demonstration when evaluating a psychomotor skill. The Cloze test, a test of reading comprehension, asks patients to fill in the blanks that are in a written paragraph.

A nurse is assessing the patient's meaning of illness. Which area of focus by the nurse is priority? a. On the way a patient reacts to disease b. On the malfunctioning of biological processes c. On the malfunctioning of psychological processes d. On the way a patient reacts to family/social interactions

ANS: A To provide culturally congruent care, you need to understand the difference between disease and illness. Illness is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or psychological processes. The way a patient interacts to family/social interactions is communication processes and family dynamics.

A patient is aphasic. The nurse notices that an aphasic patient demonstrates with intermittent hand tremors. Which nursing action is most appropriate to facilitate communication? a. Use a picture board. b. Use pen and paper. c. Use an interpreter. d. Use a hearing aid. ANS: A Using a pen and paper can be frustrating for a nonverbal (aphasic) patient whose handwriting is shaky; the nurse can revise the care plan to include use of a picture board instead. An interpreter is used for a patient who speaks a foreign language. A hearing aid is used for the hard of hearing, not for an aphasic patient.

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

A nurse is teaching about the primary focus of community wellness. Which information should the nurse include in the teaching session? a. Coordination of health care services b. Effective cost containment for services c. Appropriate service delivery to service population d. Identification of services needed to address individual needs

ANS: A Wellness care focuses on the health of populations and their communities rather than simply curing an individual's disease. In wellness care, nurses can help lead communities and health care systems in coordinating resources to better serve their populations. All the remaining options are components of care coordination.

The nurse is caring for a patient who does not follow the prescribed regimen for diabetes management. As a prescriber to Orem's theory, the nurse interviews the patient in an attempt to identify the cause of the patient's "nonadherence." What is the rationale for the nurse's behavior? a. Orem's theory is useful in designing interventions to promote self-care. b. Orem's theory focuses on cultural issues that may affect compliance. c. Orem's theory allows for reduction of anxiety with communication. d. Orem's theory helps nurses manipulate the patient's environment.

ANS: A When applying Orem's theory, a nurse continually assesses a patient's ability to perform self-care and intervenes as needed to ensure that the patients meet physical, psychological, sociological, and developmental needs. According to Orem, people who participate in self-care activities are more likely to improve their health outcomes. Leininger's culture care theory focuses on culture diversity and provides culturally specific nursing care. According to Peplau, nurses help patients reduce anxiety by converting it into constructive actions, using therapeutic communication. Nightingale's grand theory is a patient's environment can be manipulated by nurses to restore a patient to health.

The nurse uses a PICOT question to develop an evidence-based change in protocol for a certain nursing procedure. However, to make these changes throughout the entire institution would require more evidence than is available at this time. What is the nurse's best option? a. Conduct a pilot study to investigate findings. b. Drop the idea of making the change at this time. c. Insist that management hire the needed staff to facilitate the change. d. Seek employment in another institution that may have the staff needed.

ANS: A When evidence is not strong enough to apply in practice, the next option is to conduct a pilot study to investigate the PICOT question. Dropping the idea would be counterproductive; insisting that management hire staff could be seen as a mandate and could produce negative results. Seeking employment at another institution most likely would not be the answer because most institutions operate under similar established guidelines.

A nurse is implementing an evidence-based practice project regarding infection rates. After reviewing research literature, which other evidence should the nurse review? a. Quality improvement data b. Inductive reasoning data c. Informed consent data d. Biased data

ANS: A When implementing an evidence-based practice project, it is important to first review evidence from appropriate research and quality improvement data. Inductive reasoning is used to develop generalizations or theories from specific observations; this study needs specifics. Informed consent is not data but a process and form that subjects must sign before participating in research projects/studies. Biased data is based on opinions; facts are needed for this study.

A nurse exchanges information with the oncoming nurse about a patient's care. Which action did the nurse complete? a. A verbal report b. An electronic record entry c. A referral d. An acuity rating

ANS: A Whether the transfer of patient information occurs through verbal reports, electronic or written documents, you need to follow some basic principles. Reports are exchanges of information among caregivers. A patient's electronic medical record or chart is a confidential, permanent legal documentation of information relevant to a patient's health care. Nurses document referrals (arrangements for the services of another care provider). Nurses use acuity ratings to determine the hours of care and number of staff required for a given group of patients every shift or every 24 hours.

A nurse is assessing the health care disparities among population groups. Which area is the nurse monitoring? a. Accessibility of health care services b. Outcomes of health conditions c. Prevalence of complications d. Incidence of diseases

ANS: A While health disparities are the differences among populations in the incidence, prevalence, and outcomes of health conditions, diseases and related complications, health care disparities are differences among populations in the availability, accessibility, and quality of health care services (e.g., screening, diagnostic, treatment, management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their complications.

A nurse is caring for pediatric patients and using the developmental theory to plan nursing care. What is the focus of this nurse's care? a. Humans have an orderly, predictive process of growth and development. b. Humans respond to threats by adapting with growth and development. c. Humans respond with cognitive principles for growth and development. d. Humans have psychosocial domains to growth and development.

ANS: A With developmental theory, human growth and development is an orderly predictive process that begins with conception and continues through death. Stress/adaptation theories describe how humans respond to threats by adapting in order to maintain function and life. Educational theories explain the teaching-learning process by examining behavioral, cognitive, and adult-learning principles. Psychosocial theories explain human responses within the physiological, psychological, sociocultural, developmental, and spiritual domains.

Offering which community-based nursing activities indicates the nurse is working in the role of educator? (Select all that apply.) a. Prenatal classes b. A child safety program c. To defend patients' decisions d. Creative solutions to local problems e. To coordinate resources after discharge

ANS: A, B Prenatal classes, infant care, child safety, and cancer screening are just some of the health education programs provided in a community practice setting. Offers to defend patients' decisions is the role of patient advocate. Offers creative solutions to local problems indicates a change agent. Collaborator will offer to coordinate resources after discharge.

The nurse hears a health care provider say to the charge nurse that a certain nurse cannot care for patients because the nurse is stupid and won't follow orders. The health care provider also writes in the patient's medical records that the same nurse, by name, is not to care for any of the patients because of incompetence. Which torts has the health care provider committed? (Select all that apply.) a. Libel b. Slander c. Assault d. Battery e. Invasion of privacy

ANS: A, B Slander occurred when the health care provider spoke falsely about the nurse, and libel occurred when the health care provider wrote false information in the chart. Both of these situations could cause problems for the nurse's reputation. Invasion of privacy is the release of a patient's medical information to an unauthorized person such as a member of the press, the patient's employer, or the patient's family. Assault is any action that places a person in reasonable fear of harmful, imminent, or unwelcome contact. No actual contact is required for an assault to occur. Battery is any intentional touching without consent.

A home health nurse is providing care to a middle-aged couple with children at home. The patient has a debilitating chronic illness. Which areas will the nurse need to assess? (Select all that apply.) a. Adherence to treatment and rehabilitation regimens b. Coping mechanisms of patient and family c. Need for community services or referrals d. Knowledge base of patient only e. Use of a doula for care

ANS: A, B, C Along with the current health status of the chronically ill middle-aged adult, you need to assess the knowledge base of both the patient and family. In addition, you must determine the coping mechanisms of the patient and family, adherence to treatment and rehabilitation regimens, and the need for community and social services, along with appropriate referrals. A doula is a support person to be present during labor to assist women who have no other source of support.

Which government-instituted programs should the nurse include in a teaching session about controlling health care costs? (Select all that apply.) a. Professional standards review organizations b. Prospective payment systems c. Diagnosis-related groups d. Third-party payers e. "Never events"

ANS: A, B, C The federal government, the biggest consumer of health care, which pays for Medicare and Medicaid, has created professional standards review organizations (PSROs) to review the quality, quantity, and costs of hospital care. One of the most significant factors that influenced payment for health care was the prospective payment system (PPS). Established by Congress in 1983, the PPS eliminated cost-based reimbursement. Hospitals serving patients who received Medicare benefits were no longer able to charge whatever a patient's care cost. Instead, the PPS grouped inpatient hospital services for Medicare patients into diagnosis-related groups (DRGs). In 2011, the National Quality Forum (not a government facility) defined a list of 29 "never events" that are devastating and preventable. Through most of the twentieth century, few incentives existed for controlling health care costs. Insurers or third-party payers paid for whatever health care providers ordered for a patient's care and treatment.

A recently widowed older-adult patient is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the evening shift, the patient becomes acutely confused. Which possible reversible causes will the nurse consider when assessing this patient? (Select all that apply.) a. Electrolyte imbalance b. Sensory deprivation c. Hypoglycemia d. Drug effects e. Dementia

ANS: A, B, C, D Delirium, or a state of acute confusion, is a potentially reversible cognitive impairment that is often due to a physiological event. Physiological causes include electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage. Sometimes it is also caused by environmental factors such as sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional distress. Dementia is a gradual, progressive, and irreversible cerebral dysfunction.

Before conducting any study with human subjects, the nurse researcher must obtain informed consent. What must the nurse researcher ensure to obtain informed consent? (Select all that apply.) a. Gives complete information about the purpose. b. Allows free choice to participate or withdraw. c. Understands how confidentiality is maintained. d. Identifies risks and benefits of participation. e. Ensures that subjects complete the study.

ANS: A, B, C, D Informed consent means that research subjects: (1) are given full and complete information about the purpose of a study, procedures, data collection, potential harm and benefits, and alternative methods of treatment; (2) are capable of fully understanding the research and the implications of participation; (3) have the power of free choice to voluntarily consent or decline participation in the research; and (4) understand how the researcher maintains confidentiality or anonymity. Completion of the study is not needed for informed consent.

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

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

A nurse is asked by a co-worker why patient education/teaching is important. Which statements will the nurse share with the co-worker? (Select all that apply.) a. "Patient education is an essential component of safe, patient-centered care." b. "Patient education is a standard for professional nursing practice." c. "Patient teaching falls within the scope of nursing practice." d. "Patient teaching is documented and part of the chart." e. "Patient education is not effective with children." f. "Patient teaching can increase health care costs."

ANS: A, B, C, D Patient education has long been a standard for professional nursing practice. All state Nurse Practice Acts acknowledge that patient teaching falls within the scope of nursing practice. Patient education is an essential component of providing safe, patient-centered care. It is important to document evidence of successful patient education in patients' medical records. Patient education is effective for children. Different techniques must be used with children. Creating a well-designed, comprehensive teaching plan that fits a patient's unique learning needs reduces health care costs, improves quality of care, and ultimately changes behaviors to improve patient outcomes.

A nurse is working in a health care organization that has achieved Magnet status. Which components are indicators of this status? (Select all that apply.) a. Empirical quality results b. Structural empowerment c. Transformational leadership d. Exemplary professional practice e. Willingness to recommend the agency

ANS: A, B, C, D The American Nurses Credentialing Center (ANCC) established the Magnet Recognition Program to recognize health care organizations that achieve excellence in nursing practice. The five components are transformational leadership; structural empowerment; exemplary professional practice; new knowledge, innovation, and improvements; and empirical quality results. Willingness to recommend the hospital/agency is a component of the Hospital Consumer of Assessment of Healthcare Providers and Systems survey.

A community-based nursing is working with a family. For which key areas will the nurse need a strong knowledge base? (Select all that apply.) a. Family theory b. Communication c. Group dynamics d. Cultural diversity e. Individual-centered care

ANS: A, B, C, D With the individual and family as the patients, the context of community-based nursing is family-centered care (not individual-centered care) within the community. This focus requires a strong knowledge base in family theory, principles of communication, group dynamics, and cultural diversity. The nurse leans to partner with patients and families, not just with individuals.

.A nurse uses the accepted rights of delegation when providing care. Which "rights" did the nurse use? (Select all that apply.) a. Task b. Person c. Direction d. Supervision e. Circumstances f. Cost-effectiveness

ANS: A, B, C, D, E The five rights of delegation are right task, circumstances, person, direction, and supervision. Cost-effectiveness is not a right.

A nurse uses the accepted rights of delegation when providing care. Which "rights" did the nurse use? (Select all that apply.) a. Task b. Person c. Direction d. Supervision e. Circumstances f. Cost-effectiveness

ANS: A, B, C, D, E The five rights of delegation are right task, circumstances, person, direction, and supervision. Cost-effectiveness is not a right.

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.

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.

A nurse wants to incorporate psychosocial theories into nursing practice. Which elements will the nurse include? (Select all that apply.) a. Physiological needs of the patient b. Psychological needs of the patient c. Sociocultural needs of the patient d. Cognitive needs of the patient e. Spiritual needs of the patient

ANS: A, B, C, E When nursing incorporates psychosocial theories into nursing practice, the nurse strives to meet the physiological, psychological, sociocultural, developmental, and spiritual needs of patients. Cognitive needs of the patient are included in educational theories.

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

ANS: A, B, C, E You examine the results of care by using evaluative measures, which are assessment skills and techniques (e.g., observations, physiological measurements, use of measurement scales, and patient interview). Examples of evaluative measures include assessment of wound healing and respiratory status, blood pressure measurement, and assessment of patient feelings. You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed.

A nurse is describing the purposes of a health care record to a group of nursing students. Which purposes will the nurse include in the teaching session? (Select all that apply.) a. Communication b. Legal documentation c. Reimbursement d. Nursing process e. Research f. Education

ANS: A, B, C, E, F A patient's record is a valuable source of data for all members of the health care team. Its purposes include interdisciplinary communication, legal documentation, financial billing (reimbursement), education, research, and auditing/monitoring. Nursing process is a way of thinking and performing nursing care; it is not a purpose of a health care record.

A nurse is implementing nursing care measures for patients with challenging communication issues. Which types of patients will need these nursing care measures? (Select all that apply.) a. A child who is developmentally delayed. b. An older-adult patient who is demanding. c. A female patient who is outgoing and flirty. d. A male patient who is cooperative with treatments. e. An older-adult patient who can clearly see small print. f. A teenager frightened by the prospect of impending surgery.

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

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.

A nurse is assessing a middle-aged patient's barriers to change in eating habits. Which areas will the nurse assess that are external barriers? (Select all that apply.) a. Lack of facilities b. Lack of materials c. Lack of knowledge d. Lack of social supports e. Lack of short- and long-term goals

ANS: A, B, D External barriers to change include lack of facilities, materials, and social supports. Internal barriers are lack of knowledge, insufficient skills, and undefined short- and long-term goals.

A patient has approximately 6 months to live and asks about a do not resuscitate (DNR) order. Which statements by the nurse give the patient correct information? (Select all that apply.) a. "You will be resuscitated unless there is a DNR order in the chart." b. "If you want certain procedures or actions taken or not taken, and you might not be able to tell anyone at the time, you need to complete documents ahead of time that give your health care provider this information." c. "You will be resuscitated at any time to allow you the longest length of survival." d. "If you decide you want a DNR order, you will need to talk to your health care provider." e. "If you travel to another state, your living will should cover your wishes."

ANS: A, B, D Health care providers perform CPR on an appropriate patient unless a do not resuscitate (DNR) order has been placed in the patient's chart. The statutes assume that all patients will be resuscitated unless a written DNR order is found in the chart. Legally competent adult patients can consent to a DNR order verbally or in writing after receiving appropriate information from the health care provider. A health care proxy or durable power of attorney for health care (DPAHC) is a legal document that designates a person or persons of one's choosing to make health care decisions when the patient is no longer able to make decisions on his or her own behalf. This agent makes health care treatment decisions based on the patient's wishes, like a DNR. Resuscitation is performed anytime (not just for the longest length of survival) unless a DNR is written in the chart. Differences among the states have been noted regarding advance directives, so the patient should check state laws to see if a state will honor an advance directive that was originated in another state.

A nurse meets the following goals: helps a patient maintain health and helps a patient with an illness. Which factors assist the nurse in achieving these goals? (Select all that apply.) a. Understands the challenges of today's health care system. b. Identifies actual and potential risk factors. c. Has coined the term "illness behavior." d. Minimizes the effects of illnesses. e. Experiences compassion fatigue.

ANS: A, B, D Nurses are in a unique position to assist patients in achieving and maintaining optimal levels of health. Nurses understand the challenges of today's health care system. Nurses can identify actual and potential risk factors that predispose a person or group to illness. Nurses who understand how patients react to illness can minimize the effects of illness and assist patients and their families in maintaining or returning to the highest level of functioning. Nurses did not coin the phrase "illness behavior." While nurses can experience compassion fatigue, it does not help in meeting patient goals.

A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last months visit. What actions should the nurse perform first? (Select all that apply.) a. Assess the clients ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately c. Encourage the client to continue the current exercise plan. d. Have the client complete a 3-day diet recall diary. e. Teach the client about proper nutrition in the older population.

ANS: A, B, D Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging him or her to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the clients needs, which the nurse does not yet know.

A nurse is using Campinha-Bacote's model of cultural competency. Which areas will the nurse focus on to become competent? (Select all that apply.) a. Cultural skills b. Cultural desire c. Cultural transition d. Cultural knowledge e. Cultural encounters

ANS: A, B, D, E Campinha-Bacote's model of cultural competency has five interrelated components: cultural awareness, cultural knowledge, cultural skills, cultural encounters, and cultural desire. Cultural transition is not a component of this model.

A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adults kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. 1% milk b. Carrots c. Lean ground beef d. Oranges e. Vitamin D supplements

ANS: A, B, D, E Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium; carrots have vitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, but does not contain these needed nutrients.

A nurse is a member of the ethics committee. Which roles will the nurse fulfill in this committee? (Select all that apply.) a. Educator b. Case consultant c. Purchasing Agent d. Direct patient care provider e. Policy reviewer and recommender

ANS: A, B, E An ethics committee devoted to the teaching and processing of ethical issues and dilemmas exists in most health care facilities. It is generally multidisciplinary and it serves several purposes: education, policy recommendation, and case consultation. It does not have purchasing power or provide direct patient care.

A nurse is preparing to teach patients. Which patient finding will cause the nurse to postpone a teaching session? (Select all that apply.) a. The patient's pain is not controlled. b. The patient is reporting being fatigued. c. The patient is mildly anxious about their condition. d. The patient is asking numerous questions about their health status. e. The patient is currently febrile with an oral temperature of 101.2° F. f. The patient is in the acceptance phase of dealing with their medical diagnosis.

ANS: A, B, E Any condition (e.g., pain, fatigue) that depletes a person's energy also impairs the ability to learn, so the session should be postponed until the pain is relieved and the patient is rested. Postpone teaching when an illness becomes aggravated by complications such as a high fever or respiratory difficulty. A mild level of anxiety motivates learning. When patients are ready to learn, they frequently ask questions. When the patient enters the stage of acceptance, the stage compatible with learning, introduce a teaching plan.

A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.) a. Constipation b. Dehydration c. Mania d. Urinary incontinence e. Weakness

ANS: A, B, E Common adverse medication effects include constipation/impaction, dehydration, and weakness. Mania and incontinence are not among the common adverse effects, although urinary retention is.

A nurse is attempting to establish a respectful relationship with a newly admitted patient from Africa. Which actions should the nurse take? (Select all that apply.) a. Engage in face-to-face interactions. b. Help the patient overcome barriers. c. Consciously attempt to suspend judgment. d. Stress that they will be working together to address problems. e. Know limitations in addressing medical issues across cultures.

ANS: A, C Ongoing development of cultural competence will present as your ability to interact effectively with people from different cultures, identifying the need to be respectful and responsive to the health belief practices or linguistic needs of our diverse population. Cultural awareness is the process of conducting a self-examination of one's own biases toward other cultures and the in-depth exploration of one's cultural and professional background. Cultural encounter is a process that encourages health care professionals to directly engage in face-to-face cultural interactions and other types of encounters with patients from culturally diverse backgrounds. The remaining options are not specific to a cultural competent plan of nursing care.

A nurse is using a nursing metaparadigm to define nursing. Which concepts will the nurse include? (Select all that apply.) a. Person b. Disease c. Health d. Nursing e. Environment

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

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

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

A nurse 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.

ANS: A, D, E By ranking a patient's nursing diagnoses in order of importance and always monitoring changing signs and symptoms (defining characteristics) of patient problems, you attend to each patient's most important needs and better organize ongoing care activities. Prioritizing the problems, or nursing diagnoses, will help the nurse decide which problem to address first. Symptom pattern recognition from your assessment database and certain knowledge triggers help you understand which diagnoses require intervention and the associated time frame to intervene effectively. Planning requires critical thinking applied through deliberate decision making and problem solving. The nurse avoids setting priorities based solely on physiological factors; other factors should be considered as well. The order of priorities changes as a patient's condition and needs change, sometimes within a matter of minutes

The nurse is preparing to conduct research that will allow precise measurement of a phenomenon. Which methods will provide the nurse with the right kind of data? (Select all that apply.) a. Surveys b. Phenomenology c. Grounded theory d. Evaluation research e. Nonexperimental research

ANS: A, D, E Experimental research, nonexperimental research, surveys, and evaluation research are all forms of quantitative research that allow for precise measurement. Phenomenology and grounded theory are forms of qualitative research.

A nurse is caring for vulnerable populations in a local community. Which patients will the nurse care for in this community? (Select all that apply.) a. A 47-year-old immigrant who speaks only Spanish b. A 35-year-old living in own home c. A 22-year-old pregnant woman d. A 40-year-old schizophrenic e. A 15-year-old rape victim

ANS: A, D, E Individuals living in poverty, older adults, people who are homeless, immigrant populations, individuals in abusive relationships (rape), substance abusers, and people with severe mental illnesses (schizophrenic) are examples of vulnerable populations. Middle-aged people living in their own home are not an example of a vulnerable population. Pregnancy is not an example of a vulnerable population.

A nurse is teaching the staff about the Institute of Medicine competencies. Which examples indicate the staff has a correct understanding of the teaching? (Select all that apply.) a. Use informatics. b. Use transparency. c. Apply globalization. d. Apply quality improvement. e. Use evidence-based practice.

ANS: A, D, E The Institute of Medicine competencies include: provide patient-centered care, work in interdisciplinary teams, use evidence-based practice, apply quality improvement, and use informatics. Transparency is included in the 10 rules of performance in a redesigned health care system, not a competency. While globalization is important in health care, it is not a competency

The nurse calculates the medication dose for an infant on the pediatric unit and determines that the dose is twice what it should be based upon the drug book's information. The pediatrician is contacted and says to administer the medication as ordered. Which actions should the nurse take next? (Select all that apply.) a. Notify the nursing supervisor. b. Administer the medication as ordered. c. Give the amount listed in the drug book. d. Ask the mother to give the drug to her child. e. Check the chain of command policy for such situations.

ANS: A, E If the health care provider confirms an order and the nurse still believes that it is inappropriate, the nurse should inform the supervising nurse and follow the established chain of command. Nurses follow health care providers' orders unless they believe the orders are in error or may harm patients. Therefore, the nurse needs to assess all orders. If an order seems to be erroneous or harmful, further clarification from the health care provider is necessary. The supervising nurse should be able to help resolve the questionable order, but only the health care provider who wrote the order or a health care provider covering for the one who wrote the order can change the order. Harm to the infant could occur if the medication is given as ordered. The nurse cannot change an order by giving the amount listed in the drug book. Asking the mother to give the drug is inappropriate

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

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

The nurse is admitting a patient with uncontrolled diabetes mellitus. It is the fourth time the patient is being admitted in the last 6 months for high blood glucose levels. During the admission process, the nurse asks the patient about employment status and displays a nonjudgmental attitude. What is the rationale for the nurse's actions? a. External variables have little effect on compliance. b. A person's compliance is affected by economic status. c. Employment status is an internal variable that impacts compliance. d. Noncompliant patients thrive on the disapproval of authority figures.

ANS: B A person's compliance with treatment is affected by economic status. A person tends to give a higher priority to food and shelter than to costly drugs or treatments. External variables can have a major impact on compliance. Employment status is an external variable, not an internal variable. A person generally seeks approval and support from social networks, and this desire for approval affects health beliefs and practices; noncompliance does not occur from thriving on disapproval of authority figures

Which action will the nurse take when taking a telephone order? a. Print out a copy of the order once entered into the electronic health record. b. Read back the order as written to the health care provider for verification. c. Ask that another registered nurse listen to the call over an extension line. d. Verify that the health care provider will write the order within 24 hours.

ANS: B A read back of a telephone order is required and should contain all pertinent information so that verification can be secured. None of the other options provide verification of the details related to the order itself.

A nurse has instructed the patient regarding the proper use of crutches. The patient went up and down the stairs using crutches with no difficulties. Which information will the nurse use for the "I" in PIE charting? a. Patient went up and down stairs b. Demonstrated use of crutches c. Used crutches with no difficulties d. Deficient knowledge related to never using crutches

ANS: B A second progress note method is the PIE format. The narrative note includes P—Nursing diagnosis, I—Intervention, and E—Evaluation. The intervention is "Demonstrated use of crutches." "Patient went up and down stairs" and "Used crutches with no difficulties" are examples of E. "Deficient knowledge regarding crutches" is P.

How can a nurse assigned to a medical unit at a local hospital best address issues related to the delivery of quality nursing care? a. Serve as a volunteer patient advocate at the local free health clinic. b. Become active in professional nursing organizations at the state level. c. Ask to be a member of the hospital's policy and procedure committee d. Agree to act as a preceptor for nursing students during their clinical experience

ANS: B As a professional nurse, it is important to remain aware of current issues in health care. Become involved in professional organizations and committees that define the standards of care for nursing practice. If current laws, rules and regulations, or policies under which nurses practice are not evidence based, advocate to ensure that the scope of nursing practice is defined accurately. While the other options are all associated with effecting quality nursing care, none have the degree of effectiveness as working directly with nursing organizations to define standards of nursing care.

While recovering from a severe illness, a hospitalized patient wants to change a living will, which was signed 9 months ago. Which response by the nurse is most appropriate? a. "Check with your admitting health care provider whether a copy is on your chart." b. "Let me check with someone here in the hospital who can assist you." c. "You are not allowed to ever change a living will after signing it." d. "Your living will can be changed only once each calendar year."

ANS: B As long as the patient is not declared legally incompetent or lacks the capacity to make decisions, living wills can be changed. It is the nurse's responsibility to find an appropriate person in the facility to assist the patient. Checking with the health care provider about the presence of a living will on the chart has nothing to do with the patient's desire to change the living will. The question states that the patient wants to change a living will. A living will can be changed whenever the patient decides to change it, as long as the patient is competent.

A novice nurse is working in a unit that uses interdisciplinary collaboration. Which action will the nurse take to help assure effectiveness as a team member? a. Act as a leader of the health care team. b. Develop good communication skills. c. Work solely with experienced 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.

The nurse has become aware of missing narcotics in the patient care area. Which ethical principle obligates the nurse to report the missing medications? a. Advocacy b. Responsibility c. Confidentiality d. Accountability

ANS: B Responsibility refers to one's willingness to respect and adhere to one's professional obligations. It is the nurse's responsibility to report missing narcotics. Accountability refers to the ability to answer for one's actions. Advocacy refers to the support of a particular cause. The concept of confidentiality is very important in health care and involves protecting patients' personal health information.

A nurse is using the World Health Organization definition of health to provide care. Which area will the nurse focus on while providing care? a. Focusing on helping patients be disease free b. Providing care that involves the whole person c. Assuring that care is strictly personal in nature d. Directing focus only on the pathological state

ANS: B The World Health Organization (WHO) defines health as a "state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity." Therefore, nurses' attitudes toward health and illness should consider the total person, as well as the environment in which the person lives. All people free of disease are not necessarily healthy. Strictly personal and a focus only on pathological states do not correlate to WHO's definition.

During a severe respiratory epidemic, the local health care organizations decide to give health care workers priority access to ventilators over other members of the community who also need that resource. Which philosophy would give the strongest support for this decision? a. Deontology b. Utilitarianism c. Ethics of care d. Feminist ethics

ANS: B Utilitarianism focuses on the greatest good for the most people; the organizations decide to ensure that as many health care workers as possible will survive to care for other members of the community. Deontology defines actions as right or wrong based on their "right-making characteristics" such as fidelity to promises, truthfulness, and justice. Feminist ethics looks to the nature of relationships to guide participants in making difficult decisions, especially relationships in which power is unequal or in which a point of view has become ignored or invisible. The ethics of care and feminist ethics are closely related, but ethics of care emphasizes the role of feelings.

A patient just received a diagnosis of cancer. Which statement by the nurse demonstrates empathy? a. "Tomorrow will be better." b. "This must be hard news to hear." c. "What's your biggest fear about this diagnosis?" d. "I believe you can overcome this because I've seen how strong you are."

ANS: B "This must be hard" is an example of empathy. Empathy is the ability to understand and accept another person's reality, accurately perceive feelings, and communicate this understanding to the other. An example of false reassurance is "Tomorrow will be better." "I believe you can overcome this" is an example of sharing hope. "What is your biggest fear?" is an open-ended question that allows patients to take the conversational lead and introduces pertinent information about a topic.

The nurse is teaching a novice nurse about protocols. Which information from the novice 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.

A nurse is assessing the ability to learn of a patient who has recently experienced a stroke. Which question/statement will best assess the patient's ability to learn? a. "What do you want to know about strokes?" b. "Please read this handout and tell me what it means." c. "Do you feel strong enough to perform the tasks I will teach you?" d. "On a scale from 1 to 10, tell me where you rank your desire to learn."

ANS: B A patient's reading level affects ability to learn. One way to assess a patient's reading level and level of understanding is to ask the patient to read instructions from an educational handout and then explain their meaning. Reading level is often difficult to assess because patients who are functionally illiterate are often able to conceal it by using excuses such as not having the time or not being able to see. Asking patients what they want to know identifies previous learning and learning needs and preferences; it does not assess ability to learn. Motivation (desire to learn) is related to readiness to learn, not ability to learn. Just asking a patient if he or she feels strong is not as effective as actually assessing the patient's strength.

A nurse is testing meditation for migraine headaches and the expected outcome of care when performing this intervention. Which type of theory is the nurse using? a. Grand b. Prescriptive c. Descriptive d. Middle-range

ANS: B A prescriptive theory details nursing interventions (meditation) for a specific phenomenon (migraine headaches) and the expected outcome of the care. Grand theories are broad in scope and complex and require further specification through research; it does not provide guidance for specific nursing interventions. Descriptive theories do not direct specific nursing activities but help to explain patient assessment. A middle-range theory tends to focus on a concept found in a specific field of nursing, such as uncertainty, incontinence, social support, quality of life, and caring, rather than reflect on a wide variety of nursing care situations.

A nurse is using Maslow's hierarchy to prioritize care for an anxious patient that is not eating and will not see family members. Which area should the nurse address first? a. Anxiety b. Not eating c. Mental health d. Not seeing family members

ANS: B According to Maslow, in all cases an emergent physiological need takes precedence over a higher-level need. Nutrition is a physiological need and should be addressed first. Anxiety, mental health, and not seeing family members are all higher-level needs.

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

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

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

ANS: B Acute pain is the only NANDA-I approved diagnosis listed. Sleep apnea and heart failure are medical diagnoses, and sore throat is subjective data.

A nurse is discussing the advantages of a nursing clinical information system. Which advantage should the nurse describe? a. Varied clinical databases b. Reduced errors of omission c. Increased hospital costs d. More time to read charts

ANS: B Advantages associated with the nursing information system include reduced errors of omission; better access to information (not more time to read charts); enhanced quality of documentation; reduced, not increased, hospital costs; increased nurse job satisfaction; compliance with requirements of accrediting agencies (e.g., TJC); and development of a common, not varied, clinical database.

A nurse is trying to help a patient begin to accept the chronic nature of diabetes. Which teaching technique should the nurse use to enhance learning? a. Lecture b. Role play c. Demonstration d. Question and answer sessions

ANS: B Affective learning deals with expression of feelings and acceptance of attitudes, beliefs, or values. Role play and discussion (one-on-one and group) are effective teaching methods for the affective domain. Lecture and question and answer sessions are effective teaching methods for the cognitive domain. Demonstration is an effective teaching method for the psychomotor domain.

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

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

A nursing student has been written up several times for being late with providing patient care and for omitting aspects of patient care and not knowing basic procedures that were taught in the skills course one term earlier. The nursing student says, "I don't understand what the big deal is. As my instructor, you are there to protect me and make sure I don't make mistakes." What is the best response from the nursing instructor? a. "You are practicing under the license of the hospital's insurance." b. "You are expected to perform at the level of a professional nurse." c. "You are expected to perform at the level of a prudent nursing student." d. "You are practicing under the license of the nurse assigned to the patient."

ANS: B Although nursing students are not employees of the health care facility where they are having their clinical experience, they are expected to perform as professional nurses would in providing safe patient care. Different levels of standards do not apply. No standard is used for nursing students other than that they must meet the standards of a professional nurse. Student nurses do not practice under anybody's license; nursing students are liable if their actions exceed their scope of practice or cause harm to patients.

A nurse is assessing a patient's ethnic history. Which question should the nurse ask? a. What language do you speak at home? b. How different is your life here from back home? c. Which caregivers do you seek when you are sick? d. How different is what we do from what your family does when you are sick?

ANS: B An ethnohistory question is the following: How different is your life here from back home? Caring beliefs and practice questions include the following: Which caregivers do you seek when you are sick and How different is what we do from what your family does when you are sick? The language and communication is the following: What language do you speak at home?

A recent immigrant who does not speak English is alert but requires hospitalization. What is the initial action that the nurse must take to enable informed consent to be obtained? a. Ask a family member to translate what the nurse is saying. b. Request an official interpreter to explain the terms of consent. c. Notify the nursing manager that the patient doesn't speak English. d. Use hand gestures and medical equipment while explaining in English.

ANS: B An official interpreter must be present to explain the terms of consent if a patient speaks only a foreign language. A family member or acquaintance who speaks a patient's language should not interpret health information. Family members can tell those caring for the patient what the patient is saying, but privacy regarding the patient's condition, assessment, etc., must be protected. A nurse can take care of requesting an interpreter, and the nurse manager is not needed. Using hand gestures and medical equipment is inappropriate when communicating with a patient who does not understand the language spoken. Certain hand gestures may be acceptable in one culture and not appropriate in another. The medical equipment may be unknown and frightening to the patient, and the patient still doesn't understand what is being said.

A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Which intervention would be most helpful in keeping the older adult safe on the steps? a. Have the client use a walker or cane on the steps. b. Install contrasting color strips at the edge of each step. c. Instruct the client to use the garage door instead. d. Tell the client to use a two-footed gait on the steps.

ANS: B As a person ages, he or she may experience a decreased sense of touch. The older adult may not be aware of where his or her foot is on the step. Installing contrasting color strips at the end of each step will help increase awareness. If the client does not need an assistive device, he or she should not use one just on stairs. Using an alternative door may be necessary but does not address making the front steps safer. A two-footed gait may not help if the client is unaware of where the foot is on the step.

The patient had a colostomy placed 1 week ago. When approached by the nurse, the patient and their spouse refuse to talk about it and reject the opportunity to be taught about how to care for it. How will the nurse evaluate this couple's stage of adjustment? a. Shock b. Withdrawal c. Acceptance d. Rehabilitation

ANS: B As the patient and family recognize the reality of a change, they become anxious and may withdraw, refusing to discuss it. This is an adaptive coping mechanism that assists the patient in making the adjustment. Initially, the patient may be shocked by the change. This is followed by withdrawal, acknowledgment, acceptance, and rehabilitation (ready to adapt to the change through use of colostomy bag).

. A patient says, "You are the worst nurse I have ever had." Which response by the nurse is most assertive? a. "I think you've had a hard day." b. "I feel uncomfortable hearing that statement." c. "I don't think you should say things like that. It is not right." d. "I have been checking on you regularly. How can you say that?"

ANS: B Assertive responses contain "I" messages such as "I want," "I need," "I think," or "I feel." While all of these start with "I," the only one that is the most assertive is "I feel uncomfortable hearing that statement." An assertive nurse communicates self-assurance; communicates feelings; takes responsibility for choices; and is respectful of others' feelings, ideas, and choices. "I think you've had a hard day" is not addressing the problem. Arguing ("How can you say that?") is not assertive or therapeutic. Showing disapproval (using words like right) is not assertive or therapeutic.

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

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

A staff member verbalizes satisfaction in working on a particular nursing unit because of the freedom of choice and responsibility for the choices. This nurse highly values which element of shared decision making? a. Authority b. Autonomy c. Responsibility d. Accountability

ANS: B Autonomy is freedom of choice and responsibility for the choices. Authority refers to legitimate power to give commands and make final decisions specific to a given position. Responsibility refers to the duties and activities that an individual is employed to perform. Accountability refers to individuals being answerable for their actions.

A patient diagnosed with both heart failure and kidney failure requires teaching about dialysis. Which nursing assessment is most appropriate for determining this patient's learning needs? a. Total health care needs b. Health literacy c. Sources of patient data d. Goals of patient care

ANS: B Because health literacy influences how you deliver teaching strategies, it is critical for you to assess a patient's health literacy before providing instruction. The nursing process requires assessment of all sources of data to determine a patient's total health care needs. Evaluation of the teaching process involves determining outcomes of the teaching/learning process and the achievement of learning objectives; assessing the goals of patient care is the evaluation component of the nursing process.

The nurse is caring for a patient whose plan of care states that a change of dressing is to occur 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.

ANS: B Because the dressing is saturated and leaking, the nurse needs to revise the plan of care and change the dressing now. Reflection-in-action involves a nurse's ability to recognize how a patient is responding and then adjusting interventions as a result. A nurse will either change the frequency of an intervention, change how the intervention is delivered, or select a new intervention. Waiting until 1800 or for another 2 hours is not appropriate because assessment data reflect that the dressing is saturated and needs to be changed now. Data are insufficient to support discontinuing the plan of care. Instead, data at this time indicate the need for revision of the plan of care.

Upon completion of the assessment, the nurse finds that the patient has quit drinking and has been alcohol free for the past 2 years. Which stage best describes the nurse's assessment finding? a. Contemplation b. Maintenance c. Preparation d. Action

ANS: B Because the patient has been alcohol free for 2 years, the patient is in the maintenance stage. These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance).

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

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

Which action by a novice nurse will cause the preceptor to provide follow up instructions? a. Documents descriptively. b. Charts consecutively on every other line. c. Ends each entry with signature and title. d. Uses quotations to note patients' exact words.

ANS: B Chart consecutively, line by line (not every other line); every other line is incorrect and must be corrected by the preceptor. If space is left, draw a line horizontally through it, and place your signature and credentials at the end. Every other line should not be left blank. All the other behaviors are correct and need no follow-up. Documenting should be as descriptive as possible. End each entry with signature and title/credentials. When recording subjective data, document a patient's exact words within quotation marks whenever possible.

A nurse is working at a health fair screening people for colorectal cancer. Which population group should the nurse monitor most closely for this form of cancer? a. Hispanic b. Asian Americans c. Non-Hispanic Caucasians d. Non-Hispanic Blacks

ANS: B Colorectal cancer incidence and mortality increased with advancing age. Incidence and death rates were highest among people aged 75 years and older. Non-Hispanic blacks had higher colorectal cancer incidence and death rates than non-Hispanic whites, Asians/Pacific Islanders, and American Indians/Alaska Natives.

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

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

In conducting a research study, the nurse researcher guarantees the subject no information will be reported in any manner that will identify the subject and only the research team will have access to the information. Which concept is the nurse researcher fulfilling? a. Bias b. Confidentiality c. Informed consent d. The research process

ANS: B Confidentiality guarantees that any information the subject provides will not be reported in any manner that identifies the subject and will not be accessible to people outside the research team. Biases are opinions that may influence the results of research. Informed consent means that research subjects: (1) are given full and complete information about the purpose of the study, procedures, data collection, potential harm and benefits, and alternative methods of treatment; (2) are capable of fully understanding the research; (3) have the power to voluntarily consent or decline participation; and (4) understand how confidentiality or anonymity is maintained. The research process is a broader concept that provides an orderly series of steps that allow the researcher to move from asking a question to finding the answer.

A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural competence? a. Communicates effectively in a multicultural context. b. Effectively provides for multifaceted healthcare needs. c. Visits a foreign country. d. Speaks a different language.

ANS: B Cultural competence refers to a developmental process that evolves over time that impacts ability to effectively function in the multifaceted context. Communicates effectively and speaking a different language indicates linguistic competence. Visiting a foreign country does not indicate cultural competence.

A nurse is assessing culturally diverse population groups for the risk of suicide. Which assessment question will provide the most culturally relevant information? a. "Is suicide common in your culture?" b. "How is suicide viewed in your culture?" c. "Has anyone here every considered suicide?" d. "Do you know anyone who as committed suicide?"

ANS: B Culturally congruent care or transcultural care emphasizes the need to provide cares based on the individual's cultural beliefs, practices, and values; therefore, effective communication is a critical skill in culturally competent care and helps you engage a patient and family in respectful, patient-centered dialogue. Asking how the act of suicide is viewed provides information on the cultural values, beliefs, and practices of a culture. None of the other options provide that insight.

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

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

An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication should he or she suggest in place of the morphine? a. Cyclobenzaprine (Flexeril) b. Hydromorphone hydrochloride (Dilaudid) c. Ketorolac (Toradol) d. Meperidine (Demerol)

ANS: B Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers list of potentially inappropriate medications for use in older adults and should not be suggested. The nurse should suggest hydromorphone hydrochloride.

The nurse caring for a patient of Hispanic descent who speaks no English, is working with an interpreter. Which action should the nurse take? a. Use long sentences when talking. b. Look at the patient when talking. c. Use breaks in sentences when talking. d. Look at only nonverbal behaviors when talking.

ANS: B Direct your questions to the patient. Look at the patient, instead of looking at the interpreter. Pace your speech by using short sentences, but do not break your sentences. Observe the patient's nonverbal and verbal behaviors.

A patient is being discharged home. Which information should the nurse include? a. Acuity level b. Community resources c. Standardized care plan d. Signature for verbal order

ANS: B Discharge documentation includes medications, diet, community resources, follow-up care, and who to contact in case of an emergency or for questions. A patient's acuity level, usually determined by a computer program, is based on the types and numbers of nursing interventions (e.g., intravenous [IV] therapy, wound care, or ambulation assistance) required over a 24-hour period. Many computerized documentation systems include standardized care plans or clinical practice guidelines (CPGs) to facilitate the creation and documentation of a nursing and or interprofessional plan of care. Each CPG facilitates safe and consistent care for an identified problem by describing or listing institutional standards and evidence-based guidelines that are easily accessed and included in a patient's electronic health record. Verbal orders occur when a health care provider gives therapeutic orders to a registered nurse while they are standing in proximity to one another.

The nurse researcher is preparing to publish the findings and is preparing to add the limitations to the manuscript. Which area of the manuscript will the nurse researcher add this information? a. Abstract b. Conclusion c. Study design d. Clinical implications

ANS: B During results or conclusions, the researcher interprets the findings of the study, including limitations. An abstract summarizes the purpose of the article with major findings. Study design involves selection of research methods and type of study conducted. The researcher explains how to apply findings in a practice setting for the type of subjects studied in the clinical implications section.

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

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

A nurse is experiencing an ethical dilemma with a patient. Recognizing what information as a factor indicates the nurse has a correct understanding of the primary cause of ethical dilemmas? a. Unequal power b. Presence of conflicting values c. Judgmental perceptions of patients d. Poor communication with the patient

ANS: B Ethical dilemmas almost always occur in the presence of conflicting values. While unequal power, judgmental perceptions, and poor communication can contribute to the dilemma, these are not causes of a dilemma. Without clarification of values, the nurse may not be able to distinguish fact from opinion or value, and this can lead to judgmental attitudes.

A nurse is developing a plan of care for an older adult. Which information will the nurse consider? a. Should be standardized because most geriatric patients have the same needs. b. Needs to be individualized to the patient's unique needs. c. Focuses on the disabilities that all aging persons face. d. Must be based on chronological age alone.

ANS: B Every older adult is unique, and the nurse needs to approach each one as a unique individual. The nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health. Aging does not automatically lead to disability and dependence. Chronological age often has little relation to the reality of aging for an older adult.

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.

A nurse is caring for a young adult. Which goal is priority? a. Maintain peer relationships. b. Maintain family relationships. c. Maintain parenteral relationships. d. Maintain recreational relationships.

ANS: B Family is important during young adulthood. Challenges may include the demands of working and raising families. Peer is more important in the adolescent years. Young adults are much freer from parental control. While recreation is important, the family and work are the priorities in young adults.

A nurse is planning care for a 30 year old. Which goal is priority? a. Refine self-perception. b. Master career plans. c. Examine life goals. d. Achieve intimacy.

ANS: B From 29 to 34, the person directs enormous energy toward achievement and mastery of the surrounding world. The years from 35 to 43 are a time of vigorous examination of life goals and relationships. Between the ages of 23 and 28, the person refines self-perception and ability for intimacy.

Which patient statement is the most reliable indicator that an older adult has the correct understanding of health promotion activities? a. "I need to increase my fat intake and limit protein." b. "I still keep my dentist appointments even though I have partials now." c. "I should discontinue my fitness club membership for safety reasons." d. "I'm up-to-date on my immunizations, but at my age, I don't need the influenza vaccine."

ANS: B General preventive measures for the nurse to recommend to older adults include keeping regular dental appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercising regularly, and maintaining immunizations for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and pneumococcal disease.

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

ANS: B Health behavior involves demonstrating a psychomotor skill such as self-injection. Health status is a clinical indicator such as exercise tolerance or blood pressure control. The skill is psychomotor, not psychological self-control. Health service utilization is readmission within 30 days or emergency department use.

A nurse is providing home care to a home-bound patient treated with intravenous (IV) therapy and enteral nutrition. What is the home health nurse's primary objective? a. Screening b. Education c. Dependence d. Counseling

ANS: B Health promotion and education are traditionally the primary objectives of home care, yet at present most patients receive home care because they need nursing care. Screening is preventive care. The home health nurse focuses on patient and family independence. Counseling is through psychiatric care.

A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most common to least common conditions that can lead to death in older adults? 1. Chronic obstructive lung disease 2. Cerebrovascular accidents 3. Heart disease 4. Cancer a. 4, 1, 2, 3 b. 3, 4, 1, 2 c. 2, 3, 4, 1 d. 1, 2, 3, 4

ANS: B Heart disease is the leading cause of death in older adults followed by cancer, chronic lung disease, and stroke (cerebrovascular accidents).

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

ANS: B If a nursing diagnosis is unresolved or if you determine that a new problem has perhaps developed, reassessment is necessary. A complete reassessment of patient factors relating to an existing nursing diagnosis and etiology is necessary when modifying a plan. After reassessment, determine which nursing diagnoses are accurate for the situation; revise as needed. When revising a care plan, review the goals and expected outcomes for necessary changes after the diagnosis. Then evaluate and revise interventions as needed.

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.

A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What action by the nurse is best? a. Call Adult Protective Services. b. Discuss concerns with the health care team. c. Do not allow the client to sign the consent. d. Have the clients family sign the consent.

ANS: B In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client to be temporarily too confused or incompetent to give consent. If an acute condition is ruled out, the staff should follow the legal procedure and policies in their facility and state for determining competence. The key is to bring the concerns forward. Calling Adult Protective Services is not appropriate at this time. Signing the consent should wait until competence is determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts as to the clients ability to provide consent.

A nurse is discussing sexuality with an older adult. Which action will the nurse take? a. Ask closed-ended questions about specific symptoms the patient may experience. b. Provide information about the prevention of sexually transmitted infections. c. Discuss the issues of sexuality in a group in a private room. d. Explain that sexuality is not necessary as one ages.

ANS: B Include information about the prevention of sexually transmitted infections when appropriate. Open-ended questions inviting an older adult to explain sexual activities or concerns elicit more information than a list of closed-ended questions about specific activities or symptoms. You need to provide privacy for any discussion of sexuality and maintain a nonjudgmental attitude. Sexuality and the need to express sexual feelings remain throughout the human life span.

A nurse is determining if teaching is effective. Which finding best indicates learning has occurred? a. A nurse presents information about diabetes. b. A patient demonstrates how to inject insulin. c. A family member listens to a lecture on diabetes. d. A primary care provider hands a diabetes pamphlet to the patient.

ANS: B Learning is the purposeful acquisition of new knowledge, attitudes, behaviors, and skills: patient demonstrates how to inject insulin. A new mother exhibits learning when she demonstrates how to bathe her newborn. A nurse presenting information and a primary care provider handing a pamphlet to a patient are examples of teaching. A family member listening to a lecture does not indicate that learning occurred; a change in knowledge, attitudes, behaviors, and/or skills must be evident.

During the initial home visit, a home health nurse lets the patient know that the visits are expected to end in about a month. Which phase of the helping relationship is the nurse in with this patient? a. Preinteraction b. Orientation c. Working d. Termination

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

Which goal is priority when the nurse is caring for a middle-aged adult? a. Maintain immediate family relationships. b. Maintain future generation relationships. c. Maintain personal career relationships. d. Maintain work relationships.

ANS: B Many middle-aged adults find particular joy in helping their children and other young people become productive and responsible adults. While immediate family is important, this goal is priority in young adults, not as important in middle-aged adults. During this period, personal and career achievements have often already been experienced; therefore, these goals are not priority.

A nurse is teaching patients about health care information. Which patient will the nurse assess closely for health literacy? a. A patient 35 years old b. A patient 68 years old c. A patient with a college degree d. A patient with a high-school diploma

ANS: B Many people in the United States experience challenges in using health care information. Patients who are especially vulnerable are the elderly (age 65+), immigrants, persons with low incomes, persons who do not have a high-school diploma or GED, and persons with chronic mental and/or physical health conditions. A 35-year-old patient and patients with high-school and college education are not identified in the vulnerable populations.

Upon assessment, the nurse notices that the patient's respirations have increased, and the tip of the nose and earlobes are becoming cyanotic. The nurse finds that the patient's pulse rate is over 100 beats per minute. According to Maslow's hierarchy of needs, which patient need should the nurse address first? a. Self-esteem b. Physiological c. Self-actualization d. Love and belonging

ANS: B Maslow's hierarchy is useful in setting patient priorities. Basic physiological and safety needs are usually the first priority. After the physiological and safety needs are met, the nurse can move to love and belonging, self-esteem, and self-actualization.

An older adult is brought to the emergency department because of sudden onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important? a. Assess for orthostatic hypotension. b. Determine if there are new medications. c. Evaluate the client for gait abnormalities. d. Perform a delirium screening test.

ANS: B Medication side effects and adverse effects are common in the older population. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse should determine if the client is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the clients condition.

Which assessment finding will best indicate that the patient is ready to learn? a. The ability to grasp and apply the elastic bandage. b. Expresses the motivation to walk with an assistive device. c. Demonstrates sufficient coordination to handle a syringe safely. d. Has sufficient upper body strength to move from a bed to a wheelchair.

ANS: B Motivation underlies a person's desire or willingness to learn. Motivation is a force that acts on or within a person (e.g., an idea, emotion, or a physical need) to cause the person to behave in a particular way. For example, a patient with a below-the-knee amputation is motivated to learn how to walk with assistive devices, indicating a readiness to learn. Do not confuse readiness to learn with ability to learn. All the other answers are examples of ability to learn because this often depends on the patient's level of physical development and overall physical health. To learn psychomotor skills, a patient needs to possess a certain level of strength, coordination, and sensory acuity. For example, it is useless to teach a patient to transfer from a bed to a wheelchair if he or she has insufficient upper body strength. An older patient with poor eyesight or an inability to grasp objects tightly cannot learn to apply an elastic bandage or handle a syringe.

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

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

Which characteristic tends to make a nurse the best communicators with patients? a. Effective psychomotor skills b. Developed critical thinking skills c. An interest in different kinds of people d. Ability to maintain perceptual biases

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

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.

The nurse is trying to determine risk factors unique to home care patients. What resource should the nurse access? a. Pew Health Professions Commission b. The Outcome and Assessment Information Set (OASIS) c. American Nurses Credentialing Center (ANCC) Magnet Recognition Program d. Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS)

ANS: B OASIS (the Outcome and Assessment Information Set), includes a group of standardized core assessment items for an adult home care patient. OASIS forms the basis for measuring patient outcomes for the purposes of outcome-based quality. Data items within OASIS include socio-demographic, environmental, support system, health status, functional status, and health service utilization characteristics of a patient (ResDac, 2016). The OASIS assessment tool was designed to gather the data items needed to measure both outcomes and patient risk factors in the home setting. The Pew Health Professions Commission, a national and interdisciplinary group of health care leaders, recommended 21 competencies for health care professionals in the twenty-first century. The Hospital Consumer of Assessment of Healthcare Providers and Systems (HCAHPS) is a standardized survey developed to measure patient perceptions of their hospital experience. The Magnet Recognition Program recognizes health care organizations that achieve excellence in nursing practice.

The nurse is caring for a patient diagnosed with essential hypertension. The health care provider prescribes blood pressure medication that the nurse administers. The nurse then monitors the patient's blood pressure for several days to help determine effectiveness. Which system component is the nurse evaluating? a. Input b. Output c. Content d. Feedback

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

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

ANS: B Personal space is 18 inches to 4 feet and involves things such as sitting at a patient's bedside, taking a patient's nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves things such as performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. The socio-consultative zone is 9 to 12 feet and involves things such as giving directions to visitors in the hallway and giving verbal report to a group of nurses. The public zone is 12 feet and greater and involves things such as speaking at a community forum, testifying at a legislative hearing, or lecturing.

A nurse is caring for an immigrant with low income. Which information should the nurse consider when planning care for this patient? a. There is a decreased frequency of morbidity. b. There is an increased incidence of disease. c. There is an increased level of health. d. There is a decreased mortality rate.

ANS: B Populations with health disparities (immigrant with low income) have a significantly increased incidence of disease or increased morbidity and mortality when compared with the general population. Although Americans' health overall has improved during the past few decades, the health of members of marginalized groups has actually declined.

A nurse provides immunization to children and adults through the public health department. Which type of health care is the nurse providing? a. Primary care b. Preventive care c. Restorative care d. Continuing care

ANS: B Preventive care includes immunizations, screenings, counseling, crisis prevention, and community safety legislation. Primary care is health promotion that includes prenatal and well-baby care, nutrition counseling, family planning, and exercise classes. Restorative care includes rehabilitation, sports medicine, spinal cord injury programs, and home care. Continuing care is assisted living and psychiatric care and older-adult day care.

A nurse is teaching a patient and family about quality of life. Which information should the nurse include in the teaching session about quality of life? a. It is deeply social. b. It is hard to define and deeply personal c. It is an observed measurement for most people. d. It is consistent and stable over the course of one's lifetime.

ANS: B Quality of life remains deeply individual (not social) and difficult to predict. Quality of life is not just a measurable entity but a shared responsibility. Quality of life measures may take into account the age of the patient, the patient's ability to live independently, his or her ability to contribute to society in a gainful way, and other nuanced measures of quality.

A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find? a. Lives in a nursing home. b. Lives with a spouse. c. Lives divorced. d. Lives alone.

ANS: B Recent research found that 59% of older adults in noninstitutional settings lived with a spouse (48% of older women, 72% of older men); 28% lived alone (34% of older women, 20% of older men); and only 3.1% of all older adults resided in institutions such as nursing homes or centers. Most older adults have lost a spouse due to death rather than divorce.

The patient is admitted to the emergency department of the local hospital from home with reports of chest discomfort and shortness of breath. The patient is placed on oxygen, has labs and blood gases drawn, and is given an electrocardiogram and breathing treatments. Which level of preventive care is this patient receiving? a. Primary prevention b. Secondary prevention c. Tertiary prevention d. Health promotion

ANS: B Secondary prevention focuses on individuals who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions. Activities are directed at diagnosis and prompt intervention. Primary prevention precedes disease or dysfunction and is applied to people considered physically and emotionally healthy. Health promotion includes health education programs, immunizations, and physical and nutritional fitness activities for healthy people. Tertiary prevention occurs when a defect or disability is permanent and irreversible. It involves minimizing the effects of long-term disease or disability through interventions directed at preventing complications and deterioration.

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

ANS: B Setting realistic goals and outcomes often means you must communicate these goals and outcomes to caregivers in other settings who will assume responsibility for patient care. The plan of care communicates nursing care priorities to nurses and other health care professionals. Know also that a plan of care is dynamic and changes as the patient's needs change. All health care professionals involved in the patient's care need to be informed of the plan of care. The plan of care is not sent to the administrative office or quality assurance office.

A nurse is developing a care delivery outcomes research project. Which population will the nurse study? a. Nurses b. Patients c. Administrators d. Health care providers

ANS: B Similar to the expected outcomes you develop in a plan of care, a care delivery outcome focuses on the recipients of service (e.g., patient, family, or community) and not the providers (e.g., nurse or physician/health care provider). Administrators are not recipients of service.

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

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

A pediatric oncology nurse floats to an orthopedic trauma unit. Which action should the nurse manager of the orthopedic unit take to enable safe care to be given by this nurse? a. Provide a complete orientation to the functioning of the entire unit. b. Determine patient acuity and care the nurse can safely provide. c. Allow the nurse to choose which mealtime works best. d. Assign nursing assistive personnel to assist with care.

ANS: B Supervisors are liable if they give staff nurses an assignment that they cannot safely handle. Nurses who float must inform the supervisor of any lack of experience in caring for the types of patients on the nursing unit. They should request and receive an orientation to the unit. A basic orientation is needed, whereas a complete orientation of the functioning of the entire unit would take a period of time that would exceed what the nurse has to spend on orientation. Allowing nurses to choose which mealtime they would like is a nice gesture of thanks for the nurse, but it does not enable safe care. Having nursing assistive personnel may help the nurse complete basic tasks such as hygiene and turning, but it does not enable safe nursing care that the nurse and manager are ultimately responsible for.

A nurse is performing a cultural assessment using the LEARN mnemonic for communication. Which area will the nurse assess for the "L"? a. Look b. Listen c. Liken d. Leave

ANS: B The "L" in Learn stands for Listen: Listen to the patient's perception of the problem. Be nonjudgmental and use encouraging comments such as, "Tell me more" or "I understand what you are saying."

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.

ANS: B The best answer is implementing interventions based on scientific research. Using results of a literature search to a PICOT question can help a nurse decide which interventions to use. Practicing based on evidence presented in court is incorrect. Practice is based on current research. Using standardized care plans may be one example of evidence-based practice, but it is not used on all patients. The nurse must be careful in using standardized care plans to ensure that each patient's plan of care is still individualized. Planning care based on tradition is incorrect because nursing care should be based on current research.

A new nurse notes that the health care unit keeps a listing of patient names in a closed book behind the front desk of the nursing station so patients can be located easily. Which action is most appropriate for the nurse to take? a. Talk with the nurse manager about the listing being a violation of the Health Insurance Portability and Accountability Act (HIPAA). b. Use the book as needed while keeping it away from individuals not involved in patient care. c. Move the book to the upper ledge of the nursing station for easier access. d. Ask the nurse manager to move the book to a more secluded area.

ANS: B The book is located where only staff would have access so the nurse can use the book as needed. The privacy section of the HIPAA provides standards regarding accountability in the health care setting. These rules include patient rights to consent to the use and disclosure of their protected health information, to inspect and copy their medical record, and to amend mistaken or incomplete information. It is not the responsibility of the new nurse to move items used by others on the patient unit. The listing is protected as long as it is used appropriately as needed to provide care. There is no need to move the book to a more secluded area.

The nurse is caring for a patient who is actively bleeding. The health care provider prescribes blood transfusions. The patient is a Jehovah's Witness and does not want blood products. The nurse contacts the health care provider to request alternative treatment. Which theory is the nurse using? a. Roy's theory b. Leininger's theory c. Watson's theory d. Orem's theory

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

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

ANS: B The goal of Orem's theory is to help the patient perform self-care. In Watson's theory, the nurse is concerned with promoting and restoring health and preventing illness. Roger's theory considers caring as a fundamental component of professional nursing practice and is based upon 10 curative factors. Henderson defines nursing as assisting patients with 14 activities until patients can meet these needs for themselves.

A nurse is assessing the risk of intimate partner violence (IPV) for patients. Which population should the nurse focus on most for IVP? a. White males b. Pregnant females c. Middle-aged adults d. Nonsubstance abusers ANS: B The greatest risk of violence occurs during the reproductive years. A pregnant woman has a 35.6% greater risk of being a victim of IPV than a nonpregnant woman. White males, middle-aged adults, and nonsubstance abusers are not as high risk as pregnant women.

ANS: B The greatest risk of violence occurs during the reproductive years. A pregnant woman has a 35.6% greater risk of being a victim of IPV than a nonpregnant woman. White males, middle-aged adults, and nonsubstance abusers are not as high risk as pregnant women.

The patient is reporting moderate incisional pain that was not relieved by the last dose of pain medication. The patient is not due for another dose of medication for another 2 1/2 hours. The nurse repositions the patient, asks what type of music the patient likes, and sets the television to the channel playing that type of music. Which health care model is the nurse using? a. Health belief model b. Holistic health model c. Health promotion model d. Maslow's hierarchy of needs ANS: B The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health belief model addresses the relationship between a person's beliefs and behaviors. The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The basic human needs model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs.

ANS: B The holistic health model recognizes the natural healing abilities of the body and incorporates complementary and alternative interventions such as music therapy. The health belief model addresses the relationship between a person's beliefs and behaviors. The health promotion model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The basic human needs model believes that the extent to which basic needs are met is a major factor in determining a person's level of health. Maslow's hierarchy of needs is a model that nurses use to understand the interrelationships of basic human needs.

A nurse is teaching a patient about heart failure. Which environment will the nurse use? a. A darkened, quiet room b. A well-lit, ventilated room c. A private room at 85° F temperature d. A group room for 10 to 12 patients with heart failure

ANS: B The ideal environment for learning is a room that is well lit and has good ventilation, appropriate furniture, and a comfortable temperature. Although a quiet room is appropriate, a darkened room interferes with the patient's ability to watch your actions, especially when demonstrating a skill or using visual aids such as posters or pamphlets. A room that is cold, hot, or stuffy makes the patient too uncomfortable to focus on the information being presented. Learning in a group of six or less is more effective and avoids distracting behaviors.

The nurse is reviewing a research article on a patient care topic. Which area should entice the nurse to read the article? a. Literature review b. Introduction c. Methods d. Results

ANS: B The introduction contains information about its purpose and the importance of the topic to the audience who reads the article. The literature review or background offers a detailed background of the level of science or clinical information about the topic of the article. The methods or design section explains how a research study was organized and conducted. The results or conclusion section details the results of the study and explains whether a hypothesis is supported.

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.

ANS: B The most appropriate intervention for the diagnosis of Impaired skin integrity is to turn the patient. Choose interventions to alter the etiological (related to) factor or causes of the diagnosis. The other options do not directly address the shearing forces. The patient may need pain medication, but Acute pain would be another nursing diagnosis. Monitoring vital signs does not have when or how often these should be done. Keeping the side rails up addresses safety, not skin integrity.

The community health nurse is administering flu shots to children at a local playground. What is the rationale for this nurse's action? a. To prevent individual illness b. To prevent community outbreak of illness c. To prevent outbreak of illness in the family d. To prevent needs of the local population groups

ANS: B The nurse is trying to prevent a community outbreak of illness. By focusing on subpopulations (children), the community health nurse cares for the community as a whole and considers the individual or the family as only one member of a group at risk. Community-based nursing, as opposed to community health nursing, focuses on the needs of the individual or family. Public health nursing focuses on meeting the population groups' needs.

The nurse questions a health care provider's decision to not tell the patient about a cancer diagnosis. Which ethical principle is the nurse trying to uphold for the patient? a. Consequentialism b. Autonomy c. Fidelity d. Justice

ANS: B The nurse is upholding autonomy. Autonomy refers to the freedom to make decisions free of external control. Respect for patient autonomy refers to the commitment to include patients in decisions about all aspects of care. Consequentialism is focused on the outcome and is a philosophical approach. Justice refers to fairness and is most often used in discussions about access to health care resources. Fidelity refers to the agreement to keep promises.

A nursing assistive personnel (NAP) reports seeing a reddened area on the patient's hip while bathing the patient. Which action should the nurse take? a. Request a wound nurse consult. b. Go to the patient's room to assess the patient's skin. c. Document the finding per the NAP's report. d. Ask the NAP to apply a dressing over the reddened area.

ANS: B The nurse needs to assess the patient's skin. Assessment should not be delegated; it is the responsibility of the licensed registered nurse. The nurse needs to document the assessment findings objectively, not subjectively, per the nursing assistive personnel. Before requesting a consult or determining treatment, the nurse needs to assess the skin.

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?"

ANS: B The nurse needs to first ensure that the symptoms support the diagnosis. By definition, diarrhea means that a patient is having frequent stools; therefore, asking about the number of bowel movements is most appropriate. Asking about irritating foods and medications may help the nurse determine the cause of the diarrhea, but first the nurse needs to make sure the diagnosis is appropriate. Asking the patient if he can make it to the bathroom will help to establish a diagnosis of incontinence, not diarrhea. The question is asking for the most appropriate statement to establish the diagnosis of Diarrhea.

A nurse is using the Healthy People 2020 to establish goals for the community. Which goal is priority? a. Reduce health care costs. b. Increase life expectancy. c. Provide services close to where patients live. d. Isolate patients to prevent the spread of disease.

ANS: B The overall goals of Healthy People 2020 are to increase life expectancy and quality of life and eliminate health disparities through an improved delivery of health care services. It does not focus on reducing health care costs, providing services close to where patients live, or isolating patients to prevent the spread of disease.

After a teaching session with a nurse, a patient learns that a normal adult heartbeat is 60 to 100 beats/min. In which domain did learning take place? a. Kinesthetic b. Cognitive c. Affective d. Psychomotor

ANS: B The patient acquired knowledge, which is cognitive. Cognitive learning includes all intellectual skills and requires thinking. In the hierarchy of cognitive behaviors, the simplest behavior is acquiring knowledge. Kinesthetic is a type of learner who learns best with a hands-on approach. Affective learning deals with expression of feelings and development of attitudes, beliefs, or values. Psychomotor learning involves acquiring skills that require integration of mental and physical activities, such as the ability to walk or use an eating utensil.

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

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

The nurse is evaluating whether patient goals and outcomes have been met for a patient with impaired physical mobility 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.

ANS: B The patient's being able to ambulate in the hallway with crutches is an expected outcome of nursing care. The outcomes of nursing practice are the measurable conditions of patient, family or community status, behavior, or perception. These outcomes are the criteria used to judge success in delivering nursing care. The option stating, "The patient's level of mobility will improve" is a broader goal statement. The nurse's assisting a patient to ambulate is an intervention. The patient's denying pain is an expected outcome for pain, not for physical mobility problems.

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

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

Upon completing a history, the nurse finds that a patient has risk factors for developing lung disease. How should the nurse interpret this finding? a. A person with the risk factor will get the disease. b. The chances of getting the disease are increased. c. Risk modification will have no effect on disease prevention. d. The disease is guaranteed not to develop if the risk factor is controlled.

ANS: B The presence of risk factors does not mean that a disease will develop, but risk factors increase the chances that the individual will experience a particular disease or dysfunction. Control of risk factors does not guarantee that a disease will not develop. However, risk factor modification can assist patients in adopting activities to promote health and decrease risks of illness.

Before a patient with beginning stage of Alzheimer's disease is discharged, the community-based nurse is making a visit to the patient's home. The patient's daughter and family live in the home with the patient. What is the major focus of this visit? a. Teach the family how to monitor blood pressure. b. Demonstrate techniques for providing care. c. Stress to the family how difficult it will be to provide care at home. d. Encourage the family to send the patient to an extended care facility.

ANS: B The role of the community health nurse, when dealing with patients with Alzheimer's disease, is to maintain the best possible functioning, protection, and safety for the patient. The nurse should demonstrate to the primary family caregiver techniques for dressing, feeding, and toileting the patient while providing encouragement and emotional support to the caregiver. Monitoring blood pressure is not necessary for an Alzheimer's patient; blood pressure would be for a patient with hypertension. The nurse should protect the patient's rights and maintain family stability, not encourage placement in an extended care facility.

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

ANS: B The standard formal nursing diagnosis serves several purposes. Nursing diagnoses distinguish the nurse's role from that of the physician/health care provider and help nurses focus on the scope of nursing practice (not medical) while fostering the development of nursing knowledge. A nursing diagnosis provides the precise definition that gives all members of the health care team a common language for understanding the patient's needs. A diagnosis is a clinical judgment based on information

A nurse wants to find all the pertinent patient information in one record, regardless of the number of times the patient entered the health care system. Which record should the nurse access? a. Electronic medical record b. Electronic health record c. Electronic charting record d. Electronic problem record

ANS: B The term electronic health record/EHR is increasingly used to refer to a longitudinal (lifetime) record of all health care encounters for an individual patient by linking all patient data from previous health encounters. An electronic medical record (EMR) is the legal record that describes a single encounter or visit created in hospitals and outpatient health care settings that is the source of data for the EHR. There are no such terms as electronic charting record or electronic problem record that record the lifetime information of a patient.

A nurse is observing for the common loss in an older-adult patient. What is the nurse assessing? a. Loss of finances through changes in income b. Loss of relationships through death c. Loss of career through retirement d. Loss of home through relocation

ANS: B The universal loss for older adults usually revolves around the loss of relationships through death. Life transitions, of which loss is a major component, include retirement and the associated financial changes, changes in roles and relationships, alterations in health and functional ability, changes in one's social network, and relocation. However, these are not the universal loss.

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

ANS: B There are defining characteristics (observable assessment cues such as patient behavior, physical signs) that support each problem-focused diagnostic judgment. The signs and symptoms, or defining characteristics, for the diagnosis Activity intolerance include decreased oxygen saturation when ambulating and reports of shortness of breath when getting out of bed. The key to supporting the diagnosis of Activity intolerance is that only these two characteristics involve how the patient tolerates activity. Decreased oral intake and productive cough do not define activity intolerance.

A female patient has been overweight for most of her life. She has tried dieting in the past and has lost weight, only to regain it when she stopped dieting. The patient is visiting the weight loss clinic/health club because she has decided to do it. She states that she will join right after the holidays, in 3 months. Which stage is the patient displaying? a. Precontemplation b. Contemplation c. Preparation d. Action

ANS: B This patient is planning to make the change within the next 6 months and is in the contemplation stage. These stages range from no intention to change (precontemplation), to considering a change within the next 6 months (contemplation), to making small changes (preparation), to actively engaging in strategies to change behavior (action), to maintaining a changed behavior (maintenance).

A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause the most improvement in core measures? a. Caucasians b. Poor people c. Alaska Natives d. American Indians

ANS: B To improve results, the nurse should focus on the highest disparity. Poor people received worse care than high-income people for about 60% of core measures. American Indians and Alaska Natives received worse care than Caucasians for about 30% of core measures.

A nurse assigned to an intensive care unit (critical care) is most likely using what type of nursing care delivery model?? a. Team nursing b. Total patient care c. Primary nursing d. Case-management

ANS: B Total patient care is found primarily in critical care areas. Total patient care involves an RN being responsible for all aspects of care for one or more patients. In the team nursing care model, the RN assumes the role of group or team leader and leads a team made up of other RNs, practical nurses, and nursing assistive personnel. The primary nursing model of care delivery was developed to place RNs at the bedside and improve the accountability of nursing for patient outcomes and the professional relationships among staff members. Case-management is a care approach that coordinates and links health care services to patients and families while streamlining costs.

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

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

When professionals work together to solve ethical dilemmas, nurses must examine their own values. What is the best rationale for this step? a. So fact is separated from opinion. b. So different perspectives are respected. c. So judgmental attitudes can be provoked. d. So the group identifies the one correct solution.

ANS: B Values are personal beliefs that influence behavior. To negotiate differences of value, it is important to be clear about your own values: what you value, why, and how you respect your own values even as you try to respect those of others whose values differ from yours. Ethical dilemmas are a problem in that no one right solution exists. It is not to separate fact from opinion. Judgmental attitudes are not to be used, much less provoked.

A nurse is providing screening at a health fair. Which finding indicates the person may be a vulnerable patient who is most likely to develop health problems? a. One who is pregnant. b. One who has excessive risks. c. One who has unlimited access to health care. d. One who uses nontraditional healing practices.

ANS: B Vulnerable populations are the patients who are more likely to develop health problems as a result of excessive risks or limits in access to health care services or who are dependent on others for care. Pregnancy is not a cause of vulnerability, except in cases where the mother is an adolescent, is addicted to drugs, or is at high risk for other reasons. A person who has unlimited access to health care is not vulnerable. Frequently, the immigrant population practices nontraditional healing practices. Many of these healing practices are effective and complement traditional therapies.

Upon assessment of a middle-aged adult, the nurse observes uneven weight bearing and decreased range of joint motion. Which area is priority? a. Abuse potential b. Fall precautions c. Stroke prevention d. Self-esteem issues

ANS: B With uneven weight bearing and decreased range of joint motion, falling is a priority. Abuse potential would indicate other findings such as bruising or unkept appearance. While stroke prevention is important in a middle-aged adult, these are not the signs of stroke. While self-esteem issues may arise from physical changes, safety is a priority over self-esteem issues.

A novice 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."

ANS: B You conduct evaluative measures to determine if your patients met expected outcomes, not if nursing interventions were completed. Evaluative measures are assessment skills and techniques. Evaluative measures are not multiple-page documents, and they are used to assess the patient's status, not the nurse's performance or progress from novice to expert.

A nurse is getting ready to discharge a patient who is experiencing impaired 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.

ANS: B You evaluate whether the results of care match the expected outcomes and goals set for a patient before discontinuing a patient's plan of care. The patient needs transportation, but that does not address the patient's mobility status. Whether the patient has a follow-up appointment and ensuring that prescriptions are filled do not evaluate the problem of mobility.

A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes which components? (Select all that apply.) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain

ANS: B, C, D Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this cluster of manifestations.

The nurse is reviewing nursing research literature related to a potential practice problem on the nursing unit. What is the rationale for the nurse's action? (Select all that apply.) a. Nursing research ensures the nurse's promotion. b. Nursing research identifies new knowledge. c. Nursing research improves professional practice. d. Nursing research enhances effective use of resources. e. Nursing research leads to decreases in budget expenditures.

ANS: B, C, D Nursing research is a way to identify new knowledge, improve professional education and practice, and use resources effectively. Nursing research itself does not lead to a decrease in budget expenditures; however, it does lead to using health care resources effectively. A promotion is not a direct result of nursing research.

A nurse is evaluating care based upon the nursing quality indicators. Which areas should the nurse evaluate? (Select all that apply.) a. Patient satisfaction level b. Hospital readmission rates c. Nursing hours per patient day d. Patient falls/falls with injuries e. Value stream analysis for quality

ANS: B, C, D The American Nurses Association developed the National Database of Nursing Quality Indicators (NDNQI) to measure and evaluate nursing-sensitive outcomes with the purpose of improving patient safety and quality care. Nursing quality indicators include the following: hospital readmission rates, nursing hours per patient day, and patient falls/falls with injuries. While every major health care organization measures certain aspects of patient satisfaction, it is not a nursing quality indicator. Value stream analysis is a method that focuses on improvement of processes in a health care institution.

Which behaviors indicate the nurse is using critical thinking standards when communicating with patients? (Select all that apply.) a. Instills faith. b. Uses humility. c. Portrays self-confidence. d. Exhibits supportiveness. e. Demonstrates independent attitude.

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

A nurse is using the explanatory model to determine the cause of an illness. Which questions should the nurse ask? (Select all that apply.) a. How should your sickness be treated? b. What do you call your problem? c. How does this illness work inside your body? d. What do you fear most about your sickness? e. What name does it have?

ANS: B, C, E The questions for etiology include "What do you call your problem?" and "What name does it have?" Recommended treatment is asked by the question "How should your sickness be treated?" Pathophysiology is asked by the question "How does this illness work inside your body?" The course of illness is asked by the question "What do you fear most about your sickness?"

A nurse is teaching the staff about professional negligence or malpractice. Which criteria to establish negligence will the nurse include in the teaching session? (Select all that apply.) a. Injury did not occur. b. That duty was breached. c. Nurse carried out the duty. d. Duty of care was owed to the patient. e. Patient understands benefits and risks of a procedure.

ANS: B, D Certain criteria are necessary to establish nursing malpractice: (1) the nurse (defendant) owed a duty of care to the patient (plaintiff), (2) the nurse did not carry out or breached that duty, (3) the patient was injured, and (4) the nurse's failure to carry out the duty caused the injury. If an injury did not occur and the nurse carried out the duty, no malpractice occurred. When a patient understands benefits and risks of the procedure that is informed consent, not malpractice.

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

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

A nurse is providing prenatal care to a first-time mother. Which information will the nurse share with the patient? (Select all that apply.) a. Regular trend for postpartum depression b. Protection against urinary infection c. Strategies for empty nest syndrome d. Exercise patterns e. Proper diet

ANS: B, D, E Prenatal care includes a thorough physical assessment of the pregnant woman during regularly scheduled intervals. Information regarding STIs and other vaginal infections and urinary infections that will adversely affect the fetus and counseling about exercise patterns, diet, and child care are important for a pregnant woman. Empty nest syndrome occurs as children leave the home. Postpartum depression is rare.

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.

ANS: B, D, E The expected outcomes established during planning are the standards against which you judge whether goals have been met and if care is successful. You evaluate whether the results of care match the expected outcomes and goals set for a patient. Documentation and reporting are important parts of evaluation because it is crucial to share information about a patient's progress and current status. Using self-reflection and correcting errors are indicators a nurse is performing evaluation. Setting priorities is part of planning and ambulating with a patient in the hallway is an intervention, so it is included in the implementation step of the nursing process

A nurse is developing a plan to reduce data entry errors and maintain confidentiality. Which guidelines should the nurse include? (Select all that apply.) a. Bypass the firewall. b. Implement an automatic sign-off. c. Create a password with just letters. d. Use a programmed speed-dial key when faxing. e. Impose disciplinary actions for inappropriate access. f. Shred papers containing personal health information (PHI).

ANS: B, D, E, F When faxing, use programmed speed-dial keys to eliminate the chance of a dialing error and misdirected information. An automatic sign-off is a safety mechanism that logs a user off the computer system after a specified period of inactivity. Disciplinary action, including loss of employment, occurs when nurses or other health care personnel inappropriately access patient information. All papers containing PHI (e.g., Social Security number, date of birth or age, patient's name or address) must be destroyed immediately after you use or fax them. Most agencies have shredders or locked receptacles for shredding and incineration. Strong passwords use combinations of letters, numbers, and symbols that are difficult to guess. A firewall is a combination of hardware and software that protects private network resources (e.g., the information system of the hospital) from outside hackers, network damage, and theft or misuse of information and should not be bypassed.

A nurse is teaching a family about health care plans. Which information from the nurse indicates a correct understanding of the Affordable Care Act? a. A family can choose whether to have health insurance with no consequences. b. Primary care physician payments from Medicaid services can equal Medicare. c. Adult children up to age 26 are allowed coverage on the parent's plan. d. Quality hospital outcome scores are tied directly to patient satisfaction.

ANS: C The Affordable Care Act ties payment to organizations offering Medicare Advantage plans to the quality ratings of the coverage they offer. If hospitals perform poorly in quality scores, they receive lower payments for services. Quality outcome measures include patient satisfaction, more effective management of care by reducing complications and readmissions and improving care coordination. All individuals are required to have some form of health insurance by 2014 or pay a penalty through the tax code. Primary care physician payments for Medicaid services increased to equal Medicare payments. Implementation of insurance regulations prevents private insurance companies from denying insurance coverage for any reason and from charging higher premiums based on health status and gender.

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

ANS: C A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and actualize human health potential. A problem-focused nursing diagnosis describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community. A risk nursing diagnosis is a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes. A collaborative problem is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's health status.

The nurse is caring for a dying patient. Which intervention is considered futile? a. Giving pain medication for pain b. Providing oral care every 5 hours c. Administering the influenza vaccine d. Supporting lower extremities with pillows

ANS: C Administering the influenza vaccine is futile. A vaccine is administered to prevent or lessen the likelihood of contracting an infectious disease at some time in the future. The term futile refers to something that is hopeless or serves no useful purpose. In health care discussions, the term refers to interventions unlikely to produce benefit for a patient. Care delivered to a patient at the end of life that is focused on pain management, oral hygiene, and comfort measures is not futile.

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

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

A nurse is focusing on acute and chronic care of individuals and families within a community while enhancing patient autonomy. Which type of nursing care is the nurse providing? a. Public health b. Community health c. Community-based d. Community assessment

ANS: C Community-based nursing involves acute and chronic care of individuals and families and enhances their capacity for self-care while promoting autonomy in decision making. Public health nursing focuses on the needs of a population. Community health nursing cares for the community as a whole and considers the individual or the family as only one member of a group at risk. Community assessment is the systematic data collection on the population, monitoring the health status of the population, and making information available about the health of the community.

A nurse works full time on the oncology unit at the hospital and works part time on weekends giving immunizations at the local chain pharmacy. While giving an injection on a weekend, the nurse caused injury to the patient's arm and is now being sued. What initial action should the nurse take to initiate an effective legal defense? a. Notify the hospital of the situation to secure legal counsel by the hospital's private attorney. b. Notify the manager of the pharmacy so that the corporation can provide legal counsel. c. Inform the insurance company that is providing one's professional licensure defense insurance. d. Immediately contact the State Board of Nursing to assure protecting the validity of the nursing license.

ANS: C Nurses often presume that either their personal or their employer's malpractice insurance will include costs of defending and retaining their nursing license. In most instances this is not true. Professional licensure defense insurance is a contract between a nurse and an insurance company. When a complaint is made to the State Board of Nursing, an action is initiated that could result in a restriction, suspension, or revocation of the nurse's license to practice. When a nurse specifically has professional licensure defense insurance, the nurse notifies the company. In this situation, neither employer should be relied upon to provide effective legal counsel.

A nurse is charting. Which event is critical for the nurse to document? a. The patient had a good day with no complaints. b. The family is demanding and argumentative. c. The patient received a pain medication. d. The family is poor and had to go on welfare. ANS: C

ANS: C Nursing interventions and treatments (e.g., medication administration) must be documented. Avoid using generalized, empty phrases such as "status unchanged" or "had good day." Do not document retaliatory or critical comments about a patient, like demanding and argumentative. Family is poor is not critical information to chart

The nurse researcher is evaluating whether holding pressure at an injection site after injecting the anticoagulant enoxaparin will reduce bruising at the injection site. This study involves a prescriptive theory. What is the nurse's rationale for involving a prescriptive theory? a. It explains why bruising occurs. b. It is broad in scope and complex. c. It tests a specific nursing intervention. d. It reflects a wide variety of nursing care situations.

ANS: C Prescriptive theories detail nursing interventions for a specific phenomenon and the expected outcome of the care but it does not explain why. Grand theories are broad in scope and complex and focus on a wide variety of nursing care situations.

Which approach will be most appropriate for a nurse to take when faced with the challenge of performing many tasks in one shift? a. Do as much as possible by oneself before seeking assistance from others. b. Evaluate the effectiveness of all tasks when all tasks are completed. c. Complete one task before starting another task. d. Delegate tasks the nurse does not like doing.

ANS: C The appropriate clinical care coordination skill in these options is to complete one task before starting another task. Good time management involves setting goals to help the nurse complete one task before starting another task. Evaluation is ongoing and should not be completed just at the end of task completion. The nurse should not delegate tasks simply because the nurse does not like doing them. The nurse should use delegation skills and time-management skills instead of trying to do as much as possible with no help.

A nurse is working in a facility that has fewer directors which allows for managers and staff to make shared decisions. In which type of organizational structure is the nurse employed? a. Delegation b. Research-based c. Decentralization d. Philosophy of care

ANS: C The decentralized management structure often has fewer directors, and managers and staff are able to make shared decisions. The American Nurses Association defines delegation as transferring responsibility for the performance of an activity or task while retaining accountability for the outcome. Research-based means care is based upon evidence. A philosophy of care includes the professional nursing staff's values and concerns for the way they view and care for patients. For example, a philosophy addresses the purpose of the nursing unit, how staff works with patients and families, and the standards of care for the work unit.

A nurse wants to change a patient procedure. Which action will the nurse take to easily find research evidence to support this change? a. Read all the articles found on the Internet. b. Make a general search of the Internet. c. Use a PICOT format for the search. d. Start with a broad question.

ANS: C The more focused the question is, the easier it becomes to search for evidence in the scientific literature. The PICO format allows the nurse to ask focused questions that are intervention based. Inappropriately formed questions (general search or broad question) will likely lead to irrelevant sources of information. It is not beneficial to read hundreds of articles. It is more beneficial to read the best four to six articles that specifically address the question.

A nurse has provided care to a patient. Which entry should the nurse document in the patient's record? a. Status unchanged, doing well. b. Patient seems to be in pain and states, "I feel uncomfortable." c. Left knee incision 1 inch in length without redness, drainage, or edema. d. Patient is hard to care for and refuses all treatments and medications. Family is present.

ANS: C Use of exact measurements establishes accuracy. Charting that an abdominal wound is "approximated, 5 cm in length without redness, drainage, or edema," is more descriptive than "large abdominal incision healing well." Include objective data to support subjective data, so your charting is as descriptive as possible. Avoid using generalized, empty phrases such as "status unchanged" or "had good day." It is essential to avoid the use of unnecessary words and irrelevant details or personal opinions. "Patient is hard to care for" is a personal opinion and should be avoided. It is also a critical comment that can be used as evidence for nonprofessional behavior or poor quality of care. Just chart, "refuses all treatments and medications."

Which information concerning a goal indicates a nurse has a good understanding of its purpose? 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.

ANS: C A goal is a broad statement that describes a desired change in a patient's condition or behavior. A goal is mutually set with the patient. An expected outcome is the measurable changes (patient behavior, physical state, or perception) that must be achieved to reach a goal. Expected outcomes are time limited, measurable ways of determining if a goal is met.

A nurse is a member of an interdisciplinary team that uses critical pathways. According to the critical pathway, on day 2 of the hospital stay, the patient should be sitting in the chair. It is day 3, and the patient cannot sit in the chair. What should the nurse do? a. Add this data to the problem list. b. Focus chart using the DAR format. c. Document the variance in the patient's record. d. Report a positive variance in the next interdisciplinary team meeting.

ANS: C A variance occurs when the activities on the critical pathway are not completed as predicted or the patient does not meet expected outcomes. An example of a negative variance is when a patient develops pulmonary complications after surgery, requiring oxygen therapy and monitoring with pulse oximetry. A positive variance occurs when a patient progresses more rapidly than expected (e.g., use of a Foley catheter may be discontinued a day early). When a nurse is using the problem-oriented medical record, after analyzing data, health care team members identify problems and make a single problem list. A third format used for notes within a POMR is focus charting. It involves the use of DAR notes, which include D—Data (both subjective and objective), A—Action or nursing intervention, and R—Response of the patient (i.e., evaluation of effectiveness).

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

ANS: C Abdominal distention, no reported bowel movement, and abdominal pain are the defining characteristics. Decreased gastrointestinal motility secondary to pain medication is an etiology or related to factor. Constipation (problem or NANDA-1 diagnosis) is the identified problem derived from the defining characteristics.

A nurse is caring for an older adult. Which goal is priority? a. Adjusting to career b. Adjusting to divorce c. Adjusting to retirement d. Adjusting to grandchildren

ANS: C Adjusting to retirement is one of the developmental tasks for an older person. A young or middle-aged adult has to adjust to career and/or divorce. A middle-aged adult has to adjust to grandchildren.

A nurse is teaching a patient about healthy eating habits. Which learning objective/outcome for the affective domain will the nurse add to the teaching plan? a. The patient will state three facts about healthy eating. b. The patient will identify two foods for a healthy snack. c. The patient will verbalize the value of eating healthy. d. The patient will cook a meal with low-fat oil.

ANS: C Affective learning deals with expression of feelings and acceptance of attitudes, beliefs, or values. Having the patient value healthy eating habits falls within the affective domain. Stating three facts or identifying two foods for a healthy snack falls within the cognitive domain. Cooking falls within the psychomotor domain.

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

ANS: C After identifying a patient's nursing diagnoses and collaborative problems, a nurse prioritizes the diagnoses, sets patient-centered goals and expected outcomes, and chooses nursing interventions appropriate for each diagnosis. This is the third step of the nursing process, planning. The assessment phase of the nursing process involves gathering data. The implementation phase involves carrying out appropriate nursing interventions. During the evaluation phase, the nurse assesses the achievement of goals and effectiveness of interventions.

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.

A charge nurse is reviewing outcome statements written by a novice nurse. The nurse is using the SMART approach. Which patient outcome statement will the charge nurse identify as appropriate 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

ANS: C An expected outcome should be patient centered; should address one patient response; should be specific, measurable, attainable, realistic, and timed (SMART approach). The statement "The patient will feed self at all mealtimes today without reports of shortness of breath" includes all SMART criteria for goal writing. "The patient will ambulate in hallways" is missing a time limit. Administering pain medication and monitoring the patient's heart rhythm are nursing interventions; they do not reflect patient behaviors or actions.

What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center? a. Have the family members evaluate nursing home staff according to their ability to get tasks done efficiently and safely. b. Make sure that nursing home staff members get patients out of bed and dressed according to staff's preferences. c. Explain that it is important for the family to visit the center and inspect it personally. d. Suggest a nursing center that has standards as close to hospital standards as possible.

ANS: C An important step in the process of selecting a nursing home is to visit the nursing home. The nursing home should not feel like a hospital. It is a home, a place where people live. Members of the nursing home staff should focus on the person, not the task. Residents should be out of bed and dressed according to their preferences, not staff preferences.

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

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

An obstetric nurse comes across an automobile accident. The driver seems to have a crushed upper airway, and while waiting for emergency medical services to arrive, the nurse makes a cut in the trachea and inserts a straw from a purse to provide an airway. The patient survives and has a permanent problem with vocal cords, making it difficult to talk. Which statement is true regarding the nurse's performance? a. The nurse acted appropriately and saved the patient's life. b. The nurse stayed within the guidelines of the Good Samaritan Law. c. The nurse took actions beyond those that are standard and appropriate. d. The nurse should have just stayed with the patient and waited for help.

ANS: C An obstetric nurse would not have been trained in performing a tracheostomy (cut in the trachea) and doing so would be beyond what the nurse has been trained or educated to do. If you perform a procedure exceeding your scope of practice and for which you have no training, you are liable for injury that may result from that act. You should only provide care that is consistent with your level of expertise. The nurse did not act appropriately. The nurse is not protected by the Good Samaritan Law because the nurse acted outside the scope of practice and training. The nurse should have acted within what was trained and educated to do in this circumstance, not just stay with the patient.

The nurse is working with a 16-year-old pregnant female who tells the nurse that she needs an abortion. The nurse, acting as a counselor, provides the patient with information on alternatives to abortion, but after several sessions, the patient still insists on having the abortion. What should the nurse, in the counselor role, do next? a. Encourage the patient to speak with a "Right-to-Life" advocate. b. Refuse to provide a referral to an abortion service. c. Provide referral to an abortion service. d. Delay referral to an abortion service.

ANS: C As a counselor, the nurse is responsible for providing information, listening objectively, and being supportive, caring, and trustworthy and providing a referral to an abortion service. The nurse does not make decisions, like going to a "Right-to-Life" advocate, but rather helps the patient reach decisions that are best for him or her. To refuse to provide a referral or to delay referral would not be supportive of the patient's decision

A patient presents to the emergency department following a motor vehicle crash that causes 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

ANS: C Based on the assessment data provided, the only supportive evidence for one of the diagnosis options is "Reports only moderate discomfort," which would support Acute pain. No supportive evidence is provided for any of the other diagnoses. The patient may indeed develop signs or symptoms of the other problems, but supportive data are presently lacking in the provided information.

A newly admitted patient who is morbidly obese asks the nurse for assistance to the bathroom. 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.

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

ANS: C Collaborative interventions, or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals. Health care provider-initiated (HCP) interventions are dependent nursing interventions, or actions that require an order from the HCP. Nurse-initiated interventions are the independent nursing interventions, or actions that a nurse initiates without supervision or direction from others.

An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying Those are for old people. What action by the nurse would be most helpful? a. Arrange medications by time in a drawer. b. Encourage the client to use easy-open tops. c. Put color-coded stickers on the bottle caps. d. Write a list of when to take each medication.

ANS: C Color-coded stickers are a fast, easy-to-remember system. One color is for morning meds, one for evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might be helpful if the person doesnt accidentally put them back in the wrong spot. Easy-open tops are not related. Writing a list might be helpful, but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder is always with the medication.

Vital signs for a patient reveal a 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 first action? 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.

A nurse attended a seminar on community-based health care. Which information indicates the nurse has a good understanding of community-based health care? a. It occurs in hospitals. b. Its focus is on ill individuals. c. Its priority is health promotion. d. It provides services primarily to the poor.

ANS: C Community-based health care is a model of care that reaches everyone in the community (including the poor and underinsured), focuses on primary rather than institutional or acute care, and provides knowledge about health and health promotion and models of care to the community. Community-based health care occurs outside traditional health care institutions such as hospitals.

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

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

A 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

ANS: C Developing nursing diagnoses before completion of the database needs to be corrected by the charge nurse. Always identify a nursing diagnosis from the data, not the reverse. The data should be clustered and reviewed to see if any patterns are present before a nursing diagnosis is assigned. Risk for infection is an appropriate diagnosis for a patient with an intravenous (IV) site in place. The IV site involves a break in skin integrity and is a potential source of infection. The diagnostic process should proceed in steps. Completing the interview and physical examination before adding a nursing diagnosis is appropriate. The patient's cultural background and developmental stage are important to include in a patient database.

A nurse is preparing to teach a patient about smoking cessation. Which factors should the nurse assess to determine a patient's ability to learn? a. Sociocultural background and motivation b. Stage of grieving and overall physical health c. Developmental capabilities and physical capabilities d. Psychosocial adaptation to illness and active participation

ANS: C Developmental and physical capabilities reflect one's ability to learn. Sociocultural background and motivation are factors determining readiness to learn. Psychosocial adaptation to illness and active participation are factors in readiness to learn. Readiness to learn is related to the stage of grieving. Overall physical health does reflect ability to learn; however, because it is paired here with stage of grieving (which is a readiness to learn factor), this is incorrect.

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

ANS: C Diagnostic reasoning is defined as a process of using the assessment data gathered about a patient to logically explain a clinical judgment, in this case a nursing diagnosis. Defining characteristics are assessment findings that support the nursing diagnosis. Defining characteristics are the subjective and objective clinical cues, which a nurse gathers intentionally and unintentionally. The nurse organizes all of the patient's data into meaningful and usable data clusters, which lead to a diagnostic conclusion. Diagnostic labeling is simply the name of the diagnosis

A nurse is caring for a patient in the hospital. When should the nurse begin discharge planning? a. When the patient is ready. b. Close to the time of discharge. c. Upon admission to the hospital. d. After an order is written/prescribed.

ANS: C Discharge planning begins the moment a patient is admitted to a health care facility. When the patient is ready may be too late. Close to the time of discharge and after an order is written/prescribed are too late.

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

ANS: C Disruption of tissue integrity is a possible cause or etiology of pain. A report of pain, headache, and discomfort are examples of things a patient might say (subjective data or defining characteristics) that may lead a nurse to select Acute pain as a nursing diagnosis.

A nurse develops the following PICOT question: Do patients who listen to music achieve better control of their anxiety and pain after surgery when compared with patients who receive standard nursing care following surgery? Which information will the nurse use as the "C"? a. After surgery. b. Who listen to music? c. Who receive standard nursing care? d. Achieve better control of their anxiety and pain.

ANS: C Do patients (P) who listen to music (I) achieve better control of their anxiety and pain (O) after surgery (T) when compared with patients who receive standard nursing care following surgery (C)?

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

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

A nurse is engaged in therapeutic communication with a patient. Which technique will the nurse use to ensure effective communication? a. Interpersonal communication to change negative self-talk to positive self-talk b. Small group communication to present information to an audience of children c. Electronic communication to communicate with the health care provider d. Intrapersonal communication to build strong teams

ANS: C Electronic communication is the use of technology to create ongoing relationships with patients and their health care team. Secure messaging provides an opportunity for frequent and timely communication with a patient's physician or nurse via a patient portal. Intrapersonal communication is self-talk. Interpersonal communication is one-on-one interaction between a nurse and another person that often occurs face to face. Public communication is used to present information to an audience. Small group communication is interaction that occurs when a small number of persons meet. When nurses work on committees or participate in patient care conferences, they use a small group communication process.

A nurse is teaching a culturally diverse patient with a learning disability about nutritional needs. What must the nurse do first before starting the teaching session? a. Obtain pictures of food. b. Get an interpreter. c. Establish a rapport. d. Refer to a dietitian.

ANS: C Establishing trust is important for all patients, especially culturally diverse and learning-disabled patients, before starting teaching sessions. Obtaining pictures of food, getting an interpreter, and referring to a dietitian all occur after rapport/trust is established.

A novice 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."

ANS: C Evaluation is a methodical approach for determining if nursing implementation was effective in influencing a patient's progress or condition in a favorable way. During evaluation, you do not simply determine whether nursing interventions were completed. The evaluation process is not used to determine when to downsize staffing or how to eliminate paperwork and care planning.

In caring for patients, what must the nurse remember about evidence-based practice (EBP)? a. EBP is the only valid source of knowledge that should be used. b. EBP is secondary to traditional or convenient care knowledge. c. EBP is dependent on patient values and expectations. d. EBP is not shown to provide better patient outcomes.

ANS: C Even when the best evidence available is used, application and outcomes will differ based on patient values, preferences, concerns, and/or expectations. Nurses often care for patients on the basis of tradition or convenience. Although these sources have value, it is important to learn to rely more on research evidence than on nonresearch evidence. Evidence-based care improves quality, safety, patient outcomes, and nurse satisfaction while reducing costs.